Free contraception criteria ‘punitive, stigmatising and restrictive’ – doctor

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Some women are paying hundreds of dollars for the insertion of Mirena and Jaydess contraceptives when, under a multi-million government scheme, they should be getting the highly effective intra-uterine devices free. Susan Strongman reports.

A copper IUD

A copper IUD Photo: RNZ / Samuel Rillstone

Emily paid $500 to get a Mirena. That cost came as a shock, as she’d expected it to be free.

The 26-year-old office worker, whose GP had referred her to a private gynaecologist to get the device inserted, didn’t have $500 spare, so she arranged to pay it off in instalments.

It was December 2019 and she’d heard, correctly, that the Mirena intrauterine device (IUD) was fully funded by government drug buying agency Pharmac.

But Emily, not her real name, hadn’t considered the cost of insertion. And because her GP didn’t know how to do it, she’d suggested she go private.

The Mirena is a type of long-acting reversible contraceptive (LARC) that is inserted into the uterus and lasts up to five years. This type of ‘fit and forget’ intrauterine device (IUD) is more than 99 percent effective at preventing pregnancy, making it more reliable than the pill, which needs to be taken daily.

But it wasn’t until November 2019 that the Mirena – which previously came with a price tag of between $300 and $500 (excluding insertion and removal costs) – was fully funded by Pharmac.

This made the device more cost effective than many other contraceptives that may require regular GP visits and prescription fees.

“Before the Mirena, I was on a non-funded contraceptive, which cost $50 per three months”, Emily says. “I wanted the Mirena as it was supposedly going to be more cost effective. But I didn’t consider the consultation costs”.

Emily doesn’t recall her GP telling her about cheaper options for getting the device – like via Family Planning, which charges about $60 for insertion. (It’s less for people who fit certain criteria.)

And she certainly wasn’t told that based on the criteria set by the Ministry of Health, she was eligible to get the device inserted for free.

Despite this, she’s very happy with her decision to get a Mirena and, even with the $500 insertion fee, it still works out to be cheaper than the pill in the long run.

***

The funding that should have saved Emily $500 was announced by the government in 2019.

“Thousands of women” were to benefit from the initiative, a media release said. The extra $6 million-a-year would reduce the cost of fit and forget contraceptive devices for “women who have a Community Service Card, those living in low income areas, and various others who could benefit”.

Of the $6m, the Ministry of Health distributed about $4.5m across the country’s 20 district health boards (DHBs) to develop services providing free insertion and removal of IUDs and other fit and forget contraceptive devices for those who met certain criteria.

The objective of the scheme, according to a Ministry of Health document, was to decrease the rate of unplanned pregnancy, “which can negatively impact physical and mental health, and social wellbeing”.

New Zealand stands out among developed countries for its high rates of unplanned pregnancy, which is estimated to be between 40 and 60 percent of all pregnancies. In 2019, 18 percent of all known pregnancies ended in an abortion.

According to the Health Ministry, unplanned pregnancies come with a 31 percent increased risk of preterm birth and a 36 percent increased risk of low birth weight babies. This can result in conditions like cerebral palsy, cognitive, motor and language delays.

In its service specification for the scheme, the Ministry says unplanned pregnancies also come with “persistently poorer mental health outcomes for mothers, particularly young mothers” and “a higher risk of foetal alcohol spectrum disorder”.

According to the document, the scheme aims to reduce unplanned pregnancies by increasing equity of access to fit and forget contraceptive devices for those who want and need them.

Despite this, RNZ has spoken to a number of people who, like Emily, were eligible for funding under the scheme, but were unaware it existed.

Why? That is a question that Dr Orna McGinn has asked – and attempted to answer – in a paper on the initiative that she co-authored, published in the New Zealand Medical Journal last month.

McGinn says criteria developed by the DHBs responsible for implementing the scheme are, in some cases, “punitive, stigmatising and restrictive”, or non-clinical – including relating to ethnicity and family violence.

Auckland GP and women's health advocate Dr Orna McGinn

Auckland GP and women’s health advocate Dr Orna McGinn Photo: supplied

And, like with much of New Zealand’s public health system, whether or not a person can access funding under the scheme may differ depending on which DHB area they live in.

“It’s very much a postcode lottery. It is so confusing for women, it is almost impossible for them to navigate the services”, says McGinn, a GP who teaches at the University of Auckland.

She believes Health Ministry criteria stipulating who does and doesn’t qualify for the scheme was left deliberately vague; aside from holders of Community Services Cards, and those living in economically deprived areas, the target population was described as being anyone “at high risk of unplanned pregnancy and poor health and social outcomes”.

