Telehealth changes risk sexual and reproductive health delivery

WHEN COVID-19 hit Australian shores, governments and health care workers scrambled to prepare a response to the looming crisis unfolding around the globe. Like many places, including Canada, France and the UK, the Australian response in the sexual and reproductive health sector included a rapid upscaling of telehealth services.

Enhanced telehealth accessibility, funded through the Medicare rebate system, allowed people to access healthcare in their own homes through the March–May 2020 lockdown. The switch to telehealth was in line with growing international evidence of how the pandemic response has dramatically altered health care delivery in high income countries, given the imperative to provide physically distanced health care where feasible.

However, this early win for the health of Australians has been short-lived with new restrictions making telehealth inaccessible for many and leaving the nation at risk of falling behind similar countries such as Canada and France and the UK.

The 20 July federal government changes to Medicare mean Family Planning NSW, like other similar services, can no longer offer telehealth to new clients or anyone not seen face-to-face by our doctors in the past year, which represents a great many of the patients who come to us for help.

“From July 20, telehealth GP providers will be required to have an existing and continuous relationship with a patient in order to provide telehealth services. This will ensure patients continue to receive quality, ongoing care from a GP who knows their medical history and needs. A relationship is defined as the patient having seen the same practitioner for a face-to-face service in the last 12 months, or having seen a doctor at the same practice for a face-to-face service during the same period.”

These cutbacks, while aimed at preventing rogue operators, also affect the most vulnerable patients. Global predictions of higher rates of unintended pregnancies, unsafe abortion, short interpregnancy intervals and untreated sexually transmissible infections (STIs) are all highlighted in our recent BMJ Sexual and Reproductive Health editorial.

Telehealth delivered health care to more than 1500 Family Planning NSW patients from 30 March to 20 July 2020, and accessing advice on contraception was the number one reason people used our telehealth service. We found telehealth greatly improved access to essential health care – particularly for people living in rural and remote areas, young people and those not connected with a regular GP. Assessments for long-acting reversible contraception and provision of contraceptive pill scripts, medical abortion and STI screening were all important health care services being delivered effectively by telehealth.

Telehealth is truly valuable for improving health and outcomes both in this pandemic environment and beyond, as we move to our “new normal” way of life. Telehealth delivers health care access to marginalised patients unable to attend in person because they live in a rural or remote area, have a disability, or live busy lives juggling work, young children and caring for elderly relatives.

It also opens access for young people who were the largest users of our telehealth service. In fact, from March to July 2020, 700 people aged 20–29 years used our telehealth service to access health care. We know this age group is particularly unlikely to have a regular doctor or may still be tied to a family GP with whom they prefer not to discuss sensitive sexual and reproductive health concerns.

The very nature of our specialised practice means we do not routinely provide continuity of care but rather see people when the need arises, with referral back to their GP for their ongoing care.

These telehealth restrictions mean many of our potential patients can no longer access our services nor those of other service providers, including GPs with specialised skills, as they do not fall within the current criteria. It is a sad reality that for the most vulnerable people in our society, these changes which can block access to telehealth will simply mean health care is not available.

Since the new restrictions rolled in, many of our patients can no longer access vital health care, including contraception, STI care, and medical abortion. So far, since 20 July, 48 people have been unable to access essential health care through our telehealth services due to the Medicare rebates changes.

The increasing chlamydia rates among young people, rising numbers of gonorrhoea diagnoses in women and men and the rise in new human immunodeficiency virus (HIV) infection diagnoses in the Aboriginal and Torres Strait Islander population mean there is no room for complacency in relation to STIs. Complications including infertility and chronic pain from untreated STIs can create ongoing cost burdens to individuals as well as governments.

Similarly, a recent survey found that one in four Australian women has experienced an unintended pregnancy in the past 10 years and that most were not using contraception or used a method with relatively low effectiveness. Unintended pregnancies, whether they end in abortion or continuation of the pregnancy and parenting, or more rarely adoption, also carry a considerable cost, emotionally as well as financially, to individuals, families, and society.

For people choosing medical abortion, the opportunity to provide care with telehealth is profound. We can offer medical abortion safely and effectively entirely through telehealth with counselling, assessments, treatment overviews and post-treatment check-ups, all suitable via a virtual health model. A recent Australian study shows that delivering medical abortion by telehealth is both convenient and acceptable to patients. Virtual models of abortion care are supported by international guidelines and are endorsed by multiple professional bodies (here, here and here) as they enhance access to this vital service, including for those in rural and remote areas for whom the costs of travel and accommodation to visit a city-based service would be prohibitive.

Australia has 41 000 GPs in the workforce but only 2317 are registered to provide medical abortion. When you shut down telehealth access to this service, women who choose not to continue with a pregnancy will unnecessarily face barriers that may push them to travel to find services at times when governments are trying to contain community movement, or be pushed to more expensive and invasive surgical abortions at later stages of their pregnancies.

Family Planning NSW implemented extensive processes to ensure our clinics stayed open during lockdown for those who preferred this model of care or those requiring a clinical examination for conditions such as pelvic inflammatory disease and procedures such as intrauterine device and contraceptive implant insertions. While telehealth should never completely replace face-to-face consultations, we have found it to be a very important complementary component of the care we offer.

This is an issue gripping the entire sexual and reproductive health sector, with numerous bodies and coalitions including the SPHERE NHMRC Centre of Research Excellence and Family Planning NSW releasing position and advocacy statements and lobbying government to secure access to health care for our patients.

Having people turned away from essential health care such as contraception, STI checks and medical abortions in Australia in 2020 is a cause for alarm, and patients seeking these specialised services need their access to telehealth reinstated through an exemption to the federal government cutbacks.

Clinical Associate Professor Deborah Bateson is the Medical Director of Family Planning NSW.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.