Introduction by Croakey: For the 12th year in a row, Iceland has been judged the world’s most gender-equal country.
Will anyone be surprised to learn that Australia, however, is not rating so well?
Indeed, the World Economic Forum’s 2021 Global Gender Gap Report places Australia at number 50 out of 156 countries, a slip from 44th in 2020.
For so many reasons, it is timely to be hearing from a women’s health summit convened in Canberra by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) on 27 May.
Croakey editor Jennifer Doggett live-tweeted the summit discussions from @WePublicHealth for the Croakey Conference News Service, and a wrap from her tweets follows below, covering wide-ranging issues including cultural safety, endometriosis treatment, the mental health impacts of violence and data matters.
Jennifer Doggett tweets:
An Acknowledgement of Country from the Hon Linda Burney MP, Shadow Minister for Indigenous Australians and Shadow Minister for Families and Social Services.
Burney is a Wiradjuri woman – the first Indigenous people in Australia to experience war with Europeans.
Women deserve a seat at the table – it’s time for our voices to be heard, she says. Sixty-four years ago today 90 percent of Australians voted in a referendum to include Indigenous Australians in the census.
For the first ten years of her life, Burney was not considered a citizen of Australia.
Crucial to hear the voices of migrant and refugee women, LGBTQI+ women and women with disabilities and First Nations women who experience violence and assault and inequity of access to care at much greater rates, according to Burney.
Health services are responsible for cultural safety, she says. This includes understanding the importance to First Nations women of kinship, caring for country, family relationships, relationships with the land.
If you strengthen Indigenous women you strengthen Indigenous communities, says Burney. Aboriginal women are not statistics, they are our mothers, daughters, sisters and aunties.
First Nations people view health from a community rather than an individual perspective and include social, cultural and environmental components. Intergenerational trauma, dislocation from community and land and racism all impact health, she says.
Up to one-third of the health gap between Aboriginal and Torres Strait Islander people and non-Indigenous Australians can be explained by social determinants, she says urging delegates at the summit to take these into account in their work.
Birthing on country is about providing a culturally appropriate service, both the physical and social/emotional, for Indigenous women; she cites research demonstrating the health benefits of birthing on country.
Respect and listening
The way we treat women is a cultural issue. When women are unsafe and unequal – it is a lost opportunity for everyone, says the RANZCOG president, Dr Vijay Roach. Empowering women won’t make anyone worse off – there is no negative.
Language is important, the president says, emphasising respect for all gender identify and pronoun preferences.
The health of women has been neglected – women must be heard, they need a seat at the table to lead. When women speak up they are told to sit down, when women demand to be heard they are told to be quiet. Today this will not happen.
This needs to start with listening to women and recognising social and economic security. Women’s health care should not be limited to physical health but include family, culture, environment and economic status etc.
Important to include women whose stories are often not included in women’s health panels – it is an opportunity for us to listen and learn. Aboriginal history is our history and our opportunity, says Roach.
Reconciliation belongs to all of us, says Roach; it is an opportunity and responsibility of all Australians, not only Indigenous people. Clarifying that RANZCOG has signed the Uluru Statement from the Heart.
Women’s health policy
Endometriosis is a personal passion for Health Minister Greg Hunt. “No women should have to suffer in silence,” he says.
He outlines the women’s health strategy, including: screening programs – cervical and breast cancer; diagnosis – listing of new PBS medicines for breast cancer; and research – rare cancers and diseases.
The Minister says there was $350m for women’s health in Federal Budget, including $47m for perinatal mental health, important to normalise mental health challenges and provide support early.
Also $27m for eating disorders, affecting 1 million Australians. These mostly affect young women and have the highest mortality rate of all mental illnesses.
He says there is: “$100m to expand breast and cervical cancer screening” and also budget funding to reduce pre-term births due to a very powerful presentation to by the pre-term birth alliance.
Officially declaring the summit open, Minister Hunt says he is very pleased to launch clinical guidelines for endometriosis.
