4.3 Interpretation
Our findings show that women with SCI are represented in all life
stages, underlining the need for tailored services related to their
obstetric and gynaecological needs (3). In
our sample, one-fourth of the women were in the fertile life stage,
where counselling on family planning, contraception,
infertility/sterility treatment and pregnancy/lactation is predominant.
For example, contraception counselling usually considers the female’s
age, personal and family history, family planning and the personal
preferences. Counselling women with SCI who are at additional increased
risk for venous thromboembolism due to their medical history, requires
additional expertise. This because they are not optimal candidates for
combined oral contraception; rather, they should be prescribed a
non-hormonal or progestin-only contraception
(18).
Family planning decisions and health care service utilisation depend on
several individual factors as well as societal- and institutional-level
factors. In our study, only women with a lower incomplete lesion became
mothers. Thus, a woman’s personal characteristics (e.g. age, education,
health status, social identity) may interfere with health care system
structures and processes, creating a barrier to accessing family
planning services (19). This potential
barrier could be further aggravated by environmental barriers, such as
the lack of physical accessibility (20).
Furthermore, institutional-level barriers, such as the lack of national
guidelines on reproductive care in WPD and issues with insurance
coverage and affordability, may present obstacles to the development of
high-quality, responsive gynaecological services.
However, most of the study participants were in the peri- and
postmenopausale life stage. In this stage, womens’ service needs change,
with focus on acute menopausal symptom relief and long-term prevention
of chronic non-communicable diseases. At this age, menopause has usually
occurred, and this may be associated with various oestrogen
deficiency-related acute symptoms (e.g. hot flushes, insomnia,
depression, urogenital atrophy) and chronic health conditions (e.g.
osteoporosis, cardiovascular disease). For example, due to estrogen
deficiency the risk of recurrent urinary tract infections is increased
in all menopausal women. In women with SCI, this risk is already
increased by self-catheterising. To avoid further risks, it is
preferable to initiate a local estrogen therapy
(6).
In Switzerland, some first steps have been taken to improve ObGyn health
care services for women with SCI. For example, an interdisciplinary
international guideline on maternity care has recently been published
(21). However, more needs to be done to
address the multifaceted barriers affecting WPD
(20). In this regard, specific modules
should be added to the standard gynaecological residency curriculum
along with continuous professional development courses for practicing
gynecologists. The goal is to establish the necessary knowledge base for
counselling women with disability-specific complications
(22). Development of on-line training
tools such as videos explaining aspects of the gynaecological
examination and care, could aid providers in aligning their practice
with best evidence and help institute a culture of patient centeredness,
respect for autonomy and holistic care
(23).
Health care providers and clinics could also take measures to make their
practice more accessible and inclusive by ensuring that equipment,
facilities and information are accessible to WPD. In Switzerland, the
umbrella organisation for disabled persons has developed a checklist to
assist health care providers in assessing physical accessibility of
their facilities and their conformance with national standards. Finally,
stereotypes and discriminatory attitudes against women with disabilities
must be eliminated through appropriate health professional education and
awareness. An overall national framework for improving the reproductive
health of women with disabilities and SCI would be in alignment with WHO
recommendations (24) and published
evidence (25) is needed to ensure that
women with disabilities enjoy their fundamental right to access
reproductive and sexual healthcare.