Womens sexual and reproductive health

Improving women’s health improves health for everyone

Communities are only as strong as the health of their women.

– Michelle Obama¹

Each year in Australia, around one in 10 women will become pregnant.² For those women who have a viable pregnancy and are able to proceed with the pregnancy, the in utero environment will, along with genetic and epigenetic factors, dynamically shape the health of that women’s offspring, and the generations and subsequent communities that follow. Alongside the familiar associations of in utero health with dyslipidaemia, type 2 diabetes and obesity, the future reproductive health of female offspring also appears to be influenced by the intrauterine environment.³ Epigenetics, changes in the way our DNA code is ‘read’ rather than changes to the code itself, are implicated in the development of many conditions, including cardiovascular disease, neurodivergence and some cognitive disorders,⁴ and are forged by a wide array of environmental factors. Imprints of our ancestors’ environmental tapestry and life experiences – good and bad – including their exposures to trauma, stress and abuse might thus be passed to us and subsequent generations by these epigenetic changes. In utero, we are, simultaneously, incredibly vulnerable, and incredibly adaptable. Reflecting on this, Dorney and Black discuss why the need for universal, holistic, preconceptual care is greater than ever before.²

Some estimates suggest that up to 50% of pregnancies in Australia are unplanned, and one in four Australian women will undergo a termination during their lifetime.⁵ For women who seek a medical termination, many barriers exist, including financial, cultural and linguistic. Saldanha et al discuss their qualitative study, which explored some of the barriers and enablers to accessing medical terminations via telehealth.⁶

Sadly, 15–25% of pregnancies will end in miscarriage, meaning that between 100,000 and 150,000 women in Australia will experience pregnancy loss every year.⁷ Shalou and Polyakov reflect on the profound physical and psychological implications of pregnancy loss, and how these might impact on the planning and timing of future pregnancies.⁸ They provide a poignant reminder that, nine months after miscarriage, at least 20% of people continue to experience significant mental health symptoms.⁸

Pregnancy and the postpartum period are times when women are particularly vulnerable to experiencing domestic and family violence.⁹ There is also a strong association between unintended pregnancies and domestic and family violence, with reproductive control, coercion and sexual assault by an intimate partner resulting in both unintended pregnancies and forced terminations of pregnancy.⁹ The adverse effects of domestic and family violence occurring in pregnancy include low birthweight, premature delivery, and increased risks of maternal smoking and substance use.⁹ Epigenetic influences might mean that the effects of family violence during pregnancy ripple out unseen beyond that pregnancy, moulding and sculpting the health of the generations that follow.

Today, the front page of a leading newspaper featured the very recent murders of three women in Australia, all, allegedly, by men known to those women, with at least two being perpetrated by an intimate partner.¹⁰ This was not an unusual day; in Australia, one in six girls will have experienced domestic and family violence by the age of 15 years, and domestic and family violence remains the leading cause of premature death and ill-health in women under the age of 45 years.¹¹ Gill and Greenstock evaluated a Victoria-based program designed to enhance the response of general practices to family violence.¹¹

Also in my reading material today was the tenth edition of the Red Book, which contains new, very welcome, chapters on providing universal, holistic care at the end of a woman’s reproductive years (refer to pages 300–303).¹² Alongside the impacts of menopause on cognition, sleep, menstruation and mental health, multiple changes also occur in the vulva, urethra and vagina.¹¹ The case study by de Oliveira Coelho and Santos, in this edition of the AJGP, highlights the importance of clinical assessment of these changes, and discuss a case of vulval ulceration in a postmenopausal woman.¹³

Why human females, and some other female species such as orcas, experience menopause at all is still debated. Some studies suggest that, historically, human children were more likely to survive to adulthood if their grandparents were alive, so perhaps caring for grandchildren, rather than continuing to reproduce, is part of the evolutionary answer.¹⁴ And this might be another intrinsic link between the health of grandparents and their grandchildren.

These complex, intergenerational layers exist, Russian doll-like in every beginning, and might make us wonder how much of a beginning is new, and how much a continuation of what came before. Disparities for women and girls, in healthcare, education and beyond, ripple deeply and endlessly into the generations that follow. Addressing these disparities will benefit us all.