Geographical access to termination of pregnancy services in New Zealand

Background: The New Zealand government has made a commitment to reducing inequalities in health among its population through the New Zealand Health Strategy. Termination of Pregnancy (TOP) services are an important part of women's health services, and equity in access to services must be ensured. Objective: Assess geographic accessibility to first trimester termination of pregnancy services in New Zealand, and discuss implications for equity in access to services. Methods: TOP service information was obtained nationwide through online resources, and approximate driving distances between all major centres and the closest TOP service to which patients are referred to were calculated for each region. Census data and Statistics NZ data are used to compare population characteristics between regions with reduced geographic accessibility of TOP services. Results: Women who live in regions that do not offer local TOP services must travel on average 221km to access TOP services. This equates to an average return‐trip distance of 442km. Three of the five regions that do not have local TOP services available have a higher than average proportion of Maori population. Conclusions: The results of this study demonstrate that first‐trimester TOP services are relatively difficult to access for over one‐sixth of the women in New Zealand.     

微型吸宫器终止早早孕效果评价

目的　探讨微型吸宫器终止早早孕 (孕 31～ 4 5 d)的优越性和临床应用价值。　方法　采用微型吸宫器对 30 0例早早孕妇女进行子宫内膜及孕囊负吸法终止妊娠 ,并与常规人工流产组(简称人流组 )和药物流产组 (简称药流组 )对比 ,观察完全流产率、术中疼痛、出血量、术后出血等情况。　结果　完全流产率 ,微型吸宫器组 (简称微管组 ) 99.7% (2 99/ 30 0 )与药流组 92 .7%(2 78/ 30 0 )比较 ,差异有显著性 (P<0 .0 0 5 ) ,与人流组 99.0 % (2 97/ 30 0 )比较 ,差异无显著性(P<0 .0 5 ) ;无痛率 ,微宫组、药流组和常人流组 0级分别为 87.7% (2 6 3/ 30 0 ) ,0 .7% (2 / 30 0 ) ,9.3% (2 8/ 30 0 ) ,差异有显著性 (P<0 .0 0 5 ) ;术中出血量 ,微宫组平均为 4 .5 ml,药流组平均为9.6 m l,人流组为 9.5 ml。微管组分别与药流组和人流组比较 ,差异有显著性 ,(P<0 .0 0 5 )。　结论　微型吸宫器法终止早早孕 ,手术简单、无损伤、腹痛轻、出血少、术后恢复快、无术时和术后并发症 ,易被受孕妇女接受 ,可作为安全有效的方法用于临床。     

Second trimester termination of pregnancy: a review by site and procedure type

BACKGROUND: We hypothesized that complications for second trimester terminations are higher in a low-volume residency training program than in a high-volume private practice. STUDY DESIGN: Complications and cost were compared between three groups undergoing second trimester terminations: patients undergoing dilation and evacuation (D&E) at a university hospital (Hospital D&E, n=83) or medical pregnancy termination at a university hospital (Hospital Induction, n=89) and D&E at a private outpatient facility (Clinic D&E, n=253). RESULTS: Major complications occurred in 11% of the Hospital D&E, 10% of the Hospital Induction, and 1% of the Clinic D&E patients (p=.0019). Complication rates remained statistically significant when a logistic regression model was applied to the data. The mean total charge for the three respective groups was US$4625, US$5029 and US$1105 (p<.001). CONCLUSION: Second trimester terminations of pregnancy by D&E in well-selected patients in a dedicated outpatient facility can be safer and less expensive than hospital-based D&E or induction of labor.     

Medical termination of pregnancy during the second versus the first trimester and its effects on subsequent pregnancy

Objective

The objective was to compare the risks of preterm birth, low birth weight, small for gestational age (SGA) infants and placental complications in subsequent pregnancy after second vs. first trimester medical termination of pregnancy (MTOP) in primigravid women.

Study Design

A total of 88,522 women who underwent termination of pregnancy during 2000–2009 were identified using Finnish health registers. Of them, primigravid women who underwent MTOP and had subsequent pregnancy ending in live birth up to the end of 2009 (n= 3843) were included in the study. The incidences and risks of preterm birth, low birth weight, SGA infants and placental complications after first- (n= 3427) vs. second-trimester MTOP (n= 416) were compared.

