The Domino Effect: Women’s Sexual and Reproductive Health Policy

Roberta Heale, Associate Editor of EBN, @robertaheale @EBNursingBMJ

When I signed up to write this blog, I was given the topic of “women’s health”.  There are so many possible topics to choose from, however, women’s health is so intrinsically tied to women’s reproductive issues that makes the most sense to me to discuss an issue related to women’s sexual health.  Culture, values and beliefs play a very large role in the care of women in reproductive and sexual health issues and often policy is designed to reflect these values without taking into consideration the broader implications, even if the outcomes seem inevitable.  For example, it seems logical to expect that if a woman’s health benefits plan does not cover the cost of birth control, that the woman will be less likely to take birth control (particularly if she can’t afford it) and will have more unintended pregnancies…a circumstance with additional impact on the woman’s life and health care system as a whole

The same can be true of policies related to women’s sexual and reproductive health that are implemented without consideration of broader implications.  A few years ago, PAP test guidelines were changed in my province.  Rather than annual checks, the recommendations are now a routine PAP test every 3 years, as long as there have been no abnormalities.  Timing of first PAP test changed from after first sexual encounter, to first PAP test at the age of 21.  Although there was evidence to support these changes they are specific to the PAP test and did not take into consideration the education opportunity and sexually transmitted infection (STI) testing that occurs in the PAP test appointment. My colleagues and I were concerned about the impact. In our nurse practitioner practices, it was routine for women to be counselled about testing for STIs and offered testing when they attended appointments for PAP tests.  It seemed obvious to us that as the requirement for PAP tests moved from annual to every 3 years, the rate of STI testing would decline.  That’s exactly what has happened.  The rates of testing have gone down…a lot.  Unfortunately, this has occurred at a time when STI rates are steadily increasing.

There is a significant public health concern related to these changes. It’s my experience and that of NP colleagues that the stigma for booking a PAP test for a young woman seems to be less than to book an appointment for STI testing.  We haven’t seen an increase of women scheduling appointments for STI testing in replacement of the PAP test appointment. Long-term implications are many more undiagnosed and untreated STIs.  The outcome may be pelvic inflammatory disease, which can lead to chronic pelvic pain, infertility or an ectopic pregnancy in women who do conceive. Likely young women now will pay a high price as an unintended results of this one health policy change.

Women’s sexual health is complex.  Changes to one policy can a domino effect on other issues.  It seems intuitive that a parallel campaign to encourage STI testing for women would have been developed along with the changes to PAP testing.  Unfortunately that didn’t happen and only now, after research confirmed a suspected negative outcome of the PAP policy changes, that there are recommendations of increasing availability and education about STIs and testing.  Nurses working with women in the field of sexual and reproductive health have a role to play. We know these women and are in a unique position to predict the potential impact of policy changes and advocate for policies and programs that will encourage the best health outcomes.




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