IN 2020, during the height of the COVID-19 pandemic, I spoke to my GP about self-testing for the human papillomavirus (HPV) – an option under the national cervical screening program in Australia if you are more than 2 years overdue for your test (which I was) or have never been tested.
Honestly, I prefer doing my own swab over a speculum exam – even if as a gynaecologist I am constantly pressing women to have their cervical screening on time.
As doctors, we know that the barriers to women accessing health care are long-standing and we need to offer alternative pathways. Self-care is a crucial part of the toolkit when we think about expanding access to care. It sits within a patient-centred approach to health care, allowing patients to become active decision makers in their health. Self-care empowers people with the knowledge and autonomy to access safe, effective and timely care, with support from a skilled health care provider if and when they need it.
This might seem counterintuitive to what ideal health care delivery looks like. Despite believing in patient empowerment and self-determination, I have struggled with “what ifs” in our implementation of self-care: what if they get the dose wrong, what if they can’t follow the instructions, what if there is a problem, what if, what if, what if …
In reality, evidence shows that self-care, when implemented with the appropriate back-up, is safe and can improve access and outcomes compared with traditional health care alone. In Australia, when thinking of self-care practices, you might consider self-swabbing for HPV or the bowel cancer screening test, but it can also include something as simple as taking a home pregnancy test or accessing medical abortion at home after receiving a prescription rather than having to go to a hospital. Given the right support, information and tools, self-care can help overcome some of the barriers to health care and improve the quality of care patients receive.
In humanitarian settings where Médecins sans Frontières (MSF) works, the barriers to health care can be much greater than those faced by most women in Australia. In many of these contexts, women do not have agency to make decisions about their own health care. In countries where I’ve worked, such as Afghanistan and Yemen, women have to ask permission to travel for health care. They might not have enough money to be able to get the care they need – even if the health care is free, there could be costs associated with travel or care for their children. Add to that a web of other barriers such as language, social norms, and the geopolitical context, including the risk of becoming a target of violence.
When women are weighing up whether to seek health care or not, they are assessing these risks. And if they have to do it more frequently, they’re less likely to commit to it. When you offer guided self-care options, it means that some women can access care they otherwise would not. For women seeking our sexual reproductive health services, such as contraception or safe abortion care, self-care gives them the tools to care for themselves in the privacy of their own home. It also promotes women’s agency to manage their own bodies.
Traditionally, MSF has focused on immediate health care needs including those that stem from outbreaks or conflict. Often our emphasis has been on opening clinics or hospitals to access care. However, we have learnt that we can safely expand women’s access and empower them to have better health care by offering supported self-care options, alongside clinics and hospitals.
In Ituri Province in the Democratic Republic of Congo, MSF introduced the self-injectable, long-acting contraceptive Sayana Press (Pfizer). While Depo-Provera (Pfizer) has been available in our clinics for many years, now women can manage the injections themselves. With guidance from clinical staff on self-injecting, women can take away up to four devices at a time to self-inject at home every 3 months. This ensures access to highly effective contraception for up to a year without repeat visits to the clinic, which can be difficult in this conflict-affected area.
Self-swabbing for HPV is another area we’ve invested in. MSF and the Ministry of Health in Gutu, Zimbabwe, compared HPV self-swabbing with being swabbed by a nurse. The trial found that nurses and patients were equally effective in collecting a sample (unpublished data). But importantly, the results also showed most women found the self-collection procedure comfortable (I’m clearly not alone in my preferences), and almost all would recommend self-collection for HPV testing to a friend. This was equally positive news given that word-of-mouth is pivotal for screening to be successful.
At MSF, we have always prided ourselves on providing high quality, safe and effective medical care. Now, we’ve been able to demonstrate that we can deliver health care safely while adding elements of self-care. The COVID-19 pandemic has accelerated those efforts, as barriers to accessing sexual reproductive health care increased overnight (lockdowns, fear of going to medical facilities, and physical distancing adding to all the other vulnerabilities already present), and thus reducing the number of women we saw in our projects. At the same time, there are still many barriers to offering self-care; for example, we have struggled to get sufficient supplies of Sayana Press doses and HPV testing is still much more expensive than other options which limits our capacity to use it more broadly.
The past year with the COVID-19 pandemic has been tough, but adaptations like self-care have been important for continuing to provide care, and I hope they are something positive we can take away from the pandemic and continue to grow and expand.
As clinicians, whether working overseas or in Australia, we have a responsibility to provide women with the care that suits them best. Together, we can help women overcome barriers to access by providing choice through self-care initiatives. Let’s empower women by trusting that given the right information and tools, self-care can be a key part of maintaining their health, no matter where they live.
Join MSF’s webinar on Monday 8 March, International Women’s Day, to hear more about what the organisation is doing in the self-care space.
Dr Claire Fotheringham is an obstetrician-gynaecologist and the Head of the Medical Unit with Médecins sans Frontières Australia. She leads a team of medical advisors dedicated to providing medical support and strategic advice on women’s health, paediatrics and neonatal care, sexual violence and nursing care across a number of MSF projects around the world.
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.