Women living in urban areas may take for granted their relatively easy access to family planning services that provide information and ways to freely determine the number, timing, and spacing of their children. For women in rural areas, the picture can be very different.
Recent research in rural Victoria found these women face extra hurdles and feelings of “judgement” when seeking out these services. The project I worked on with Dr Julie Kruss investigated the barriers for women seeking emergency contraception, pregnancy termination or pregnancy-related options counselling in rural western Victoria. Options counselling refers to services that explore available alternatives regarding an unplanned pregnancy.
We conducted in-depth interviews with health professionals and others whose current employment was connected to the issue of family planning, including nurses, doctors and counsellors. These frank discussions focused on issues they had witnessed for women accessing family planning services.
The study highlighted an overall lack of women’s health services in rural communities, as well as some alarming patterns in reported barriers to accessing them.
A significant issue was the feeling of being “judged” by health professionals, with some doctors refusing to make referrals based on their own moral judgement. Other doctors were suspected of deliberately delaying women’s access to abortion, for example by sending them for multiple ultrasounds, and withholding information about how to access appropriate services.
As time is of the essence in reaching decisions about an unwanted or unplanned pregnancy, delays can obviously compromise timely decision-making. The experience of being blocked produces distress and reduced self-efficacy, but can also turn women off accessing these and other health services altogether.
There were also examples of doctors who agreed to perform an abortion but then warned the patient that it wouldn’t be carried out if there was a “next time”. Threatening to withhold a health service on the basis of what is acceptable to the doctor’s moral judgement breaches medical ethics. The doctor starts to “play God” in more ways than one by assuming the power to provide or withhold a service (or information), and by imposing a moral judgement on a patient’s behaviour.
While these issues could arise anywhere, the problem is compounded in rural areas where there might only be one doctor in a town and limited opportunity for a second opinion.
There were also examples of misleading information being provided to women in rural areas. One pharmacy distributed scary pamphlets on emergency contraception that were not evidence-based.
Elsewhere, myths about abortion leaving women infertile were still being spread, despite declarations by medical bodies such as the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (2005) that there’s no proof of such links if abortion is conducted by a medical professional in a medical facility.
It’s clearly a major concern if women cannot trust the information they receive from health professionals.
It also became apparent through the research that differences in cultural norms between city and country created more barriers for women in accessing the support and information they needed. Privacy, for instance, was a frequently raised issue; it’s hard to seek emergency contraception or termination in a small town where everybody knows everyone’s business.
Rural communities might also be more conservative and less likely to talk about sexual health issues in general. People can be wary of change, which makes it difficult to develop a new service, especially one such as sexual health. Young rural women may have fewer educational and employment options, and this may normalise and validate the cycle of early pregnancy.
Beyond the barriers related to judgemental attitudes and limited availability of family planning services, rural women were seen to confront a number of interconnected, practical hurdles. For example, if a woman must arrange childcare while travelling to Melbourne, she may struggle to find the money and have to reluctantly confide in friends and family, all while taking time off work. All this adds to her financial stress.
The title of our study “Country women are resilient but….” referred to one comment that, just because they do tend to deal well with adversity, women in rural towns shouldn’t have to put up with these extra burdens, and the added distress, when accessing family planning services.
More open and widely available education campaigns on the prevention of unwanted pregnancy, as well as normalising pregnancy termination within the service system, could be ways forward. Changes to service delivery, such as having family planning professionals visit rural areas and incentives for rural doctors to train to perform terminations, could be other possibilities. Whatever the solutions, these issues are real and need to be addressed.
The longer these barriers continue and are not openly discussed, the harder is it is for women to make timely decisions about pregnancy. At such a stressful time, the emphasis needs to be on timely, accurate, evidence-based and judgment-free advice and support. This is what women in the city expect and can readily seek out. Women in rural areas deserve the same choice.
Acknowledgement: The research discussed in this article was completed as part of Dr Julie Kruss' doctorate in community and health psychology. Dr Kruss also contributed to this article.