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.