It is known that women experiencing homelessness are at high risk of unintended pregnancy (Gelberg 2007). Homeless women cite multiple deterrents to the use of contraception, leading to recommendations that family planning services need to be tailored to the specific populations of women experiencing homelessness (Gelberg 2002). There are considerable barriers to engaging, and maintaining ongoing care of pregnant women and families who are subject to homelessness.
Currently there are no reproductive health services in the identified geographical area which provide a proactive, flexible ongoing, tailored, appropriate support for this particular group of vulnerable pregnant women. More specifically there are:
- No free and accessible antenatal services within walking distance of the geographical areas that are frequented by women experiencing homelessness
- No outreach clinics from the two tertiary maternity services, the Royal Hospital for Women or Royal Prince Alfred Hospital
- No parenting classes located easily in this area that provide for the complex needs of this client group
The acknowledged gaps in effective intersectorial linkages, care planning and case management processes between health, housing and other service providers further act to limit the potential for improvements to the ongoing complex social and health issues experienced by these women and their families. It is believed that identifying and addressing systemic service gaps will result in connecting women and their families to a range of services that may optimise their health outcomes.
This study aims to map and consult service providers based in the statistical local areas of Sydney-Inner and Sydney-East to identify the perceived reproductive health issues for young women aged 16 to 24, and women aged over 24, who have no fixed abode or are residing in temporary accommodation.
- Identification of health and welfare services accessible to women subject to homelessness
- In-depth literature review
- Ethics and access approvals
- Consultation with a minimum of five expert service providers and 2-3 focus groups
- Collation and analysis of available data
- Provide a final report to Women’s Health and Community Partnerships including recommendations.
The study was conducted via qualitative interviews with 15 service providers across mainstream and non-government services to determine what they considered to be barriers to improved health outcomes, including gaps in service delivery models and within the homelessness sector. All interviews were analysed using qualitative analysis techniques for recurring themes and their variations. The major themes that emerged as part of the analysis are summarised below.
- Many women found accessing certain services difficult due to stringent appointment requirements, with many missing appointments due to chaotic schedules
- Service providers were often required to act as advocates for consumers, occasionally accompanying women to services when resources were available to do so
- Often dialogues on contraception use were ill-timed as they occurred when the consumer was engaging with the service due to a pregnancy. Contraception was not seen as a priority during that time
- The opportunities for spontaneous discussions of contraceptive methods were rare as other needs (e.g. related to current crisis, homelessness) usually took precedence
External reasons often influenced contraceptive use, such as:
- Difficulty in retaining possessions due to their chaotic lifestyle
- Negotiations with intimate partners or clients during sex work for its use
- The oral contraceptive was not seen as a viable contraceptive option for these women due to the reliance on daily usage, nor was implanted methods such as Implanon due to apprehension from the women about side effects, as well as infection risks
- Long term injectable contraceptive methods were seen as the most viable option due to the minimal requirement for follow-up and relative lack of associated risks or side effects
Access to Termination
- Due to poor usage of contraceptive methods, rates of unintended pregnancy were high. Many women denied their pregnancies or delayed access to healthcare services until late in gestation, making termination either very expensive or no longer an option
- There is no public funding for termination available for women. While brokerage funds may be available for some vulnerable women under 25, women outside this age bracket had few options available
- Community services often assumed care of the child at birth
Sexually Transmissible Infections
- High rates of sexually transmissible infections (STIs) such as Chlamydia Trachomatis and Hepatitis C was the norm in this population
- Rates of testing for STIs were low, with diagnosis of many infections only through mandatory screening offered by antenatal services
- Service providers often felt uncomfortable discussing sexual health with consumers, often only after extensive rapport was established was the topic broached
- Polydrug use and mental health issues were seen to be the norm in this population
- Although many women received opioid diversion therapies during pregnancy, after the baby was born this support often reduced and old patterns of drug use were resumed, highlighting the need for assertive follow up
- Often violence from partners or family members was tolerated by women as a trade-off between the violence likely to be experienced on the street
- Violence was often not reported as it was accepted as ‘part of the lifestyle’ as well as due to previous negative experiences with police
- Lack of regular engagement with health care services occasionally led to exacerbation of mental health issues
- A mental health diagnosis and/or lack of mental health assessment can be a barrier to services e.g. detoxification and accommodation services
Disengagement with Healthcare Services
- Issues relating to the complex needs of these women often took precedence over needs relating to sexual health
- Due to the unpredictable and chaotic schedules of these women, referrals and appointments in mainstreams services were often not followed-up by them
- Women experiencing homelessness were aware of belonging to a stigmatised population, and often felt apprehensive about engaging with services as a result
- Referrals to Community Services during pregnancy due to mandatory child protection reporting requirements were occasionally seen as a betrayal of the trust that had been built with antenatal services
Pregnancy and Postpartum Support
- Women experiencing homelessness often engaged with services quite late in pregnancy due to other priorities taking precedence or prior negative experiences with antenatal services
- Late entry into antenatal care often made positive outcomes of pregnancy less likely, with a high rate of newborns being assumed into care by Community Services
- Facilitating access to services is the key to ensuring positive outcomes for women experiencing homelessness
- Empowering workers to broach the topic of sexual health with consumers was imperative, or at the least providing service providers of referral pathways to have specific issues addressed Many participants spoke of the ideal system consisting of a ‘one-stop shop’, in which as many services were offered at the one site, to minimise the need for travel and referral between services
- Alternatively, the adoption of an assertive outreach approach in which services are brought directly to women, either where the women were staying or at services with which they engaged, was also seen as a viable option
- Barriers identified were not always indicative of a lack of services in the community, but rather related to barriers in accessing the services that do exist.
- There is a need to acknowledge that women experiencing homelessness have a complex set of immediate needs, focussing on food and shelter. In this context the delivery of sexual health services was often a low priority, for consumers and health care workers alike.
Assertive outreach models that promote trust and respect between consumers and health care providers are imperative. Strategies in such models may include:
- Follow up of referrals and offering transport/accompanying women to these appointments;
- The use of a mobile van to provide these services, that did not necessitate prior appointments; and
- Other outreach services based within agencies with whom the women are already engaged, for example specialist homelessness services.
- To enhance the engagement of women who are experiencing homelessness with reproductive health services, these services should be offered in a model of respectful assertive outreach with flexible service delivery options.