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Sexual and reproductive health services in New Zealand primary care settings: A mixed-methods survey

Orna McGinn

Corresponding Author

Orna McGinn

Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand

Correspondence: Dr Orna McGinn, Primary Care Women's Health, University of Auckland, Auckland, New Zealand. Email: [email protected]Search for more papers by this author
Michelle Wise

Michelle Wise

Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand

Search for more papers by this author
First published: 11 January 2024

Conflict of Interest: The authors report no conflicts of interest.

Abstract

Background

New Zealand's recently released Women's Health Strategy aims to provide accessible, equitable care which prioritises prevention, early intervention and areas of unmet need. An example of such care is the management of common sexual and reproductive health (SRH) issues by appropriately trained primary care practitioners in the community.

Aims

The aim was to identify primary care SRH program initiatives currently operating in New Zealand, how they are accessed and funded, whether they have been co-designed using mātauranga (knowledge) Māori principles and whether any have undergone formal evaluation.

Methods

A mixed-methods electronic anonymous survey of primary care practitioners and secondary care obstetrics and gynaecology clinical directors was distributed in April 2023. Qualitative analysis of free text answers was undertaken.

Results

Few funded SRH services are available in community settings in New Zealand. Access and eligibility criteria to those which exist varies by region. A lack of co-design and governance was reported, along with difficulties in access to skills training and specialist advice.

Conclusions

The current SRH landscape in New Zealand appears fragmented and lacks an overarching strategic focus. To achieve the aims of the Women's Health Strategy, a suite of core community-based SRH programs should be developed and formally evaluated, focusing on equitable access, integration and specific outcomes. These should be co-designed using mātaurangi Māori principles.

INTRODUCTION

Women's health has recently been identified as a priority area in New Zealand, with the release of New Zealand's first Women's Health Strategy in July 2023. Lack of investment in primary care management of common treatable sexual and reproductive health (SRH) issues affecting women/wāhine creates a burden on secondary care gynaecology services, capacity in which is currently limited. The assessment and management of many of these conditions such as abnormal uterine bleeding (AUB) require practical skills, training for which can be difficult to access.1 This combination of circumstances leads to long waiting times for assessment and may result in delayed diagnosis of serious conditions.2 Throughout this paper we refer to SRH as encompassing mainly contraception, menopause and menstrual disorders.

Different regions of New Zealand have responded to these challenges in a variety of ways, such as developing integrated care pathways and enabling general practitioners and other primary care providers such as nurse practitioners, to manage certain conditions in the community with a ‘best for patient, best for system’ approach.3

The aims of this study were to identify inequities in access to SRH in primary care in New Zealand and the contributory factors to these, to assess whether primary care providers can access specialist support when providing these services and to assess respondents' attitudes as to whether primary care providers could take on more of these services in the community.

MATERIALS AND METHODS

Ethics approval was granted by the Auckland Health Research Ethics Committee on 1 December 2021 for a period of three years, reference number AH23486.

A mixed-methods 17-question survey of health practitioners was developed. The questions consisted of multiple-choice, dichotomous (yes/no) questions and open-ended questions allowing free text, giving the study both quantitative and qualitative elements. The draft survey was reviewed by a panel of primary care leads from General Practice NZ, which represents 23 of the 30 New Zealand primary health organisations (PHOs). The panel's feedback was incorporated. There was no formal pilot of the survey.

The survey (see Table S1) was hosted on Qualtrics, a secure platform. The answers were visible only to the researcher and supervisor, and responses could be identified only by region. Respondents were sent an explanatory participant information sheet. Consent was implied by completion of the survey.

The respondents were selected by purposeful sampling, to cover both primary/community and secondary care. There are 30 PHOs and 20 district hospitals with obstetrics and gynaecology departments: whereas each geographical region has one district hospital, some regions include more than one PHO. The survey was sent to each PHO clinical director (primary care) and district hospital clinical director of obstetrics and gynaecology (secondary care). ‘Snowballing’ was also used: respondents recommended others to whom the survey was sent, thus increasing the number of respondents.

