Delegates from the following countries and organisations met in Suva, Fiji on 5-6
December 2019 and agreed the Call to Action below:
Delegates from Papua New Guinea, Vanuatu, Solomon Islands, Kiribati, Federated States
of Micronesia, Fiji and Samoa together with representatives of the Pacific Society for
Reproductive Health, Papua New Guinea Obstetrics and Gynaecology Society, Fiji
Obstetrics and Gynaecology Society, Papua New Guinea Institute of Medical Research,
Cervical Cancer Prevention in the Pacific, The Pacific Community (SPC), VCS Foundation,
Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Kirby
Institute at the University of New South Wales, Family Planning Australia, Australian
Cervical Cancer Foundation, Fiji Cancer Society, Fiji National University, University of
Otago, National University of Samoa and Victoria University. Also present were
representatives of the United Nations Population Fund and the United Nations Children’s
Fund.
We agreed to the following principles:

1. We support the global target to achieve elimination of cervical cancer as a public
   health problem, noting the current high burden of cervical cancer in the Pacific
   and the current lack of adequate vaccination, screening and treatment.
2. In line with the World Health Organization (WHO) draft targets for 2030, in the
   Pacific our targets are:
   1. a. 90% of girls are fully vaccinated against human papillomavirus (HPV) by
      15 years of age.
   2. b. 70% of women have had an HPV screening test between 30 – 39 years of
      age and a second HPV test between 40 – 49 years of age1.
   3. c. 90% of women identified with cervical pre-cancer and cancer have
      received appropriate treatment and care
3. We support the principles of equity in striving for the elimination of cervical
   cancer in the Pacific so that no woman or community is left behind.
4. We support the principle of meaningful collaboration between Pacific Island
   nations in planning, procurement and knowledge sharing.

We are committed to the following actions:

1. Raising awareness of cervical cancer in the Pacific and its impact on families and
   communities and strengthening advocacy for elimination.
2. Vaccination
   Exploring funding options including public-private partnerships for ongoing HPV
   vaccination in the Pacific.
   These two tests should be 10 years apart. Clinically validated PCR based tests should be used.
3. Urging Pacific Island governments to include HPV vaccination against HPV onto
   existing immunization schedules.
4. Screening
   Urging Pacific Island governments to transition to the delivery of effective cervical
   cancer screening with HPV testing and pre-cancer treatment services.
   Consideration should be given to self-collection of vaginal samples in order to
   facilitate scale up and acceptability.
5. Treatment:
   Urging cooperation between Pacific Island Governments to establish a treatment
   centre for cervical cancer, including radiotherapy, to act as a referral hub within
   the Pacific.
6. Workforce:
   Assisting Pacific Island governments and training agencies to develop an essential
   workforce for the delivery of HPV vaccination, cervical cancer screening and the
   management of cervical cancer.
7. Registry establishment:
   Assisting in establishing an adequate registry to record information about
   vaccination, screening and treatment for the prevention of cervical cancer; and
   with potential linkage to a cancer registry. This will facilitate follow-up of the
   young with incomplete vaccination and women through the screening pathway. It
   will also enable robust monitoring and evaluation of vaccination and screening
   program performance.

For more information, please email/call any of the following:
Professor Alec Ekeroma, HOD, Department of Obstetrics and Gynaecology,
University of Otago, Wellington, New Zealand. E: alec.ekeroma@otago.ac.nz; M:
+64212767975.
Professor Diana Sarfati, Head of Department, Public Health, University of Otago,
Wellington, New Zealand. diana.sarfati@otago.ac.nz
Professor Marion Saville, Executive Director, VCS Foundation, Melbourne, Australia.
E: msaville@vcs.org.au