She says this wording should allow DHBs to be “laissez faire” over who fit criteria, making it easier for GPs to offer the devices free “to pretty much all of their patients” who needed them; people “at high risk of unplanned pregnancy” could include those with conditions like diabetes, obesity, hypertension and renal disease. It could also cover anyone taking teratogenic drugs, that can disturb an embryo or fetus – like lithium, which is used to treat depression and bipolar disorder and isotretinoin, for acne.

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But most DHBs developed their own criteria instead, essentially “ring fencing” the money for a more specific target population than what was suggested by the Ministry, McGinn says

As part of her research, she spoke to GPs who shared stories of patients needing the devices for significant medical conditions that could impact on a healthy pregnancy, but who could not access the funding via their DHB.

Others said criteria could be “punitive, stigmatising and restrictive”, McGinn told RNZ.

In various parts of the country, criteria may include someone who’s had an abortion in the last five years, a person at risk of family violence, or someone aged under 30 with more than four children. Criteria can also relate to substance abuse, Māori or Pacific ethnicity, or anyone living in a youth justice residence.

McGinn’s research also found that the level of mental illness or substance abuse that qualified a person for free access ranged between areas, from anyone who disclosed any mental health issue, to only people who were currently under their DHB’s secondary (specialist) mental health and addiction services.

“There are currently no other medical services in New Zealand that rely on the application of inconsistent non-clinical criteria in order to access funding”, the study concludes.

“Contraception is an entirely predictable healthcare cost required by up to 50 percent of the population at some point in their lives… It is therefore surprising that it is seen as a low priority for health-policy makers rather than a central part of an integrated, well-resourced and country-wide women’s health service.”

Differences across DHBs creates confusion for service users wanting to access the government-funded healthcare they’re entitled to.

Furthermore, there is no nationwide website or app that allows a person to insert their address to find where local, publicly funded contraception providers are, or if they meet criteria for free fit and forget contraceptive access.

This leaves many reliant on their GP for information, but McGinn’s research also uncovered a lack of information and training among primary care practitioners. As was the case for Emily, many GPs simply don’t know how to insert the devices, or the criteria by which patients can access them free.

Maia*, another woman who spoke to RNZ on the condition of anonymity, paid $190 to have a Mirena inserted by her GP. The GP did not tell her she could have accessed the device free, based on the criteria of her DHB, because she’s Māori.

Teuila* got her IUD inserted for $55 though Family Planning in Hamilton. She waited about a month to get the procedure done and next month she’ll pay about $40 for a follow-up appointment, to check everything is ok. But if she lived in Auckland, the West Coast, Canterbury, MidCentral, Nelson Marlborough, Hawke’s Bay, the Bay of Plenty, or within the Southern DHB catchment, she would have got it free because she’s Samoan. Depending on how the Ministry’s funding criteria is interpreted, she may have been able to access it free through her own DHB, too.

Other people who RNZ spoke to had the devices inserted at no cost, or for a $5 prescription fee, via organisations like Family Planning, local youth hubs and university health centres, though some described months-long waits.

But even a $5 prescription fee can be a barrier for some people; Research has shown fees are more likely to prevent Māori and Pacific people from collecting prescriptions. On top of this, factors like where a person lives, their ability to get time off work and the availability and cost of transport are also likely to affect whether they collect a prescription.

Several of the people RNZ spoke to who got free (or $5) devices, would have been eligible via the Ministry of Health-funded initiative to access the service at no cost – and potentially with shorter wait times – through their DHB.

“I think there probably isn’t a lot of awareness”, Family Planning chief executive Jackie Edmond says of the government funded initiative.

“It’s complex, it’s not easy to figure out. I think most DHBs are doing their best with it, but it’s not easy to advertise.”

In contrast, information about what is available to whom and how much it costs, is clearly set out on the Family Planning website.

But the not-for-profit, charitable organisation, which has been providing contraception for New Zealanders since 1936, has major troubles of its own.

Aside from a $1m boost as part of the Health Ministry’s fit and forget initiative and a one off Covid-19 grant of $427,000 last year, the organisation’s annual report says it’s not received a “sustainable” funding increase from the government – which provides about 75 percent percent of its money – in 12 years.

Earlier this month the New Zealand Nurses Organisation announced members working for Family Planning would strike for the first time ever (the strike has since been called off). At the time, the union said nurses working at Family Planning were paid at least eight percent less than their DHB counterparts and nurse practitioners earned between 10 and 27 percent less, as a result of “a decade of underfunding”.

Meanwhile, the demand for Mirena through Family Planning remains high: within the first month of the devices being funded by Pharmac back in 2019, more than 800 were inserted at Family Planning clinics. (Prior to this, the organisation had inserted about 40 per-month.)

Wait times at clinics in some parts of the country are up to eight weeks, which Edmonds describes as “unacceptable”.

