Barriers to Responding to Reproductive Coercion and Abuse in Australian Primary Care

Background: Reproductive coercion and abuse is dened as any behaviour that seeks to control a woman’s reproductive autonomy. In Australia, women often access reproductive health care through a primary care clinician, however, little is known about clinicians’ experiences responding to reproductive coercion and abuse. This study aims to address this gap by exploring the barriers to responding to reproductive coercion and abuse in Australian primary care. Methods: Twenty-four primary care clinicians from diverse clinical settings in primary care across Australia were recruited to participate in a semi-structured interview. Data were analysed thematically. Results: Through analysis, three themes were developed: It’s not even in the frame, There’s not much we can do and There’s no one to help us. Conclusions: Many clinicians felt ill-equipped to identify and respond to reproductive coercion and abuse. Some clinicians hadn’t received any formal training, others were trained but had nowhere to refer women. Further complicating responses was a lack of support from referral services. This study highlights the need for more training and a streamlined referral pathways for women who experience reproductive coercion and abuse, as well as better access to reproductive health services in rural areas.

and a streamlined referral pathways for women who experience reproductive coercion and abuse, as well as better access to reproductive health services in rural areas.

Background
Reproductive coercion and abuse (RCA) is a form of violence against women. 1 It refers to any behaviour that seeks to control a woman's reproductive autonomy, typically encompassing; tampering or removing access to contraception (contraceptive sabotage), threats or acts of violence to force a woman to become pregnant (pregnancy pressure or coercion) and forcing a woman to terminate a wanted pregnancy or continue an unwanted pregnancy (controlling the outcome of a pregnancy). 2 Although most commonly labelled 'reproductive coercion' in literature and practice, recent research in the area has recommended the word 'abuse' be included since it highlights the intention and effect of the behaviours it describes. 1,3 Male intimate, dating or ex-partners are often perpetrators of RCA, however, family members and other people can be responsible. 4 RCA shares commonalities with both intimate partner violence (IPV) and sexual violence (SV). Women who experience RCA are likely to co-experience IPV, 2,5 yet the nuances of this association are unclear. The relationships between physical, psychological and sexual IPV and RCA have not been explored to any great extent. This highlights an overall lack of knowledge about intersections between RCA and other forms of violence. Further, RCA is linked to negative physical and mental health outcomes both speci c to RCA 6,7 and more broadly in conjunction with IPV and SV. 8 Health services are an effective setting to identify and respond to IPV and SV more broadly. 9,10 The World Health Organisation (WHO) has highlighted primary care as a health setting that is well placed to identify and respond to IPV and SV. 11 Primary care in Australia is universal access, diverse and complex consisting of all clinics having government subsidies per patient encounter, with some clinics charging additional fees for services. 12 Clinics can be large (more than three doctors) and also offer nursing and allied health services 13 , or small with only one or two general practitioners (GPs) working with a single primary care nurse. Women generally access contraceptives and reproductive health services through primary care. To commence antenatal care, or access a termination of pregnancy, women need to see a GP to have their pregnancy con rmed, and some GPs can prescribe medical termination of pregnancy pills. 14 Additional barriers exist in the Australian health system around rural/remote settings and access to care such as termination of pregnancy and other reproductive health services. 15,16 Given the reasons women access primary care, it is a setting where clinicians are likely to encounter women experiencing RCA.
Studies looking at RCA and health settings are scarce. An interview study (n = 17) into how clinicians understand RCA, showed that hospital doctors and nurses had varying opinions and understandings of what constitutes RCA and how it should be responded to. 3 Further, clinicians are aware of the issue and its impacts on their patients but believe that it is still mostly hidden and unacknowledged. 3 A lack of common understanding and the hidden nature of RCA in healthcare makes it di cult to implement interventions. Studies in the broader IPV context indicate that women trust clinicians and are willing to disclose experiences of violence to them, depending on the response given by the clinician. 17 Despite this trust, clinicians in primary care have identi ed barriers to responding to IPV in practice, such as a lack of skills, training and time constraints. 18 In Australia, surveys have shown that GPs are professionals that women would chose to disclose IPV to, over other professionals such as justice workers or domestic/family violence workers. 19 Although GPs are trusted clinicians, very little is known about their experiences with RCA in their patients. One study (n = 17) conducted in a hospital have provided some insight into how RCA is responded to in a tertiary health setting, 20 however there are no studies exploring primary care and the challenges they face in responding to RCA. In response to these gaps, this paper aims to qualitatively explore primary care clinicians' perceptions of the barriers to responding to RCA in Australia. In particular, we focus on the barriers that are unique to RCA as a distinct form of violence against women.