The concept of a Pacific Society emerged in 1993 in Suva, Fiji by a group of reproductive health professionals who met at an educational meeting organized by the Fiji School of Medicine and the Royal Australian and New Zealand College of Obstetricians and Gynecological (RANZCOG).  Their vision was to establish a Society that fosters continuing medical education and ongoing support for reproductive, maternal and newborn health among Pacific health professionals. The Society would support various forms of capacity building, partnerships, conferences, meetings and networking.  The name South Pacific Regional Obstetrics and Gynaecology Society (SPROGS) was given at that time. RANZCOG through the commitment of Professor Brian Spurret supported the initiative and made it possible for the Secretariat to be located at the College House in Melbourne during its early development.
1995 – The first inaugural meeting of the Society was held in Port Vila, Vanuatu. A structured executive committee was established to run the affairs of the Society. Dr Wame Baravilala (Fiji) was elected the first President. He was the Dean of the Fiji School of Medicine and Head of Obstetrics and Gynaecology.
1997 – At the biennial meeting in Apia, Samoa the name changed to Pacific Society for Reproductive Health (PSRH), a change put forward by country members to reflect the inclusiveness of country membership.  The term “Reproductive Health” in the Society name also broadens the core business of the Society so that other health professionals become members including midwives, nurses, non-O&G doctors, researchers and academics.
Thereafter, PSRH conferences have been held every two years, preceded by a series of technical skills building workshops on specific topics to respond to the needs of both doctors and midwives. Locations of biennial conferences are listed below:
1999 – Suva, Fiji. The Secretariat was moved to Fiji School of Medicine.
2001 – Madang, Papua New Guinea
2003 – Nadi, Fiji. The Secretariat moved to the Secretariat of the Pacific Community, SPC
2005 – Nadi, Fiji
In April 2006 the Secretariat moved to the Pacific Women’s Health Research & Development Unit which was set up by Dr Alec Ekeroma. The Unit was under the auspices of the University of Auckland and the Counties Manukau District Health Board, New Zealand. The PSRH became registered for the first time as a Charitable Trust with the NZ Charities commission in August 2008 when Salausa Dr John Ah Ching was President and Dr Ekeroma was instrumental in realising that move. The Secretariat was moved to Aiono Dr Alec Ekeroma’s private practice at 525 Remuera Rd, Remuera, Auckland in 2012 as the University no longer had office space for the Trust.
2007 –  Apia, Samoa
2009 – New Zealand hosted (Auckland)
2011 – Solomon Islands hosted (Honiara)
2013 – Samoa hosted (Apia)
2015 – Fiji hosted (Suva)
2017 – Port Vila, Vanuatu
2019 – Port Moresby, Papua New Guinea
 
PSRH Presidents
1995-1999:    Dr Wame Baravilala (First president, Fiji)
1999-2001:    Dr Emosi Puni (Samoa)
2001-2003    Prof Glen Mola (PNG)
2003-2007:      Dr Rufina Latu (Fiji)
2007-2011:    John Ah Ching (Samoa)
2011-2015:    Dr Alec Ekeroma (NZ)
2015-2017:    Ms Kathleen Gapirongo (Sol)
2017-current:    Dr Pushpa Nusair (Fiji)
 
PSRH has gained new heights in the last 25 years of development. It is the only Society in the Pacific whose membership includes doctors, midwives and nurses. It has a unique organization that engages both doctors and midwives in maternal and reproductive health, and has maintained its relevance in the Pacific.

• Its biennial conferences have been successfully conducted in the last 20 years
• It has conducted numerous up-skilling training activities for health professionals, inclusive of midwifery and specialist doctors
• Expended its membership for building a stronger Society
• Engaged new partners for joint efforts towards common goals
• Developed stronger links with UNFPA, who has the global mandate for reproductive health
• Conducted various types of capacity building in collaboration with RANZCOG and other partners
• Reaffirmed its commitment for a regional initiative and moving together to shape the direction of Reproductive Health in the Pacific.

As PSRH enters its 25th year, we salute the dedicated members of the Secretariat and Board for keeping the organizational affairs afloat.  Appreciation goes to RANZCOG who contributed significantly in the early development of PSRH and continues to assist. We also thank the members across the Pacific, NZ and Australia for your dedication and support; and to the professional partners and donors for believing and trusting in the work that PSRH does.
The future of PSRH depends on a strong Secretariat, an effective Board and dedicated members and partners to work jointly in supporting organizational growth and development.
 

