Public Health Association of Australia: Policy-at-a-glance Preconception Health and Fertility Policy

Transcription

1 Public Health Association of Australia: Policy-at-a-glance Preconception Health and Fertility Policy Key message: PHAA will: 1. Empower women with adequate fertility-related knowledge to enable informed reproductive choices. 2. Educate and provide resources for health care professionals about optimising fertility and preconception health. 3. Promote infertility prevention among individuals and policy-makers 4. Work towards an integrated sexual and reproductive health education strategy which includes fertility and preconception health optimisation. 5. Promote the development of health promotion programs related to fertility preservation and optimisation, and preconception health. Summary: PHAA will promote the inclusion of preconception health and fertility awareness within sexual and reproductive health education; and training and skills development among health care professionals. PHAA will also advocate for a nationally-based Commonwealth government policy initiative that addresses; fertility optimisation; preconception health; and the delivery of integrated fertility, sexual and reproductive health promotion programs. Audience: Responsibility: Australian, State and Territory, and Local Governments, policy makers and program managers. Industry, health service and community stakeholder groups. PHAA s Women s Health Special Interest Group (SIG). Date policy adopted: September 2013 Contacts: Co-Convenors: Catherine Mackenzie & Louise Johnson, Women s Health SIG (catherine.mackenzie@flinders.edu.au ; ljohnson@varta.org.au ) 1

2 Preconception Health and Fertility Policy The Public Health Association of Australia recognises: 1. The Melbourne proclamation; Advancing sexual and reproductive wellbeing in Australia, and that all Australian people have the right to full and enjoyable lifelong sexual and reproductive health and wellbeing. The proclamation advances several goals: including the following key action areas: the improvement of health literacy and education; developing an effective workforce; making fertility control services accessible and affordable; promoting lifelong sexual and reproductive wellbeing; and coordinating strategies at primary care level.[1] 2. Related PHAA Women's Health policies including: Gender and Health; Lesbian and Bisexual Women s Health; and Emergency Contraception. The Public Health Association of Australia notes that: The following definitions: 3. The International Committee for Monitoring Assisted Reproductive Technology and the World Health Organization (WHO) define (clinical) infertility as a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse[2] 4. The definition of reproductive health and reproductive rights within the Programme of Action of the 1994 International Conference on Population and Development[3] (chapter 7.2) states that: Reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. [4] Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant.[3] 5. This definition of reproductive health and reproductive rights was also incorporated into the WHO s definition of health.[4] WHO also recognises that building a family should be: the choice of each individual and couple, within their own sense of conscience, to determine if they intend pregnancy and if so, the size of their family unit and the timing of when to have a child or children.[4] 2

3 6. Acknowledging the above definition of reproductive rights within the Programme of Action, the Beijing Declaration and Platform for Action of the United Nations Fourth World Conference on Women[5] reaffirmed that: reproductive rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents.[5] Research related to fertility and infertility 7. There has been a significant downward trend in fertility over the past few decades in Australia with a fertility rate of 1.8 babies per women.[6] This trend is attributed to delayed couple formation and childbearing, and a reduced rate of subsequent childbearing.[6] The findings from the Australian Longitudinal Study on Women's Health indicated that 4-in-10 women aged years in 2006 had yet to report a pregnancy outcome.[6] 8. In Australia, approximately one in six couples is unable to conceive within 12 months of trying.[6] Approximately one third of cases of infertility are due to female related factors, one third to male related factors and one third is attributable to both partners or have unexplained origins. 9. Risk factors associated with reduced female fertility include:[7] Demographic factors: o age >34 years. Lifestyle factors: o alcohol >14 units per week; o smoking (tobacco, marijuana) 7 units per day; o weight > 25 BMI (underweight body mass index [BMI], < 19, overweight BMI > 25); o caffeine 7 units per day; o unprotected sexual intercourse with multiple partners. Reproductive factors: o endometriosis; o polycystic ovary syndrome; o menstrual cycle irregularities (<21 days, >35 days); o pelvic inflammatory disease; o sexually transmitted diseases (e.g. chlamydia, gonorrhoea); o severe menstrual pain; o pelvic surgery.[7] 10. Risk factors associated with reduced male fertility include: Demographic factors: o age >45 years.[8] Lifestyle factors: o alcohol >20 units of alcohol/week;[9] o smoking (tobacco) >15 units per day;[9] o weight BMI <19 and BMI > 25;[8] o unprotected sexual intercourse with multiple partners;[10] o steroid use.[11] Reproductive factors: o sperm production problems;[11] 3