Results

Differences between the study groups in the incidences of preterm birth (3.9% in both groups), low birth weight (3.9% in the second- vs. 3.2% in the first-trimester group), SGA infants (2.4% vs. 2.5%) and placental complications (1.9% vs. 2.6%) were statistically insignificant. Second-trimester MTOP was associated with similar risks of preterm birth, low birth weight, SGA infants and placental complications compared with first-trimester MTOP after adjustment for background characteristics. After second-trimester MTOP, 51.2% of women underwent surgical evacuation, and 4.3% were diagnosed with infection. The differences in the risks of preterm birth, low birth weight, SGA infants and placental complications were statistically insignificant between women with vs. without these complications following second-trimester MTOP.

Conclusions

Second-trimester MTOP among primigravid women did not increase the risks of preterm birth, low birth weight, SGA infants or placental complications in subsequent pregnancy compared with first-trimester MTOP.

Implications

The present study suggests that medical termination of pregnancy in primigravid women during second vs. first trimester does not increase the risks of adverse outcomes in subsequent pregnancy and delivery. The data are of value when counseling women undergoing second-trimester TOP.     

不同方式终止14～24周妊娠的效果探讨

目的:探讨不同方法终止14~24周妊娠的临床效果。方法:将117例妊娠14~24周妇女随机分为3组,A组采用米非司酮联合米索前列醇引产(40例);B组采用米非司酮联合羊膜腔内依沙吖啶注射引产(39例);C组采用羊膜腔内依沙吖啶注射引产(38例),比较3组引产效果。结果:A组与B组、C组相比,宫缩发动时间及产程短,清宫率低,镇痛药使用率低,出血量少,差异均有统计学意义(P<0.05);B组与C组相比,宫缩发动时间及产程短,清宫率低,差异有均统计学意义(P<0.05)。引产成功率3组间差异无统计学意义(P>0.05)。结论:米非司酮联合米索前列醇引产简单、安全、高效,引产后不需常规清宫,优于米非司酮联合依沙吖啶引产和传统依沙吖啶引产,而米非司酮联合依沙吖啶引产优于传统依沙吖啶引产。     

Medical termination of pregnancy in the early first trimester

Surgical abortion using vacuum aspiration or dilatation and curettage has been the method of choice for termination of pregnancy up to 63 days' gestation since the 1960s. Over the last three decades many studies have explored the use of medical methods for inducing abortion at these gestations. Earlier regimens assessed the systemic and intrauterine injection of prostaglandins. This was followed in the 1980s by the introduction of the antiprogesterone, mifepristone. Since its introduction, the uptake of medical abortion has been steadily increasing in countries where it has been available for routine use. Most current clinical protocols require the use of prostaglandins in combination with anti-progesterones or antimetabolites. The safety, efficacy and acceptability of the medical regimen are now well established at all gestations of pregnancy. Provision of medical abortion increases the choice available to women, in particular those wishing to avoid surgery.     

Growing Up in New Zealand cohort alignment with all New Zealand births

Objective: To compare the birth characteristics of the Growing Up in New Zealand cohort with those of all New Zealand (NZ) births over a similar time period, and to describe cohort alignment to current NZ births. Method: The Growing Up in New Zealand longitudinal study recruited 6,846 children from before birth via their pregnant mothers who were residing in the greater Auckland and Waikato regions during 2009 and 2010. Data were collected from mothers antenatally and six weeks after their expected delivery date, and from routine perinatal health records. These data were compared to Ministry of Health data for all births in NZ between 2007 and 2010. Results: The proportion of males and singleton births were not statistically different to national births. Compared to national births fewer of the cohort children were born low birth weight (4.9% vs. 6.1%, p<0.0001) or preterm (6.4% vs. 7.4%, p=0.001) and the cohort was expected to be more ethnically diverse than national births. Conclusion: Birth parameters for the cohort were generally closely aligned to all NZ births in 2007–2010. Some statistically significant differences reflected small absolute differences, attributable in some part to cohort recruitment requiring survival to six weeks post expected delivery. Implications: The explicit documentation of the alignment of the cohort to national data provides assurance that the study is well placed to deliver findings that can inform policy development relevant to the diversity of the contemporary NZ child population.     