Dr Pushpa Nusair
Pacific Greetings to our Readers of the PSRH newsletter.
Through this issue of the PSRH newsletter, I am honoured to highlight a number of important PSRH events, on behalf of the Board. First and foremost, I am delighted to share with you that plans are on-track for the 2019 PSRH Biennial Meeting scheduled to take place in Port Moresby in July next year. I was privileged to have visited the O&G Society of PNG a few weeks ago and held discussions with the local organizing committee under the capable hands of Dr Mary Bagita, President of the O&G Society. One of the amazing things I found was the joint collaborative efforts by both the O&G Society and the Midwifery Society in planning next PSRH conference. The launch of the 13th PSRH Meeting was held in Port Moresby on 11th September 2018. The launch was successfully organized by the local committee.
The biennial conference is a major activity of the Society, a unique occasion that allows members and maternal and reproductive health professionals to network, share experience, debate, discuss and agreeing to actions.  This is a meeting not be missed and I encourage you to start planning your mission to Port Moresby ahead of time. The committee reassured me that intending visitors and participants need not be overly concerned about security issues in Port Moresby. We will be taken care of by our local counterparts.
Following the election of the new Board at the last biennial BGM in Port Vila in July 2017, the Board has been kept busy discussing issues on emails and skype. The membership of the Board includes both doctors and midwives and this is particularly important, noting the complementary roles of the two professions when it comes to maternal and newborn care in Pacific settings. In August this year, we held a face to face meeting in Nadi, Fiji which coincided with the conduct of a number of PSRH workshops and the Fiji O&G Society annual symposium.
In February 2018, I was invited by RANZCOG President Dr Steve Robson to hold a meeting in Melbourne. Much to my delight, it was a meeting that led to the establishment of stronger professional ties between RANZCOG and PSRH. An MOU was signed between the two organisations to seal the partnership and to allow for more functional engagements and collaboration that can strategically lead to improved maternal and newborn care in the Pacific.
We do remember that the PSRH conference in 2017 in Vanuatu called for a focus on prevention and management of cervical cancer in the Pacific. Related to this agenda, I was privileged to participate at the Cervical Cancer Meeting in Samoa in May this year. This was a high level meeting organized by the government of Samoa whose invitation extended to international and regional speakers and participation. At this meeting, I facilitated a discussion on developing a Regional Pacific Policy on Cervical Cancer Screening, Management and Prevention.  The discussion was positive and well received but we need to keep the momentum for policy dialogue and even moving towards initial steps for action. At the upcoming PSRH conference in Port Moresby, we will need to revisit this agenda and aim to arrive at some action plans at regional and national levels. We are banking on our partners to assist us with resources, both technically and financially. I call on you all to start taking a thorough country analysis about this subject before the next PSRH conference. Country voices are important in the discussion of what is feasible and what is not for the management and prevention of cancer of cervix.
Urogynecology is often a forgotten topic in health services for women. In Pacific settings, it is often not talked about. Nevertheless, this year PSRH has engaged Dr Jackie Smallbridge to carry out a feasibility study for urogynecology services in Fiji. Results will be shared and if services can be strengthened in Fiji, it is possible to model in other Pacific Island countries.
PSRH worked with Fiji O&G Society to deliver a series of pre-conference workshops. With support of the PSRH Secretariat, Board members and Partners namely RANZCOG, Ministry of Health (Fiji), Fiji National University, UNFPA, SPC and RACs. We organized and successfully ran six workshops. The six workshops were:
 

• PEMNeT Workshop:  focusing on maternal and neonatal safety

• Research Workshop:  focusing on Fiji obstetric audit

• Family Planning Workshop: focusing on Key to SDGs

• Colposcopy Workshop:  focusing on standardizing care to prevent cervical cancer

• Palliative Care Workshop: focusing on giving life to days rather than days to life

• Professional Development Workshop: focusing on leadership and safety in health practice

 
Details of these workshops can be accessed from the PSRH website. The success of these workshops is attributed to the PSRH Secretariat, resource persons, Board members and partners. It was also encouraging to have Board members co-facilitating the workshops. PSRH intends to hold similar preconference workshops at the PSRH Meeting in Port Moresby.

