Access to intrauterine contraceptives in the Southern District Health Board catchment
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Ensuring access to preferred contraceptive methods is a vital part of any healthcare service. Effective family planning is essential to the wellbeing and autonomy of women, allowing them to choose to have their children when they are physically, psychologically and economically ready.1,2 The development of highly effective, long-acting reversible contraceptives (LARC) has had a marked impact on family planning. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recommends LARC as a first-line method for their excellent efficacy, acceptability, cost-effectiveness and reversibility.3 In New Zealand, increased uptake of the copper intrauterine device (IUD), Mirena intrauterine system and Jadelle implant has been significantly associated with a declining abortion rate, particularly among younger women.4 Nevertheless, a 2013–2015 survey found LARC were still less commonly used than condoms and the oral contraceptive pill.5
The decision by PHARMAC in October 2019 to widen access to levonorgestrel intrauterine systems (LIUS) by funding the Mirena and Jaydess without restriction followed sustained advocacy from many dedicated people.6 Despite reduced cost to patients of these LIUS, barriers to uptake persist. Barriers include misperceptions about LARC from both patients and clinicians,7 lack of training of healthcare providers, lack of funding for primary carers for contraceptive procedures, and cost to the patient.8
IUD and LIUS differ from other contraceptives such as the oral contraceptive pill or condoms in two key respects. First, although in New Zealand there is no accredited training scheme for practitioners (unlike in other comparable countries such as the UK), and no system to ensure minimum standards of competency,8 not all general practitioners (GP) have the facilities or willingness to insert these devices, so people may have to travel further than their closest GP to obtain this service. Second, insertion of these devices often requires two or three separate appointments in close succession: a pre-insertion consultation, the insertion and sometimes a follow-up appointment. This presents a potentially insurmountable logistical and financial challenge to women who lack independent transport, may already be caring for small children, struggle to arrange time off work, or live far from an appropriate provider. This challenge is compounded for people living in socioeconomic deprivation—disproportionately Māori and Pacific populations—for whom cost is already a recognised barrier to LARC access.9
The problem in New Zealand is twofold. For one, there is no single authoritative resource that lists and locates providers that can insert IUD or LIUS. This makes it impossible to know how far patients are having to travel to access these effective methods of contraception. Second, as only the device and not the insertion is funded, the costs to patients are unknown.
This descriptive study therefore sought to identify, survey and locate all potential providers of IUD or LIUS within the Southern District Health Board (SDHB) catchment area, and apply spatial analysis using a geographical information system (GIS) to explore to what extent cost and distance to nearest provider may still affect accessibility to intrauterine contraceptive devices.
Methods
Data collection
Using the HealthLink EDI Account Directory for Otago, Southland, Timaru and Oamaru,10 and on the advice of individuals working within the gynaecological and sexual health services, all the potential providers of IUD/LIUS within the SDHB catchment were identified.
Table 1: Potential providers of IUD/LIUS within the SDHB catchment.
Physical locations and e-mail addresses were found online for as many of these practices and clinics as possible. A short survey developed on the Qualtrics software was sent to these e-mail addresses with unique links for each practice. If respondents did not complete the survey within two weeks, a reminder was sent, after which the outstanding respondents were contacted by phone and/or e-mail to ask the survey questions directly. General practices with no e-mail address were asked the survey questions by phone. Information from providers other than general practices was obtained by e-mail correspondence. Data were collected during December 2019 and January 2020.
Survey questions are presented in Table 2.
Table 2: Survey results.
Ethics approval for data collection was granted by the University of Otago Human Ethics Committee (reference D19/381).
Data preparation
Prior to spatial analysis, population, provider and road network data were collated, collected and prepared. Within the SDHB catchment area, Māori and general electoral population data—hereafter referred to as the Māori and general populations respectively—were obtained from Statistics NZ at the meshblock level,11 the smallest geographic unit for which data is reported by this organisation. Publicly available data on New Zealand deprivation level (NZDep2018) by meshblock were also obtained.12
Meshblocks each enclose a similar number of people, and therefore vary enormously in size from small city blocks to large tracts of rural land. Using generalised population data at this level can greatly distort calculations of distance to a nearest provider. While populations can reasonably be assumed to be distributed throughout a central city meshblock, in rural areas they are likely clustered in only a small portion of the total meshblock area. This is a common artefact in situations where single values purport to represent an entire area (ecological fallacy).13 Therefore, to better approximate the actual geographical distribution of population, the general and Māori populations in each meshblock were distributed evenly to each address point within that meshblock in a process known as dasymetric mapping.14
The obtained addresses of all potential providers were geolocated by matching them with attributes attached to address point data (source: Land Information New Zealand (LINZ)15) in a geocoding process. Where addresses could not be identified, the nearest neighbouring address point was chosen for spatial analytical purposes. Access to facilities by the population was calculated using a roads dataset acquired from LINZ,16 which was converted using the GIS into a connected network capable of calculating specific distances from the providers.
Spatial analysis
Service areas covering parts of the road network that were within 5km, 20km and 50km of travel along the road network were calculated for each provider able to insert an IUD and/or LIUS. Using the refined estimate of spatial population distribution as described previously, the populations within each of these zones were calculated by summating the population attributed to the address points within that zone. Each point was also given the NZDep2018 score of the meshblock in which it fell,12 thus the mean deprivation level of address points in each of these service area zones was also able to be calculated.
All spatial data preparation and spatial analysis stages were carried out using ArcGIS 10.6.1 software at the School of Surveying, University of Otago.
Results
Survey results
Of the 86 potential primary IUD/LIUS providers in the SDHB catchment, complete answers were obtained from 77 providers (89.5%). The remaining nine practices indicated that they did provide either IUD or LIUS insertion but were unwilling (one practice) or unable to provide further details (eight practices). Thus 86/86 (100%) of potential primary IUD/LIUS providers in the SDHB catchment provided enough information for the intended spatial analysis to be carried out. This excludes the two regional gynaecology outpatient clinics, which differ from the other providers in that they are not able to be directly accessed by patients but instead require a referral process (ie, they are secondary providers). Results of the survey are summarised in Table 2.
Network analysis
The spatial distribution of current primary providers of IUD/LIUS within the SDHB catchment is wide. This is reinforced by the service areas created, which show that much of the road network is within 50km of such providers. However, significant areas remain more than 50km away, symbolised in red in Figure 1.
Figure 1: Service areas of (a) current primary providers and (b) potential primary providers, if all primary services were able to provide IUD/LIUS. Address and road data from LINZ.15,16 SDHB outline data from Statistics NZ.17
In the hypothetical scenario where every primary practice in the SDHB catchment was able to provide IUD/LIUS, the network analysis showed improved coverage, particularly in the areas between Invercargill and Owaka, and to the west of Dunedin. Notably, the area northwest of Kurow remained isolated in this scenario.
Populations within service areas
71.3% of the general population and 79.4% of the Māori population were estimated to live within 5km of a current primary provider. This would increase to 75.2% and 85.9% respectively if every primary practice in the catchment was an IUD/LIUS provider. A further breakdown of these results is shown in Figure 2 and Table 3 below.
