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NZ contraception - a scandal down under

A silent group of mostly brown, poor and obese women are going without a contraceptive device that could drastically improve the quality of their lives. Emma Espiner looks at a deadly inequity happening in our poorest communities.

Last week my cohort of medical students was told off for not being able to say the word vagina during a clinical exam. Some people were squeamish and talked about 'down below' which the examining obstetrics and gynaecology specialists took passionate exception to.

It was ironic for me, because one of the things my husband has least celebrated about my transition from normal person to medical student in the past five years has been my lack of boundaries around discussing health issues in social situations. I'm sure he would prefer I said the word vagina far less. At the very least he would prefer I kept it away from the dinner table.

Wait until you see this week’s column, I told him.

But it’s not funny at all when you realise that there is a deadly inequity happening in our poorest communities.

Our country prides itself on our progressive approach to women’s rights while a silent group of mostly brown, poor and obese women go without a safe, effective contraceptive device that could drastically improve the quality of their lives. For some, it could even prevent cancer.

The device is the Mirena. It is as effective at preventing unwanted pregnancy as invasive surgical procedures like tubal ligation or vasectomy but it is easily reversible. It treats heavy menstrual bleeding and reduces the thickness of the lining of the uterus, preventing a condition called endometrial hyperplasia which is a precursor to endometrial cancer. Incidentally, rates of endometrial cancer in New Zealand are rising the fastest among young Pasifika women.

This is before you even begin to explore the benefits to women from gaining control of their reproductive capacity. Countless studies globally have proven the benefits to entire communities when women are empowered to plan their families. Downstream effects of universal access to safe, affordable and effective contraception include increased access to education, better job prospects and improved health indicators across every measurable facet of wellbeing.

We’re effectively rationing contraception by offering Mirena to people who can afford it, rather than the people who need it.

In 2016, the Royal New Zealand College of General Practitioners (RNZCGP) made an application to Pharmac to fund Mirena. Normally the preserve of drug companies, the College felt so strongly about access to this device that they took the unusual step of applying directly to Pharmac for the first time in the College’s history. This is on a background of more than 20 years of health practitioners urging the drug-buying agency to fully fund Mirena.

In 2018, Pharmac recommended funding Mirena with high priority for three purposes: contraception, heavy menstrual bleeding and endometriosis. But since this recommendation was made, there has been no movement. Health practitioners are so concerned about this unexplained loss of momentum that a petition was presented to Parliament last month in the name of Auckland GP Dr Orna McGinn, urging parliamentarians to force action on the issue.

Here in New Zealand, you have two options to get the Mirena - you can be wealthy enough to afford the device which costs up to $500 (plus the insertion fee) or you can meet a strict set of criteria proving you have heavy menstrual bleeding or surgically confirmed (they look at your insides with a camera) endometriosis severe enough to warrant the health system shelling out.

Bizarrely, the criteria applied by our health system is unique to New Zealand. The ‘evidence-based’ approach - which we’re told is sacrosanct in the decision-making process undertaken by Pharmac - isn’t used anywhere else in the world, and is not, according to Dr McGinn when I spoke to her earlier this week, valid nor equitable.

“Coming from the UK where all contraception including Mirena is fully funded, with the sole prescribing criteria being that a woman wants it and it is a suitable method for her, it was quite odd for me to see the process women have to undertake to qualify for Mirena to be funded in New Zealand,” McGinn said.

She says we’re effectively rationing contraception by offering Mirena to people who can afford it, rather than the people who need it. This is the inverse care law in practice - the most healthcare goes to those who least need it.

I also need to point out that ‘heavy menstrual bleeding’ isn’t code for ‘a slight bother’ or ‘women’s issues’ - it can be utterly debilitating and even life-threatening for some women. I challenge anyone to carry on with a normal life when you’re changing your soaked tampon or pad hourly, fatigued from anaemia induced by the chronic blood loss, worried about staining your clothes, the seats on the train, ruining your sheets.

Until all women in New Zealand - regardless of the colour of their skin, the amount of money in their bank account or their BMI - have access to safe, effective, affordable contraception, our national belief in our progressive approach to women’s rights is simply a fiction.

McGinn and the signatories to the petition believe that not only could Mirena relieve the suffering of high-needs (and, apparently ‘high-priority’ for this Government) groups like Māori and Pasifika women, it could also reduce our rates of teenage pregnancy, abortions and miscarriages. Because Mirena often causes women’s periods to cease altogether, it would also contribute to alleviating period poverty.

And it’s cost effective for the health budget - guidelines in the UK found these devices were more cost-effective than the oral contraceptive pill.

Speaking of the oral contraceptive pill, I can hear some of you thinking 'Don’t we have other contraceptives available?'. Yes. In New Zealand we have other funded options including the oral contraceptive pill, the Jadelle (a hormonal contraceptive device that comprises two plastic rods which sit just below the skin on your upper arm), a copper intrauterine device, hormonal injections and barrier contraception like condoms.

Unfortunately, none of those options are quite as good as Mirena for the subset of women who really need it. The most stark reason is the higher risk of endometrial cancer experienced by women with increased body mass index (BMI). Jadelle is often recommended as a viable alternative to Mirena. There is concern regarding contraceptive efficacy in women over 60kg in weight with Jadelle, but the main issue with this method is bleeding. Irregular bleeding is the most common reason for women to have Jadelle removed, compared with much higher satisfaction rates with Mirena – meaning they’re more likely to stick with it.

One of the best parts of undertaking an obstetrics and gynaecology rotation as a student is meeting the different groups of health practitioners united by the common cause of advocacy for women. I spoke to midwife Adrienne (Ady) Priday - a midwife in South Auckland and co-chair for the College of Midwives for the Greater Auckland Region - who epitomises the advocacy I’ve come to expect in this field.

“I was brought up in provincial New Zealand and I know poverty. I also know that education and empowering women can get entire families out of poverty." - Midwife Adrienne (Ady) Priday

When I asked why she had worked for more than 20 years in one of our most high-needs communities she told me: “I was brought up in provincial New Zealand and I know poverty. I also know that education and empowering women can get entire families out of poverty. I need to give to these families because I know I can help.”

Most of the women Ady cares for have a BMI over 40 (‘healthy’ is 18-24.9 and yes there’s a debate to be had about the legitimacy of BMI as an indicator of health but that’s another column) and she would love to be able to offer them Mirena. “Grand multips [women who have had more than five children] are more likely to experience heavy menstrual bleeding. Eight to nine children is the average number of children per woman among my repeat clients so I know what I’m talking about."

She went on to tell me sternly: “If I know a woman is being disrespected by a service that has been set up for them, that service will hear from me. I’m quite well-known in the Counties Manukau DHB.” I’m happy to take her at her word, and quietly hope never to be on the receiving end.

Asked why she wants to be able to offer the Mirena to her patients, she told me it came down to three things: "It works, it’s convenient and it’s acceptable to the women." In the health sector, we say something is ‘acceptable’ to a patient and that’s code for - they’ll take the pill, or use the cream, or wear the device. No point having a range of options that nobody wants to use.

Until all women in New Zealand - regardless of the colour of their skin, the amount of money in their bank account or their BMI - have access to safe, effective, affordable contraception, our national belief in our progressive approach to women’s rights is simply a fiction.

A note to readers: I haven’t been paid by ‘Big Pharma' to write this column. Feel free to dislike or disagree with this content, but you won’t be able to do so on the basis that I’m compromised by some sort of conspiracy involving the pharmaceutical industry.

Editors note: Since publication Pharmac announced the Merina and Jaydess will be fully funded without any restrictions from 1 November 2019.