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Sexual and reproductive health update: lessons learned from COVID-19

Jessica Floreani:
Welcome to this evening’s webinar on Sexual and reproductive health update: lessons learned from COVID-19. My name is Dr. Jessica Floreani and I'll be your host for this evening. I'm a GP in South Australia working in sexual health and women's health, the current LARC coordinator and Medical Educator at SHINE SA and work in private practice in a women's health clinic here in Adelaide.
We'd like to start tonight's webinar with making an acknowledgement of country. We recognize and acknowledge the traditional custodians of the land and sea on which we live and work. We pay our respects to elder's past present and emerging.
 
So I'll now run through a few housekeeping issues. So, this webinar is being recorded and will be made available for you in the coming weeks. To interact with us today. You need to use the zoom control panel. If you cannot see a panel like the image on the slide in front of you. Hover your cursor over the bottom of section of the shared presentation screen and the panel should appear. The control panel allows you to select your preferred audio settings, like which speaker, you are using and interact with the presenters. So we've put all attendees on mute tonight and to ensure the learning will not be disrupted by background noise.
 
As this is a webinar we're not able to see you as participants, so please interact with us using the Q&A box at the bottom of the screen. You can see that on the slide in front of you at the moment. Please don't enter any personal information outside your name and question because all the other attendees are able to see this information. If someone else has asked a question that you would like answered please give it a thumbs up. Questions that have more likes will move to the top of the list in terms of being asked those first. We do have a dedicated Q&A session at the end of our webinar, but please ask any questions throughout and we'll try and answer them as we go. I'll interrupt our presenters and as we need to. So ASHM has partnered with the RACGP tonight to deliver this webinar. And I'd like to thank them for supporting general practice and providing this educational opportunity for us all.
 
So we have two presenters with us here tonight. Dr. Amy Moten and Dr. Catriona Melville. Our first presenter this evening is Dr. Amy Moten. She's the coordinator of medical education at SHINE SA, where she provides clinical education to doctors, registered nurses and midwives, and other health professionals in South Australia. She also works as a GP with a special interest in sexual and reproductive health care, and is currently Chair of the RACGP Specific Interest Group in Sexual Health Medicine. So you'll see that there's a poll in front of you. If you have a couple of seconds just quickly answer that. Our other presenter tonight is Dr. Catriona Melville. She's a specialist in Sexual and Reproductive Health and a Fellow of the Royal College of Obstetricians and Gynecologists.
 
She provides client centered care, including abortion has been a passion of Catriona's for over 20 years. She has a keen interest in medical education and clinical research. She's also the author of the Sexual & Reproductive Health at a Glance book and Catriona is the Deputy Medical Director of Marie Stopes Australia. So I'd now like to hand over to Amy to commence the presentations.
 
Dr Amy Moten:
Thank you very much Jessica and I'm not sure if we're going to see the results of that poll up on screen. I think that was it. So we can see that. Yeah, it's pretty even split around half the people have had a sexual reproductive health consult over telehealth and a half hasn't. So that's really interesting. I'll just start with sharing my screen. And hopefully all technical difficulties will be erased.
 
So Sexual reproductive health update: Lessons learned from COVID-19. Hasn't it been an interesting time. How has COVID-19 impacted the sexual reproductive health needs of Australians? Well, I think something really important to recognize is that it had impacts across different jurisdictions. So, I'm sitting here in South Australia where we're relatively free and have a lot of social interaction. We see most of our patients face to face now, but people seen in the inner city Melbourne are under level 4 lockdown and have a completely different experience.
 
We know that sexual reproductive health provision continues to be an essential service and that despite the introduction of Telehealth Medicare items. There are limitations to providing a sexual health service remotely and we just alluded to it by asking, you know, how many of you are actually providing sexual health consults over Telehealth. It's a little bit more awkward, asking someone over the phone, 'When was the last time they had unprotected sex' than it is face to face. It is likely that telehealth will be an enduring feature of primary healthcare in the future. So I think we all do have to get used to it, and we have to think about how it's going to apply to Telehealth, or to sexual health consults in the future. And what are the implications for contraceptive consults, STI services, and cervical screening.
 
Now, these are some of the essential sexual reproductive health services that I think need to be provided face to face. And one of them is emergency contraception. I'll talk a little bit more about the emergency contraceptive pill. But the copper IUD is the most effective form of emergency contraception and it does require face to face consultation, because you are inserting it into a person's body and any consult around emergency contraception should touch on this and it should be offered to people and provided to them if their preferred emergency contraception of choice. Also important in terms of accessing long acting reversible contraception or LARC. So people should be able to present to a sexual health clinic or a GP, face to face, to have provision of their IUD or contraceptive implant. You may be able to do the initial consult by Telehealth, but again, the actual insertion process does involve face-to-face contact. And this is true for both new people, or people new to having a LARC, and people who need a LARC change over. They also often need face to face consults for complications of LARCs. So if someone's having ongoing pain and bleeding after a LARC insertion. So again, an IUD or an implant, then they often need to have a speculum examination to have look at the cervix, the amount of bleeding and if they had an IUD, the length of the string or whether it's present.
 
If someone is symptomatic of sexually transmitted infection. They do need access to a doctor or health professional to have an examination. So self-collected STI testing is fine when people are asymptomatic. But if they have symptomatic, then the gentles need to be visualized and all swabs need to be taken manually. Cervical screening - depends on whether again, they're symptomatic or asymptomatic, and we'll talk a bit more about the exceptions to delaying cervical screening. But we are certainly considering that all cervical screening should continue as normal, even in the most extreme lockdown, during COVID. If someone needs access to abortion and they've chosen the surgical termination. Obviously, again, they will need a face-to-face consult. And also just thinking about vulnerable groups. So things that you might otherwise be considering something to be easily available over the phone. If someone is not having English as their first language, if they are mentally or physically disabled. Then you might want to consider giving them a face-to-face consult as well because some of these things don't translate well over the phone. And I should point out that despite the new Telehealth items estimated about 3% of GPs are actually doing video consultations. So 97% are doing them over the phone. There are lots of things that you can do over the phone, but sexual health is a particularly difficult thing to do.
 
In terms of remote services during COVID, then oral contraception, such as the progestogen-only pill, or the combined hormonal contraceptive pill. These are potentially able to be done over the phone. LARC counselling, including your pre consultation and also discussing the extended use of LARC, which I'll mention a bit more later. These can also be done over the phone. So someone ringing up asking, 'well I think my IUD is expired, or about to be expired. What can I do?' Doing STI testing for people who are asymptomatic can definitely be done remotely with, again, some appropriate counselling and discussion with your pathology providers. Non-directional pregnancy counselling, which Catriona is going to talk much more about, and also abortion care, such as early medication abortion.
 
So what is the impact of COVID-19 on sexual and reproductive health practices. General practices have reported fewer people attending and pathology companies report up to 40% less tests of preventive health screen, such as, HbA1c for diabetes. And we have seen reports from pathology providers that up to 60% less cervical screening tests were done at the peak of COVID-19 lockdown. So in March and April. The ASHM COVID-19 taskforce has also reported a 30 to 50% reduction in demand for services and anecdotally, I can tell you that both my private practice and SHINE SA saw a significantly lower number of people walking through the door. Because people were afraid to come in and also services were closing their doors until they knew what was happening or until they could get personal protective equipment. It's also uncertain as to whether there has been a change in sexual health behaviour impacting STI rates. So, we're not sure whether certain declines in STI rates are actually because people are testing less or because they're having less casual sex. And again, this will depend on the jurisdiction you're in. In South Australia, I think, there's been a return to a lot of social behaviours that are probably not being seen, or not able to be seen in inner city Melbourne.
 