4 o blockage of sperm transport;[11] o sexually transmitted diseases (e.g. chlamydia, gonorrhoea).[10] Research related to fertility knowledge 11. A telephone survey of men and women aged 18 to 45 years living in Australia and who were planning to have a child found that there are considerable knowledge gaps about the effect on fertility of age, weight, smoking, alcohol consumption and timing of intercourse.[12] The survey found that the majority of men and women underestimated, by about 10 years, the age at which male and female fertility starts to decline. Moreover, while around 60 per cent of those surveyed were aware that female obesity and smoking affect fertility, fewer recognised that male obesity (30 per cent) and smoking (36 per cent) also influence fertility. More than 60 per cent of people surveyed also had inadequate knowledge of when in the menstrual cycle a woman is most likely to conceive. The research concluded that there are considerable knowledge gaps about modifiable factors that affect fertility. 12. A Canadian survey of more than 2,500 childless women and men examined their childbearing intentions and attitudes to using assisted reproductive treatments.[13] The study found that for both men and women there were significant differences in what they believed was the ideal age to have a first child, in the mid-20s, and the expected age. It also indicated that later childbearing has become a social norm reflecting the beliefs that men and women in their 30s have time to start a family. The study found widespread belief that assisted reproductive treatments, such as IVF, can address age related fertility challenges. This study concluded that people should be educated about the limitations of assisted reproductive treatments to address aged related fertility decline and recommended that: fertility testing and preservation [should be] more available and affordable, and provide women and men with accurate information upon which to base their fertility timing decisions. Similar to the situation 20 years ago when IVF was not a common part of the public discourse, there appears to be a need for greater public education about, and psycho-social support for, collaborative reproductive family-building options.[13] 13. Fertility knowledge gaps are also reflected in the findings of an international survey of men and women actively trying to conceive. The study involved more than 10,000 participants across 79 countries and examined fertility knowledge and treatment attitudes relating to three areas; 1. indicators for reduced knowledge, including about the effects on fertility of smoking, weight, history of sexually transmitted diseases and mumps after puberty; 2. misconceptions about fertility, such as women are fertile even without periods ; and 3. knowledge of basic facts about infertility. These areas referred to important content that could help people safeguard their fertility.[14] The study found that fertility knowledge was modest with an average score across the total sample of 57 per cent, and it was concluded that educational interventions should therefore be directed at improving knowledge of fertility health and at ensuring people have a realistic view of fertility treatment from the start.[14] Research related to family formation and parenthood 14. In Australia, as in many other high-income countries, women are having their first child later compared to previous generations. In 2011, fertility rates were highest among women aged 30 to 34 years,[15] and the mean age of first-time mothers was 30.6 years.[16] In comparison, in 1981 fertility rates were highest among women aged 25 to 29 years and the mean age at first birth was 25.6 years.[17] In 2011, the total fertility rate in Australia was 1.88 children per woman compared to 1.93 children in 1981.[15, 17] The fertility rate is well below the replacement level 4

5 of 2.1, and aside from a slight increase in 2008, the rate has steadily declined since the early 1970s.[17, 18] 15. With access to reliable contraception it is assumed that childbearing is an individual woman s choice and that they are free to decide if and when to have a child.[18] However, there is a range of biological, psychological and social factors associated with women s childbearing outcomes.[18] These factors include: relationship formation and stability: multiple partnerships and higher rates in the breakdown of marriage and de facto relationships contributing to the inability to find a partner; greater participation and longer time periods spent in education, and debt associate with education; housing security, and home ownership; adverse health conditions; access to maternity leave and suitable childcare; and a shift in child-bearing behaviours, and attitudes toward women and motherhood.[6, 16, 18-20] 16. In Australia, one of the key factors that contribute to postponement of childbearing and the low fertility rate is the participation of women in the workforce. Job security and the economic uncertainty of having an unstable job, temporary employment, or the pursuit of a career through a series of jobs, is for many, incompatible with caring for children, contributing to later births and fewer children than desired.[18, 19] Furthermore, shifts in aspirations, social norms and values related to parenthood, smaller family sizes, and the value of children also contribute to this postponement and low fertility rate.[6, 18, 19] 17. An Australian survey of 569 women aged 30 to 34 years examined women s childbearing desires, expectations and outcomes to understand the factors that contribute to women s childbearing decisions.[18] The study found that most women (75%) wanted to have children, however, biological, psychological and social factors contributed to their childbearing outcomes.[18] The study found that these factors meant that of the women who wanted children, most (80%) had fewer children than they desired, and that if their circumstances were different most women would have more children.[18] The Public Health Association of Australia affirms the following principles: 18. Five principles are included in the framework for the Australian Government s National Women s Health Policy 2010.[21] Drawn from the first National Women s Health Policy 1989, the principles were strongly endorsed following an extensive consultation and submission process. Overall, the principles remain important elements in the planning and delivery of health services that are suited to the needs of women in all their diversity, and include: gender equity; health equity between women; a life course approach to health; a focus on prevention; and a strong and emerging evidence base.[21] 19. The principles for a national strategy recommended by the Sexual and Reproductive Health Strategy Reference Group of the Public Health Association of Australia (PHAA) in the Time for a National Sexual and Reproductive Health Strategy for Australia: Background Paper, include: Sexual and reproductive health is a human right; 5