Women in rural areas now having to move to regional centres to give birth, says Mark Coulton, the Minister for Regional Health, Regional Communications and Local Government.
He describes how his 32-year-old son was one of the last babies born in his hometown.
Boosts for rural MBS rebates and support for medical students to undertake training in rural areas should help address the health and life expectancy gap between rural and urban Australians, he says.
The failure of the federal and state/territory governments to coordinate services between hospitals, general practice, aged and disability sectors in rural areas is highlighted by Minister COulton.
Rural medicine is not second best, he says, we want the youngest and brightest to look at careers in regional Australia.
Three years ago, the Government launched the rural workforce distribution strategy. The rural generalist pathway should help provide rural communities with safe and high quality care as well as reducing hospital admissions, he says.
Gender and health equity panel
Session on gender and health equity is kicking off, speakers include: @vase_jovanoska, Gulnara Abbasova, Migrant & Refugee Health Partnership, @LGBTIQHealthAu @NickyBath, LaVerne Bellear, NACCHO, @TriciaMalowney @WWDA_AU, Professor Ruth Stewart, Dept of Health @RuralHC_Aus.
Asking for a national LGBTQI+ strategy to map and understand what is happening across sectors, says Nicky Bath, Chief Executive Officer, LGBTIQ+ Health Australia.
“Lots of words but a lack of investment in LGHBTQI+ sector”
Most of the $ for LGBTQI+ health going into generalist care rather than community controlled services, says Nicky Bath. No funding ATM but hopeful of getting some soon.
Religious discrimination bill currently before parliament will cause us stress and harm, says Bath, we need co-design and to work together.
Read more about LGBTQI+ health priorities here.
Women with disabilities experience discrimination, high rates of violence, says @TriciaMalowney, President, Women with Disabilities Australia. We also intersect with other communities, such as LGBTQI+, migrant, Indigenous etc.
People make assumptions about us – we are women first. We are not counted in the census as having a disability – categorisation of disability is gendered, according to Malowney.
Many women with intellectual disabilities are not on the electoral roll – this is used for breast screening so excludes these women.
Women want safe, evidence-based care as close to home as possible. Lots of evidence that birthing in rural areas is safe, says Prof Ruth Stewart, National Rural Health Commissioner.
We need to recognise the cultural authority of Indigenous women, says Stewart, describing a birthing service on Thursday Island which has halved the rate of premature births and reduce maternal smoking rates.
Women want safe, evidence-based care as close to home as possible. Lots of evidence that birthing in rural areas is safe, says Stewart.
Community codesign and culturally safe birthing services very important – also integrated primary healthcare.
Migrant and refugee women also have lower levels of health literacy and also health system literacy which means they do not receive equity of access to care. This impacts not just the individuals but also the communities.
Gulnara Abbasova, Executive Officer, Migrant and Refugee Health Partnership, says 460,000 women in Australia don’t speak English well and even those who do don’t have the language skills needed to access healthcare adequately.
Close to four million migrant and refugee women in Australia, according to Abbasova, their experiences are shaped by pre and post migration experience.
Bridging the gap between the consumer and the system requires action from both sides, says Abbasova.
Sexual and reproductive health panel
Second panel session at #RWHS on Sexual and reproductive health, speakers: Dr John Regan, @RANZCOG, Deborah Bateson, @FamPlanningNSW@CarolineHomer @BurnetInstitute @Nishaobgyn Consumers Ms Tessa Kowaliw,@omta_australia @Danielle_Mazza @SPHERE_CRE.
Final insights from panel members:
1) Every women with a disability is an expert in their own bodies – policy writers need to employ women with disability to help write policies.
2) Increased numbers of rural generalists, GPs, nurses, allied health etc in multi-disciplinary teams – it’s primary care that turns around the health of a national. Stop closing rural birthing services.
3) Intersectionality is not just a sum of parts – it’s a much more complex interaction with health systems. From data collection, workforce training, service provision, quality and safety etc, we need to be at the core.