So, a survey that was done from the 23rd of April to the 11th of May, was an online survey of 518 participants and self-reporting participants were able to continue to access their usual contraceptive method during the first lockdown. Those people who did report difficulties accessing the visual contraceptive methods were younger people, and people who are unemployed. It is important to be aware, for those people providing contraception, that there is a current shortage of the 35mcg ethinyl estradiol pill, which contains norethisterone. So the brand names are Norimin and Brevinor or Norimin and Brevinor One. Now this is a particularly important pill for people who've experienced breakthrough bleeding on other forms of oral contraceptive pills. It's the main reason why they're on it. And they have found it quite distressing to not be able to access it during COVID. And in fact, the shortage was occurring prior to COVID and it was a manufacturers issue. But it is really important to be aware that people often spend a lot of time finding the perfect contraception for them. They may have gone through multiple oral contraceptive pills and have settled on this one because it is the only one that doesn't give them side effects. And to suddenly have it unavailable means they're likely to either discontinue their contraception or restart another form of contraception, which they don't like. And then again, potentially discontinue it. And accessing your preferred contraceptive method is essential to the prevention of unintended pregnancy.
 
Most participants in the study did report they were intending to avoid pregnancy and that many of them who were planning to become pregnant this year, actively deferred that decision to become pregnant based on COVID. We are not really aware of the impact of COVID on an ongoing pregnancy, or indeed the newborn baby. And so again, any absence of any sort of real health advice around that people are choosing or preferring to choose not to become pregnant. Interesting, also, a third of participants or nearly a third reported having difficulties in accessing their normal feminine hygiene products, their pads and tampons and nearly half of those reported changing their use as a result. And down the bottom is the link to this study. It's not yet been published, but it will be available via these slides to access that link.
 
Now this is a slide which shows STI rates during COVID. So this is a slide based on the Kirby Institute data. It shows STI rates from 2015 to 2020 by month. And what you can see is that, this is Chlamydia, sorry. Over the years we've been seeing a steady increase in Chlamydia. But this year, we saw a sudden decrease around March, April, May, particularly compared to year to date data. Now, again, we are unsure whether this is because of COVID changing sexual health practices or is actually related to less STI testing. We certainly know that around half of STI tests done in general practice are opportunistic versus people having symptoms. So people who are not having symptoms are far less likely to present to a GP at this time. Certainly, people who are having symptoms should be seen, and there is a concern that we might be seeing people who are who were symptomatic during the lockdown, whose symptoms have evolved from not presenting. We know that people with Chlamydia and Gonorrhoea may have an initial range of symptoms, which then settle, but they are still infectious for up to several months afterwards. And certainly with syphilis and HIV, they, they have ongoing infection risks but because they didn't present during the syphilis crisis, that they might be sorry the COVID pandemic, that they might not have presented and we'll never know how many people might have tested positive during this time.
 
And again, that was the link before to the Kirby Institute report. So how has COVID-19 changed sexual and reproductive health provision in Australia. It's made a big impact, some for the good and some for the bad. Telehealth is a big game changer. I'm a GP and I think this is a big deal for GPs. I think other specialists already had access to Telehealth item numbers prior to this, but I think it's also going to change specialist access to patients as well. It does have the potential to improve access to sexual and reproductive health. But again, it's not the ideal medium for sexual and reproductive health in some circumstances. And again, obviously, if someone has a rash on their genitals, we don't really want them taking pictures on their phone and emailing us.
 
There are concerns. I personally have concerns around Skype and Zoom as a medium for patient private concerns. If you're not using Telehealth, which most of us GPs are not doing. As I said, it's only around 3% are using video consults. It's very difficult to pick up on non-verbal cues.
 
In a normal sexual health consult, I've had a couple of instances of mental health consults of patients actually crying and not being aware that they were crying. Until, you know, a bit after they started to tear up. I couldn't see that they were becoming distressed because of that. And again asking someone about when was the last time you had sex, who was the last partner you had it with, it's always a bit easier in person, a bit nicer. It's also easier to send someone to your toilet in your clinic room when you're doing an opportunistic screen. So my standard advice if I'm doing a opportunistic chlamydia test is to say to someone, 'well, while I'm typing up the script, why don't you go next door to the toilet and do this swab or do this urine sample while I'm here.' For patients who are offsite, it actually involves them coming somewhere or us posting out a swab for them to do. So again, it's making things less convenient for the patient. We also need the ability to provide examination, if required. So if someone rings up and says they have a symptom. They have a new discharge, dysuria, a new change in their bleeding. It's actually a requirement of the Telehealth items that we have to provide them with somewhere to have a physical examination. It doesn't necessarily need to be us, but we need somewhere that will see them on the same day. So, one of the things I did when South Australia was in lockdown was I booked all my Telehealth consults in the morning, and I had a slot for a couple of hours in the afternoon where anyone who needed to be examined be able to come in. And, I did find that a significant number of people who rang up needed to be examined.
 
There are implications for GPs and sexual health services with a specialized interest. Not only sexual health, but all GPS with a special interest. So, if for example, you are known in your area for being a GP with the expertise in sexual health or skin lesions or respiratory medicine, you're not likely to see every patient within the last 12 months. So you might see people on an as needed basis. So people come to a Family Planning Organisation, for example, for an IUD once every five years, or if they have problems. The new restriction on Telehealth items has said that they need to be seen now, within the last 12 months. And it's not a likely thing for people who are attending for IUDs, or even Implanons, which are every three years. So I think the idea behind that was to stop people from doctor shopping. I personally think if you can see people face to face without having to see them in the last 12 months. I'm not sure why you need to have seen them for a phone consult, but it is a real issue for sexual health services and special interest GPs.
 
There also implications for private billing GPs. So GPs who may charge a gap fee and that is their right to do so. Some of the Telehealth items are specifically designed to be bulk billed. So people who are pregnant, for example, and I think maybe Catriona might expand on that a bit more, that some implications for abortion services where people by definition are pregnant and they're ringing up for Telehealth. And they're also implications for patients who don't want to see their family GP. So younger people, who may have being going to a general practice for years because it's their parents general practice, but all of a sudden they want to talk about contraception, or they want an STI test. They don't really want to see the same GP that mum and dad goes to. Even though we know that confidentiality is continued. They might feel that it's a bit weird, but they now have no choice if they want to have a Telehealth consult. So these are all things we have to think about when we're providing Telehealth, sexual health and phone consults.
 
Now just briefly, access to LARCs, so long acting reversible contraception. We know these are the most effective form of contraception. They're generally the best tolerated, well we know they're the best tolerated. So IUDs and Implanon, and they can still be facilitated during COVID-19. The idea is to minimise face-to-face consult. So you can still have a Telehealth consult, do all of your screening, your history and your consent over the phone. Any STI or cervical screening can be discussed on a case by case basis. If someone needs an STI test, they can organise to have a self-collected swab. If they need cervical screening, it can be done at the time of the IUD, or indeed the Implanon. Insertions and removals of both IUDs and Implanons can occur using personal protective equipment. Including both patient, the inserter and also any assistance, which is the nurse who might be involved in that consult. And the use of assistants can be minimised now. IUDs, in particular, are traditionally known to having a nurse assistant or an assistant. Someone who not only helps out the inserter, but also provides what we call vocal local to the patient, which is the reassurance and the chat that keeps people distracted during a potentially painful procedure. Follow up visits of intrauterine devices are not recommended by the UK Faculty of sexual reproductive health as essential and certainly Family Planning Alliance Australia. So again, it's not essential.
 