6 Sex should be a positive, normal and healthy aspect of life; Enhancement of sexual and reproductive health will be best achieved by a broad public health and health promotion approach, incorporating a range of interventions; All interventions should be safe, effective and evidence based; Access to sexual and reproductive health programs and services should be equitable and responsive, and not limited by discrimination based on age, gender, cultural background, language, marital status, sexual orientation, religion, socio-economic status, disability or geographic location.[22] 20. One of the priority areas within the National Men s Health Policy 2010 focuses on preventive health for males, particularly actions that strengthen health awareness, and reduce chronic disease. Across government, health service providers, and the non-government sectors, strategies should aim to raise awareness about chronic diseases among males, improve the knowledge of males about lifestyle factors influencing health, and practical ways to make a difference especially in the areas of:[23] mental health and wellbeing; preventing chronic disease; sexual and reproductive health; healthy limits and reduction in risky behaviours.[23] The Public Health Association of Australia believes that: Key action areas should advance the following goals: 1. Empower women to have appropriate knowledge to enable reproductive choice: a. Promote greater understanding in the community about the effects of: i. women s age; ii. lifestyle factors, including smoking, alcohol consumption and weight; iii. health problems, including endometriosis and polycystic ovarian syndrome; iv. sexually transmitted infections, particularly chlamydia infection, and the National Human Papillomavirus (HPV) Vaccination Program; v. the interaction between women s and men s lifestyles and ages; on fertility, conception and pregnancy outcomes. b. Incorporate knowledge from a partner s perspective about the effects of age, lifestyle factors, health problems and sexually transmitted infections on fertility, conception and pregnancy outcomes. c. Promote greater understanding in the community about the importance of preconception planning and optimising fertility through health and lifestyle choices, and timing when planning a family. d. Minimise the personal suffering associated with infertility and unplanned conception. e. Promote access to trusted sources of information. 2. Educate and resource health care professionals about preconception health and optimising fertility: 6

7 a. Promote greater understanding by health care professionals about preconception health and optimising fertility through lifestyle choices; and the effects of many factors including age, health problems such as endometriosis, and sexually transmitted infections on fertility. b. Promote greater understanding by health care professionals about how they can help patients or clients by providing accurate information about preconception planning, and the effects of age, lifestyle factors, health problems, including endometriosis and polycystic ovarian syndrome, and sexually transmitted infections on fertility. 3. Promote infertility prevention on the agenda of individuals and policy-makers, driving a more integrated sexual and reproductive health strategy: a. Improve understanding of the importance of preconception planning and the effects of factors including age, lifestyle factors, health problems, and sexually transmitted infections on fertility, conception and pregnancy outcomes in sexual and reproductive health education in secondary school curricula. b. Promote awareness about the limitations of assisted reproductive technology treatment in alleviating age-related infertility. c. Advocate for preconception health plans to be supported through the Medicare system. 4. Promote development of programs to support behavioural change related to the lifestyle factors that affect fertility: a. Integrate information about the effects of lifestyle factors such as weight, particularly obesity, smoking, alcohol consumption, and sexually transmitted infections on fertility into current commonwealth, state/territory and local governments sexual and reproductive health education programs. b. Establish models of care to support lifestyle change for people seeking assisted reproductive technology treatment. c. Integrate sexual and reproductive health information into current programs and policies that aim to support people in making healthy lifestyle choices, with a focus on obesity, the harmful consumption of alcohol, and the use of and exposure to, tobacco. 7