Figure 2: Percentage of population within service areas of current primary providers.
Table 3: Population within service areas of current primary providers (current) and if all primary services were able to provide IUD/LIUS (potential).
NZDep2018 scores for service areas
In neither the current nor the hypothetical case was there an observable trend in mean NZDep2018 scores of addresses within each of the service areas from closest to farthest.
Table 4: Mean NZDep2018 scores for service areas.
Discussion
Cost and travel time are likely still barriers
The results of the spatial analysis in this study must be considered highly optimistic in that they allocate patients to the nearest possible provider without any regard for what patients can afford or where they are enrolled, which is almost certainly not the case in reality. A further simplification is that no provision is made for the temporal accessibility of services. Many current primary providers have very limited hours, eg, the sexual health clinic in Gore operates one day a month, and many GPs doing insertions work part time.
With these simplifications in mind, this study supports the finding in another recent qualitative study that cost is likely still a barrier.8 Even with the changes in funding for the Mirena and Jaydess, the median insertion cost is $115 with the maximum more than twice this amount at $270, excluding the cost of two or three GP visits. These costs are comparable to, if not in excess of, the estimate of $150 from a recent study.8 GPs in that study described such costs as forcing them to redirect patients, particularly those in rural areas, to cheaper services, often some distance away.8
For some rural populations, the distance to their nearest provider as estimated in this analysis contribute further to the cost. It is encouraging that a large majority of people live within 5km of a current provider (71.3% of the general population, 79.4% of the Māori population). Nonetheless, there remain a significant number of people who need to travel at least 5km to their nearest possible provider, with some needing to travel more than 50km. Using the Inland Revenue Department’s 2019 mileage rate of $0.79/km, return journeys to three appointments would cost between $23.70 and $237.00 for patients 5km and 50km away respectively.
The number of providers requiring two (pre-insertion and insertion) and three (additional check-up) appointments were roughly equal. This division is interesting, given that both are rooted in the same current RANZCOG guidelines. On the subject of pre-insertion appointments/tests, the guidelines state that for women at high risk of having a sexually transmitted infection (STI):
“Ideally [STI screening] results should be available prior to IUC insertion. However, in asymptomatic women there is no need to wait for the screening results, nor provide antibiotic prophylaxis, providing the woman can be contacted and treated if a positive result is found.”3
Regarding post-insertion follow up appointments, they state:
“A follow-up visit at 3–6 weeks may be undertaken to exclude infection, perforation or expulsion. More importantly, the patient should also be advised to present if abnormal bleeding, or symptoms suggestive of infection or pregnancy occur, or if they are unable to locate the string of the device.”3
Thus, for low risk and asymptomatic high-risk women, there is no need to have STI screening results available prior to insertion. Furthermore, it is more important to advise patients of symptoms that might require follow up than require them to attend a compulsory follow-up visit. It therefore appears that there is potential for the number of appointments required by some practices to be reduced, which would further reduce monetary and time costs to patients for whom these may be decision-making factors.
The finding of no simple correlation between distance to nearest provider and NZDep2018 should not be simplistically interpreted as distance not being a barrier for low-income patients. As noted previously, the aggregation of statistical data into meshblocks can introduce an ecological fallacy whereby small pockets of low-income populations are obscured by larger, wealthier areas. It would be more accurate to say that distance and travel time are not the only factors in determining how accessible an IUD or LIUS is for a given person living in a high-deprivation area, but these would certainly be contributing factors.
Increasing the number of providers
Operating under the assumption of people travelling to their nearest provider, the hypothetical scenario in which all general practices were able to insert IUD/LIUS would result in better coverage. The benefits would be relatively greater for the Māori population than the general population when calculating the number of people who would reside within 5km service area of a provider. Anecdotally, it would seem that increasing the number of healthcare professionals able to do insertions would be valuable; many practices spoken to were clear that they were stretched to the limit and were not enrolling new patients, while others who did not insert IUD or LIUS described months-long waiting lists at services to which they referred their patients. With 42 out of 48 providers having only GPs able to do insertions, nurse practitioners and clinical nurse specialists would seem to be a potentially underutilised resource. However, increasing the numbers of providers, and enabling them to perform enough procedures to maintain competence is not without its own challenges.8 The problems of accessibility of IUD/LIUS for patients and of getting enough procedures for inserters to maintain competence are mutually dependent.
Mobile services for rural populations
SDHB is a challenging catchment to provide services for, given the large and unevenly populated area it encompasses. While populations are concentrated in urban centres, 24.2% of the general population is spread over very low-density meshblocks comprising 99.7% of the area of all inhabited meshblocks (Appendix Table 1). In this catchment, Māori are more urban than the general population, but the proportion of this population in very low-density meshblocks is still sizeable at 11.6% (Appendix Table 1). Thus, the population in low-density areas cannot be ignored in service planning.
It is not the intention of this descriptive study to offer solutions to the challenges of contraceptive provision in the SDHB catchment. Nonetheless, the geographical challenge of a thinly distributed population lends itself to the consideration of a mobile service as a cost-effective solution, and during the course of the study, it was found that Te Waka Wahine Hauora/The Woman’s Health Bus has recently been established to provide precisely this. Further geographical analysis could optimise routes for such a service.
Limitations and strengths of the study
This study has several caveats. The electoral populations used are calculated estimates. Statistics NZ suppresses information on meshblocks with fewer than six inhabitants for privacy reasons. The dasymetric mapping used to distribute the populations of meshblocks to address points is a better estimate of reality than simply using meshblocks to estimate population distribution, but it remains a simplification nonetheless. As many rural address points are likely to be uninhabited tracts of land, it is likely that this technique overestimates the population in very remote areas. However, the use of broad service area bands ameliorates this to some extent—this study does not attempt to calculate precise distances to nearest provider for each address point, it merely groups address points and their corresponding inhabitants into a distance zone. Edge effects may be impacting the analysis along the northern border of the SDHB catchment. As Canterbury providers are not modelled, some of the parts of the network identified as >50km from a current SDHB provider may in fact be within close range of a Canterbury provider.
As described, complete results were not obtained for all current primary providers. It is possible that there are outliers in terms of cost, but they are unlikely to greatly change the median cost estimate, and the findings from this study support those of others.8 Also, this analysis assumes people travel to their nearest provider regardless of cost and enrolment, resulting in an over-optimistic estimate of access.
The fact that 100% of potential IUD/LIUS providers in the area provided sufficient information for the spatial analysis (ie, answered whether or not they provided IUD/LIUS insertion) is a particular strength of this study, and thus the spatial distribution of current primary providers can be considered an accurate snapshot at this period of time.
As this study only considers the SDHB catchment, it is unable to draw conclusions about the situation in other areas of the country. There is potential for this approach to be scaled up to a nation-wide level to address this.
Conclusion
While widening funding for the Mirena and Jaydess has been a welcome development, this paper indicates that there are populations in the SDHB catchment for whom distance and cost remain potential barriers to accessing an IUD/LIUS. A combination of increased funding for community insertion of IUD/LIUS, improved training opportunities for both medical and nursing staff, minimising the number of appointments required by providers, and optimised mobile services would improve access for people in this region to some of the most cost-effective and acceptable contraceptives available. With all the physical, social, economic and financial benefits that effective family planning confers to individuals and communities, this is arguably a public health priority.