Patients should be provided with the information that they need to represent or to contact a service if they have symptoms, but certainly a consult of three to six weeks post insertion is absolutely fine. And there's no need to have a follow up appointment for contraceptive implant insertions.  If someone does have a LARC, so an Implanon or an IUD and they're not desiring to become pregnant. If it is expired and they don't need ongoing contraception for whatever reason, then removal can be delayed. So there's no harm in leaving an implant or an IUD for the next three to six months, possibly even a couple of years after it's expired. Ideally it would be removed. But again, if people are in extreme lockdown and they don't particularly want to come into their GP or their GPs not available. These things can be delayed. We know that LARC methods are more than 99% effective with extended use. And we do think that with extended use oh sorry with normal use. With extended use we can't guarantee the effectiveness but all the studies so far does support the fact that IUDs and Implanons can be extended beyond their current manufactured device. So the 52 microgram sorry milligram hormonal IUD is known as Mirena is now currently supported during COVID to be able to be left for up to six years instead of five years. And the shorter Copper T or the load Copper IUD is extended to six years versus five years and the full size Copper T is extended to 12 years due to COVID. There is also evidence support leaving a contraceptive implant implement NXT to leave. Again this is if removal and replacement can't be easily facilitated
 
Now that does cause concern for patients who have been up until now drummed into their heads that this is the expiry date and you must have it removed and replaced and certainly for health professionals as well. So if someone does have a LARC and you are counselling them on extended use. It is still acceptable if they're concerned or you're concerned that it has reached the expiry date that you were previously advised on. That they should discuss that with you and use some additional contraception including oral contraceptive pills can be advised. And it is absolutely ok to use the combined oral contraceptive pill or the progestogen oral contraceptive pill with any of the LARCs including the Implanon IUD.
 
What about Depot. Well Depot progesterone is a injection administered every 12 weeks. So it does require face to face consult. And again, this is something that can be facilitated with a Telehealth consult first by coming in with people wearing their protective equipment. And the actual injection can take you know, less than a minute. If someone is self-isolating or has been a COVID contact or has symptoms and they can't come in or you're worried about them coming in. Then again you could advise on additional precautions that has condoms or a contraceptive pill. And Depot is recommended to be given 12 weekly. I think it can be extended up to 14 weeks. So if someone is at 12 weeks and they're under quarantine for 2 weeks. It is safe to give them the injection at 14 weeks, as long as it's not more than 14 weeks.
 
What about combined hormonal contraception. So we're really talking mostly about the combined oral contraceptive pill. Although the contraceptive vaginal ring carries all the same caveats. So for new users it's really important or even for continued users that you conduct a thorough contraceptive history and also look at risk factors. We know that estrogen is a risk factor, the venous thromboembolism and we need to take a thorough history of that, including migraine with aura, a family relative under the age of 45 who has had thromboembolism and also things like smoking and hypertension. BMI is also significant when it comes to the risk of VTE and BMI over 35 is a contra indication, or what we call a Medical Eligibility Criteria 3 to the combined oral contraceptive pill. If we're not seeing people and we've potentially never seen them before. Then we should ask a self-estimation of height and weight and that should be documented. Height and weight or weight in particular is always a sensitive subject. So I would introduce it by saying well body mass index is actually really important in prescribing the combined pill. I just need a bit of an idea as to what you think your height and weight may be and whether or not that's suitable for you. It's reasonable to start people on the combined oral contraceptive pill or indeed the vaginal ring. If they are under 30 with a normal BMI based on that self-estimation. And if they're not smokers and they have no other risk factors or hypertension or cardiovascular disease. So someone with type two diabetes that is poorly controlled. I might want to see them face to face versus someone who's well controlled
 
In providing the first prescription, it's advisable to review it three to four months to assess any side effects, new contraindications and talk about adherence to pill taking. Now this is regardless of whether you see them face to face or over the phone. But generally, if you can, again it would be a really good idea to get someone back at three to four months to check their blood pressure to make sure there hasn't been any increase. Also a time where we often talk about things like skipping your pill or what we call extended use of tricycling. We certainly don't recommend people do that in the first 3 to 4 months because it can mean that they get more breakthrough bleeding.
 
If people are reaching out for a repeat pill script. It's reasonable provide a further 4-12 months repeat without checking BMI or blood pressure. If the chance of them coming in, exposes them to COVID because we know that the risk of thromboembolism is greatest during pregnancy and in the immediate postpartum period. And so the risk of unintended pregnancies and increased risk of BTE but also it's a very bad thing to happen to people. It would be again you know great if they could find their blood pressure anywhere else. But I think as GPs it's incumbent on us to provide the services to do the blood pressure check and other BMI checks, rather than deflecting it to other services such as pharmacies. And for anyone on the progesterone only pill 6 to 12 months of prescription can be given without any physical review because we know it is a very, very safe medication. It only has three real contraindications, which include breast cancer and undiagnosed bleeding and no pregnancy. And just important to be aware, some people are recommending transitioning people from the combined oral contraceptive pill to the progesterone only pill based on their risks. Maybe they are a smoker, they will need their blood pressure checked, but be aware, the efficacy window is 3 hours versus 24 hours. So someone needs to take the progesterone only pill within 3 hours of the last well at the same time as the, the last time they took it.
 
So emergency contraception is also something that we are discussing more over Telehealth. It can be obtained over the counter. There are two types of emergency contraceptive pill available over the counter in Australia and the choice depends on a number of factors. So it really is important to discuss this with either pharmacist or GPs when they're recommending an emergency contraceptive pill. If you can provide a prescription via a Telehealth consult that will reduce the time that they have to spend face to face in the pharmacy because Pharmacists do have to ask them a series of questions to prescribe it. And alternatively if they don't want a Telehealth consult or can't access one they can ring ahead to their pharmacy to discuss the choice of emergency contraceptive pill. But again do remember that Copper IUD should remain as the first-line EC emergency contraception, even during the COVID pandemic. It is more effective and it provides ongoing contraception
 
People with symptoms of STIs should be examined due to the high morbidity from undiagnosed PID and epididymo-orchiditis, but certainly we can facilitate asymptomatic STI screening with the provision of self-collected specimens. Blood-borne virus testing can be still facilitated via pathology collection centres and so self-collected testing could either be a urine sample with some with a penis or even some with a vagina. But generally, we recommend a self-collected vaginal swab for someone with a vagina. Three site testing can still be facilitated with a urine sample and swabs for people who identify was anything. But it's really important to check with your pathology provider as to what swab is appropriate for their lab because different labs use different swabs and you can look at the appropriate testing by the Australian STI guidelines on this website.
 
All people screened for cervical cancer since December the 1st 2017 and have a low risk result are not overdue so they are safe until 2022. But anyone who has not had a CST since their last Pap test is now overdue. And again, all people with symptoms should be examined. New screeners turning 25 are considered to have either vaccination or herd immunity. So they may be deferred their first test by up to 3 to 6 months, depending on whether they're in a hot spot or a lockdown area, if necessary, but that should be discussed by a phone consultation or a Telehealth consultation.
 
You should still be sending out your reminders if that's something you do, and certainly the national cervical screening program will do that and people who are more than two years overdue may be eligible for self-collection. People who are due for a repeat test either due to having a previous intermediate risk or they've test of cure should be seen without delay. So we should not be deferring these patients. High risk results still need Gynae referral and review and we are now seeing new guidelines under review for universal self-collection and deferring the need for coloposcopy after a 2nd intermediate risk.
 
In terms of the ongoing implications. I think Telehealth is here and it's here to stay. Extended use of LARC may become the new guidelines. Ideally, all oral combined oral contraceptive pill consults should involve a blood pressure check. But we need to do that under consideration of of their circumstances. Again STI screening may move to Telehealth online if self-collection can be facilitated including self-collection for CST. And contraception, emergency contraception and the provision of related sexual and reproductive health services remain essential services. We know the increased rates of unintended pregnancies, not only important for an individual, but they have an impact on the public health system in terms of abortion services. And STI and cervical screening remain essential services for both symptomatic and asymptomatic people
 
So this is my take home something I've learned in the last few months is, I wish I did blood pressure on more people because sometimes I'm doing a phone consult, where I really want a reading and I look and they haven't had one in the last two years. And also I'm going to pause here and see if there any questions or if I've left any time for questions.
 
Jessica Floreani:
Thanks Amy that was a fantastic talk
 
We've got a couple of questions. Now we might, there was 1, 1 I'll leave until the end because Catriona might want to add into that as well. There was one question though around from Anthony Bolton, so thank you for that, around a comment with the STI rates and chlamydia testing rates and made a comment about there seemed to be a dip of that in January already sort of pre COVID. Is that something that you can account for or something else that was happening or just making a comment about about those numbers.
 