Qualitative analysis of free text answers used thematic analysis.4 Comments were collated and coded to develop categories and themes. As part of the survey, respondents were asked whether their region had a publicly funded SRH clinic to which GPs (general practitioners) could refer. This was defined as a clinic seeing patients and offering advice on complex contraception, menopause, dyspareunia and sexual dysfunction, separate from sexual health (sexually transmitted infection). ‘Yes’ answers were then cross-checked with the district hospital obstetrics and gynaecology clinical director.

The second part of the survey focused on availability of funded women's health services in the community. Answers were analysed by region to determine where specific services were present or absent.

RESULTS

The survey was distributed to 20 obstetrics and gynaecology clinical directors, of whom 16 responded. There were a further 53 primary care–based respondents (a group of GPs and nurses). All regions were represented. Of the 73 total respondents, not all completed all questions.

Inequities in access to care

Of 42 respondents, 33 considered that inequities existed in access to women's health services in their region. The most common example of inequity cited was transport to and distance from services.

Rural women are expected to travel to specialist services. Telehealth opportunities for access are limited.

The next most common inequity identified was lack of access to a GP:

GPs act as gatekeepers to accessing secondary care, but women are not being referred if they cannot register with a GP (lack of GPs in community), [or] do not attend GPs (GP fees are a barrier and in smaller communities there is no choice of GPs, and women can't choose a GP they feel comfortable [with]).

Other examples of inequities included access to funded community imaging and the cost of services such as long-acting reversible contraception (LARC) insertion and ring pessary placement in the community:

There are multiple options for primary care provided services to manage abnormal uterine bleeding and pessary management, but this is not funded or only partially funded. Any women unable to pay the primary care costs will need referral to secondary care but the current wait time is over a year. This leads to inequities in accessing care in a timely fashion for anyone not able to self-fund what is provided for free in secondary [care].

Two respondents stated that services were not provided in a way which engaged Māori wāhine due to factors such as a lack of flexibility and a system which has ‘structural and cultural elements that embed institutional racism resulting in higher “DNA” [did not attend] rates for Māori’.

Support for primary care provision of women's health services

When specialist advice is required for sexual and reproductive health issues such as complex contraception provision or management of menopause, there are a few clear pathways. Where then can GPs turn for advice? Almost all respondents suggested referral to a gynaecology clinic (see Fig. 1). Fourteen respondents (34%) covering 13 of the 20 regions identified local SRH expertise as sitting with GPs with special interests (GPwSI), and 50% recommended referral to a family planning clinic. Access issues with these options were mentioned:

GPwSI is private so patient has to pay.

Gynae clinic don't do menopause medicine. FPA [Family Planning Association] has a wait list 3–6 months long.

Details are in the caption following the image
Sources of advice for difficult sexual and reproductive health issues. DHB, District Health Board; GPwSI, general practitioner with special interest; SRH, sexual and reproductive Health.

It was identified that only two large urban centres in New Zealand currently have a publicly funded SRH clinic.

Availability of services in the community

All 20 regions reported availability of funded contraception counselling and LARC insertion in the community. Eight regions reported having a funded ring pessary scheme for management of prolapse and 10 regions for pipelle biopsy (endometrial sampling) in primary care; four funded a package of care for investigation and management of AUB (ultrasound scan, pipelle biopsy and Mirena intrauterine system (IUS) insertion if required). Where services exist, they may not be funded to a level where a GP can afford to provide them. One third of respondents answered that co-payments by patients were disallowed as part of the contracted terms of service. Where a co-payment was allowed, for example, for a funded contraception consultation, the maximum co-payment permitted was $5.

There has been a steady devolution of care into primary care with women's health services including pessary fits and pipelle biopsy as examples. These services will now be declined by secondary care and are expected to be done in primary care. Unfortunately funding has not followed.