The annual scientific meeting of the Fiji Society of Obstetricians and Gynaecologists (FOGS) took place on 27th-29th August 2018. Six workshops were delivered in the lead up to this meeting.

The Chief Guest was Professor Alec Ekeroma and the key note address was given by Professor Rajat Gyaneshwar. Both have been key influential agents in the on-going development of PSRH. Other international speakers included Dr Roy Watson from RANZCOG, Ireen Manuel from PSRH, Dr Tapa Fidow from Samoa and the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) President, Dr Angela Makris who was able to offer clinical advice on the difficult clinical cases via video conference.
The main resolutions from the FOGS 2018 were:

1. Critical Incident Protocol:  there is a need to develop standard protocols to facilitate reviews of critical obstetric incidents such as maternal and perinatal deaths. This tool helps to review case by case events and facilitates positive learning among team members, and eventually leads to improved care and prevention of unnecessary deaths.  A workshop is planned for February 2019 to further address maternal death reviews.
2. New partners such as the SOMANZ network offer an additional avenue for discussing complex clinical obstetric cases with Pacific specialists.
3. Increasing numbers of Fetal Anomalies was raised as a common cause of early neonatal deaths. The meeting advocated for diligence in preconception Folic Acid administration to prevent such events.

The FOGS annual general meeting was also held where it elected a new and younger membership of FOGS Executives. Nevertheless, they will need mentoring and development in during their term of 2 years.  The team plans to hold regular quarterly meetings, initiate a membership drive, conduct workshops on Critical Incident Protocol, Intrapartum Care, Perineal Care, Gynecology and Subfertility; sourcing assistance from PSRH, RANZCOG and the Fiji Midwifery Society.
 
The FOGS meeting ended on a high note. Dr Nitik Ram of CWM Hospital in Suva Fiji had his first phase of research published in The Pacific Journal of Reproductive Health, an independent publication of the Pacific Society for Reproductive Health (PSRH) Charitable Trust and administered by the Pacific Women’s Health Research Unit of the University of Auckland. The Journal began publishing in 2015 as a means to increase research evidence from the Pacific region in collaboration with Pacific-rim countries. PSRH has been working with researchers in the Pacific region to help develop research and audit capabilities and drive research in the workplace.
 
We are very proud of Dr Nitik Ram, pictured here (second from the left) with a number of PSRH founders. We hope more young doctors will follow his footsteps. You can read Dr Ram’s research findings at:
https://pacificjournalreproductivehealth.org/…/issue/current

by Christine Jackson, Midwifery Technical Advisor
The first ever Graduate Diploma students of Midwifery in Vanuatu completed the studies in June 2017. This has been a great achievement for the government in training their own midwives and taking ownership in future capacity building in maternal and newborn health. Fifteen trained midwives are now deployed and working in rural hospitals and health facilities.
 
The 15 students were selected from all provinces in Vanuatu, many in remote rural settings. Therefore the students have already been exposed to the challenges of maternal and newborn care, and have dealt with many maternal complications while working in rural health facilities.  It has been a rewarding experience for tutors and facilitators to build capacity on experienced health workers. Ms Christine Jackson (NZ) played a major role in supporting the local team in steering the course and providing technical guidance and assistance to achieve this level of qualification.
 
The application of midwifery skills and knowledge in Primary Health care is pivotal to improving community health, especially maternal and newborn care. Midwifery functions as a key component of the health system and facilitates improved basic care when well integrated in primary healthcare settings. The health of a community is profoundly dependent on the health of the mother and her family. To ensure informed healthy reproductive choices birth spacing is essential. Access to quality, and appropriate antenatal care and removing the “three delays” for seeking safe delivery, ensures quality care in pregnancy and delivery.
 
Six months following the graduation of the first batch of midwifery students, a second cohort of 15 students were recruited to take the same Graduate Diploma of Midwifery. This is in line with national plans of government to train enough midwives so that every health centre has a trained midwife and therefore the capacity to provide quality maternal and newborn care at primary level.
 