4) Important to build capacity of the health system to understand its own privilege using an intersectional lens and involving the community.
5) We need to invest in communities and building their expertise in health partnerships, specific community engagement in government-funded programs.
Deborah Bateson, Medical Director, Family Planning NSW, says adolescents are diverse and need support which recognises their diversity. Australia in reducing unwanted teenage pregnancies but still a way to go.
Teenage mothers nine more likely to come from low SES area, also very diverse and not all unplanned. Need to support young women who choose to become mothers and do more to prevent unwanted pregnancies.
Cost is an issue – Australia one of the few countries where there is an out-of-pocket cost for contraception. Implants great for adolescents but we have low uptake in Australia.
Only four percent use it but evidence suggests that with information and the removal cost barriers this could increase to over 70 percent. Also workforce skill shortages – need remuneration pathway for nurses, such as MBS item numbers.
National data shows that abortion rates decreasing – medical abortion. Sex ed patchy nationally and often not relevant. Need universal access and need to provide services that young people want to use, inclusive, non-judgemental and culturally safe, ‘one stop shops’.
Co-design important. Many young people not comfortable accessing these services from their GP. Important to continue to fund telehealth. National evidence-based online platform to enhance health literacy.
The first step is to work out how to improve health literacy for all women. Women who are refugees have worse outcomes than those from the same ethnic background who are not refugees.
All of us who are not First Nations women are migrants, says @Nishaobgyn. No single solution will work for all women.
We should also acknowledge that women come to doctors asking for help but are denied simple services such as pain relief in pregnancy or contraception due to assumptions about them.
New technologies and social media have an important role to play. People do trust doctors so we have to provide information through all mechanisms.
Migrant and refugee women never reach parity with non-migrant women. Many are not used to voicing what they want – we can’t just ask we need to support them to work out what they want.
This affects how doctors present to women – they might not understand English but they understand body language. Why does a seven year old girl of immigrant parents die in a hospital emergency department? Let’s stop putting women in boxes.
Focus on prevention
Preventative health, chronic conditions and healthy ageing – were the focus of discussions.
We need greater recognition of endometriosis and understanding of the impact of pain on women’s lives: Donna Ciccia, Director & Cofounder, Endometriosis Australia, says endometriosis can start as early as eight and cause lifelong pain. It us unrecognised and under-diagnosed.
Jo Root, Policy Director, @CHFofAustralia @positiveage, says women feel their pain is invisible, people with chronic pain often say they feel dismissed by health professionals. Finding the cause is just one step but can help manage it. Consumer engagement is critical.
Professor Susan Davis, Chair, Past President, International Menopause Society, says women’s pain is under diagnosed and under treated. The upskilling of primary health doctors in areas like endometriosis and other conditions which cause pain is crucial.
Dr John Regan, Board Director, Royal Australian and New Zealand College of Obstetricians and Gynaecologists chairing the Preventative health, chronic conditions and healthy ageing at #RWHS21. He says there needs to be more of a focus on women’s experience of pain.
Women often say the day they are diagnosed is the best day of their lives.
Donna Ciccia says the average time for diagnosis for women with endo is 6.5 years.
Jo Root says the cost of chronic pain is huge, it can take over women’s whole lives and impact their financial and psychological well-being. The out-of-pocket costs to women are huge and impact on society is also massive.
Menopause affects 100 percent of women. The average woman spends 40 percent of their lives after menopause, says Professor Susan Davis. Most women know about acute symptoms but many don’t understand the impact on their bones or cardiovascular risk.
Many GPs not educated about this – Medical Services Adivsory Committee (MSAC) rejected bone density testing at menopause despite evidence that this is crucial for preventing osteoporosis, Professor Peter Ebeling AO, Board Chair, Healthy Bones Australia.
Jo Root makes the point that women shouldn’t be responsible for finding out what health services they need for menopause – GPs need to take responsibility for this.