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The organisation is hamstrung. Without the money to pay for extra staff, or increased hours, there is no solution in sight.

So instead of using the government’s $1m to offer free contraceptive insertions to more people (the organisation is already funded to provide free or cheap access to for those who meet certain criteria, including low-income), Family Planning played catch up, extending clinic hours in higher needs areas like Gisborne and Whangarei, so they could offer more appointments and reduce wait times.

“We believed that was the most efficient way for us to do it. We’ve got a high demand for our clinics, and long waiting time. So it made the most sense to just open the doors,” Edmond says.

It worked. But Family Planning, which turns 85 this year, is still struggling with a high demand for all services and barely enough money to stay afloat.

Meanwhile, more than half of the country’s DHBs failed to achieve the number of LARC insertions for which they were funded in the 12 months to 31 June 2020.

***

BIRTH CONTROL 
Birth control. 

CHASSENET / BSIP

Photo: AFP

The World Health Organisation describes access to high-quality, affordable sexual and reproductive health services and information as being “fundamental to realising the rights and well-being of women and girls, men and boys.”

It also makes economic sense: A growing body of research has shown governments that spend money on those services can save money as a result – in areas such as abortion services, workforce retention and medical care related to unplanned pregnancy. A US study found that for every public dollar spent on family planning services, the government saved $7.

And in New Zealand, a growing chorus of voices are calling for the government to make that investment.

Obstetrician and gynaecologist Dr Helen Paterson says ideally, she’d like to see contraception free for everyone who wants it, anywhere in the country.

But at a minimum, she says people need to know that if they have a funded insertion, the removal will be funded too – even if they move to another DHB area. Removal of the Jadelle implant, which sits under the skin of the arm, requires local anaesthetic and can cost up to $150 for people who don’t fit funding criteria.

It’s unclear if all DHBs fund the removal of devices under the initiative when the person had it inserted while living in a different area.

“It’s unreasonable to put a contraceptive into someone when it’s funded, and not guarantee that they can get it out funded.”

But while working as a GP in South Auckland, Dr McGinn saw exactly that; women who’d had IUDs inserted free post-natally or after an abortion and who kept them in for between two and four years longer than their recommended timeframe, because they couldn’t afford the cost of removal.

She agrees with Paterson that funding devices like Mirena only removes part of the cost barrier and access will remain inequitable until the cost of insertion and removal is free for all women.

RNZ asked the Associate Minister of Health, Dr Ayesha Verrall, whether the scheme was working as intended, and if the government would consider calls to fund insertion and removal of fit and forget contraceptive devices for all New Zealanders.

In response, Dr Verrall said the government was “actively working” to improve access to the contraceptive devices, “but there is clearly a lot more work to do”.

She said the cost of the devices was one of the main barriers to access, but workforce capability to provide insertions and removals also needed to be improved.

“This includes upskilling the workforce so they can have meaningful conversations with women about the benefits and whether they’re eligible for free or subsidised LARCs.”

Dr Verrall said that since mid-2019, more than 30,000 women had attended “low cost contraceptive consultations” and about a third of them chose to receive a LARC. She said she expects those numbers to increase this year.

She said primary care disruption due to Covid-19 had exacerbated the situation, but she would seek advice from the Ministry on what more could be done.

***

LARC FUNDING CRITERIA BY DISTRICT HEALTH BOARD:

*DHBs, as with almost all health services, have the flexibility to fund contraception and other sexual health services as they see fit for their community. Because of this, other funding criteria not listed below may be available within your DHB. For more information, speak to your GP or primary healthcare provider.

**If you are unsure of your DHB, speak to your primary healthcare provider, [https://www.health.govt.nz/new-zealand-health-system/key-health-sector-organisations-and-people/district-health-boards/location-boundaries-map or check the map here.]

***Use this map to determine which quintile area you live in.

Northland

Women aged 15 to 44 who are at high risk of pregnancy, and who:

Live in a quintile 5 area, or

Hold a Community Services Card, or

Experience intimate partner violence (IPV) at any age, or

Are under 25 and in full time education, or

Have had an abortion in the last 5 years, or

Are under 30 with more than 4 children, or

Have had a complex mental health or alcohol or other drug diagnosis with medication at any age, or

With a chronic health condition that could be worsened with pregnancy, e.g. diabetes, or

Need emergency contraception within 4 days following a sexual assault.

Auckland and Waitematā

Live in a quintile 5 area, or

Hold a Community Service Card, or

Are of Māori or Pacific Ethnicity, or

Are at risk of poor outcomes from unplanned pregnancy

A list of providers in Auckland and Waitematā can be found here.