Appendix
Appendix Table 1: Meshblocks (MB) grouped by general and Māori population density percentiles, with corresponding populations and land areas. Population data from Statistics NZ.11
Summary
Abstract
Aim
Recent changes in funding have reduced the cost of the highly effective levonorgestrel-releasing intrauterine system (LIUS) contraceptives (Mirena and Jaydess). This paper explores equity of access to intrauterine contraceptives for Māori and the general population by locating and surveying all potential providers within the Southern District Health Board catchment area.
Method
Using online survey, e-mail or phone, we asked if intrauterine contraceptive insertion was provided, what device was provided, cost and number of appointments required. ArcGIS 10.6.1 software was used to estimate population distribution, and to create service areas showing distance to nearest current providers for Māori and the general population.
Results
All 88 potential providers agreed to participate; two thirds (66.3%) provided some intrauterine contraceptive insertion. Approximately three quarters of the Māori and general population live within 5km of a primary provider. Costs ranged from $0 to $270, in addition to the cost of the required consultations. Number of consultations required varied from one to three.
Conclusion
Cost and travel time likely remain barriers to accessing intrauterine contraceptives for a significant population within this catchment. Increasing the capacity for all primary providers to offer insertion, funding the insertion process, minimising the number of appointments required and providing mobile services would improve access.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1. Starbird E, Norton M, Marcus R. Investing in Family Planning: Key to Achieving the Sustainable Development Goals. Glob Health Sci Pract. 2016; 4:191–210.
2. Naik R and Smith R. 2015. Impacts of family planning on nutrition. Washington, DC: Futures Group, Health Policy Project.
3. RANZCOG. Intrauterine contraception. 2017. Retrieved 28/11/2019 from www.ranzcog.edu.au
4. Whitley C. Improved access to long-acting reversible contraception (LARC) and the declining abortion rate (Thesis, Master of Public Health). University of Otago. 2018. Retrieved 2/12/2019 from http://hdl.handle.net/10523/7935
5. Chesang J, Richardson A, Potter J, Coope P. Prevalence of contraceptive use in New Zealand women. N Z Med J. 2016; 129:58–67.
6. PHARMAC. Decision to widen access to levonorgestrel intrauterine (LIUS) systems (Mirena and Jaydess). 2019. Retrieved 4/2/2020 from http://www.pharmac.govt.nz/news/notification-2019-10-14-lius-mirena-jaydess/
7. Mazza D, Bateson D, Frearson M, et al. Current barriers and potential strategies to increase the use of long-acting reversible contraception (LARC) to reduce the rate of unintended pregnancies in Australia: An expert roundtable discussion. Aust N Z J Obstet Gynaecol. 2017; 57:206–212.
8. McGinn O, Fulcher HJ, Arroll B, McCowan L. Barriers to the prescription of LARCs in general practice in New Zealand – a qualitative research study. N Z Med J. 2019; 132:63–69.
9. Murray C, Roke C. Who can afford a Mirena® for contraception? J Prim Health Care. 2018; 10:201–206.
10. EDI Account Guide – Otago, Southland Timaru & Oamaru. 2019. Retrieved 27/11/2019 from http://nz.healthlink.net/knowledge-base/edi-guides/
11. Statistics NZ. Meshblock electoral populations 2020. 2019. Retrieved 10/1/2020 from http://datafinder.stats.govt.nz/layer/104209-meshblock-electoral-populations-2020/
12. Salmond C, Crampton P, Sutton F, Atkinson J. Socioeconomic Deprivation Indexes: NZDep and NZiDep, Department of Public Health. 2018. Retrieved 11/2/2020 from http://www.otago.ac.nz/wellington/departments/publichealth/research/hirp/otago020194.html#2018
13. Longley P, Goodchild M, Maguire D, Rhind D. Geographic Information Science and Systems (4th ed.). 2015; New York: Wiley.
14. Zandbergen PA. Dasymetric mapping using high resolution address point datasets. Transactions in GIS.15:5–27.
15. Land Information New Zealand. NZ Street Address. 2019. Retrieved 12/12/2019 from http://data.linz.govt.nz/layer/3353
16. Land information New Zealand. NZ Road Centrelines (Topo, 1:50k). 2020. Retrieved 7/2/2020 from http://data.linz.govt.nz/layer/50329-nz-road-centrelines-topo-150k/
17. Statistics NZ. District Health Board 2015. 2015. Retrieved 12/12/2019 from http://datafinder.stats.govt.nz/layer/87883-district-health-board-2015/
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Access to intrauterine contraceptives in the Southern District Health Board catchment
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Ensuring access to preferred contraceptive methods is a vital part of any healthcare service. Effective family planning is essential to the wellbeing and autonomy of women, allowing them to choose to have their children when they are physically, psychologically and economically ready.1,2 The development of highly effective, long-acting reversible contraceptives (LARC) has had a marked impact on family planning. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recommends LARC as a first-line method for their excellent efficacy, acceptability, cost-effectiveness and reversibility.3 In New Zealand, increased uptake of the copper intrauterine device (IUD), Mirena intrauterine system and Jadelle implant has been significantly associated with a declining abortion rate, particularly among younger women.4 Nevertheless, a 2013–2015 survey found LARC were still less commonly used than condoms and the oral contraceptive pill.5
The decision by PHARMAC in October 2019 to widen access to levonorgestrel intrauterine systems (LIUS) by funding the Mirena and Jaydess without restriction followed sustained advocacy from many dedicated people.6 Despite reduced cost to patients of these LIUS, barriers to uptake persist. Barriers include misperceptions about LARC from both patients and clinicians,7 lack of training of healthcare providers, lack of funding for primary carers for contraceptive procedures, and cost to the patient.8
IUD and LIUS differ from other contraceptives such as the oral contraceptive pill or condoms in two key respects. First, although in New Zealand there is no accredited training scheme for practitioners (unlike in other comparable countries such as the UK), and no system to ensure minimum standards of competency,8 not all general practitioners (GP) have the facilities or willingness to insert these devices, so people may have to travel further than their closest GP to obtain this service. Second, insertion of these devices often requires two or three separate appointments in close succession: a pre-insertion consultation, the insertion and sometimes a follow-up appointment. This presents a potentially insurmountable logistical and financial challenge to women who lack independent transport, may already be caring for small children, struggle to arrange time off work, or live far from an appropriate provider. This challenge is compounded for people living in socioeconomic deprivation—disproportionately Māori and Pacific populations—for whom cost is already a recognised barrier to LARC access.9
The problem in New Zealand is twofold. For one, there is no single authoritative resource that lists and locates providers that can insert IUD or LIUS. This makes it impossible to know how far patients are having to travel to access these effective methods of contraception. Second, as only the device and not the insertion is funded, the costs to patients are unknown.
This descriptive study therefore sought to identify, survey and locate all potential providers of IUD or LIUS within the Southern District Health Board (SDHB) catchment area, and apply spatial analysis using a geographical information system (GIS) to explore to what extent cost and distance to nearest provider may still affect accessibility to intrauterine contraceptive devices.