The 15 midwifery students have just completed a two-week course on Pacific Maternal & Neonatal Emergency Training. PEMNeT (including Early Essential newborn care, EENC) with funds from Australian government sourced to the Ministry of Health and administered by Vanuatu College of Nursing Education (VCNE). The course aims to upskill midwifery students in emergency obstetric and neonatal care, a core component of their formal 18month training programme.  The workshops allowed the students to interact with other primary health providers so that they learn team work with other categories of health professionals and maximize joint efforts in addressing maternal and newborn health. The ultimate result is to have competent graduate midwives who can provide quality reproductive and maternal-newborn services throughout the six provinces of Vanuatu.

Three male midwifery students come from remote rural areas who have a combined nursing experience for over twenty years. Using acquired critical knowledge they will play an important role in the necessary changes required to improve maternal and newborn outcomes, by implementing safe, respectful and expert midwifery care. These 3 men along with other male midwives will be pivotal in changing the attitudes in a male dominated society, to ensure all women have access to maternal reproductive health.
 
The midwifery students are exposed to both clinical and managerial topics that highlight the importance of the midwife who contributes to reviewing and the development of health policies at local and national levels. On completion of the Graduate Diploma the students will return to their provinces and take up multi-skill midwifery role in health centres and hospitals.
 

Dr Mary Bagita
The annual scientific symposium was held in Madang during 29-31 August. The President, Dr Mary Bagita delivered the opening address and highlighted the theme of the meeting to focus on adolescent health, “Adolescent Health – a growing challenge”.
 
It was pleasing to see large numbers of O&G Specialists, clinicians, health extension officers, nurses and midwives turn up to the meeting. The host team in Madang, Dr John Bolnga and his colleagues extended a warm welcome to the visitors and made special efforts to keep the discussions interesting and dynamic.  The Society also managed to hold its annual general meeting with its members to discuss its business.
 
At its opening session, a moment of silence was observed in remembrance of Dr John Maku who passed on during the course of the last 12 months. Dr Maku was an expert Paediatrician who dedicated his life in serving his people. The President provided an excellent opening speech which highlighted the achievements of the Society despite the many challenges in providing health care in PNG. She paid tribute to two women: Ms Carmel Walker of the Royal Aust and NZ College of Obstetricians and Gynaecologists and Dr Rufina Latu from WHO, both of whom have made significant support and contribution to the work of the PNG O&G Society and overall support in the Pacific region through the Pacific Society of Reproductive Health. Both ladies recently retired from their respective organisations in June 2018.
 
As was the practice in previous O&G annual symposium, Provincial SMOs made presentations on maternal and newborn statistics and described achievements and challenges. The keynote address was given by Mr Koffi Kouame, UNFPA Country Representative in PNG.  Other speakers included representatives from National Dept of Health, WHO, UNFPA, IPPF and Port Moresby General hospital. Mr Moses Sariki from the Madang Provincial Education Office spoke on the need for educating our young people on Adolescent Sexual and Reproductive Health Issues in PNG. Other relevant topics in line with the theme included: update on the HPV Vaccination, mental health and youth-friendly services. One of the main areas for discussion was prevention of adolescent pregnancy and supporting adolescents to use effective contraception. A panel group discussed how to manage minority groups that oppose contraception.
One of the highlights of the conference was the presentation of research projects by postgraduate students attending University of Papua New Guinea medical school.
 
The research topics included:
 

• Reasons for not booking to ANC and comparing with the fetal and maternal outcomes for the booked mothers at Popondetta General Hospital – Dr Thomas Aiyak

• Prevalence of Gestational Diabetes at Vunapope General Hospital – Dr Christine Tipayamb

• Socio-demographic factors in IUD users at Kundiawa Hospital – Dr Megan Kona

• A retrospective analysis of the Primary Indications of Caesarean Sections and the Maternal and Fetal Outcomes over 12 months at Kimbe General Hospital – Dr Samson Vava

• Factors associated with initial Antenatal Care Visit at Buka General Hospital – Dr Oliver Ketauwo

• Adolescent Pregnancy: A prospective study demonstrating the demographics and pregnancy outcomes in adolescents at Kavieng General Hospital – Dr Pauline Masta

• Births before Arrival (BBA): Contributing Factors to BBA and Maternal and Fetal Outcomes at Modilon General Hospital – Dr Wendy Sapau

 
 
The 2018 symposium concluded with a panel to discuss “the Way Forward for Reproductive and Maternal Health in PNG, focusing on Adolescent Health”.  The panel was followed with a session to agree on the Resolutions of the meeting. The 2018 O&G Symposium identified the following Resolutions and proposed that the Society and its members take action in order to improve reproductive and maternal-newborn health, with special emphasis on adolescent health.