Dr Amy Moten:
Yeah look, that's a really good pickup and we were actually seeing a decrease in chlamydia rates in particular. Certainly in South Australia, but also in Australia prior to COVID. I'm not sure why that is because most of the other STI rates are increasing, including gonorrhoea and syphilis, I think, personally, but we've been going really well with our campaign to get both GPs and patients to screen for chlamydia and that has led to a decrease in rates, but it was definitely seen pre COVID.
 
 
 
Jessica Floreani:
Yeah okay thanks for that. And then there is a question about some PrEP as well but I might leave that to the end so you can talk a bit further about that.
 
So we'll now move on to Dr. Catriona Melville's talk. So she's going to share her screen hopefully, and we look forward to hearing her talk. Again please encourage you to use the Q&A button for any questions that you may have. As I said, if it's appropriate at the time I'll butt in and ask the questions. Otherwise you can you know there's multiple questions you want to ask, put them in there and we'll have a look at through all of those at the end and do a bit of a Q&A too. So I'll pass over to Catriona and thank you very much.
 
Dr Catriona Melville:
Thank you Jessica. And that was really interesting Amy and hopefully I can help answer some questions at the end as well. And so and first of all, I would like to make my own acknowledgement of the traditional owners of the stolen lands on which we are holding this meeting and there are many lands across Australia and actually, I believe, internationally tonight as well. And here in Brisbane I'm on the home of the Turrbal people. And I'd like to pay my respects to elder's past, present and emerging and also acknowledge any Aboriginal, Torres Strait Islander and South Sea Islander people who are with us tonight. So just a little bit of background about my organization. I work for Marie Stopes Australia and that comes under the umbrella organization of Marie Stopes International. Marie Stopes International has  11,000 team members in 37 countries and all across the globe, including Africa, Europe, and Asia. So we're part of a very big global organization and we're a not for profit. And and Marie Stopes Australia and the organization for which I'm the deputy medical director and has now been in Australia for 20 years and we started in 2000. I wasn't here for those last 20 years and and we've got 260 staff and those are across our 16 clinics in 6 states and territories. We don't have clinics in Tasmania or South Australia but we do, we do offer Telehealth in Tasmania.
 
So how has COVID-19 impacted the sexual and reproductive health needs of Australians? Well, I really want to start off with a disclaimer because we actually don't really know what the full impacts are going to be and we certainly don't have the full picture and as Amy mentioned, for example, particularly concerning things like pregnancy outcomes. It's going to take maybe a number of years before we actually know potentially what the full impact of COVID-19 is on reproductive health.
 
What we can do is, you know, we can gain some some data that's emerging and we can also look at information from past epidemics. So, for example, like Zika and Ebola. We can couple this together with some real time data that we are collecting. As I say we certainly don't have the full picture yet. So, watch this space. So, one of the first impacts that we've noticed in reproductive health is the impact on decision making and and my, this part of the session is mainly going to focus on unplanned pregnancy, but I'm going to also talk a bit about violence against women and also some permanent methods of contraception. So, concerning specifically pregnancy outcomes and pregnancy.
We have noticed that there's been a great deal of uncertainty in the patients and clients we are seeing and also the pandemics caused a lot of anxiety. This is things around, you know, just simple things like. Will I be able to afford a child? We've obviously got a lot of job and security at the moment. People are losing jobs, people's partners are losing jobs. We've also got women asking, you know, what will antenatal and intrapartum care look like. We know in areas where there's been lock down that people aren't allowed to have their partners in the birthing suites, So even issues like that are actually becoming part of people's pregnancy decisions.
 
And then there's obviously bigger questions that are around for people planning a family at the moment. Which are things like, what will the future look like for the next generation but we really don't know because we keep talking about the the sort of new normal but really um we're not sure entirely what will, what the future will hold. So this has sort of led to an increase, we've noticed in case complexity and also needing more psycho-social support. You know there's issues such as, for example, temporary residents who have been trapped in Australia, essentially, because an inability to travel. And they don't have access to Medicare. So those kind of  complexities will also help form decisions around pregnancy and planning.
 
We have certainly notice noticed that anxiety has increased and a lot of that is tied into financial impacts of COVID as I've already mentioned. But also it's you know for many women they feel that it's not a good time to take maternity leave, if they are in fact lucky enough to still have a job. It's quite a vulnerable time for them in the workplace. Pregnant people have also expressed to us anxiety about changes to their support networks. Particularly family and not being able to be close to their loved ones and that's due to obviously travel and movement restrictions. So all these very complex issues that are going on in people's minds, are helping to form the decision making around pregnancy outcomes.
 
And what this really means for sexual reproductive health is that we need to have, make sure that there is clear evidence and information available to the public about what is and isn't available. We also need to ensure that essential services are available. So as Amy actually mentioned moving on to the impact of sexual activity. We don't actually currently know what is happening with sexual activity. I think when lock down first happened to various states we thought all you know the the unplanned pregnancy rate is going to soar because people don't have much else to do at home. The opportunities for sexual activity may increase and then there's been another voice that said well actually people in particular younger people, aren't out socializing and meeting up and doing Tinder dates. Actually, the amount of sexual activity will reduce. Ultimately, we don't know and there is conflicting evidence, but the University of Melbourne, Melbourne has already started a study concerning this issue. So I'm hoping that we will have some data to actually confirm or refute this.
 
What we do know is that the impact of sexual activity has changed. You know, in a pre COVID world the access to contraception and abortion services was certainly quite different in various states from what it is now. So Amy mentioned that there has been a shortage of the norethisterone containing pills. That was a manufacturing issue isn't directly, indirectly related to the pandemic, but it does just limit choice in some people. But additionally, and particularly, we notice when the lockdown and the pandemic first really struck in Australia. A lot of providers in general practice and even in specialist services, very quickly moved to Telehealth and services like LARC were temporarily stocked in a lot of locations. That was just really people you know getting in place COVID safe plans and working out how they could provide these services safely. But that did definitely impact access to contraception. And as I'll go on to explain access to abortion has definitely changed since the pandemic. Some of it has been in good ways, but there has certainly been some restrictions because of the pandemic. So what about violence and coercion. So there's certainly has been quite a lot in the media over the last few months about the increase in intimate partner violence associated with the pandemic.
 
We've noticed with travel and movement restrictions that the ability to control your own sexual reproductive health has definitely been impacted. This link that I've shown at the bottom of this slide is about is from the Australian Institute of Criminology and they did quite a large online survey of 15,000 people and they looked at their experiences of domestic violence during the first few months of the COVID pandemic. And what they found is that 1 in 10 Australian women have experienced violence and coercion during COVID. And more than half of these have seen an escalation in the frequency and severity of violence. This is a really good report. It's definitely worthwhile having a read at that.
 
So what are the reasons, potentially, that this violence has increased. I use the word explanations there and I want to make it quite clear that this isn't an excuse for the violence. This is just some of the factors that have come out through the research I've cited, but also other research. So clearly if people are trapped in their homes in lock down. You know, as we were speaking to our Victorian colleagues earlier, you're soon going to be let out for two hours a day. But at the moment, it's one hour. And if you're at home with somebody who's a perpetrator of domestic violence for 23 hours at a time, then obviously that can cause an escalation. We also know that people have been more and more socially isolated. So, as far as intimate partner violence is concerned, that means that people are less likely to be able to access their usual support networks.
 
There's also increased situational stressors. And again, this isn't an excuse it's just that when perpetrators are in couples or families are under more stress, for example, financial stress. That may act as a trigger to cause, cause domestic violence, but also to exacerbate an existing abusive relationship. Domestic and intimate partner violence is very much about control. It's about the perpetrator having control. And often offenders feel out of control, and particularly at a time like this when there's a pandemic and they may be unable to control other aspects of their life. So it may be that domestic violence is increasing because the offenders are using this as a means of gaining some sort of control over an aspect of their lives. And then we have drugs and alcohol and, you know, again, some light hearted comments have been made about you know people drinking too much wine when they're home schooling, but you know being very serious they're  obviously has been an increase in alcohol consumption in many, many households.
 
