When international student Sharan Chahal discovered she was pregnant just two months after arriving in Sydney last year to pursue a masters in information technology, she and her husband faced some stark choices.

With no entitlement to Medicare, she could either abandon her studies and return home to India, terminate the unplanned pregnancy, or find the money – potentially more than $15,000 – to cover a hospital delivery plus other medical bills.

“The insurance has a waiting period of 12 months, so we have to pay everything,” said Chahal. To go ahead with the pregnancy would be “very expensive for us”.

Her experience goes to the heart of long-standing concerns about the reproductive rights, health and wellbeing of international students, questions which gain urgency as their numbers grow at record rates. In December, the Federal Government initiated moves to slow the surge, with figures indicating there were now 650,000 international students in the country.

While all students arriving in Australia are required to obtain health insurance, many policies have a 12-month waiting period on reproductive health and pregnancy. This is the legacy of a controversial clause introduced in 2011 as a result of a deal between insurers and the federal government at a time of high and rising pregnancy-related claims by international students.

In May 2023, after more than a decade of campaigning by health and human rights experts and student advocates to overturn the clause, a senate inquiry into barriers to reproductive health care recommended that pregnancy related waiting periods for international students be abolished.

The waiting period represents a “significant disadvantage” to Australia’s growing community of international students, many of whom “might not have had sexual and reproductive health information and education in their home country”, said Alison Coelho, a public health and inclusion expert consultant and co-chair of the International Students Sexual Health Network.

The government “should absolutely support students to waive the 12 month waiting free”, she said.

Some who become pregnant might feel they have no choice but to have an abortion, some of them reluctantly, Coelho said.

“The ones that decide to keep the pregnancy can’t afford antenatal care and all the screening that is involved that the rest of us take for granted in the country.”

There has so far been no government response to the senate recommendation, which responded to expert evidence to the inquiry detailing the experiences of students.

Case studies related to the inquiry included the story of an international student in Melbourne who, while in labor, was “shunted and shunted and ended up in a (suburban hospital) car park giving birth”, multicultural health expert Dr Adele Murdolo testified.

Murdolo, the executive director of Melbourne’s Multicultural Centre for Women’s Health (MCWH), told The Citizen that this was not an isolated incident.

“[Students] would go to the hospital where they were planning the birth. And that hospital would say, ‘look, you’re not covered by insurance’,” Murdolo said.

The maternity fee for a public hospital delivery for uninsured women giving birth could be over $15,000, according to the fee schedule published by Melbourne’s Royal Women’s Hospital. In addition to that are fees for ante and postnatal appointments, scans, medications etc.

Murdolo and Coelho argue that the waiting period clause has directly impacted international students’ reproductive health.

On the concern raised by Coelho that it may have pushed up the number of terminations, reproductive policy expert Bonney Corbin said it was impossible to know because privacy laws mean that there is very little abortion data.

Corbin, head of policy and research at reproductive choice provider MSI Australia, said there were too many variables to draw any conclusions from the birth rate trend.

“We need a national mechanism for data collection on the abortion act,” she said.

“We don’t know what to advocate for … if we don’t have the data.”

Corbin points out that the fees for an abortion, also not covered under the waiting period clause, can cost up to $8000. She said that 12 to 15 per cent of MSI Australia’s clients who request abortions are on temporary visas, including student visas. Many are supported through a philanthropic fund for vulnerable populations.

In 2011, before the pregnancy waiting clause was introduced, insurers reported that between 33 per cent and 48 per cent of hospital claims by international students related to pregnancy, the vast majority occurring in their first year in Australia.

The Labor government of the day defended the waiting period in terms of market flexibility, arguing the clause aligned with private health policies for Australian citizens and for long-stay visa holders.

Experts then, and in the years since, have strenuously opposed the waiting period, arguing it functioned as a “proxy for tighter immigration control”  and posed grave health risks given many students arrived in Australia with a limited understanding of sexual and reproductive health and were highly vulnerable.

Analysis of Department of Home Affairs and Department of Education’s data by The Citizen tracks a dramatic decrease in the international student birth rate after the introduction of the 2011 pregnancy clause.

The graph shows an increasing birth rate among international students from 2008 to a peak of six children per 1000 students in 2011, when the federal government signed the new deed of overseas student health cover (OSHC) with insurers, including the waiting period of pregnancy-related service.

In the following year, the birth rate declined sharply and reached its lowest point in 2016. Apart from a brief increase during the pandemic, birth rates among international students have remained lower than 2 children per 1000 students.

“That was really what the government wanted to see with their policy change, that there would be a drop in pregnancies, [and] that did happen,” said Coelho.

The policy signed between insurers and the commonwealth government was mostly driven by insurers’ economic concerns but was also “an immigration deterrent”, said Coelho, referencing allegations that some students might see pregnancy as a path to residency. This “taps into broader issues around racism”, she said.

Professor Benjamin Avanzi, an actuarial studies expert at the University of Melbourne, told The Citizen the use of waiting periods in legal contracts was generally to “avoid people gaming the system”.

But Avanzi said the restriction could be particularly onerous for overseas students because “they do not have an automatic basic health cover” as Australian citizens who “are automatically covered by Medicare and have access to free care in public hospitals.

“Being covered by private health insurance is optional [to Australian citizens], and moreover is subsidised by the government.”

Overseas students, in contrast, have no alternative but to take out private health insurance that can preclude coverage of the pregnancy-related costs in the first 12 months. “It is not a decision that is free to them. If they want to come here and study, they have to take it,” Avanzi said.

He argued that international students contribute to Australia’s diversity and prosperity, contributing at least $29 billion to the country’s economy last year, according to the Australian Bureau of Statistics.

A 2014 expert study investigating the experiences of international students after the introduction of the pregnancy clause argued that limitations on students’ mandatory health insurance appeared “to conflict with Australia’s human rights obligations to take all appropriate measures to eliminate discrimination and ensure appropriate services in connection with pregnancy.

“Given the social, cultural and economic benefits international students bring to the country in which they choose to study, state action on equitable health access for international students is urgently called for.”

“We just would like to see them get the same treatment and care that Australian-born students get,” said Coelho.

Students “are already paying out of pocket for all their education”, said Murdolo.

The Australian government had not responded to the committee’s final report, which was supposed to be released within three months, she said.

“It’s due out, and that will tell us if they are going to implement that Recommendation 31 or not.”

A spokesman from the Department of Health and Aged Care said that “the government is considering the report recommendations and will respond in due course”.

In the meantime, Coelho said the International Students Sexual Health Network “will be putting in a submission directly to the deed” and “be clear on talking about the 12-month waiting period and the need for more education” this year.

As for Indian student Sharan Chahal, she and her husband became parents to a healthy boy delivered at Sydney’s Blacktown Hospital in July, at a cost to them of $8,000. She said her “little one” brought priceless happiness to her family.

“It’s a little bit tricky to handle a baby and do work simultaneously but I am happy, and I will try my best.”

This is Gwen Liu’s last story for The Citizen. Having completed her time as the Centre for Advancing Journalism Schiavon cadet, next week she starts work at the Ballarat Courier, one of two CAJ graduates to join the 2024 Australian Community News cadetship program.