8 The Public Health Association of Australia believes that the following steps should be undertaken: 21. To improve the health literacy of children and young people, promote fertility control and enhancement within sexual and reproductive health education that incorporates comprehensive and age appropriate strategies. Train and support teachers and parents to implement educational strategies. 22. To enhance the reproductive choice of women, educate various professionals within the health workforce through targeted training and skills development to promote preconception health and fertility optimisation. 23. To promote infertility prevention, implement a national policy initiative that incorporates fertility control and enhancement within an integrated sexual and reproductive health strategy. 24. To enhance the reproductive choice of women and promote infertility prevention, develop program information to support behavioural change related to the effects of lifestyle factors including obesity, smoking, alcohol consumption, and sexually transmitted infections on fertility that can be integrated into current commonwealth, state and territory, and local governments sexual and reproductive health education programs. Establish models of care to support behavioural change for women seeking assisted reproductive technology treatment. The Public Health Association of Australia resolves to undertake the following actions: The Board and Branches, with advice from the Women s Health Special Interest Group, will: 1. Advocate to the three levels of government to implement the recommendations listed above. 2. Incorporate a session at the next Public Health Association of Australia Sexual and Reproductive Health Conference on this topic to raise awareness of the issues within the public health sector. ENDORSED 2013 First endorsed at the 2013 Annual General Meeting of the Public Health Association of Australia. References: 1. Public Health Association of Australia, Advancing sexual and reproductive wellbeing in Australia: the Melbourne proclamation., in First National Sexual & Reproductive Health Conference, November : Melbourne. 2. F, Z.-H., et al., The International Committee for Monitoring Assisted Reproductive Technology (ICMART) and the World Health Organization (WHO) Revised Glossary on ART Terminology, Human Reproduction, (11): p United Nations Fund for Population Activities, ICPD - Programme of Action, in International Conference on Population and Development1994: Cairo. 4. World Health Organization. Health topics - Reproductive health. 2013; Available from: 5. United Nations. Fourth World Conference on Women, Beijing Declaration and Platform for Action Beijing 8

9 6. Loxton, D. and J. Lucke, Reproductive Health: Findings from the Australian Longitudinal Study on Women's Health, Bunting, L. and J. Boivin, Development and preliminary validation of the fertility status awareness tool: FertiSTAT. Human Reproduction, (7): p Homan, G.F., M.J. Davies, and R.J. Norman, The impact of lifestyle factors on reproductive performance in the general population and those undergoing infertility treatment: a review. Human Reproduction Update, (3): p Hassan, M.A.M. and S.R. Killick, Negative lifestyle is associated with significant reduction in fecundity. Fertility and Sterility, (2): p Ochsendorf, F.R., Sexually transmitted infections: impact on male fertility. Andrologia, (2): p McLachlan, R., Male Infertility Fact Sheet 2010, Andrology Australia: Melbourne. 12. Hammarberg, K., et al., Knowledge about factors that influence fertility among Australians of reproductive age: a population-based survey. Fertility and Sterility, Daniluk, J. and E. Koert, Childless Canadian men's and women's childbearing intentions, attitudes towards and willingness to use assisted human reproduction. Hum Reprod., (8): p Bunting, L., I. Tsibulsky, and J. Boivin, Fertility knowledge and beliefs about fertility treatment: findings from the International Fertility Decision-making Study. Hum Reprod, (2): p Australian Bureau of Statistics, Births, Australia, Australian Bureau of Statistics: Canberra. 16. Schmidt, L., et al., Demographic and medical consequences of the postponement of parenthood. Human Reproduction Update, (1): p Australian Bureau of Statistics, Australian Demographic Trends, Commonwealth of Australia: Canberra. 18. Holton, S., J. Fisher, and H. Rowe, To have or not to have? Australia women's childbearing desires, expectations and outcomes. Journal of Population Research, (4): p Mills, M., et al., Why do people postpone parenthood? Reasons and social policy incentives. Human Reproduction Update, (6): p Holton, S., J. Fisher, and H. Rowe, Attitudes Toward Women and Motherhood: Their Role in Australian Women s Childbearing Behaviour. Sex Roles: A Journal of Research, (9-10): p Ageing, D.o.H.a., National Women s Health Policy 2010, 2010, Commonwealth of Australia: Canberra. 22. O Rourke, K., Time for a national sexual and reproductive health strategy for Australia - Background Paper. February 2008, 2008, Public Health Association of Australia, Sexual Health & Family Planning Australia, Australian Reproductive Health Alliance. 23. Ageing, D.o.H.a., National Male Health Policy 2010: Building on the strengths of Australian males, 2010, Australian Government: Canberra. 9