And certainly abuse of alcohol is related to an increase in in domestic violence and abuse. And then finally, just to highlight there is already a pre-existing good solid evidence base about the strong correlation between domestic violence and unplanned pregnancy. And you know, particularly around what we've termed reproductive coercion. So essentially, that is the removal of autonomy for one's, one section reproductive function. And this may be in terms of somebody coercing you into having an unplanned pregnancy and keeping that pregnancy. But it can also be coercing people to have an abortion when they don't want to. And also control of a person's contraception which makes them unable to control their own fertility. So we've got all these complex factors sort of feeding into an increase in domestic violence and unplanned pregnancy.
 
So how has COVID-19 changed sexual and reproductive health provision in Australia. So I just wanted to pause and have a little poll there.  So have you seen an increase in patient’s encountering difficulty in accessing an abortion during the pandemic? I'll just give a few minutes for you to answer that. Okay, I think we could probably close that now and just look at the result.
 
Well, that's great. So, just over 70% of you have said that you haven't seen an increase in difficulty accessing an abortion during the pandemic. I'm really that's really pleasing to hear not so pleasing that a third of people have noticed a difference. But I'll talk a little bit around around that also, but you know what the changes to abortion and delivery have been during this time.
 
So, one of the first things that happened at the beginning of the pandemic was that we lobbied the government and various bodies very on a daily basis until we managed to get abortion categorized as an essential service and RANZCOG endorsed that actually pretty quickly, which is fantastic. So abortion was categorized, along with other things like gynaecological cancers as a category one service. And this meant that regardless of what levels of lock down or restrictions were happening in different states and territories in Australia. Surgical abortion services and medical abortion services were prioritized as essential. So that's that's something good that happened right in the beginning and this enabled us to carry on providing a service.
 
What we did notice that was that restrictions and interstate travel and in fact restrictions and travel, even with within a state did have an impact on some of our services and one of the  big issues was that, one of our clinics we had a gestational age limit of 24 weeks. And the doctors that were very specialized, specialized that provided that service, they flew in from one state to another. And once that border was shut down, which actually happened way back in April, immediately we, we were stuck with somebody in pretty much the whole of Australia to offer that service. So, we have a sort of innovated around that and we have found some replacements, but in fact overall still there probably is a slight reduction in gestational age for those women at higher gestations. Movement of staff I've mentioned, but also movement of clients was quite difficult.
 
And still is. So, you may or may not be aware that some clients who seek abortion particularly at later gestations will have to travel quite a vast difference, distance to access abortion. So for example, if I see somebody in North Queensland, who's 18 weeks gestation. They'd have to travel to Brisbane, if they're eligible to have an abortion. But if you are over 20 weeks in some states, you may have to travel to somewhere like Victoria. And obviously, with the border closures moving patients around the country has been incredibly difficult
 
We have got some exemptions in place even recently, for example patients are allowed to travel from New South Wales into Queensland depending on where they live and for essential services but that has been incredibly challenging. And then we have had an increase in Telehealth abortion services and I will mention that more specifically on another slide because that was a really big part of our service pre pandemic as well. So Amy's done a really thorough job of going through all the contraceptives and I said I would mention vasectomy and tubal ligation. We offer tubal ligation in our WA clinic and vasectomy all over Australia. So if vasectomy was essentially not classified as anything but we very much viewed it as elective surgery. Because I think it was really important to abide by the regulations and the thought process behind the regulations which was, you know, to minimize infection risk. So, even when we've been on restricted services, we've been unable to offer vasectomy for a while so for example, in areas like Victoria, we are keeping a waitlist at the moment, whereas some states such as Queensland we've opened backup our vasectomy services. And this has an impact on an unplanned pregnancy and I know that personally because I've seen at least two patients in the last month, whose partners were booked for a vasectomy and who had to cancel that vasectomy because of the pandemic and they are now pregnant. So it's not to be underestimated the impact of reducing access to really reliable methods of contraception.
 
So the innovations and service delivery were introduced rapidly and they have been pretty successful. The Telehealth demand in access increase for certainly for our service. And I know that many other providers have started using Telehealth to provide services such as medical abortion. And again I will mention a little bit more about that shortly.
 
We also launched some follow up innovations regarding medical abortion because we had previously seen everyone face to face for their follow up and I'll explain that in a little bit more detail. We did have to have sort of more support for women psychosocial, psychosocial needs in terms of counselling and we do have a free counselling service, but we did notice that there was increased complexity of people that were presenting and there still is. And not just sort of psychological support, but also, people needing financial support because of restrictions on salaries and people losing their job. So we've certainly been supporting a lot more women to access services who otherwise would not be able to afford service. Then there's been the logistical complexity of delivering our face to face services.
 
As Amy's mentioned surgical abortion obviously has to be done, face to face and there are other contraceptive options that we offer that are done face to face. So we have had to look at ways of trying to maintain that service during the pandemic. So Telehealth medical abortion has been provided by my organization since 2015 and we actually established this as what we call an access model. So essentially, our Telehealth service is an incredibly thorough service. And it's really essentially essentially the same as what you would have in a face to face consultation. But it's all provided over the phone, but there's quite actually involves quite a lot of staffing in put in terms of results checking and processes and packaging up parcels, and having a 24 hour helpline.
 
So it's, it's certainly a model that's incredibly expensive to run, but it's always been something that we've run just purely for access and specifically for people in regional and rural areas. Not very long after the launch probably within the first year or so it became very obvious that actually people in in metro areas were very keen to access medical abortion by Telehealth as well. So it actually has been available since since very early days throughout Australia and that includes Tasmania, where we don't have any clinics. The only state where it's not available is in South Australia. And that's unfortunately due to the legislation which precludes people having medical abortion by Telehealth because they have to have the medications within a hospital. And that's something that many providers in South Australia lobbied hard to have changed at the beginning of the pandemic. The reproductive health coalition that amend that we you know that we did make recommendations and that was one of the recommendations because this would increase access to women throughout South Australia, but unfortunately that's not been tackled and is still restricted in South Australia. But otherwise it's provided in all states and territories and we have noticed that if you compare May 2020 to May 2019 there was an increase in demand by 200% for women seeking medical abortion by Telehealth and that could be due to a variety of reasons. I mean, some of that has been that essentially people just are unable to leave their houses to access help at clinic. It's also been that financially perhaps people can't afford to travel.
 
Or also the Telehealth abortion services is sometimes more cost effective, depending on whether you know who you access it from. So as I mentioned, it's not just Marie Stopes that offers a Telehealth abortion. There are some medical abortion providing GPs, who are also offering it now by Telehealth and some of the family planning organizations are too. And so maybe it's more cost effective. What we noticed was that anytime there was an announcement about an increase in cases or further restrictions in terms of lock down. The numbers of people wanting to attend a clinic reduced and the number of people seeking Telehealth increased. So I do agree with Amy that Telehealth is incredibly popular and it's definitely here to stay. Amy also mentioned the MBS item numbers and this was great news and then incredibly disappointing. So, as I say, we had to have this service since 2015. It was certainly not a corporate pop up model. It was a not for profit used to provide access throughout Australia where nobody else was offering access, particularly in regional areas. So this had been an organized, a service that we just absorbed the cost of.
 
When the Telehealth item numbers were introduced and they were applicable to pregnant women. That was something that we could temporarily access, which made the service just a bit more sustainable and affordable. Unfortunately, on the 20th or 21st of July, the numbers were restricted and they've now been restricted as Amy mentioned to only being available if you've seen the person within the last 12 months. Now that causes incredible, incredible difficulties for any medical abortion providers who are doing this by Telehealth. In fact, it's also impacted providers who are offering specialist services. So, GPs who are s100 prescribers for HIV drugs, who perhaps offer PREP to patients who are not in their practice. They are then unable to access the MBS item numbers for this. So again we have been lobbying and we wrote a very large and well signed letter to the Federal Government, an open letter to request that specifically medical abortion and sexual health around HIV care that these patient consultations would have exemptions from the new restrictions.
 
