By: 

Dr Celia Devenish, The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Te Kāhui Oranga ō Nuku (NZ Committee) Chair

Dr Samantha Murton President, Royal New Zealand College of General Practitioners

Jackie Edmond, Chief Executive, Family Planning

Today (26 September) is World Contraception Day. The mission of the annual observance is to improve awareness of contraceptive methods and enable women and their partners to make informed choices about their sexual and reproductive health. Three leading health care organisations reflect on contraception as essential primary health care, and what changes could make contraception more accessible in New Zealand.

Contraception has been recognised as one of the greatest public health achievements of the past century. It allows women to plan and space pregnancy, and to avoid unwanted pregnancies. Access to contraception globally has contributed to a significant reduction in maternal and infant mortality, and a reduction in teenage pregnancy. By enabling reproductive autonomy, it has increased women’s participation in education and employment, and the status of women in society. Most women will use contraception at some point during their lives –many for about three decades. Contraception is essential primary health care for women.

Access to contraception is linked to abortion – a topic under the spotlight since the introduction of the Abortion Legislation Bill. Up to a third of New Zealand women have an abortion during their lifetime. While abortions happen for a range of reasons, access to contraception reduces unintended pregnancies, which prevents the need for abortion.

While contraceptive options and access have expanded for women globally during the past few decades, not all New Zealand women are reaping the benefits of what medicine has to offer. Women in New Zealand face multiple barriers to accessing the most effective methods of contraception. Unsurprisingly, many pregnancies are unplanned, which sometimes results in abortion and can also lead to poorer pregnancy outcomes.

The Growing Up New Zealand study found that about 40% of pregnancies are unplanned, and a more recent analysis suggests the figure is closer to 50%. While declining, New Zealand has high rates of teenage pregnancy compared to other OECD countries. Barriers to effective contraception are amplified for Māori and Pasifika women, young women and women on a low income, who already experience barriers to primary care services.

There are two specific actions which could make a difference – universal funding and access for all contraceptive options, and a long term national strategy for reproductive and sexual health.

Today, the most reliable methods of contraception are called long-acting reversible contraceptives or LARCs. They are more cost-effective than the oral contraceptive pill for every one year of use and people using LARCs are 20 times less likely to have an unintended pregnancy. There are three different types of LARCs available – the implant, copper intra uterine device (IUD) and hormonal IUD.

Called “fit and forget” methods, LARCs are inserted by a health practitioner, then remain in place for three to ten years, relieving women of further steps like taking a pill every day or getting a shot every three months.  They have higher continuation rates than shorter acting methods meaning that women are satisfied with them. They can be removed at any time if a woman decides she would like to become pregnant. Despite their effectiveness, LARCs are not a common method of contraception used in New Zealand.

Assuming PHARMAC finalises its recent proposal to fund the hormonal IUD so it is available to all women, it is our view that it will have a significant and positive impact on rates of unintended pregnancy and women’s reproductive health. We applaud PHARMAC for this step forward. To date the hormonal IUD has not been funded, however, PHARMAC has just completed a consultation on a proposal to fund two hormonal IUDs, Mirena and Jaydess, after years of requests from our organisations and other health professionals. With a cost of about $340 - $500, the hormonal IUD has been unaffordable for many people, particularly young women, Māori and Pasifika women and women on a low income. This has contributed significantly to inequitable reproductive health outcomes. The hormonal IUD is the LARC method that works best for many women – but only women who could pay for it themselves have had this choice.

There are other barriers in the system that make it difficult for women to access a full range of contraceptives. There is a lack of national leadership to promote contraceptive choice and access. There has not been a national strategy for reproductive and sexual health since 2001. There is variable health professional knowledge of contraceptive options, and insufficient opportunities for professional training and development in this area. Increased provision of funded quality contraceptive services which offer LARCs as an option is needed.

There was a time in our history when sex and contraception were taboo. Women discussed these issues in hushed conversations with those doctors known among social circles for managing them. It is now 2019 and it shouldn’t be acceptable that this area of primary health care continues to be significantly neglected. We must do more to realise the vision of annual World Contraception Day and strive to make every pregnancy one that is wanted.