• RESOLUTION 1:  Prevention of Adolescent Pregnancy
• RESOLUTION 2:  Strengthen Adolescent Reproductive Health Services
• RESOLUTION 3:  Strengthen Maternal Death Reviews to reduce maternal deaths

by Prof Rajat Gyaneshwar
The modern day health professional aspires to be up to date in knowledge and skills to be able to provide the best care for their patients. The public expectation is that they will receive the highest level of care with compassion, respect and dignity. In response to these aspirations and expectations the Pacific Society for Reproductive Health (PSRH), national Obstetrics & Gynaecological (O&G) Societies of Papua New Guinea, Fiji and others have been increasingly involved in organizing biennial and annual scientific conferences, symposiums and workshops which bring together health professionals from the region to learn from each other and network. It is heartening that PSRH brings together different cadres involved in the delivery of Sexual and Reproductive Health (SRH) care, acknowledging that quality care requires a team effort to respond to the different aspects of SRH.
 
Professional development recognizes that all of us have the potential to continue to develop increasing levels of expertise as well as improvements in our approaches to deliver quality care.  It also recognizes that unless we are involved in maintaining our skill sets we tend to lose them. Thus an expert’s skills can be lost due to lack of practice. Additionally, it is important that health professionals keep abreast of evidence based best practices so that changes in management approaches are instituted appropriately. What was once best practice at some point in time may have become unacceptable practice.
 
It is important that we as individual practitioners become life-long learners and recognize that learning is our personal responsibility.  This requires regular reading, literature reviews, consultation and research. In addition, we need to search for opportunities to meet with our colleagues and learn through discussion, debating, sharing and listening. Scientific meetings and symposiums provide wonderful events for this. At these meetings we have the rare opportunity to interact with and listen to invited experts who can update us on evidence based practices.
 
The adult learning literature says that adults learn best by sharing and testing out their learning experiences with each other. The learning context must be respectful with plenty of opportunity to interact and to appreciate the exchange of experience. Our experience in the Pacific is that health professionals are most participatory and responsive to interactive learning opportunities. Conference and symposium organisers need to be cognizant of this and therefore capitalize on settings that use interactive participation.
 
From its early beginning in 1993, PSRH has worked to bring together health professionals so they can network and stimulate their learning through professional dialogue and sharing on a regular basis. Over the years, PSRH has linked up with RANZCOG, national O&G Societies, and national Midwifery Societies to broaden and expand the opportunities for adult learning in the field of maternal-newborn health and sexual and reproductive health. It is now 25 years since PSRH was established. Every 2 years it has held a well-structured scientific conference preceded by a number of technical workshops. The midwifery and O&G Societies have similar meetings at country level. Attendances at these meetings have generally been sponsored through donor contribution to PSRH, but sponsorships are becoming more difficult to negotiate. Therefore, it is logical that health professionals should start moving towards self-sponsored participation in these meetings.
 
Having worked in the Pacific for more than 40 years, I am humble to say that I am still learning from fellow professional colleagues. I wish to aspire you all to commit yourselves to doing the best for our patients by maintaining clinical competence and adhering to current best practices in all aspects of safe pregnancy and delivery and overall women’s health.  At every stage of the health profession, everyone should take responsibility for one’s own professional development and as we go up the ladder, we should adopt leadership skills and become role models for junior colleagues.