Unfortunately, there's been no action on this yet. So as it stands, we still can't access these numbers. So, I think this will have an impact on the ability of certainly individual providers to offer medical abortion by Telehealth. I'm hoping that it, it won't discourage too many. But it's just that now obviously that can't be act, we can't access the item numbers for that. So I did mention earlier on, just some of the practical changes to clinical provision and I mentioned the innovations we had around about following up our clients. So previously, our medical abortion clients attended a clinic for their appointment. They would come back to the clinic two weeks after their medical termination and they would have an ultrasound scan and an assessment to confirm that the procedure was complete. We already had in the pipeline a plan to move over to a remote follow up model of care and that was based on very robust international evidence about using models such as the low-sensitivity urine pregnancy test for follow up and the safety data associated with that. So although we have this in the pipeline and fortuitously the low-sensitivity urine pregnancy tests which I can explain if anyone has any questions at the end. This test was finally approved by the TGA in mid December 2019 and I'd already been in discussions with the manufacturer to gain access to those tests. So very quickly in March when the COVID-19 pandemic arrived in Australia. We moved over to remote follow up for nearly all our medical abortion clients, including Telehealth.
 
The Telehealth clients previously had a serum HCG for follow up, but we now post them out a low-sensitivity urine pregnancy test. And the in clinic clients are given that test to take away with them and the this is in combination with telephone assessment by a nurse which go through the symptoms they've had since their termination and what they experienced at the time and discusses contraception and all sorts of follow up. So that's been rolled out throughout our entire network and it's been really, really successful.
 
Another practical change that happened fairly early on in the pandemic was that we stopped giving Anti-D for women who are rhesus negative when they're having a medical abortion. Again, this was something that as an organization we were planning to stop anyway. In many other countries in the world Anti-D has not been given for medical abortions up to 10 weeks in fact, for several years. This was in the NICE guidelines that were produced in the UK in 20 September 2019. The National Blood Authority in Australia is currently reviewing Rhesus guidelines for all pregnant women and we suspect that they will remove the mandation for this. In the interim, what happened, which was incredibly helpful was that RANZCOG did release a statement and they also backed this position that you do not need to administer Anti-D to women having a medical abortion under 9 weeks gestation. And it may sound like a very small thing, but it just means that you've got this one more point of contact. Somebody's got to prescribe the Anti-D and somebody's got to go somewhere physically to have it administered. So it's actually been really advantageous to not require that. Oh and the other thing is that it did mean that women needed a blood test to confirm their blood group. So you're reducing all those potential points of contact for getting COVID infection.
 
We increased during the pandemic our use of pre-care telephone consultations. Because we're an Australia wide organization we, we have a National Call Centre anyway so we were used to doing quite a lot of our care by telephone. But for example in our remote clinics in the north of Queensland, it was really useful just to pre-consult with some of our patients before the weekly clinic, just to see if there were any issues arising and any investigations that we could do before we saw the people at the clinic. I say continuing one-stop LARC provision and this is something that I'm very passionate about and I know that it's incredibly difficult to provide in a general practice setting. But even in some family planning organizations pre pandemic women required at least two visits before they could have an IUD inserted. And I'm a very strong believer and that is backed by the evidence based guidelines, that LARC should be fitted at the time that a woman requests it if it is  safe to do so, and certainly in most women it is. And obviously that ties in with the concept of quick starting contraception which is not waiting until the next period to start contraception but starting at the time if it is safe to do so. So we continue to provide one-stop LARC provision which means with women present a request an IUD they have it on the day they don' get sent away and have a second appointment. I know that some family planning services have supplemented this by doing a pre-consult on the phone and I think a lot of GPs are doing that too. I think that's been a really good development because you can have a history on the phone and you can counsel the woman regarding the methods and then they really just need the appointment to have the, the method inserted.
 
We discontinued providing IUD insertion, but we the ones that we performed under IV sedation. We did suspend them during the restrictions to elective surgery. Because they did fall under that sort of grey area we really felt that they were probably Category three, Category three procedures with the caveat that anyone seeking a copper IUD for emergency contraception will always be seen in one of our services and they should always be triaged in any service that offers emergency contraception. So that's been maintained, but the IV sedation options have been limited during the pandemic. And as I mentioned in a previous slide, the vasectomy service was suspended in some states and it's been put on a waitlist, but it has resumed really in a lot of other states, which is great. So impact with the limitations to travel with that you know that has really been quite an issue for an organization like Marie Stopes where we fly staff around the country and we also fly our patients around. The picture on this slide is actually taken on the little twin propeller plane that we are currently chartering to fly to our Queensland clinics up in the north in the regional areas and we charter a plane weekly that takes up myself or another doctor, anaesthetist, a nurse and and yeah we were still doing that through the pandemic. The reason for this is that very quickly when the borders closed and in fact when international travel ceased the domestic airlines just stopped functioning and even though they were running a very small amount of flights. Those flights were very precarious. So we could arrive at an airport in Brisbane and have 20 patients waiting in the north of Queensland. And that flight could be cancelled at minutes notice. So that was just not sustainable. So we had to very much think on our feet and we managed to secure a grant from Queensland Health. So we're using that moment to fly up there. It does take about double the time but is certainly a very necessary service. The clinics up there are very busy and there's very limited other public services in places like Townsville.
 
There has been a reduction in gestational limit and I mentioned that in the beginning of my slides set and that's because we have been unable to fly our specialist providers from one state into Victoria. And we have found other providers within states which is great, but in particular there's nobody currently that can do terminations up to 24 weeks gestation. So that's definitely a gap. What it has done is it's made us as an organization look at our sustainability and our resilience and also recruit more, endeavour to recruit more local staff so that ultimately, we don't want to be having to fly people around the country. We want to have really robust services within every state.
 
So what are the ongoing implications of the pandemic for sexual and reproductive healthcare? So, there have been some positive changes to clinical provision and the positive impacts include reducing unnecessary and burdensome appointments and you know colleagues I've spoken to in family planning or other services have said, you know, as I've cited the extra visits that women needed before having an IUD fitted. This is now either just not being done at all, or they're just having a telephone consult and I think it's made all of us work in a really adaptable and flexible way which has been really positive. The remote follow up for medical abortion, medical termination of pregnancy has been really successful and we do it throughout our network now and I know a lot of other GP providers are starting to look at these kinds of models of care. Ultimately what, what a lot of services do in other countries, are that women actually do their own follow up and they only contact the service if they have any issues. And that's something I think many of us will move to in the future. Removal of the requirement for Anti-D has just been a great development. It was a long time coming. And, and we hope that with the new guideline coming out later this year it will also endorse that sort of officially for all women in Australia. And what we have noticed is that as medical abortion becomes more available, particularly by Telehealth. The total number of abortions is essentially stayed around about the same, but the ratio of medical to surgical abortion has changed.
 
So, and this is reflected in other countries where medical abortion has been around for many, many years. So, for example, as you can hear, where I'm from in Scotland. We've had medical abortion since the 1990's and now over 90% of abortions are done medically and the majority are under nine weeks gestation and that's fantastic. And that does happen in most countries when you improve access. But the other thing I think is incredibly important is that you have to maintain choice. It's absolutely critical, to offer women a choice of medical and surgical abortion because not everyone will want a medical abortion. And not only that, you have to maintain surgical abortion services because as you know medical abortion can't be undertaken after nine weeks gestation in Australia. So there's this huge gap in provision if suddenly there are no surgical services. So those skills have to be maintained and we have to you know, continue to offer choice to women regarding the procedures.
 