Ebelin asking the panel what needs to happen to get GPs on board and become more educated about menopause.
Davis says that time constraints due to under-funding of general practice one major barrier to GPs becoming more involved in prevention etc.
Women’s health has to start with good general health – 45 percent of young women are overweight and obese, inactive and eat a poor diet. We need MBS funding for specialists to refer women to dieticians to improve their diets: Davis.
Getting young women off the screens and active in a safe environment is crucial to lay down good bone density when young – much better than calcium and Vitamins D, says Ebeling.
Jo Root promotes social prescribing to help GPs link women with local services. “Women often know what to do but don’t know what services are available or how to access them.”
Susan Davis congratulates the government for rolling out telehealth during the pandemic but stressing the need to ensure that the benefits continue while addressing some of the disadvantages, such as lack of ability to examine patients.
Also challenges in using telehealth for older people, people without good English and in addressing sensitive and personal issues, she says.
Important to see telehealth as a tool to support good quality care rather than a substitute for face to face care, says Jo Root.
Final thoughts from the Preventative health, chronic conditions and healthy ageing session:
- Investigate having a sub-specialty for endometriosis
- Current 45-49 year old health check to be changed and linked to menopause rather than age, including a bone density study
- MBS funding for bone density testing at menopause
- Comprehensive health checks for women
- Social prescribing to support women to access non-medical service
- Cultural awareness training for RANZCOG trainees, in NZ this is required but not in Australia.
Facilitator Sophie Scott is informing participants that the National Action Plan on Pain will include a focus on the specific impacts of pain on women
Mental health and impact of violence
Now the session on Mental health and impact of violence against women and girls at #RWHS21 panel members include Prof Jane Fisher, Prof Jeannie Hudson, Patty Kinnersly, Emma Reid, Chair, Dr Ruth Vine, @Jane_Fisher1.
Ruth Vine says the pandemic has increased demands for mental health services – with particular impacts on women, including loss of employment and increased caring responsibilities.
Emma Reid says workforce capability in regional areas was very important during the pandemic.
@Jane_Fisher1 describes research on the mental health impacts of the pandemic – impact on most disadvantaged areas twice as high as most advantaged.
Young women at increased risk of violence and mental health conditions like anxiety and depression. We know very little about women and mental health – most research undertaken on male rats, Professor Jeannie Hudson from @blackdoginst.
Patty Kinnersly, Chief Executive Officer, Our Watch, says violence against women is a national emergency. This needs to overlap with mental health conversation – most of the intimate partner violence burden is mental health related.
Digital mental health one solution to addressing workforce shortages in the mental health sector, says Hudson.
Women journalists face online violence which impacts on mental health, says Kinnersly.
Cyberbullying is incredibly harmful says Professor Jane Fisher, Director of Global and Women’s Health, Monash University.
When women feel trapped and humiliated they are much more likely to attempt suicide says Fisher.
No simple answer for reducing suicide rates, says Vine. Social determinants important, also access to services. Government needs to think about moving beyond the health sector.
Three things women want from health services: respect, empathy and kindness, says Fisher. All services can provide this. We can learn a lot from developing countries who do this much better than Australia.
Professor Jeannie Hudson discusses lack of counsellors in schools – currently up to principals and not evidence based.
Are we taking a gender and intersectional perspective on the social determinants of health? asks Patty Kinnersly. Need to address poverty among older women, for example.
What is driving violence against women? asks Patty Kinnersly. Disrespect towards women in all aspects of life contributes to this – we all have a role to play.
COVID exposed some of the weak points in Australia’s health care system, including the reliance on international medical graduates, says Dr Ruth Vine. We need to be more creative and flexible with our health workforce.
Research, data and evaluation
Final session kicking off – Future research, data collection, monitoring and evaluation.
Panelists include Prof Gita Mishra @mishra_gita, Ass Prof Jacqueline Boyle @jacanab, Prof Cynthia Farquhar @CindyFarquharNZ, ProfJulie Ratcliffe @AusHealthEcon @JulieRatcliff19, Prof Helena Teede @HelenaTeede, Leigh Toomey, consumer.
