An examination of women’s access to and experiences of reproductive health care in England

In England, a range of services are used for reproductive health care, including general practice, community sexual and reproductive health (SRH) clinics, pharmacies and gynaecology. Understanding which service to access when can be difficult to navigate. Fractured commissioning systems for the delivery of reproductive health care have led to disjointed and un-holistic care. Calls have been made for more integrated care to ensure reproductive health needs can be addressed together, such as being able to have a cervical smear and intrauterine device insertion done in one visit rather than two visits to separate services. Lack of integrated care not only acts as an inconvenience, but can result in delays to diagnosis and treatment, and financial costs for both patients and the NHS.

As part of the 2022 Women’s Health Strategy for England, £25 million was allocated over two years to accelerate the expansion of Women’s Health Hubs (WHHs) to provide more ‘one stop shop service’.

The aim of this project was to describe the frequency of access to reproductive health services in England and people’s views and experiences accessing them.

In order to achieve this, we explored the following questions:

1. What reproductive health services are women accessing and those assigned female at birth who have other gender identities, accessing (or not) across the reproductive life-course, and how does this vary by demographic characteristics, geographical regions and early Integrated Care Board initiation of Women’s Health Hubs (WHHs)?

2. Among women with symptoms/conditions, what percentage are receiving treatment for this and how does this vary by demographic characteristics, geographical regions and early Integrated Care Board initiation of Women’s Health Hubs?

3. Among those who have accessed services, how satisfied are they with care received and how does this vary by reproductive health need, type of service accessed, receipt of treatment and demographic and geographical characteristics?

4. What influences choice of service(s) and what factors facilitate or hinder access to and acceptability of services, specifically Women’s Health Hubs?

5. From a user (actual or potential and community) perspectives, what steps will ensure access to and satisfaction with reproductive health services, and reduce disparities?

To answer our research questions, we conducted three complementary study components: 

1. An analysis of the survey data collected in the 2023 Women's Reproductive Health Survey in England, investigating if and how user's access and satisfaction varied by their personal characteristics, the reason for their visit and local area characteristics. 

2. Explored women's and those assigned female at birth who have other gender identities, views and experiences in more depth by conducting interviews with women, voluntary sector and social care representatives in selected case study sites. 

3. Held a co-produced workshop to interpret findings and develop recommendations.

Healthcare needs: Indication of reproductive healthcare need was high amongst RHSE2023 respondents: 71% reported gynaecological symptoms or conditions, 44% reported heavy menstrual bleeding and/or severe pain, 10% were trying to get pregnant or were currently pregnant, and amongst those 40 years or above, 92% had menopause-related symptoms. Interview participants described how poor reproductive health negatively affected daily life, including the ability to participate in education and work. They reported normalisation of symptoms such as pain and heavy bleeding, by family, friends and healthcare professionals, which led many to delay seeking care. Several described living with debilitating symptoms for years before seeking help. Cultural taboos and a lack of openness about reproductive health contributed to feelings of isolation and stigma.

Healthcare seeking: Most participants identified general practice as their first point of contact. Awareness of local specialist SRH clinics varied considerably, and knowledge of Women's Health Hubs was very low. Service preferences differed by age and condition, with younger participants tending to prefer specialist services such as sexual health clinics for contraception, while most defaulted to general practice for other needs. Long NHS waiting times led some to seek private care, generally as a last resort.

Healthcare reaching: Despite high levels of need, reported service access was low. Only around 35% of those with heavy bleeding or severe period pain, 45% of those with menopausal symptoms, and 55% of those with gynaecological symptoms or conditions had accessed a health service for these needs within the last year. Levels of access to services varied by demographics characteristics. Barriers included difficulties making appointments, long waiting times, incompatible opening hours, travel distances in rural areas, lost referrals, not being referred from primary to secondary care and dis-jointed pathways.

Healthcare utilisation: Amongst RHSE respondents, satisfaction with healthcare varied by condition, from 17% among those with polycystic ovary syndrome (PCOS) to 80% among those with reproductive cancers. Interview respondents described positive experiences centred on efficient diagnostic and treatment pathways, clear treatment plans and empathetic practitioners with specialist knowledge. Negative experiences were most commonly associated with dismissal of symptoms or concerns, paternalistic care, not being treated with dignity or respect, insensitivity (e.g. those with PCOS being told to ‘just lose weight’), inadequate information, lack of continuity, being offered limited treatment options (often hormonal contraception) without addressing the underlying condition, trauma (e.g. painful procedures) and long waits for diagnosis and treatment. Experiences of racial and gender identity discrimination were also reported. Satisfaction generally improved on reaching secondary or specialist care.

Health consequences: The consequences of poor or delayed care were significant. Diagnostic delays sometimes resulted in conditions becoming inoperable and fertility treatment becoming inaccessible. Negative experiences led some to disengage from care entirely, creating a cycle in which fear of further poor treatment prevented re-engagement. Others reported deteriorating mental health and reduced ability to work or study.

Health information seeking: Participants used a range of sources, with the NHS website most commonly used first, followed by broader online searches. Younger participants relied more heavily on social media for lived experience accounts, while older participants used books and podcasts. Family, peer networks and community support were also important, particularly for marginalised groups. Misinformation was a concern in both clinical and online settings. Participants with PCOS noted a particular absence of accessible information, in contrast to endometriosis where voluntary sector resources were more widely available once a diagnosis had been obtained.