Other lessons that we've learned well during the pandemic, the inequities have definitely been magnified particularly, you know. A lot of the care providers for regional women at the moment and those women who already had difficulties accessing sexual reproductive health services be that contraception, or abortion or even cervical screening. All these inequities have been magnified. Ditto the inequities for people living in a context of violence and also those living in poverty. Their health needs have been certainly magnified during the pandemic. What we've also learned is that the varying abortion laws  have definitely exacerbated challenges to access. And its really highlighted the need to harmonize abortion laws and regulations throughout Australia. So again, I do sympathize with my South Australian colleagues regarding the inability to provide Telehealth medical abortions and you know, I'm really hoping that will change because you know otherwise there's this entire state that's not running in parallel with the rest of Australia and it does cause issues for access to women in that state. We really feel that governments need to fully fund abortion care. And that's something that we've been concerned about for quite some time. But particularly as we're aware the economic impacts of this pandemic are going to go on for many, many years.  An organization such as ourselves have hardship funds but we certainly cannot provide  it's not as economically sustainable for us to provide hardship funds for every single person that can't afford an abortion and as you know it's very, very restricted in the public system. So we really do feel that government should fully fund abortion care and contraceptive care. And also models generally of sexual reproductive health care they need to be really responsive and adaptive to sort of new environments and on that note, there's my second poll.
 
So do you think provision of Sexual Reproductive Health should be an important component of future pandemic planning? Okay, I think that's given everyone enough time to click on a button. Let's see what the results are. Very pleased to see that there's a is probably unsurprising that I'm speaking to a group of passionate sexual reproductive health providers here tonight. Because nobody selected the fourth option that it shouldn't be included in pandemic planning. I'm not sure if you can see the results, but essentially majority felt that it should be prioritized and I mean I guess I can sum this up by saying that if you can't control your fertility, you cannot control your life. We're not just talking about this generation of people. We're talking about the generational effects of intimate partner violence and inadequate family spacing, which we know causes detrimental health effects on generations to come. So it's really critical that this is part of pandemic planning in the future. And on that note, we do need to rethink that we need to look at how we can ensure there's always going to be safe access to sexual reproductive health in a manner that decreases the risk of infection for staff and patients.
 
Because as Amy has mentioned earlier on this evening there are services in sexual reproductive health that absolutely have to be offered face to face. It's really important these services are defined as essential and we did have that in place at the very beginning of the pandemic, but in any future pandemic plans. We need to have sexual reproductive health services such as contraception and abortion and highlighted as essential. The collaboration, actually that has occurred between health services during this pandemic in our sector of sexual reproductive health. I think has been exemplary, you know, in terms of forming coalitions, making recommendations, lobbying government when required. And I think we've we've all worked really hard because we are all passionate about delivering these services. And we've worked hard to continue this collaboration, but it said, we can always do more. And I think it'd be great if we can work on in collaborating more in the future. We need to fully, full support from Medicare and item numbers throughout the pandemic and beyond. And I have mentioned at length how disgruntled I am about the changes with the Telehealth item numbers. But this you know this is something that we are still lobbying about because as Amy mentioned there are many reasons why somebody. I mean, I absolutely feel that you should have a good relationship with a long term GP for most of your health needs.
 
But specifically for something like sexual reproductive health. We know because we have done the research and in fact, I didn't put a link to that but we've just published in the BMJ sexual reproductive health. Women's experiences of Telehealth abortion and what we found was, it was highly acceptable, and also desirable and that many women that access the service. It was because they wanted that extra level of confidentiality and privacy, and anonymity. So they either couldn't see their own GP or they didn't want to. So for that very specific and type of service, I think it's important that we try and have a restriction to the Item number Item number an exemption to the restrictions. And also in data, I think, is very powerful. So it's important that we can capture the data in terms of reproductive health and what's going on in this, in this pandemic. Because then we can improve what our response is going to be to it in the future. And in the slide set which you'll have access to after, there's just a few and links here. The situation report is a, is a live report that we update every few weeks or whenever something dramatic happens and that's really got a summary of all things there. Sorry that are happening during the COVID pandemic.
 
I've mentioned this guideline on abortion care and infection by RCOG which is referenced by RANZCOG as well. It's interesting to know that in other countries, and I haven't really touched on that because this is an Australian focused session tonight. But the really have gone even further to provide things such as no touch abortions and that involves women not having ultrasound scans. So that has been that's been published that work, and it's happening in some areas of the US and also in the UK. We as a body of providers in Australia felt that we were, it wasn't a necessity at this current time in Australia. But it's just something to be aware of that is happening internationally and if let's hope it doesn't happen. But if we did have another wave of infection that really lock things down, it's, it's something. It's a backup plan we could have. RANZCOG has issued several statements, but this is specifically one about accessing reproductive health services and how they are category 1.And if anyone is interested on the global picture of abortion and particularly access into abortion and what the ill effects are of unsafe abortion. The Guttmacher Institute in the US has got some fantastic data a very easy readable resource. Then that's me finished so I think we're going to go to a questions now I'll stop sharing.
 
Jessica Floreani:
Thanks Catriona for a fantastic and very interesting talk. So thank you both so much to Amy and Catriona tonight for speaking. We've got a few questions that have come up during the presentation. So if you've got any other questions, now's the time to put them on to the Q&A. I'll direct, there were a couple of comments, anonymous comments really around I think people coming through Victoria. Just one was making the comment that they've seen quite a lot of chlamydia in their 18 to 22 year olds in regional Victoria obviously during the most recent lock downs. And the other one was around the pregnancy rates, that a lot of regular patients have come in, in the last few weeks, due to lock down. Noticing, you know, there are others pregnant or those that had been trying and now and now pregnant as well. So seeing an increase in pregnancy rates in most recent times in Victoria. I don't know if you've got any comments about those comments there.
 
Dr Amy Moten:
I do remember, there was a couple of years ago, the state wide blackout in South Australia Jess where they predicted that there would be an increase in a rate of pregnancies
 
Jessica Floreani:
Yes
 
 
Dr Amy Moten:
Because people had no electricity and
 
Jessica Floreani:
Nothing else to do.
 
Dr Amy Moten:
But I don't know if that's going to be seen with COVID but you never know.
 
Dr Catriona Melville:
Yeah, yeah we haven't I mean we have been asked this a lot, have we noticed an increase in the total number of women are presenting with unplanned pregnancy. And we haven't really, as I mentioned, it's really just been the ratio of the type of procedures, people have chosen. We also haven't particularly noticed late presentations. And that was our big concern at the beginning of the pandemic was that people would defer treatment and they would, you know, suddenly present at later to stations. But again, because I think access, we have done our best to maintain access as have other service providers. We haven't actually noticed this increase.
 
Jessica Floreani:
Yeah, thank you. So, there there's a couple of questions from Gordon and also from Makita Mitaliani about PrEP. Now I don't know if I want to put that on you, Amy. It was really around. Would you be able to give us an update on on demand PrEP use. Now, you could probably do a whole talk on that yourself, but you know in a quick short succinct way if you could answer that one Amy.
 
Dr Amy Moten:
Whoa, just briefly, and for people who aren't familiar with the term PrEP it's Pre-Exposure prophylaxis, as opposed to post exposure prophylaxis. So people at risk of HIV, who are not HIV positive. Yeah, in general practice in Australia we're allowed to provide PrEP for people at risk of HIV, but we're only allowed to prescribe the daily PrEP. And that's, that's just a PBS rule. On demand PrEP means you start taking it a couple of a couple of pills 48 hours before sex. It's only recommended for cisgender men who are at risk of anal sex and they have to continue taking it for the duration of their risk and for 48 hours afterwards. So technically, for PBS it has to be prescribed by an s100 subscriber but it is available in Australia. Which is really great.
 
 
 
 
Jessica Floreani:
Excellent, thank you Amy. There's another question from Ash Rash, which I'll direct to you Catriona. Just about the use of Anti-D after abortion. Now is that only stopped for medical abortion or is that for surgical abortions as well?
 