Final thoughts from the Future research, data collection, monitoring and evaluation panel at #RWHS21 on the next steps for the women’s health strategy.
- Central monitoring and evaluation for the Strategy with clear outcome measures and performance indicators
- Simple indicators are better for monitoring and evaluation
- Needs a good communications strategy to ensure findings of research are communicated
- Vaccine hesitancy highlights the importance of providing high quality communications
- Collaboratively designed data platforms
- Need person-centred outcomes in health, aged and disability sectors
- Important to include indicators relevant to the community, for Indigenous communities inter-generational trauma is crucial.
Value of routinely collected health data important to determine whether interventions are working says @jacanab.
@mishra_gita says public sector data available but hard to get data on private system.
Need more research on pelvic pain and period pain across the lifespan of women’s reproductive health years.
@CindyFarquharNZ says not enough action on fibroids. Data on social determinants vital. She says that road safety data in Victoria is the gold standard for data collection and use.
Perinatal and neonatal data is improving but there is much more we could be doing, e.g. quality of life and Patient Reported Experience Measures (PREMS) more generally.
Also need a focus for data – not just collecting for the sake of it. Need to consider duplication – too many registers and databases.
We need to integrate them and work collaboratively without asking for more data. This requires standardised definitions – harder than it seems! Federalism a barrier to this as are inconsistent regulations. Current research gaps include STIs and surgical registries.
Assoc Prof Catherine Chamberlain from the Lowitja Institute says that it’s positive to see racism and discrimination mentioned in the National Women’s Health Strategy.
Need to stop the deficit lens imposed – reinforced by education and research systems which control what knowledge is important. This compounds the worse kinds of racism.
Need research to capture hopes, strengthens resilience of Aboriginal and Torres Strait Islander Australians and also to build research capacity among Indigenous researchers. Data sovereignty is crucial – sometimes communities can’t access their own data.
Cardiovascular disease and chronic conditions have been under-recognised in women – data can help identify where current guidelines and treatments reflect a gender bias: Julie Ratcliffe, @AusHealthEcon.
Data integration and linkages across agencies important, says Ratcliffe.
The more data the better! Important to persuade women of the power of data – they need to see the value of giving their data to them and others.
Clinical registries can be used to prioritise health issues important to women. Obviously also have to ensure the data we collect is safe and secure. Government has a role here – regulating collection and storage of data as well as a central repository.
Priorities in the national strategy, such as women’s reproductive health, would benefit from better data, e.g. the issues with transvaginal mesh were revealed by electronic health records in the NHS.
Healthy ageing also important – two in three people accessing aged care are women. The ROSA database will help bridge gaps between health and aged care sectors, e.g. exposing waiting times for home care packages.
No consistent approach to data collection under the National Women’s Health Strategy says @jacanab. She says big data and real time data both important to inform care.
Gaps are due to regional, state and national differences. Also delays in collating data which make it difficult to make real time changes. Not all stakeholders involved. Need to collect disaggregated data, e.g. put young people from age 5-25 together despite very different needs.
Also there is a lack of routine data collection on needs of under-served communities and gaps in specific important areas, like abortion.
However, we also need indicators to know if we are succeeding says Leigh Toomey, goals are not SMART. For example, one aim of the strategy is lower incidence of suicide and self-harm but no target or timeframe. Need central KPI matrix.
Wrap up points
- Action on endometriosis an example of what can be achieved when sectors work together
- Access to dieticians
- Health checks and bone scans for women at menopause
- Whole of government approach to women’s health – need to educate members to acknowledge widespread depression and anxiety.
Intention of today is to compile a summary and work towards a consensus statement. The start of a conversation, not the end. Anyone with additional thoughts and input can send to Events@ranzcog.edu.au
To stay in touch with women’s health news, follow this #RWHS21 Twitter list.