Methods
Data collection
Using the HealthLink EDI Account Directory for Otago, Southland, Timaru and Oamaru,10 and on the advice of individuals working within the gynaecological and sexual health services, all the potential providers of IUD/LIUS within the SDHB catchment were identified.
Table 1: Potential providers of IUD/LIUS within the SDHB catchment.
Physical locations and e-mail addresses were found online for as many of these practices and clinics as possible. A short survey developed on the Qualtrics software was sent to these e-mail addresses with unique links for each practice. If respondents did not complete the survey within two weeks, a reminder was sent, after which the outstanding respondents were contacted by phone and/or e-mail to ask the survey questions directly. General practices with no e-mail address were asked the survey questions by phone. Information from providers other than general practices was obtained by e-mail correspondence. Data were collected during December 2019 and January 2020.
Survey questions are presented in Table 2.
Table 2: Survey results.
Ethics approval for data collection was granted by the University of Otago Human Ethics Committee (reference D19/381).
Data preparation
Prior to spatial analysis, population, provider and road network data were collated, collected and prepared. Within the SDHB catchment area, Māori and general electoral population data—hereafter referred to as the Māori and general populations respectively—were obtained from Statistics NZ at the meshblock level,11 the smallest geographic unit for which data is reported by this organisation. Publicly available data on New Zealand deprivation level (NZDep2018) by meshblock were also obtained.12
Meshblocks each enclose a similar number of people, and therefore vary enormously in size from small city blocks to large tracts of rural land. Using generalised population data at this level can greatly distort calculations of distance to a nearest provider. While populations can reasonably be assumed to be distributed throughout a central city meshblock, in rural areas they are likely clustered in only a small portion of the total meshblock area. This is a common artefact in situations where single values purport to represent an entire area (ecological fallacy).13 Therefore, to better approximate the actual geographical distribution of population, the general and Māori populations in each meshblock were distributed evenly to each address point within that meshblock in a process known as dasymetric mapping.14
The obtained addresses of all potential providers were geolocated by matching them with attributes attached to address point data (source: Land Information New Zealand (LINZ)15) in a geocoding process. Where addresses could not be identified, the nearest neighbouring address point was chosen for spatial analytical purposes. Access to facilities by the population was calculated using a roads dataset acquired from LINZ,16 which was converted using the GIS into a connected network capable of calculating specific distances from the providers.
Spatial analysis
Service areas covering parts of the road network that were within 5km, 20km and 50km of travel along the road network were calculated for each provider able to insert an IUD and/or LIUS. Using the refined estimate of spatial population distribution as described previously, the populations within each of these zones were calculated by summating the population attributed to the address points within that zone. Each point was also given the NZDep2018 score of the meshblock in which it fell,12 thus the mean deprivation level of address points in each of these service area zones was also able to be calculated.
All spatial data preparation and spatial analysis stages were carried out using ArcGIS 10.6.1 software at the School of Surveying, University of Otago.
Results
Survey results
Of the 86 potential primary IUD/LIUS providers in the SDHB catchment, complete answers were obtained from 77 providers (89.5%). The remaining nine practices indicated that they did provide either IUD or LIUS insertion but were unwilling (one practice) or unable to provide further details (eight practices). Thus 86/86 (100%) of potential primary IUD/LIUS providers in the SDHB catchment provided enough information for the intended spatial analysis to be carried out. This excludes the two regional gynaecology outpatient clinics, which differ from the other providers in that they are not able to be directly accessed by patients but instead require a referral process (ie, they are secondary providers). Results of the survey are summarised in Table 2.
Network analysis
The spatial distribution of current primary providers of IUD/LIUS within the SDHB catchment is wide. This is reinforced by the service areas created, which show that much of the road network is within 50km of such providers. However, significant areas remain more than 50km away, symbolised in red in Figure 1.
Figure 1: Service areas of (a) current primary providers and (b) potential primary providers, if all primary services were able to provide IUD/LIUS. Address and road data from LINZ.15,16 SDHB outline data from Statistics NZ.17
In the hypothetical scenario where every primary practice in the SDHB catchment was able to provide IUD/LIUS, the network analysis showed improved coverage, particularly in the areas between Invercargill and Owaka, and to the west of Dunedin. Notably, the area northwest of Kurow remained isolated in this scenario.
Populations within service areas
71.3% of the general population and 79.4% of the Māori population were estimated to live within 5km of a current primary provider. This would increase to 75.2% and 85.9% respectively if every primary practice in the catchment was an IUD/LIUS provider. A further breakdown of these results is shown in Figure 2 and Table 3 below.
Figure 2: Percentage of population within service areas of current primary providers.
Table 3: Population within service areas of current primary providers (current) and if all primary services were able to provide IUD/LIUS (potential).
NZDep2018 scores for service areas
In neither the current nor the hypothetical case was there an observable trend in mean NZDep2018 scores of addresses within each of the service areas from closest to farthest.
Table 4: Mean NZDep2018 scores for service areas.
Discussion
Cost and travel time are likely still barriers
The results of the spatial analysis in this study must be considered highly optimistic in that they allocate patients to the nearest possible provider without any regard for what patients can afford or where they are enrolled, which is almost certainly not the case in reality. A further simplification is that no provision is made for the temporal accessibility of services. Many current primary providers have very limited hours, eg, the sexual health clinic in Gore operates one day a month, and many GPs doing insertions work part time.
With these simplifications in mind, this study supports the finding in another recent qualitative study that cost is likely still a barrier.8 Even with the changes in funding for the Mirena and Jaydess, the median insertion cost is $115 with the maximum more than twice this amount at $270, excluding the cost of two or three GP visits. These costs are comparable to, if not in excess of, the estimate of $150 from a recent study.8 GPs in that study described such costs as forcing them to redirect patients, particularly those in rural areas, to cheaper services, often some distance away.8
For some rural populations, the distance to their nearest provider as estimated in this analysis contribute further to the cost. It is encouraging that a large majority of people live within 5km of a current provider (71.3% of the general population, 79.4% of the Māori population). Nonetheless, there remain a significant number of people who need to travel at least 5km to their nearest possible provider, with some needing to travel more than 50km. Using the Inland Revenue Department’s 2019 mileage rate of $0.79/km, return journeys to three appointments would cost between $23.70 and $237.00 for patients 5km and 50km away respectively.
The number of providers requiring two (pre-insertion and insertion) and three (additional check-up) appointments were roughly equal. This division is interesting, given that both are rooted in the same current RANZCOG guidelines. On the subject of pre-insertion appointments/tests, the guidelines state that for women at high risk of having a sexually transmitted infection (STI):
“Ideally [STI screening] results should be available prior to IUC insertion. However, in asymptomatic women there is no need to wait for the screening results, nor provide antibiotic prophylaxis, providing the woman can be contacted and treated if a positive result is found.”3
Regarding post-insertion follow up appointments, they state:
“A follow-up visit at 3–6 weeks may be undertaken to exclude infection, perforation or expulsion. More importantly, the patient should also be advised to present if abnormal bleeding, or symptoms suggestive of infection or pregnancy occur, or if they are unable to locate the string of the device.”3
Thus, for low risk and asymptomatic high-risk women, there is no need to have STI screening results available prior to insertion. Furthermore, it is more important to advise patients of symptoms that might require follow up than require them to attend a compulsory follow-up visit. It therefore appears that there is potential for the number of appointments required by some practices to be reduced, which would further reduce monetary and time costs to patients for whom these may be decision-making factors.
