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.