Regarding eligibility criteria, three quarters of respondents reported being ‘unsure’ whether there were criteria or what they entailed. Where respondents were able to list eligibility criteria for funded access to services, these varied widely between regions and between different women's health services in the same region. Eligibility for funded contraception included:

Māori and Pacifica, gender diverse, CSC [Community Services Card], diagnosis of HIV/Syphilis, sexual assault, IV DU [intravenous drug user].

Māori, Pacific, disability service users, Oranga Tamariki residential or foster care, users of community alcohol and drug services, users of residential or community mental health services, high users of maternity services, exceptions on a case-by-case basis.

The target population is women aged 15 to 44 years who are at high risk of pregnancy, and who … have had a previous termination of pregnancy (TOP) in the last 5 years, or are under 30 years of age with more than 4 children, or have had a complex mental health or alcohol or other drug (AOD) diagnosis with medication any age.

Where training was required to offer funded services, four of 32 (12%) reported that it was easy to access.

None of the 73 respondents answered the question about a Kaupapa Māori co-design approach to any of the women's health services. Four respondents (5%) reported that evaluation of any local initiatives had taken place. Free text comments provided further insight into what was reported as part of these assessments including ‘utilisation rate analysis’ and ‘(the)programme has contracted oversite [sic] to report outcomes’. These appear to be key performance indicators rather than formal evaluations. One respondent reported being ‘specifically unsure of data around Māori access to services and equity assessments’.

Could primary care take on a larger role in provision of women's health services?

Half of respondents strongly agreed that primary care could take on a larger role in offering women's health services (see Fig. 2). Of those who strongly disagreed, the most common reasons given were regarding lack of capability rather than lack of interest.

Details are in the caption following the image
Role of primary care in women's health. AUB, abnormal uterine bleeding.
A total of 85% of 41 respondents identified a lack of funding as the main barrier to providing women's health services in primary care (see Fig. 3). Other barriers commonly cited were lack of access to training (73%), lack of time (73%) and too many other areas of practice to cover (63%).

At present, primary care clinicians in rural, underserved regions are extremely stretched and unlikely to upskill in women's health without additional funding, supports or incentives.

Details are in the caption following the image
Barriers to provision of women's health services in primary care.

The most cited enablers to provision of women's health services in primary care were funding (31 of 41 respondents) and training (17 of 41 respondents). Others were the creation of more GP to GP referral pathways, simplicity of contracting, upskilling nursing staff to offer procedures such as LARC and ‘a recognised (ideally funded) pathway to become a GP with extended range’.

If primary care practitioners are to offer extended SRH services in the community, they will require access to specialist advice and a seamless pathway of integration and referral. Almost all respondents stated that in their area, GPs would tend to seek SRH advice from the local general gynaecology clinic. However, referral criteria are such that these patients may not reach a threshold for acceptance, or there may be a delay as long as 12 months to be seen. As one clinical director commented,

We are struggling to provide general gynaecology clinics with [staff] shortages (really only seeing HSCANs [High Suspicion of Cancer] and possible cancer – [we] rarely accept a routine gynae problem).

DISCUSSION

A wide variation in access to funded sexual and reproductive healthcare exists across New Zealand. Provision appears to vary within as well as between regions, perpetuating a cycle of inequity of access which may impact particularly on populations such as rural women and wāhine Māori. Where services exist, co-design using tikanga (Māori customary) principles appears insufficient. This is a concern and suggests that Te Tiriti obligations may be unmet.