The finding of no simple correlation between distance to nearest provider and NZDep2018 should not be simplistically interpreted as distance not being a barrier for low-income patients. As noted previously, the aggregation of statistical data into meshblocks can introduce an ecological fallacy whereby small pockets of low-income populations are obscured by larger, wealthier areas. It would be more accurate to say that distance and travel time are not the only factors in determining how accessible an IUD or LIUS is for a given person living in a high-deprivation area, but these would certainly be contributing factors.
Increasing the number of providers
Operating under the assumption of people travelling to their nearest provider, the hypothetical scenario in which all general practices were able to insert IUD/LIUS would result in better coverage. The benefits would be relatively greater for the Māori population than the general population when calculating the number of people who would reside within 5km service area of a provider. Anecdotally, it would seem that increasing the number of healthcare professionals able to do insertions would be valuable; many practices spoken to were clear that they were stretched to the limit and were not enrolling new patients, while others who did not insert IUD or LIUS described months-long waiting lists at services to which they referred their patients. With 42 out of 48 providers having only GPs able to do insertions, nurse practitioners and clinical nurse specialists would seem to be a potentially underutilised resource. However, increasing the numbers of providers, and enabling them to perform enough procedures to maintain competence is not without its own challenges.8 The problems of accessibility of IUD/LIUS for patients and of getting enough procedures for inserters to maintain competence are mutually dependent.
Mobile services for rural populations
SDHB is a challenging catchment to provide services for, given the large and unevenly populated area it encompasses. While populations are concentrated in urban centres, 24.2% of the general population is spread over very low-density meshblocks comprising 99.7% of the area of all inhabited meshblocks (Appendix Table 1). In this catchment, Māori are more urban than the general population, but the proportion of this population in very low-density meshblocks is still sizeable at 11.6% (Appendix Table 1). Thus, the population in low-density areas cannot be ignored in service planning.
It is not the intention of this descriptive study to offer solutions to the challenges of contraceptive provision in the SDHB catchment. Nonetheless, the geographical challenge of a thinly distributed population lends itself to the consideration of a mobile service as a cost-effective solution, and during the course of the study, it was found that Te Waka Wahine Hauora/The Woman’s Health Bus has recently been established to provide precisely this. Further geographical analysis could optimise routes for such a service.
Limitations and strengths of the study
This study has several caveats. The electoral populations used are calculated estimates. Statistics NZ suppresses information on meshblocks with fewer than six inhabitants for privacy reasons. The dasymetric mapping used to distribute the populations of meshblocks to address points is a better estimate of reality than simply using meshblocks to estimate population distribution, but it remains a simplification nonetheless. As many rural address points are likely to be uninhabited tracts of land, it is likely that this technique overestimates the population in very remote areas. However, the use of broad service area bands ameliorates this to some extent—this study does not attempt to calculate precise distances to nearest provider for each address point, it merely groups address points and their corresponding inhabitants into a distance zone. Edge effects may be impacting the analysis along the northern border of the SDHB catchment. As Canterbury providers are not modelled, some of the parts of the network identified as >50km from a current SDHB provider may in fact be within close range of a Canterbury provider.
As described, complete results were not obtained for all current primary providers. It is possible that there are outliers in terms of cost, but they are unlikely to greatly change the median cost estimate, and the findings from this study support those of others.8 Also, this analysis assumes people travel to their nearest provider regardless of cost and enrolment, resulting in an over-optimistic estimate of access.
The fact that 100% of potential IUD/LIUS providers in the area provided sufficient information for the spatial analysis (ie, answered whether or not they provided IUD/LIUS insertion) is a particular strength of this study, and thus the spatial distribution of current primary providers can be considered an accurate snapshot at this period of time.
As this study only considers the SDHB catchment, it is unable to draw conclusions about the situation in other areas of the country. There is potential for this approach to be scaled up to a nation-wide level to address this.
Conclusion
While widening funding for the Mirena and Jaydess has been a welcome development, this paper indicates that there are populations in the SDHB catchment for whom distance and cost remain potential barriers to accessing an IUD/LIUS. A combination of increased funding for community insertion of IUD/LIUS, improved training opportunities for both medical and nursing staff, minimising the number of appointments required by providers, and optimised mobile services would improve access for people in this region to some of the most cost-effective and acceptable contraceptives available. With all the physical, social, economic and financial benefits that effective family planning confers to individuals and communities, this is arguably a public health priority.
Appendix
Appendix Table 1: Meshblocks (MB) grouped by general and Māori population density percentiles, with corresponding populations and land areas. Population data from Statistics NZ.11
Summary
Abstract
Aim
Recent changes in funding have reduced the cost of the highly effective levonorgestrel-releasing intrauterine system (LIUS) contraceptives (Mirena and Jaydess). This paper explores equity of access to intrauterine contraceptives for Māori and the general population by locating and surveying all potential providers within the Southern District Health Board catchment area.
Method
Using online survey, e-mail or phone, we asked if intrauterine contraceptive insertion was provided, what device was provided, cost and number of appointments required. ArcGIS 10.6.1 software was used to estimate population distribution, and to create service areas showing distance to nearest current providers for Māori and the general population.
Results
All 88 potential providers agreed to participate; two thirds (66.3%) provided some intrauterine contraceptive insertion. Approximately three quarters of the Māori and general population live within 5km of a primary provider. Costs ranged from $0 to $270, in addition to the cost of the required consultations. Number of consultations required varied from one to three.
Conclusion
Cost and travel time likely remain barriers to accessing intrauterine contraceptives for a significant population within this catchment. Increasing the capacity for all primary providers to offer insertion, funding the insertion process, minimising the number of appointments required and providing mobile services would improve access.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1. Starbird E, Norton M, Marcus R. Investing in Family Planning: Key to Achieving the Sustainable Development Goals. Glob Health Sci Pract. 2016; 4:191–210.
2. Naik R and Smith R. 2015. Impacts of family planning on nutrition. Washington, DC: Futures Group, Health Policy Project.
3. RANZCOG. Intrauterine contraception. 2017. Retrieved 28/11/2019 from www.ranzcog.edu.au
4. Whitley C. Improved access to long-acting reversible contraception (LARC) and the declining abortion rate (Thesis, Master of Public Health). University of Otago. 2018. Retrieved 2/12/2019 from http://hdl.handle.net/10523/7935
5. Chesang J, Richardson A, Potter J, Coope P. Prevalence of contraceptive use in New Zealand women. N Z Med J. 2016; 129:58–67.
