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Associate Minister of Health Ayesha Verrall. Photo: Marc Daalder
Orna McGinn is a GP with an interest in women's health, and Honorary Senior Lecturer at the University of Auckland. She will chair the NZ Women in Medicine conference in May 2022.
The impending reform of the NZ health system needs to include a clear emphasis on improving women’s health, writes Dr Orna McGinn
‘Mother of God! Sure you didn’t think I’d have had 8 children if I’d had a choice?’
I had always wondered why my granny had chosen to have so many children. My parents left Ireland as economic migrants in the 1960s along with thousands of others, and I was born and grew up in London where 2.4 children was the norm.
I loved coming back to spend holidays with my huge and chaotic whānau in rural county Meath – my uncle, six aunts and ever-multiplying cousins. I still remember the shock when I realised that, had she had the option, my granny would have chosen to have a smaller family.
Of course, in Ireland in the 1950s she had no choice: a patriarchal Catholic system outlawed both contraception and abortion.
I increasingly find myself wondering if the women of New Zealand have better access to healthcare than Maisie Coyne of Meath did, 70 years ago. Women still face a number of barriers to accessing effective contraception, the main ones being cost and finding a provider trained to insert longer acting methods such as implants and the IUCD, or coil.
Over 50 percent of pregnancies in New Zealand are unintended: unintended pregnancies are more likely to result in prematurity, stillbirth and poor maternal mental and physical health.
In 2019, the Government announced an initiative to increase access to funded contraception with the aim of enabling women to manage their fertility and to reduce unintended pregnancies. Contraception funding was allocated to District Health Boards (DHBs) without a nationwide strategic plan or framework.
The lack of a strategy has resulted in a ‘postcode lottery’ of complex eligibility criteria for women. DHBs were able to determine their own criteria for funded contraception, and so depending on location women are now eligible for funding depending on their age, ethnicity, income, the number of children they have, whether they have a drug or alcohol problem, or whether they are under the care of mental health services. In some areas, contraception is funded after abortion; in other areas it is not. Unfunded, the cost of an IUD insertion can be $200 or more.
By way of contrast, abortion is available on request to any woman, regardless of her unique reasons or circumstances. Access issues were further addressed last year by the removal of abortion from the Crimes Act. The assumption is that publicly funded abortion will continue to be free at the point of access to all New Zealand citizens. Associate Health Minister Ayesha Verrall recently announced that abortion will soon be available widely in the community via primary care, as it is in many other countries such as the UK and Canada .
However, without an integrated strategy, we are now looking at a situation where contraception may become harder to access than abortion. This makes no sense at all – legally, ethically, financially.
When I say financially : it is impossible to overstate the benefits of freely available provision of contraception. In the UK it has been estimated that every pound spent on contraception saves up to £10 in abortion care, maternity care and the associated costs of unintended pregnancy. It is what is known as a ‘high return on investment’.
In fact, every dollar invested in women and their health carries a ‘high return on investment’. Healthy women can take a full part in the workforce, adding to the wealth of the nation. Healthy women raise healthy tamariki. This is why so many countries – the UK, Ireland, Australia, Canada – have created women’s health strategies, acknowledging that women are not ‘men by default’, and have specific health needs which need to be met with specific policy.
Health intersects with ‘social determinants’ – housing, welfare, racism, employment – and these disparities are more marked for women. The disparities are even more marked for women of different ethnicities : in 2012–14 life expectancy was 6.8 years less for Māori females and 5.2 years less for Pacific females in New Zealand, compared with non-Māori, non-Pacific women.
The recent World Economic Forum Global Gender Gap Report (2021) showed New Zealand ranked 4th overall out of 156 countries for gender parities across a range of parameters. This is mainly because of high ranking in the subcategories of educational attainment and political empowerment – not only does New Zealand currently have a female Prime Minister, but the country also has its highest ever number of female MPs. However, the same report ranks NZ at 106 for the gendered gap between men and women for health and survival, below countries such as Tunisia, Tajikistan, Iraq and Nigeria. This is inexcusable.
Reviews and inquiries over the past 10 years have repeatedly highlighted fragmentation and siloing of health services as contributory factors to poor outcomes for women and children. However, there is a pattern of failure to implement the recommendations following such reviews.
The 2013 Health Committee Inquiry into improving child health outcomes and preventing child abuse with a focus from preconception to three years of age heard that a lack of service co ordination, and the requirement for contact with multiple non integrated services during pregnancy and postpartum was ‘a significant barrier to improving child health’. 130 recommendations for improvement were made, most of which have not been acted on to date.
Over the past five years, more than 40 petitions have been presented to Parliament calling for changes or improvements to aspects of women’s health such as maternity care, contraception access, ovarian cancer and improved access to ACC funded treatment of sexual assault. This ‘single issue advocacy’, even when successful, does little more than paper over the cracks.
With the creation of Health NZ, there is an opportunity for New Zealand to produce a world leading Women’s Health and Wellbeing strategy. The Pae Ora Healthy Futures Bill, currently at Select Committee stage, sets out the legislation for New Zealand’s new health system. The Bill identifies priority groups for whom separate strategies have been proposed: Māori and Pacific people, and the 24 percent of New Zealanders currently living with a disability. Although disabled women, Māori and Pacific women are more likely to have difficulty accessing services, separate strategies may only highlight rather than address gaps. In addition, such an approach fails to acknowledge that women of other ethnicities may also suffer adverse health outcomes.
The Gender Justice Collective has prepared a submission to the Pae Ora Healthy Futures Bill, calling for a women’s health and wellbeing strategy. They have done a huge amount of mahi in this area and their submission will be published on their website later this week.
The WHO European Region published a women’s health and wellbeing strategy in 2016 in order to ‘[integrate] an equity element into its work, reinforcing the principles of non-discrimination, equality and participation, to ensure that every woman and child has the opportunity to fulfil their ambitions and is not held back by their gender.’ We can do the same.
Ireland has changed beyond recognition since my parents left to seek a new life abroad. Abortion was legalised in 2018, and while there are still obstacles, in just three years has become available in 30 percent of all GP surgeries.
As part of its commitment to a women’s health strategy, the country has also launched a ‘radical listening’ exercise, whereby women’s voices and their experiences of the healthcare system are heard via workshops, interviews and online submissions. The Irish Minister of Health was recently reported as saying “Listening to women is the cornerstone of our work on women’s health….What we need, and what we are working towards, is a revolution in women’s healthcare.”
Aotearoa too needs a revolution in women’s healthcare. With the inclusion of a comprehensive Women’s Health and Wellbeing Strategy as part of the creation of New Zealand’s new health system, we can invest in the future. In this way women, their children and whānau can unlock their full potential. Society will only benefit as a result.
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