Study Setting
This study was conducted in primary care settings across Australia. Funding and legislation around healthcare are often controlled by individual states rather than Federally; 21 this means that there can be large differences across the country when it comes to access to services and amount of funding put into primary care.

Participant recruitment
We aimed to recruit participants from multiple states and varying degrees of rurality to ensure diversity. To achieve this, three different stages of recruitment were completed.
The rst method involved creating a partnership with a university regional sexual health centre who advertised the project through various channels including newsletters and clinical network meetings. Expression of interest advertisements were posted on key primary care social media sites, all authors posted advertisements through additional social media channels. Every primary health network (PHN) in Australia was contacted by the researchers to seek advice and assistance in recruitment, several PHN's posted small advertisements in their monthly newsletters and on websites. Secondly, the researchers also 'cold called' clinics who advertised medical termination of pregnancy, or shared antenatal care. Finally, the research team was contacted by a member of a women's health nurse union and a sexual health organisation who had both seen the project through aforementioned methods and offered to advertise through their own channels. Once a participant had been interviewed, they were also asked to distribute through their own professional networks.

Data collection
Clinicians who showed an interest in participating were invited to undertake a semi-structured interview with Author 1, either over the phone or face to face. Interviews took place between May 2018 and September 2019. A semi-structured interview guide was developed for this study *See Additional File 1 and was utilised to allow for exibility of discussion and answers in different settings and clinical capacities of participants and. The following questions were asked: "Can you tell me about any personal experiences that you may have had treating women who have disclosed, or you suspected, have experienced reproductive coercion?", "What are the barriers or facilitators that you have encountered when trying to respond to reproductive coercion?", "How do you think the current response to reproductive coercion could be improved?" and "What do you think the ideal response to reproductive coercion would look like?" The term 'reproductive coercion' was used in the interview context to be consistent with most of the existing literature at the time. Once all interviews were conducted, audio recordings were transcribed verbatim.

Data analysis
Thematic analysis was the method used to analyse the data as it provided the most exibility in exploring diverse settings, new ideas and emerging contexts within the transcripts. 22 NVivo 12 23 was utilised to facilitate the inductive coding process laid out by Braun and Clarke. 24 This method involved an initial phase where Author 1 familiarised themselves with the data by transcribing, reading transcripts and making notes, coding the transcripts descriptively in order to group similar codes together to make interpretive codes and nally forming common themes across the dataset. The coding was then focused further to facilitate analysis at a deeper layer of meaning. At this point, crosscoding of a sample of transcripts was conducted by Authors 2 and 3 to ensure rigour of analysis and develop the nal thematic framework of the data. The remainder of the transcripts were then coded using this framework.

Ethical considerations
The study was approved by the University of Melbourne's Human Ethics Advisory Group (Project ID: 1853440.2).
Clinicians were not offered incentives and no practice managers were advised if a clinician chose to participate. Prior to commencing any interview, informed consent was obtained from participants through reading a plain language statement and signing a consent form.