6. PHARMAC. Decision to widen access to levonorgestrel intrauterine (LIUS) systems (Mirena and Jaydess). 2019. Retrieved 4/2/2020 from http://www.pharmac.govt.nz/news/notification-2019-10-14-lius-mirena-jaydess/
7. Mazza D, Bateson D, Frearson M, et al. Current barriers and potential strategies to increase the use of long-acting reversible contraception (LARC) to reduce the rate of unintended pregnancies in Australia: An expert roundtable discussion. Aust N Z J Obstet Gynaecol. 2017; 57:206–212.
8. McGinn O, Fulcher HJ, Arroll B, McCowan L. Barriers to the prescription of LARCs in general practice in New Zealand – a qualitative research study. N Z Med J. 2019; 132:63–69.
9. Murray C, Roke C. Who can afford a Mirena® for contraception? J Prim Health Care. 2018; 10:201–206.
10. EDI Account Guide – Otago, Southland Timaru & Oamaru. 2019. Retrieved 27/11/2019 from http://nz.healthlink.net/knowledge-base/edi-guides/
11. Statistics NZ. Meshblock electoral populations 2020. 2019. Retrieved 10/1/2020 from http://datafinder.stats.govt.nz/layer/104209-meshblock-electoral-populations-2020/
12. Salmond C, Crampton P, Sutton F, Atkinson J. Socioeconomic Deprivation Indexes: NZDep and NZiDep, Department of Public Health. 2018. Retrieved 11/2/2020 from http://www.otago.ac.nz/wellington/departments/publichealth/research/hirp/otago020194.html#2018
13. Longley P, Goodchild M, Maguire D, Rhind D. Geographic Information Science and Systems (4th ed.). 2015; New York: Wiley.
14. Zandbergen PA. Dasymetric mapping using high resolution address point datasets. Transactions in GIS.15:5–27.
15. Land Information New Zealand. NZ Street Address. 2019. Retrieved 12/12/2019 from http://data.linz.govt.nz/layer/3353
16. Land information New Zealand. NZ Road Centrelines (Topo, 1:50k). 2020. Retrieved 7/2/2020 from http://data.linz.govt.nz/layer/50329-nz-road-centrelines-topo-150k/
17. Statistics NZ. District Health Board 2015. 2015. Retrieved 12/12/2019 from http://datafinder.stats.govt.nz/layer/87883-district-health-board-2015/
For the PDF of this article,
contact nzmj@nzma.org.nz
Access to intrauterine contraceptives in the Southern District Health Board catchment
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Ensuring access to preferred contraceptive methods is a vital part of any healthcare service. Effective family planning is essential to the wellbeing and autonomy of women, allowing them to choose to have their children when they are physically, psychologically and economically ready.1,2 The development of highly effective, long-acting reversible contraceptives (LARC) has had a marked impact on family planning. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) recommends LARC as a first-line method for their excellent efficacy, acceptability, cost-effectiveness and reversibility.3 In New Zealand, increased uptake of the copper intrauterine device (IUD), Mirena intrauterine system and Jadelle implant has been significantly associated with a declining abortion rate, particularly among younger women.4 Nevertheless, a 2013–2015 survey found LARC were still less commonly used than condoms and the oral contraceptive pill.5
The decision by PHARMAC in October 2019 to widen access to levonorgestrel intrauterine systems (LIUS) by funding the Mirena and Jaydess without restriction followed sustained advocacy from many dedicated people.6 Despite reduced cost to patients of these LIUS, barriers to uptake persist. Barriers include misperceptions about LARC from both patients and clinicians,7 lack of training of healthcare providers, lack of funding for primary carers for contraceptive procedures, and cost to the patient.8
IUD and LIUS differ from other contraceptives such as the oral contraceptive pill or condoms in two key respects. First, although in New Zealand there is no accredited training scheme for practitioners (unlike in other comparable countries such as the UK), and no system to ensure minimum standards of competency,8 not all general practitioners (GP) have the facilities or willingness to insert these devices, so people may have to travel further than their closest GP to obtain this service. Second, insertion of these devices often requires two or three separate appointments in close succession: a pre-insertion consultation, the insertion and sometimes a follow-up appointment. This presents a potentially insurmountable logistical and financial challenge to women who lack independent transport, may already be caring for small children, struggle to arrange time off work, or live far from an appropriate provider. This challenge is compounded for people living in socioeconomic deprivation—disproportionately Māori and Pacific populations—for whom cost is already a recognised barrier to LARC access.9
The problem in New Zealand is twofold. For one, there is no single authoritative resource that lists and locates providers that can insert IUD or LIUS. This makes it impossible to know how far patients are having to travel to access these effective methods of contraception. Second, as only the device and not the insertion is funded, the costs to patients are unknown.
This descriptive study therefore sought to identify, survey and locate all potential providers of IUD or LIUS within the Southern District Health Board (SDHB) catchment area, and apply spatial analysis using a geographical information system (GIS) to explore to what extent cost and distance to nearest provider may still affect accessibility to intrauterine contraceptive devices.
Methods
Data collection
Using the HealthLink EDI Account Directory for Otago, Southland, Timaru and Oamaru,10 and on the advice of individuals working within the gynaecological and sexual health services, all the potential providers of IUD/LIUS within the SDHB catchment were identified.
Table 1: Potential providers of IUD/LIUS within the SDHB catchment.
Physical locations and e-mail addresses were found online for as many of these practices and clinics as possible. A short survey developed on the Qualtrics software was sent to these e-mail addresses with unique links for each practice. If respondents did not complete the survey within two weeks, a reminder was sent, after which the outstanding respondents were contacted by phone and/or e-mail to ask the survey questions directly. General practices with no e-mail address were asked the survey questions by phone. Information from providers other than general practices was obtained by e-mail correspondence. Data were collected during December 2019 and January 2020.
Survey questions are presented in Table 2.
Table 2: Survey results.
Ethics approval for data collection was granted by the University of Otago Human Ethics Committee (reference D19/381).
Data preparation
Prior to spatial analysis, population, provider and road network data were collated, collected and prepared. Within the SDHB catchment area, Māori and general electoral population data—hereafter referred to as the Māori and general populations respectively—were obtained from Statistics NZ at the meshblock level,11 the smallest geographic unit for which data is reported by this organisation. Publicly available data on New Zealand deprivation level (NZDep2018) by meshblock were also obtained.12
Meshblocks each enclose a similar number of people, and therefore vary enormously in size from small city blocks to large tracts of rural land. Using generalised population data at this level can greatly distort calculations of distance to a nearest provider. While populations can reasonably be assumed to be distributed throughout a central city meshblock, in rural areas they are likely clustered in only a small portion of the total meshblock area. This is a common artefact in situations where single values purport to represent an entire area (ecological fallacy).13 Therefore, to better approximate the actual geographical distribution of population, the general and Māori populations in each meshblock were distributed evenly to each address point within that meshblock in a process known as dasymetric mapping.14
The obtained addresses of all potential providers were geolocated by matching them with attributes attached to address point data (source: Land Information New Zealand (LINZ)15) in a geocoding process. Where addresses could not be identified, the nearest neighbouring address point was chosen for spatial analytical purposes. Access to facilities by the population was calculated using a roads dataset acquired from LINZ,16 which was converted using the GIS into a connected network capable of calculating specific distances from the providers.
