Sexual and reproductive health and rights in Australia: we have much to celebrate but must not be complacent

In a world where sexual and reproductive injustice continues, Australia has been quietly making changes for the better. Australian sexual and reproductive health law reforms have been prodigious in recent years: we have seen more changes in the past six years than in the previous 60. Alongside Australia's progression, however, sexual and reproductive rights have been considerably eroded in other countries. How does the global context of reproductive rights affect Australia? And how can we protect not only our hard‐fought liberties but also ensure they are equitable and clinically fit for purpose?

Sexual and reproductive health rights implies that people of all genders “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”.1 International recognition of sexual and reproductive rights was affirmed at the 1994 United Nations Cairo Declaration on Population and Development,2 shortly followed by the 1995 Beijing Declaration and Platform for Action.3 Outcomes from these global gatherings affirmed sexual and reproductive rights firmly within global human rights frameworks.4 Three decades on, progress has been patchy.

Globally, about 121 million unintended pregnancies occur each year with around 60% ending in abortion.5 Despite the introduction of restrictive laws, global abortion access has continued. This is because criminalisation of abortion does not reduce the incidence of abortions: it simply increases the number of unsafe abortions and, subsequently, maternal mortality rates.6

Induced abortion is likely the most common gynaecological procedure in Australia, with one in four women undergoing an abortion in their lifetimes.7 Fees for abortion care (and access to care itself) vary greatly depending on postcode. For some people living in progressive health regions abortion can be free, while others, particularly those without Medicare access, may pay up to $700 for a medical abortion and $8500 for a second trimester surgical abortion. Barriers to abortion beyond cost include confronting stigma within families and workplaces, childcare for the procedure, and travelling vast distances across regions and jurisdictions.

The current global reproductive rights backlash is not simply against abortion, it is against the concept of gender and human rights.8 Access to sexual and reproductive health care enables us to choose if and when we are pregnant, enhancing women's participation in education, workforce, community and political life. Following the Cairo and Beijing outcomes, an antigender movement arose which has been organised, strategic and resourced.9 The movement carefully uses the language of human rights and seeks to undermine bodily autonomy more broadly, including transgender rights, marriage equality, and adoptions by LGBTIQ+ families.10

When Roe v Wade was overturned by the United States Supreme Court in 2022, enraged crowds took to the streets advocating for abortion access.11 A series of Bills were then released advocating for fetal personhood in high income Organisation for Economic Co‐operation and Development (OECD) countries, including Canada and Australia.12 By setting precedents for fetal personhood, they seek to complicate and over‐regulate abortion access.

In Australia, our sexual and reproductive health rights are comparatively secure and our accomplishments should be lauded. Over the past 25 years, every one of the eight jurisdictions in Australia has decriminalised access to abortion, enabled abortion via telehealth and introduced safe access zones.13 Medical abortion is now safely established within primary care. A recent bipartisan Senate Inquiry into the Universal Access to Reproductive Healthcare produced a realistic and achievable roadmap to embedding abortion throughout health systems.14

Last year the Ministers for Women in every state and territory met in person to discuss how they can work together to protect abortion access across all Australian jurisdictions. All differences aside, most women in Australian politics agree that we must progress sexual and reproductive reforms in order to achieve gender equity. The Office for Women are currently finalising a National Gender Equity Strategy that will formalise this in policy.15

Australia's federated model, like the US, presents a fertile political ground for obscure opinions on reproductive rights.16 Australian antichoice opinions intermittently surface in health systems, such as hospital governance structures blanketed by conscientious objectors and medical procurement groups who restrict abortion providers’ access to medical products, including personal protective equipment.17 Antichoice sentiment is evident in state and territory parliaments through amendments introduced during the final hours of political debates on abortion law reform Bills, creating inconsistencies between state and territory abortion laws.18