The survey suggests that a few regions have extended SRH services available in primary care. Where initiatives are running, many are reported to be disjointed rather than patient focused. For example, when investigating AUB, the investigation (endometrial biopsy) may be funded, but not the treatment option, the Mirena or levonorgestrel intrauterine system (LNG-IUS). In some areas the LNG-IUS is funded only for one of its indications (contraception) and not for others such as heavy menstrual bleeding or endometrial protection as part of a menopausal hormone therapy regime. This contrasts with the UK where contraception options are fully funded for all indications. British Columbia, with a population of approximately similar size to New Zealand (5.5 million), made similar provisions in April 2023.5 This followed the publication of a cost-effectiveness analysis, demonstrating that fully funding effective contraception would save the health system approximately C$27 million (NZD $33 million) per year.6

Half of respondents recommended Family Planning for patients who required SRH advice or management. As a not-for-profit charitable organisation, Family Planning sits outside the public health system. There are long-standing access barriers as many areas of New Zealand do not have such a clinic, and where clinics are operational, respondents report that wāhine currently experience wait lists of up to six months for LARC insertion.

An area which was not explored was the role of community sexual health clinics. There is a significant overlap between sexual health and SRH, and the funding arrangements for these clinics can present barriers for patients. For example, whereas treatment of sexually transmitted infection is ‘core business’, management of unprotected sexual intercourse with emergency contraception (eg, insertion of a copper intrauterine contraceptive device) at the same consultation may not be funded or may not be available due to lack of trained clinical staff. These clinics are a vital component of public health, but the fragmentation of services between what constitutes ‘sexual health’ and ‘SRH’ is not patient centred.

A surprising finding was that many regions were able to identify a local GPwSI who could provide advice or management regarding a complex SRH issue. These roles are not recognised by the Royal New Zealand College of General Practitioners, and there is no currently available framework of training, competency, credentialing or governance around these roles.

Finally, an assumption was made that the chosen sample population was best placed to answer these survey questions; in fact, gaps in knowledge were revealed in areas such as eligibility criteria for services, training requirements and how services are funded. This highlights the need for a transparent whole-of-system mapping of SRH services in the community. If senior clinicians and managers within primary and secondary care do not have knowledge of these basic services, it can be assumed that patients may too have difficulty navigating their way through the system.

This survey is timely, as it adds important information relevant to implementing the priority areas of New Zealand's Women's Health Strategy.7 Priority 1 states that a health system will be developed that ‘works for women, focusing on system level shifts & enablers’, whereas priority 2 is focused on ‘improving care for issues specific to women: a focus on sexual and reproductive health, pelvic and menstrual health’. A strength of this survey is that all regions were represented, and responses were gathered across the system (both primary and secondary care). However, there were a number of unknowns, with respondents being unable to give definitive answers to some questions. These may require further investigation.

Eligibility criteria in many areas appear stigmatising and at odds with the World Health Organisation framework for ensuring human rights in the provision of contraceptive information and services.8 This framework reiterates the evidence, demonstrating that ‘explicitly grounding SRH policies and programmes in a human rights framework improves people's access to information and services’. Current criteria may reinforce barriers for both clinicians (reluctance to ask invasive questions) and patients (reluctance to disclose stigmatising conditions or personal details). A key component of stigma is the exercise of power.9 In the case of women's health services provided in primary care settings, that power is currently demonstrated in the allocation or withholding of funding.

To meet the key objectives of New Zealand's new Women's Health Strategy, strategic leadership with an agreed approach to the configuration, funding and delivery of a suite of core women's health services in primary care is urgently required. Governance of existing primary care–based services requires strengthening: funded programs should be evaluated to ensure they meet the needs of patients, practitioners and the system as a whole, as without this data it is difficult to recommend scaling-up services.

We recommend that in the future services should be co-designed, consistently accessible and fully funded according to nationally agreed clinical indicators. Moreover, moving from a ‘deficit-based’ approach to a national women's health service grounded in a human rights framework will improve equity of access and enable reproductive autonomy, while meeting key Te Tiriti obligations.

ACKNOWLEDGEMENTS

The authors wish to acknowledge the support of the RANZCOG CD Network and the GPNZ Primary Care Clinical Leads group in distributing the survey and offering valuable assistance and feedback. Ngā mihi nui. Open access publishing facilitated by The University of Auckland, as part of the Wiley - The University of Auckland agreement via the Council of Australian University Librarians.