Spatial analysis
Service areas covering parts of the road network that were within 5km, 20km and 50km of travel along the road network were calculated for each provider able to insert an IUD and/or LIUS. Using the refined estimate of spatial population distribution as described previously, the populations within each of these zones were calculated by summating the population attributed to the address points within that zone. Each point was also given the NZDep2018 score of the meshblock in which it fell,12 thus the mean deprivation level of address points in each of these service area zones was also able to be calculated.
All spatial data preparation and spatial analysis stages were carried out using ArcGIS 10.6.1 software at the School of Surveying, University of Otago.
Results
Survey results
Of the 86 potential primary IUD/LIUS providers in the SDHB catchment, complete answers were obtained from 77 providers (89.5%). The remaining nine practices indicated that they did provide either IUD or LIUS insertion but were unwilling (one practice) or unable to provide further details (eight practices). Thus 86/86 (100%) of potential primary IUD/LIUS providers in the SDHB catchment provided enough information for the intended spatial analysis to be carried out. This excludes the two regional gynaecology outpatient clinics, which differ from the other providers in that they are not able to be directly accessed by patients but instead require a referral process (ie, they are secondary providers). Results of the survey are summarised in Table 2.
Network analysis
The spatial distribution of current primary providers of IUD/LIUS within the SDHB catchment is wide. This is reinforced by the service areas created, which show that much of the road network is within 50km of such providers. However, significant areas remain more than 50km away, symbolised in red in Figure 1.
Figure 1: Service areas of (a) current primary providers and (b) potential primary providers, if all primary services were able to provide IUD/LIUS. Address and road data from LINZ.15,16 SDHB outline data from Statistics NZ.17
In the hypothetical scenario where every primary practice in the SDHB catchment was able to provide IUD/LIUS, the network analysis showed improved coverage, particularly in the areas between Invercargill and Owaka, and to the west of Dunedin. Notably, the area northwest of Kurow remained isolated in this scenario.
Populations within service areas
71.3% of the general population and 79.4% of the Māori population were estimated to live within 5km of a current primary provider. This would increase to 75.2% and 85.9% respectively if every primary practice in the catchment was an IUD/LIUS provider. A further breakdown of these results is shown in Figure 2 and Table 3 below.
Figure 2: Percentage of population within service areas of current primary providers.
Table 3: Population within service areas of current primary providers (current) and if all primary services were able to provide IUD/LIUS (potential).
NZDep2018 scores for service areas
In neither the current nor the hypothetical case was there an observable trend in mean NZDep2018 scores of addresses within each of the service areas from closest to farthest.
Table 4: Mean NZDep2018 scores for service areas.
Discussion
Cost and travel time are likely still barriers
The results of the spatial analysis in this study must be considered highly optimistic in that they allocate patients to the nearest possible provider without any regard for what patients can afford or where they are enrolled, which is almost certainly not the case in reality. A further simplification is that no provision is made for the temporal accessibility of services. Many current primary providers have very limited hours, eg, the sexual health clinic in Gore operates one day a month, and many GPs doing insertions work part time.
With these simplifications in mind, this study supports the finding in another recent qualitative study that cost is likely still a barrier.8 Even with the changes in funding for the Mirena and Jaydess, the median insertion cost is $115 with the maximum more than twice this amount at $270, excluding the cost of two or three GP visits. These costs are comparable to, if not in excess of, the estimate of $150 from a recent study.8 GPs in that study described such costs as forcing them to redirect patients, particularly those in rural areas, to cheaper services, often some distance away.8
For some rural populations, the distance to their nearest provider as estimated in this analysis contribute further to the cost. It is encouraging that a large majority of people live within 5km of a current provider (71.3% of the general population, 79.4% of the Māori population). Nonetheless, there remain a significant number of people who need to travel at least 5km to their nearest possible provider, with some needing to travel more than 50km. Using the Inland Revenue Department’s 2019 mileage rate of $0.79/km, return journeys to three appointments would cost between $23.70 and $237.00 for patients 5km and 50km away respectively.
The number of providers requiring two (pre-insertion and insertion) and three (additional check-up) appointments were roughly equal. This division is interesting, given that both are rooted in the same current RANZCOG guidelines. On the subject of pre-insertion appointments/tests, the guidelines state that for women at high risk of having a sexually transmitted infection (STI):
“Ideally [STI screening] results should be available prior to IUC insertion. However, in asymptomatic women there is no need to wait for the screening results, nor provide antibiotic prophylaxis, providing the woman can be contacted and treated if a positive result is found.”3
Regarding post-insertion follow up appointments, they state:
“A follow-up visit at 3–6 weeks may be undertaken to exclude infection, perforation or expulsion. More importantly, the patient should also be advised to present if abnormal bleeding, or symptoms suggestive of infection or pregnancy occur, or if they are unable to locate the string of the device.”3
Thus, for low risk and asymptomatic high-risk women, there is no need to have STI screening results available prior to insertion. Furthermore, it is more important to advise patients of symptoms that might require follow up than require them to attend a compulsory follow-up visit. It therefore appears that there is potential for the number of appointments required by some practices to be reduced, which would further reduce monetary and time costs to patients for whom these may be decision-making factors.
The finding of no simple correlation between distance to nearest provider and NZDep2018 should not be simplistically interpreted as distance not being a barrier for low-income patients. As noted previously, the aggregation of statistical data into meshblocks can introduce an ecological fallacy whereby small pockets of low-income populations are obscured by larger, wealthier areas. It would be more accurate to say that distance and travel time are not the only factors in determining how accessible an IUD or LIUS is for a given person living in a high-deprivation area, but these would certainly be contributing factors.
Increasing the number of providers
Operating under the assumption of people travelling to their nearest provider, the hypothetical scenario in which all general practices were able to insert IUD/LIUS would result in better coverage. The benefits would be relatively greater for the Māori population than the general population when calculating the number of people who would reside within 5km service area of a provider. Anecdotally, it would seem that increasing the number of healthcare professionals able to do insertions would be valuable; many practices spoken to were clear that they were stretched to the limit and were not enrolling new patients, while others who did not insert IUD or LIUS described months-long waiting lists at services to which they referred their patients. With 42 out of 48 providers having only GPs able to do insertions, nurse practitioners and clinical nurse specialists would seem to be a potentially underutilised resource. However, increasing the numbers of providers, and enabling them to perform enough procedures to maintain competence is not without its own challenges.8 The problems of accessibility of IUD/LIUS for patients and of getting enough procedures for inserters to maintain competence are mutually dependent.
Mobile services for rural populations
SDHB is a challenging catchment to provide services for, given the large and unevenly populated area it encompasses. While populations are concentrated in urban centres, 24.2% of the general population is spread over very low-density meshblocks comprising 99.7% of the area of all inhabited meshblocks (Appendix Table 1). In this catchment, Māori are more urban than the general population, but the proportion of this population in very low-density meshblocks is still sizeable at 11.6% (Appendix Table 1). Thus, the population in low-density areas cannot be ignored in service planning.