 
Dr Susan Tutty
GP Liaison for Women’s Health, Counties Manukau, Auckland, New Zealand
Counties Manukau is responsible for providing women’s health services in the Counties Manuka District Health Board boundary. It covers a population of over half a million and has one of the largest populations of Maaori, Pacific Islanders and Asian communities with relatively rapid population growth and high socio-economic deprived status. Therefore family planning is an essential service for these communities.
Improving access to contraception was highlighted as an important intervention in women’s health, and recommended in perinatal mortality meetings. Despite this, there is little data on women accessing contraception of their choice in Counties Manukau.
In an attempt to estimate planned pregnancy rates, an audit of folic acid use prior to pregnancy was undertaken. It found that only 5% of mothers start folic acid prior to pregnancy. Contraceptive data taken from pharmacies in 2015 suggested that approximately 20% of women in Counties Manukau use some form of contraception, but of that 20% only 8% use long acting reversible contraception (LARC). LARC is now considered first line contraception for all women but its uptake is still low. The Beach Study found that if women seeking contraception were given free access to the contraception of their choice, with no barriers, 67% of women would prefer a LARC.
Unplanned pregnancy: In a survey conducted at Middlemore Hospital, 54% of women reported that their pregnancies were unplanned: 62% of Pacifika women and 88% of Maaori women. Of the 16 women in the survey who were under 21, all of them had not planned their pregnancy. This demonstrates the “unmet need for family planning” and suggests inequities in access to contraception with particular disadvantages for Maaori and Pacifika women and young people.
The effect of poverty: Over half of all births in New Zealand in 2015 were to women living in quintile 4 or 5 neighbourhoods. Maori and Pacifika women are clustered in quintile 4 and 5 as shown in the table below.
 
Thirty seven percent of New Zealand’s Pacific Island people live in Counties Manukau and 76% of the Pacific Islanders of them live in the most socio-economically deprived areas in New Zealand. Pacifika women make up the largest proportion of births (30.6%) at Counties Manukau Health.
The women’s story: The stories of our women, collected from focus groups and freely shared in situations where LARCs are being made available, are incredibly moving and suggest there is a huge unmet need for contraception and for LARCs. Anecdotally, one of our midwives who agreed to help with the insertions of Jadelle on the post-natal ward has become a very strong advocate for LARCs after experiencing the appreciation and relief expressed by women who have received this service.
About LARCs
LARCs are described as “fit-and-forget contraception”, as their failure rate is not user-dependent, which makes them very suitable for the young and for women with busy and complex lives. Once Jadelle is removed the woman returns rapidly to fertility; ideal for spacing children and also for family completion. Jadelle have only been available in New Zealand since August 2010. Not all GPs are confident or skilled in the insertion of LARCs which may influence the options they present to women.
 
Postnatal Contraception
The provision of contraception to women whilst on the post-natal ward is the most cost-effective and convenient service delivery model. However, it is difficult to provide a service to reach all women. Currently, here is only a very limited number of staff doing Jadelle insertions on the postnatal ward with no service on weekends or outside normal working hours. Postnatal tubal ligations are occasionally performed on high needs women but frequently cannot be done due to pressures on theatre time. Immediate postpartum IUDs are currently not being inserted in Counties Manukau.
To accommodate the growing number of women requesting postnatal LARC insertions funding has been made available to primary care facilities for these insertions.  Whilst this is providing a more timely service than the previous referral to a secondary care clinic, there is concern over the high DNA rate of these new mums who already have to manage a new baby in a high needs area.
 
Vasectomy
Counties Manukau Health funds a vasectomy service for partners of post-natal women within 6 months of birth; services for women requesting termination and those requesting tubal ligation. Funding based on other criteria including family size has recently been withdrawn. This funding has provided vasectomies to men from high deprivation areas twice as often as men from low deprivation areas, but the numbers of Maaori or Pacifika men receiving this service are still relatively low.
 
Health Equity Project
Ko Awatea and CM Health have initiated a Health Equity campaign with the vision of reducing health disparities experienced by Maaori and Pacific communities by December 2020.  Women in high deprivation areas, Maaori and Pacific women need to be offered appropriate contraception. This project has removed barriers related to the cost of LARC insertions for women in Otara and is working on understanding other barriers within the GP practices, and build on women’s awareness or experience of LARCs.
A model for change has been introduced as illustrated by the following figure which highlights some of the change ideas being explored.
 