Dr Catriona Melville:
So in fact the RANZCOG statement that was released said that you could consider ceasing it for surgical abortions under 10 weeks gestation. We haven't done that in our service. The evidence certainly is strongest for medical abortion and there's some fantastic studies. The most recent one was looking at a huge cohort of women in Europe, compared to a cohort of women in Canada. And it compared the rates of ISO immunization one population didn't get Anti-D and the other one did routinely and it showed there was no difference in ISO immunization rates. And you know looking at the blood volume of a foetus less than seven, seven, nine weeks gestation that they're certainly it's not enough to provoke an immune response. So, I suppose yeah, the answer is that we are continuing to do the same for surgical terminations but if you if you couldn't under ten weeks you, you could stop doing that. The reason I guess it's, it's not so important for surgicals is you're seeing that person, face to face and you're genuinely I would think more 100 percent of the time cannulating them. So you've got access to, you know, taking blood. You've got access to administering Anti-D. Whereas for women having medical abortion, particularly if you're doing it by Telehealth. This was a whole extra step. Now that we don't track HCG in the blood for follow up in  Telehealth. Women don't need any blood tests at all before they have a medical abortion because they don't need a blood group and they don't need a HCG. So essentially, all they need is an ultrasound scan and it really simplifies the process. And also, you know, people say well, what's the issue with Anti-D. Well it's a blood product and yes we think it's safe but who knows. You know it's, it can also cause allergies. So essentially if we don't you know, if we don't need to give it to women we shouldn't be doing it. So sorry that was a long winded response.
 
Jessica Floreani:
Very thorough. Thank you. Catriona. There was just one other comment as well by one of our attendees about the initial poll. About accessing the abortion services and there was, you know, obviously a large proportion felt that there hadn't been an issue. The comment from this attendee was just that perhaps that they're not normally accessing that you know the the patients aren't normally or they're not trying to access abortion services for their patients. So it may not have made a big difference depends on who's here, who's here and attending, I suppose.
 
Dr Catriona Melville:
Yeah, so, so, then they're not they're not people who's, who would usually refer a patient to look for an abortion or, yeah. I mean, I guess the thing is a lot of women will self refer to different services for abortion anyway. So I think that's a fair point.
 
 
Jessica Floreani:
Yeah. There's another question probably address to both of you. What is the best alternative combined pill for Norimin, which we all know at the moment is a big bug bear that we can't get it. So for anything up, you know, Norimin or Brevinor or any of the Norethisterone containing pills. Have you got a suggestion?
 
Dr Amy Moten:
Well, yeah, I've been giving considerable thought to that this week, having had a couple of patients present in my general practice, I think. If you're looking for a progestin substitute I'd go with Valette which contains dienogest. It's a really good endometrial suppressive. If you're looking for a 35mcg EE pill you can only see cyproterone acetate so Diane or Juliet. So I'm starting with Valette followed by and after a discussion of course if they can afford it Qlaira. Yeah.
 
Jessica Floreani:
I think it's really very patient focused and dependent on why are you using Norimin in the first place.
 
Dr Amy Moten:
The other theory I have which I haven't tried yet was maybe you could take Primolut which is 5mg of norethisterone cut it in half and add it in to a low dose norethisterone containing pill or Levonorgestrel containing pill. But that's completely liberal for unevidence based
 
Dr Catriona Melville:
I would suggest just everybody move to a LARC, so yes, sorry.
 
Dr Amy Moten:
That's the best advice of all
 
Jessica Floreani:
So another question from Stephen just a side question. In your country do you give Anti-D to pregnant women with a threaten miscarriage with PV bleed in early pregnancy and if not, what gestation do you give Anti-D?
 
Dr Catriona Melville:
Is that for me?
 
Jessica Floreani:
I think that's for you Catriona
 
Dr Catriona Melville:
So I this is my country. Sorry, I'm confused. I am in Australia. But yes I come from Scotland. So I guess in this country in Australia currently everyone is getting Anti-D my understanding for a threat in miscarriage. I think what we need to do is watch for the National Blood Authority guidelines. So they went out for consultation I think it was either December or January. And it was not long after the NICE guidelines had just been published, that really said do not give Anti-D to people with a threaten miscarriage. Don't give it to anybody with a complete miscarriage under 10 weeks or a medical abortion. Unfortunately, I think the guideline development overlapped with that, so the guideline didn't mention any of that. It really doubled down on giving everybody Anti-D. To their credit lots of us sent in, you know did some missions for that guideline and they have really spent many months now reviewing it. So that's why it's the publication's been held up. They are saying that it should be out maybe in October, November, and I think you just need to watch that space and see what the new recommendations are. All I can say is in other countries, such as the UK they don't give Anti-D for uncomplicated miscarriage. So for a complete miscarriage or threaten miscarriage. They don't give Anti-D or early gestations. It's only for later gestations or a more significant bleeds or if you have a miscarriage and they require surgical intervention because we think that's the sort of agitation caused by curating the uterus. Potentially makes it more likely that foetal cells will go into the maternal circulation.
 
Jessica Floreani:
Okay, thanks Catriona. There's another comment by the lovely Danielle Mezza who suggested that perhaps some of the GPs, who are present through this presentation might be interested in joining the SPHERE coalition. Amy if you wanted to make comment on that.
 
Dr Amy Moten:
Talk a bit more about SPHERE. I think that's an excellent idea. Great group. They've been putting out some really lovely positioning statements around access to contraception and abortion. I wonder if our Host could maybe share a link via the chat. I'll see if I can do that as well. Yeah.
 
Jessica Floreani:
That'd be fantastic. Okay, so I think that's probably all we've got time for tonight. Just a reminder that, that there'll be a evaluation after the presentation and if you could all be a part of that, that'd be fantastic. Thank you very
 
Dr Amy Moten:
Interrupt Jess, sorry Catriona has shared the link in the chat so
 
Jessica Floreani:
She has fantastic
 
Dr Amy Moten:
So you shouldn't so I know so
 
Jessica Floreani:
Everybody should be able to get access to that if you've got any issues. I'm sure about accessing that that link. I'm sure you could just get in contact with Jenna or the RACGP and we'd be able to forward that on to if you're having any problems. So thanks very much to everyone for attending. Thank you to ASHM the webinar partner and we hope you enjoyed that. Thank you again very much to Dr. Amy Moten and Dr. Catriona Melville for sharing their knowledge and we'll say good night and thanks again.
 
Thank you.
 
 

Other RACGP online events

Originally recorded:

8 September 2020

This workshop will update GPs on changes in sexual and reproductive healthcare during the COVID-19 pandemic, including STI testing and treatment, contraception and abortion, and outline the vital ongoing role of GPs in delivering this care. 

Learning outcomes

  1. Describe the impact of COVID-19 on the sexual and reproductive health needs of Australians
  2. Discuss the changes to sexual and reproductive service provision during the pandemic
  3. Outline the ongoing implications of the pandemic for sexual and reproductive healthcare
This event attracts 3 CPD points

This event attracts 3 CPD points

Speakers

Dr Amy Moten
General Practitioner

Dr Amy Moten is the Coordinator: Medical Education at SHINE SA where she provides clinical education to doctors, registered nurses and midwives and other health professionals in South Australia. She also works as a GP with a special interest in sexual and reproductive health care and is currently chair of the RACGP Specific Interest Group in Sexual Health Medicine.

Dr Catriona Melville
MBChB, MSc, FRCOG, MFSRH, DipGUM

Dr Catriona Melville is a specialist in Sexual and Reproductive Health and a Fellow of the Royal College of Obstetricians and Gynaecologists (UK). Provision of client-centred care including abortion has been a passion of Catriona’s for over 20 years. Catriona has a keen interest in medical education and clinical research. She is the author of Sexual & Reproductive Health at a Glance (Wiley-Blackwell). Catriona is the Deputy Medical Director of Marie Stopes Australia.

Sponsors

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