It is not the intention of this descriptive study to offer solutions to the challenges of contraceptive provision in the SDHB catchment. Nonetheless, the geographical challenge of a thinly distributed population lends itself to the consideration of a mobile service as a cost-effective solution, and during the course of the study, it was found that Te Waka Wahine Hauora/The Woman’s Health Bus has recently been established to provide precisely this. Further geographical analysis could optimise routes for such a service.
Limitations and strengths of the study
This study has several caveats. The electoral populations used are calculated estimates. Statistics NZ suppresses information on meshblocks with fewer than six inhabitants for privacy reasons. The dasymetric mapping used to distribute the populations of meshblocks to address points is a better estimate of reality than simply using meshblocks to estimate population distribution, but it remains a simplification nonetheless. As many rural address points are likely to be uninhabited tracts of land, it is likely that this technique overestimates the population in very remote areas. However, the use of broad service area bands ameliorates this to some extent—this study does not attempt to calculate precise distances to nearest provider for each address point, it merely groups address points and their corresponding inhabitants into a distance zone. Edge effects may be impacting the analysis along the northern border of the SDHB catchment. As Canterbury providers are not modelled, some of the parts of the network identified as >50km from a current SDHB provider may in fact be within close range of a Canterbury provider.
As described, complete results were not obtained for all current primary providers. It is possible that there are outliers in terms of cost, but they are unlikely to greatly change the median cost estimate, and the findings from this study support those of others.8 Also, this analysis assumes people travel to their nearest provider regardless of cost and enrolment, resulting in an over-optimistic estimate of access.
The fact that 100% of potential IUD/LIUS providers in the area provided sufficient information for the spatial analysis (ie, answered whether or not they provided IUD/LIUS insertion) is a particular strength of this study, and thus the spatial distribution of current primary providers can be considered an accurate snapshot at this period of time.
As this study only considers the SDHB catchment, it is unable to draw conclusions about the situation in other areas of the country. There is potential for this approach to be scaled up to a nation-wide level to address this.
Conclusion
While widening funding for the Mirena and Jaydess has been a welcome development, this paper indicates that there are populations in the SDHB catchment for whom distance and cost remain potential barriers to accessing an IUD/LIUS. A combination of increased funding for community insertion of IUD/LIUS, improved training opportunities for both medical and nursing staff, minimising the number of appointments required by providers, and optimised mobile services would improve access for people in this region to some of the most cost-effective and acceptable contraceptives available. With all the physical, social, economic and financial benefits that effective family planning confers to individuals and communities, this is arguably a public health priority.
Appendix
Appendix Table 1: Meshblocks (MB) grouped by general and Māori population density percentiles, with corresponding populations and land areas. Population data from Statistics NZ.11
Summary
Abstract
Aim
Recent changes in funding have reduced the cost of the highly effective levonorgestrel-releasing intrauterine system (LIUS) contraceptives (Mirena and Jaydess). This paper explores equity of access to intrauterine contraceptives for Māori and the general population by locating and surveying all potential providers within the Southern District Health Board catchment area.
Method
Using online survey, e-mail or phone, we asked if intrauterine contraceptive insertion was provided, what device was provided, cost and number of appointments required. ArcGIS 10.6.1 software was used to estimate population distribution, and to create service areas showing distance to nearest current providers for Māori and the general population.
Results
All 88 potential providers agreed to participate; two thirds (66.3%) provided some intrauterine contraceptive insertion. Approximately three quarters of the Māori and general population live within 5km of a primary provider. Costs ranged from $0 to $270, in addition to the cost of the required consultations. Number of consultations required varied from one to three.
Conclusion
Cost and travel time likely remain barriers to accessing intrauterine contraceptives for a significant population within this catchment. Increasing the capacity for all primary providers to offer insertion, funding the insertion process, minimising the number of appointments required and providing mobile services would improve access.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
1. Starbird E, Norton M, Marcus R. Investing in Family Planning: Key to Achieving the Sustainable Development Goals. Glob Health Sci Pract. 2016; 4:191–210.
2. Naik R and Smith R. 2015. Impacts of family planning on nutrition. Washington, DC: Futures Group, Health Policy Project.
3. RANZCOG. Intrauterine contraception. 2017. Retrieved 28/11/2019 from www.ranzcog.edu.au
4. Whitley C. Improved access to long-acting reversible contraception (LARC) and the declining abortion rate (Thesis, Master of Public Health). University of Otago. 2018. Retrieved 2/12/2019 from http://hdl.handle.net/10523/7935
5. Chesang J, Richardson A, Potter J, Coope P. Prevalence of contraceptive use in New Zealand women. N Z Med J. 2016; 129:58–67.
6. PHARMAC. Decision to widen access to levonorgestrel intrauterine (LIUS) systems (Mirena and Jaydess). 2019. Retrieved 4/2/2020 from http://www.pharmac.govt.nz/news/notification-2019-10-14-lius-mirena-jaydess/
7. Mazza D, Bateson D, Frearson M, et al. Current barriers and potential strategies to increase the use of long-acting reversible contraception (LARC) to reduce the rate of unintended pregnancies in Australia: An expert roundtable discussion. Aust N Z J Obstet Gynaecol. 2017; 57:206–212.
8. McGinn O, Fulcher HJ, Arroll B, McCowan L. Barriers to the prescription of LARCs in general practice in New Zealand – a qualitative research study. N Z Med J. 2019; 132:63–69.
9. Murray C, Roke C. Who can afford a Mirena® for contraception? J Prim Health Care. 2018; 10:201–206.
10. EDI Account Guide – Otago, Southland Timaru & Oamaru. 2019. Retrieved 27/11/2019 from http://nz.healthlink.net/knowledge-base/edi-guides/
11. Statistics NZ. Meshblock electoral populations 2020. 2019. Retrieved 10/1/2020 from http://datafinder.stats.govt.nz/layer/104209-meshblock-electoral-populations-2020/
12. Salmond C, Crampton P, Sutton F, Atkinson J. Socioeconomic Deprivation Indexes: NZDep and NZiDep, Department of Public Health. 2018. Retrieved 11/2/2020 from http://www.otago.ac.nz/wellington/departments/publichealth/research/hirp/otago020194.html#2018
13. Longley P, Goodchild M, Maguire D, Rhind D. Geographic Information Science and Systems (4th ed.). 2015; New York: Wiley.
14. Zandbergen PA. Dasymetric mapping using high resolution address point datasets. Transactions in GIS.15:5–27.
15. Land Information New Zealand. NZ Street Address. 2019. Retrieved 12/12/2019 from http://data.linz.govt.nz/layer/3353
16. Land information New Zealand. NZ Road Centrelines (Topo, 1:50k). 2020. Retrieved 7/2/2020 from http://data.linz.govt.nz/layer/50329-nz-road-centrelines-topo-150k/
17. Statistics NZ. District Health Board 2015. 2015. Retrieved 12/12/2019 from http://datafinder.stats.govt.nz/layer/87883-district-health-board-2015/
Contact diana@nzma.org.nz
for the PDF of this article
Access to intrauterine contraceptives in the Southern District Health Board catchment
Ensuring access to preferred contraceptive methods is a vital part of any healthcare service. Effective family planning is essential to the wellbeing and autonomy of women, allowing them to choose to have their children when they are physically, psychologically and economically ready.
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