States and territories regularly face Bills that threaten to remove rights from people seeking abortion care and assign rights to a fetus. Common examples of these are the National Human Rights (Children Born Alive) Protection Bill (2022)19 and the New South Wales Crimes Amendment Zoe's Law Bill (2019)20 each of which incrementally proposed to expand the conceptualisation of fetal personhood while duplicating existing palliative care regulations and homicide laws.21 Similarly misconceptions about “sex selective” abortion propose to penalise the abortion seeker rather than addressing drivers of gender bias.22 Bills that criminalise people seeking abortion care risk negative consequences for those already over‐represented in prisons: Aboriginal and Torres Strait Islander people, people with disability, migrant and refugee people, sex workers and people with experiences of institutionalisation. Although each Bill is minor in isolation, collectively these Bills, which claim to be protecting women's safety, are incrementally eroding the framing of sexual and reproductive rights within human rights.

Most politicians are not doctors. This is why the next steps for abortion access reforms in Australia must be grounded in clinical evidence. We need to continue moving abortion out of legislation and into clinical guidelines and practice. Every health practitioner needs to consider if, how, when and where their work can provide access to comprehensive sexual and reproductive health care. Nurse practitioner, midwifery and related Aboriginal and Torres Strait Islander health colleges are in a position to define and refine their roles. This will require refreshed collaboration between organisations, internal policies and procedures, clinical placements and quality improvement mechanisms.

For the first time in history, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) has published abortion care guidelines.23 Related theory should be compulsory for all medical students because even if health professionals conscientiously object to abortion provision in practice, it is important that they can offer the appropriate information, support and referrals.24

The recent decision from the Therapeutic Goods Administration (TGA) to remove restrictions on medical abortion medication signals another power shift away from party politics and towards clinical leadership. Changes mean that pharmaceutical regulations no longer restrict who can prescribe medical abortion medication, and that scope of practice determination is instead delegated to states and territories. Nurse practitioners and authorised midwives will soon also access the Pharmaceutical Benefits Scheme.25 Although further reforms are required in policy, legislation and regulations, this TGA move opens doors for a new wave of practice development and multidisciplinary models of care.

Opportunities for sexual and reproductive health reform are diversifying beyond mainstream health and hospital systems. Populations that historically experienced reproductive discrimination, including forced sterilisation and forced child removals, are now in a position to redefine cultural safety in abortion care. Community controlled health organisations, including Aboriginal and Torres Strait Islander clinics, LGBTIQ+ clinics, migrant and refugee clinics, and disability clinics, can trial evolving methods of health care that privilege choice and autonomy. Telehealth and emerging methods of virtual care also mean that abortion medication can be delivered within the privacy of community care settings.26

The Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme are both overdue for review, in particular for surgical abortion care. In 2020, the Tasmanian Government trailblazed with the Women's Health Fund and the Youth Health Fund for those who cannot afford abortion and contraceptive care.27 In 2023, the Australian Capital Territory announced universal access to abortion, which includes people holding temporary visas.28 Governments in Western Australia and Queensland have long funded abortion access in specific health regions and they are currently considering how to fill access gaps. The pressure is on federal budgets to provide interim funds in jurisdictions lagging behind.

One year on from the overturning of Roe v Wade, we are at a pivotal global moment for gender equity and human rights. All health professionals in Australia are today in a position to re‐evaluate their roles. We now have national evidence‐based abortion guidelines23 for clinicians, and undergraduate institutions will inevitably follow suit in embedding these guidelines into curricula. Abortion care providers continue to share case studies of people in financial distress who cannot afford time‐critical care, and funding gaps are front of mind for politicians and health economists. Universal abortion access may be within reach, but we are still on a roller coaster of change and we all need to hold on.

We may no longer need to paint placards to uphold reproductive rights in Australia. Instead, we need to invest in evolving and advancing sexual and reproductive health care.29 This means that every one of us must reflect on our roles, responsibilities and power to reshape Australian health systems so that all people can choose if, how and when to parent.