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Counties Manukau

Priority population:

Are living in a Quintile 5 area, or

Hold a Community Service Card, or

Are of Māori or Pacific Ethnicity, or

Are under 25 and are currently engaged with maternity services

A list of providers in Counties Manukau can be found here.

Waikato

Women aged 15-44 years who:

Are living in a Quintile 5 area, or

Hold a Community Service Card, or

Are at high risk of poor health and social outcomes

Bay of Plenty

Under 26 year olds, or Māori or Pacific ethnicity

Or all women aged 15-44 who:

Live in a quintile 5 area, or

Hold a Community Service Card, or

Are at high risk of unplanned pregnancy and poor health and social outcomes

For mote information go to ProtectedandProud.nz

Lakes

Women aged 12-44 who:

Live in a quintile 5 area, or

Hold a Community Service Card, or

Are at risk of unplanned pregnancy and poor health and social outcomes.

Priority population:

Woman at high risk due to chronic health conditions,

Women accessing community alcohol and drug services, Work and Income, youth justice residential care, Oranga Tamariki, disability service provider.

Under 25-year-old Māori or Pacific maternity service users.

Under 25-year-old Māori or Pacific women having rapid repeat pregnancies.

Tairawhiti

Women aged 15-44 who:

Live in a quintile 5 area, or

Hold a community services card or,

Are at high risk of poor health and social outcomes

Hawkes Bay

People aged between 21 and 44 years (younger women are covered under another agreement) if they are:

Community Service Card holders, or

Living in a quintile 5 area, or

Of Māori or Pacific ethnicity, or

Receiving mental health and addiction services through community alcohol and drug services, or

Engaged in maternity services aged under 25 years, having rapid repeat pregnancies.

The service is delivered free to eligible people by two iwi providers, the DHB’s Community, Women and Children directorate (Maternity and Sexual Health Services) and Directions.

Taranaki

Women aged 15-44 who are at risk of an unplanned pregnancy. This includes:

Women living in quintile 5 areas, or

Community Services Card holders, or

Any patients determined to be at-risk by a GP.

Whanganui

Women aged 15-44 years who:

Live in a quintile 5 area, or

Hold a Community Services Card, or

Are at high risk of unplanned pregnancy and poor health and social outcomes, for example due to factors such as mental health or alcohol or other drug use

MidCentral

Participating primary care practitioners in the MidCentral DHB region provide or refer for free insertion and removal of funded LARCs using the following criteria:

Hold a Community Services Card, or

Live in a quintile 5 area, or

Of Māori or Pacific ethnicity

Have a high risk of unplanned pregnancy, poor health, or poor social outcomes; or

Use community alcohol or drug services.

Wairarapa

Free for all people up to and including 19 years of age. Women aged 15-44 years are eligible for free sexual health and contraception consultations if they:

Hold a Community Services Card, or

Live in a quintile 5 area, or

Are at high risk of unplanned pregnancy and poor health and social outcomes.

Capital and Coast and Hutt Valley

Women aged 15-44 years who:

Hold a Community Services Card, or

Live in a quintile 5 area, or

Are at high risk of unplanned pregnancy and poor health and social outcomes – for example due to factors such as mental health, or alcohol or other drug use.

Nelson Marlborough

Women who hold a Community Services Card,

Women who live in Quintile 5 areas,

Māori and Pacific women

West Coast

The DHB funds the West Coast Primary Health Organisation to deliver free LARC insertion and removal via general practice. The West Coast PHO enables all people under 25 years to receive free contraception.

For women over 25, the insertion and removal of LARC devices is funded if they meet the following criteria:

Live in a quintile 5 area, or

Hold a Community Services Card, or

Are at high risk of unplanned pregnancy or poor health and social outcomes, such as: Māori or Pacific, disability service users, are in Oranga Tamariki residential or foster care, are users of community alcohol and drug services, are users of residential or community mental health services, are high users of maternity services, with exceptions on a case-by-case basis.

Canterbury

Women, transgender men and non-binary people who have a uterus who:

Hold a Community Services Card, or

Are under 18, or

Live in a quintile 5 area, or

Identify as Māori or Pacific, or

Are alcohol or illicit drug dependent, or

Are a high user of maternity services or have a history of termination of pregnancy, unplanned pregnancy or miscarriage in the last 5 years, or

Has a current active long term severe mental health disorder, including any psychotic disorder, bipolar affective disorder, severe depression.

South Canterbury

Women aged 15-44 who:

Live in a quintile 5 area, or

Hold a Community Services Card, or

Are at high risk of unplanned pregnancy and poor health and social outcomes.

Southern

Insertions are funded for Māori, Pacific Island, and quintile 5 patients aged under 45, or Community Service Card holders aged under 45.

Removals are funded for any patient who had their insertion done under our programme regardless of age at time of removal (i.e can be over 45.)

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