The future
At a recent focus group discussion with Maaori and Pacifika women who had recently given birth, the women surprised us by saying, “why are you working with doctors and the nurses, let us know what is there for us.” This is a challenge to go out into the community; to discuss, to challenge and inform women.  The social, economic and health benefits of LARCs have been clearly documented; these should be recognised politically, and funded nationally. Our women, and particularly our Pacifika women, are missing out on appropriate contraception and resulting in many unplanned pregnancies. It is inequitable and unjust.  All women should be informed about contraception, and have timely access to the contraception of their choice. Planned pregnancy provides the opportunity to optimise healthcare and address issues prior to pregnancy; and to give babies the best possible start in life.
 

(Dr Rufina Latu, WHO Country Office, Port Moresby and a/Prof Pushpa Nusair, Fiji National University)
 The benefits of effective contraception have been well documented and family planning is widely promoted in the last 40 years as an essential intervention for improved maternal health. Studies show that investment in family planning incurs far-reaching health and economic gains at individual, community and national levels. However, despite global movements to step up the family planning agenda and increase access to service, contraceptive use is still low among Pacific island countries.
The concept of unmet need for family planning is not well understood by many service providers. It is defined as the proportions of women of reproductive age, either married or fecund (productive), who desire to delay childbearing or wish to stop having further children, but are not using an effective method of contraception. An unmet need points to the gap between a woman’s child-bearing intentions and contraceptive use.
Quite often, a health worker sees cases of unmet need. For instance, a mother becomes pregnant again when her baby is only six months old – this demonstrates an unmet need; similarly, when a 17-year-old student becomes pregnant; a 36 year-old mother enters her 7^th pregnancy; or a 44 year-old mother becomes pregnant again ten years after her last delivery. We are too familiar with these kinds of cases of unmet need and yet we don’t put enough emphasis and actions to prevent them.
The level of unmet need for contraception remains high. Today, 214 million women in developing countries globally want to avoid pregnancy but are not using a modern method of contraception. This number has dropped by 10m during the last three years due to global movements in family planning. Among Pacific island countries, the unmet need ranges from 20% to as high as 50%.  Various studies show that nearly half of women attending antenatal clinics had not intended to get pregnant.
The unmet need is especially high among particular groups such as adolescents, single mothers, urban settlement dwellers, refugees, older women with many children, women in the postpartum period, and those living in remote communities with poor access to health services.
The reasons for not using contraception can be a combination of various factors, including: not knowing about contraception, a perceived low risk of getting pregnant, lack of motivation, limited access to contraception inconvenience in seeking and receiving services, concerns about side-effects, cultural or religious opposition, providers’ bias and attitudes, gender-based barriers, cost to users, and concerns about social acceptability especially among young and/or unmarried people. For decades we continue to live with this list of familiar reasons, and unfortunately, there is a general tendency to accept them as the norm without finding practical solutions to address them. Consequently, the unmet need for family planning propagates among communities, resulting in more unplanned pregnancies, and subjecting more women and families to various levels of disadvantaged socio-economic circumstances and hardships.
It is a social responsibility for couples to plan the desired number of children they wish to have, and to determine the spacing between them. It is also a human right for a woman to choose if and when to become pregnant. Family planning has a direct impact on securing the well-being and autonomy of women, and has far-reaching benefits on the health and development of families and communities.
Family planning allows delaying pregnancies, spacing of pregnancies, and completing the size of families at the desired time. Evidence suggests that women who have more than 4 children are at more risk of life threatening maternal complications than those with fewer children. This also holds true for pregnancies among younger women under age 18 and those with short birthing intervals of less than two years.
The vicious cycle of events contributing to unmet need for family planning has to be interrupted if we are to gain the full health and socio-economic benefits of contraception. This involves taking pragmatic steps to get non-users to become dedicated contraceptive users. Effective contraception must be an essential part of basic healthy living.
The message is clear – we need to reduce the unmet needs for family planning. The unmet need declines as more non-users become users.  Women and their partners should be empowered to use effective contraception. We need to return to basics – make family planning simple, practical and essential, provide client-friendly services, remove unnecessary barriers, and make every contact with health care a golden opportunity to talk about contraceptive needs.