Results
Twenty-four clinicians participated who worked across various settings and in different clinical roles. Clinical settings included; private general practices, subsidised community health hubs, subsidised general practices, sexual health clinics, drop-in clinics/outreach workers, GP run rural hospital and termination of pregnancy/contraception clinics.
Participants were recruited from all states and territories in Australia, except the Australian Capital Territory. Speci c participant demographics can be seen below in Table 1. Interviews lasted on average thirty-ve minutes. Two interviews were conducted as pairs; the rest of the interviews were individual. Three themes were developed which describe the barriers primary care clinicians perceived to be hindering their response to RCA: It's not even in the frame, There's not much we can do and There's no one to help us. These themes are outlined below in detail.  It's not even in the frame Most of the clinicians acknowledged that a barrier to responding to RCA is that it is not a phenomenon that many clinicians have an awareness of. Several participants admitted their own de ciencies in this area.
Well to be quite honest with you, I don't think I've seen it [RCA], but I don't think I've been keeping an eye out for it either… the fact that I don't know very much about it or how to approach it con dently with a patient might be a barrier, on my part at least -Participant 21 (General Practitioner) Whether I've been fully aware of it or the depth of it I doubt in all cases…-Participant 14 Other participants felt that they personally had a good grasp on the issue but had concerns that primary care clinicians more broadly were not aware that RCA might be an issue in primary care. I think probably awareness needs to be the rst thing. I think [the] majority of people aren't really aware of it, or they're aware of it in a really vague way. -Participant 1 (Sexual Health Physician) I think there's a lack of awareness in this sort of general health, health profession… your average GP maybe has a slight naivete and lack of awareness of the way men use pregnancy as a controlling state… And you know I think if people aren't aware and aren't asking, they're not going to nd out -Participant 6 (General Practitioner) Many clinicians cited a lack of training -either formally or on-the-job -as being connected to this lack of awareness of the issue. Recognising this as a de ciency, clinicians expressed a desire to learn more around identi cation and responding, to provide better care to their patients. Although participants recognised this as a shortcoming in their own practice, there was no access to such training, and it was not covered in their initial medical education.
We did have two days of a women's health and reproductive health workshop which I think we had maybe one There's not much we can do Participants spoke of their low levels of con dence in responding to RCA. Some clinicians suggested that even if they suspected RCA they were reluctant to ask patients about it, because they were not con dent that they would respond in the "correct" manner. I must have to say, I do need to look it up each time…I Google domestic violence Victoria, there are some that I've used. It's terrible that I'm using Google but there's nowhere else that I can search. -Participant 12 (General Practitioner) I think it's perceived to be a very di cult topic to discuss, and people feel that they might not be able to manage the disclosure, and that they don't feel that they have the skills to be able to deal with it. I think that they don't necessarily know what services are available. Some clinicians were trained in screening for family and domestic violence, as well as guidelines for practice in the family and intimate partner violence context. Despite using these in practice (some because they were mandated to do so) clinicians did not think that these screening questionnaires were suited to women experiencing RCA and had reservations about their overall usefulness.
It's one of the things we've always complained about in the screening tool [universal domestic violence screening tool]. It's been going for about 10, 12 years now and they still haven't changed it. So, we only asked about being hit, slapped or hurt, or if they're frightened to go home and if there are any children in the house. -Participant 17 (Women's Health Nurse) Who are you having sex with? Is it consensual? Are you okay? Do you feel comfortable negotiating that? But again, I don't want to [ask like that]. Sometimes I do feel like it's a bit tokenistic. Kind of part of a process as opposed to exploring." -Participant 8 (Nurse) Many clinicians expressed frustration that although they may be trained in identifying women experiencing RCA, there wasn't much use in doing so because there were limited services to refer women to. This was particularly an issue in rural areas, where often there were no services at all, which left clinicians on their own with nowhere to send women.
GPs are very quick on the uptake for these things from -my experience is that if you tell us something, we'll go 'oh right' and start looking out for it. But if we've got nowhere to refer to or no help then it will seem like a pointless exercise…-Participant 18 (General Practitioner) I think there's services around… like there's not a lot of safety houses around here, there's not services you can send people off to and say they'll be able to look after things. You sort of have to do a bit more leg work" -Participant 4 (General Practitioner, Regional) In rural and remote areas, a lack of con dentiality meant that it was not always possible to refer women to services. Often women were not willing to be referred because of the possibility of their situation being made worse by other community members becoming aware.
The tricky bit with services in your own town in rural areas is the issue of con dentiality. People are fearful that the people they know work in the services and therefore people are gonna know what they're accessing or their issues that come with that. There's no one to help us Many clinicians found themselves in a di cult position when attempting to refer women experiencing RCA to other services. Some clinicians spoke about how they were unable to refer women they identi ed as experiencing RCA because services wouldn't accept these women. At times, participants felt that specialist domestic violence services did not recognise the level of risk associated with RCA, or did not perceive RCA as a form of domestic violence. Further complicating the disconnect between RCA and domestic violence services was the overall lack of 'space' in programs. Services weren't taking new clients, or prioritised women experiencing severe physical violence. This was a challenge for clinicians when responding to RCA, across both urban and rural areas.
If they [women] did want to go through our Family Violence program, they're not taking any new clients at the moment -Participant 14 (General Practitioner, Rural) The issue with the services we have is that we just do not have enough refuge beds on a daily basis … which is kind of the tip of ice of the iceberg stuff. So, if we can't even manage the really tip of the iceberg, then I think the others, we really do need to focus on more service provision at the very, very basic primary care level. -Participant 20 (General Practitioner, Urban) Responding to women experiencing pregnancy coercion or pressure in a timely manner was emphasised as being a concern. Unlike identifying and responding to other forms of intimate partner violence, RCA often has a small window of time within which women must receive a response before a pregnancy will have progressed too far for clinicians to be able to offer women choices. Clinicians expressed the di culties they encountered in trying to bring in other services to help support patients when these services could not connect within medical timeframes.
They can um they can see psychologists, but you know there's often costs and things involved and um if they're wanting a medical termination then they've got a fairly nite time that they can make the decision in. -Participant 2 (General Practitioner, Urban) Timing is pretty crucial as I said, the longer the pregnancy goes on, the more complicated the abortion might be and also it might not be an option because a surgical termination might be too expensive and there's more out of pocket expenses. -Participant 24 (Women's Health Nurse, Urban) The other problem is if you do pick it up then ok refer off to services but in the service their own waiting times and trying to get things in place. -Participant 10 (General Practitioner, Rural) When asked what barriers they experienced speci c to their area in Australia, clinicians highlighted the negative impact laws around abortion in each state had on their ability to either provide or facilitate access to abortion for their patients. Clinicians spoke of the negative effect that high costs of abortion had on women, meaning that some women were forced to continue pregnancies that they didn't want.
If that person then decides that the pregnancy continuation is the only option because they can't afford $1200 to go two hours' drive to get this termination -and even to get the medical termination, they've still got to drive, get the pills, and then they've got to go back in two weeks for an ultrasound. So that's a system thing. -Participant 17 (Women's Health Nurse, Rural) For medical abortions, in South Australia because termination has to occur in a hospital setting, that means that medication abortion has to occur in the hospital, so they have to be given the tablets in the hospital. Which, you know, you've got your country areas that it's just not feasible -Participant 19 (Nurse, Urban) I think probably just access to abortion is a terrible barrier in NSW of if you do need to get someone quickly somewhere, or quickly through some clinics, that's a terrible barrier for us. That that process often ends up in negotiating the abortion provider and the social worker as well. It ends up taking more time and that ends up having more risk for that person as well. -Participant 23 (Nurse)

Discussion
This study highlighted several barriers to responding to RCA in Australian primary care, both directly from the clinician themselves and more systemically. Clinicians were insightful in being able to evaluate their own practice and how they acted as a barrier themselves through their own lack of awareness. This is the rst study that investigated clinicians experiences in primary care, however a lack of awareness around RCA by clinicians and the community has been identi ed as an issue in Australia. 3 Previous studies in Australia were conducted in a tertiary hospital setting, where the challenges for clinicians centred around a lack of shared understanding between different clinicians and the need for a multidisciplinary approach. 3,20 The clinicians in the hospital did not face any barriers to access any services like the clinicians in primary care do. Guidelines for best practice are yet to be formulated in the Australian context, but comparing the current Australian literature with this study shows that guidelines can't be a 'one size ts all' like current guidelines in the US 25  intimate partner violence (such as the need for 'woman centred care'), 9 these US guidelines simply do not translate into the Australian healthcare system. These guidelines rely on a system that is specialised to sexual health and gynaecological care, which is not the case in Australia where a major portion of sexual and reproductive health occurs in primary care, rather than specialist centres.
Many of the clinicians in this study felt disheartened and exasperated when trying to assist their patients. Although they identi ed RCA, often there was nowhere to refer women for further assistance, especially in rural areas. This is an extremely serious barrier in terms of women's safety, given that we know that women who experience RCA are more often than not experiencing other forms of abuse. 2,5 Although this issue was experienced across different locations, it was of more concern to clinicians working rurally. It was emphasised that women living rurally have less access to health services overall. This is consistent with previous literature that shows women living rurally are more disadvantaged when it comes to access to healthcare. 15,27−28 Regardless of location, many clinicians described how domestic violence services often did not recognise the risk associated with reproductive coercion and abuse. Future research needs to focus on domestic and family violence services and how they respond to RCA in Australia. It may be that while this form of violence has become more recognised in the health context due to the nature of the necessity for treatment, it is not recognised in the same way in these services. This could also help to make improvements to the current referral pathways from healthcare into domestic violence services.
A key nding of this study is the incompatibility between the numerous barriers to identi cation and response in primary care, problems around safe access to abortion, and the time-sensitive nature of an unwanted pregnancy, particularly for rural women. Literature shows that there are barriers to access abortion in primary care in rural areas as GPs in the area are conscientious objectors to abortion. 29 For women experiencing RCA, accessing medical termination of pregnancy medication is important as they can take this in the safety of their home, which in some cases may be the safest option. As the law in Australia requires women to access to medical abortion only up to nine weeks gestation, 14 women experiencing RCA may present outside that window, leaving them at greater risk.