The organization and financing of dialysis and kidney transplantation services in New Zealand

In New Zealand, patients receive treatment for end-stage renal disease (ESRD) within the tax-funded health system. All hospital and specialist outpatient services are free, while general practitioner consultations and pharmaceuticals prescribed outside of hospitals incur copayments. Total ESRD prevalence is 0.07%, half the U.S. rate, and the prevalence of home-based and self-care dialysis is the highest in the world. Medical staff are not subject to direct financial incentives that could affect treatment choice. Estimated total expenditure per ESRD patient is relatively low. Funding constraints encourage physicians and patients to consider the probable benefit of dialysis for a patient before treatment is prescribed.      

Deviant insiders: medical acupuncturists in New Zealand

Acupuncture gained considerable attention in anglophone countries in the 1970s. As part of that popularity many medical practitioners became interested in the therapy and learned acupuncture techniques. A number of studies have indicated that medical practitioners were able to take up the practice of acupuncture without threatening the cultural authority of medicine so long as they limited the scope of its practice and redefined acupuncture concepts in Western biomedical terms. These analyses tend to present the medical profession as monolithic and emphasize a dichotomous relationship between biomedicine and alternative therapies such as acupuncture. This study examines the ways in which acupuncture has been represented in different medical forums, suggesting that in order to understand the relationships between biomedicine and alternative medicine we need to be more aware of the changing nature of these representations and their dependency upon the context of the representation. Rather than emphasizing a duality between orthodox medicine and alternative medicine, it is argued here that there are pluralities of medical and healing worldviews.     

Measuring ethnicity in New Zealand: developing tools for health outcomes analysis

Objective. This study examines the development of new tools for analysing links between ethnicity and health outcomes. In a New Zealand context, it focuses on (1) how ethnicity is increasingly articulated as a social construct, (2) how individuals belonging to more than one ethnic group have been recorded and reported in research, and (3) health research and policy implications of the growing proportion of New Zealanders who claim multi-ethnic affiliations.

Design. New Zealand provides a microcosm in which to consider ethnicity, indigeneity, migration and intermarriage, and their interacting effects on society, culture, identity and health outcomes. Against a backdrop of historical debates about the measurement of race, and then ethnicity, the paper explores recent changes in the recording and reporting of ethnicity in the five-yearly Census of Population and Dwellings, and in death registrations. These changes are then considered in relation to the study of ethnic health disparities and the development of policies to overcome them.

Results. In the 2001 Census, of those who responded to the ethnicity question, at a level 1 classification 7.9% gave more than one response. In relation to the indigenous people of New Zealand, of all those who recorded Māori as one or more of their ethnic groups, only 56% recorded Māori only. In the younger age groups, less than half the Māori ethnic group were Māori only. Single ethnic categories disguise considerable within-group diversity in outcomes.

Conclusion. While single ethnic group disparity studies have been useful in the past, we suggest that more sophisticated ways of conceptualising and analysing ethnicity data in relation to health disparities are now required in New Zealand. Based on the New Zealand experience, we also suggest that as international migration continues, and as intermarriage becomes more frequent in most countries, there will be pressure to move from single group race-based measures towards culturally-based complex ethnicity measures.     

Kaupapa Maori Action Research to improve heart disease services in Aotearoa,New Zealand

Action Research can be a powerful tool for change and improvement in health services for indigenous people when utilised within an appropriate framework. The project Maori Utilisation & Experience of Ischaemic Heart Disease Management illustrates this convergence in its use of Kaupapa Maori Action Research methods in its efforts to improve the health and well-being of Maori within the northern region of Aotearoa/New Zealand. We outline the research processes and outcomes obtained through the application of ‘by Maori for Maori’ approaches to understanding Maori pathways and barriers to care for ischaemic heart disease. Maori understandings of their illness and experiences of treatment, and healthcare providers' perspectives on care of Maori with ischaemic heart disease, were combined into Maori-led actions to improve service provision. The paper examines critical factors in an action research approach to health service innovations and implications for efforts to reduce entrenched health disparities.     

The first sunrise: an experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand

CONTEXT: Cultural factors in health and illness, and an awareness of community health needs analysis, are important issues for medical education. Both have received relatively little recognition in the medical education literature. This paper describes the development of an educational attachment to remote predominantly Maori rural communities in New Zealand. The twin purposes of the programme were to encourage students to adopt broad public health approaches in assessing the health needs of defined communities, and to increase their awareness of the importance of cultural issues. METHODS: During a one week attachment, 51 students from the Wellington School of Medicine were hosted in six small communities in the East Cape region of New Zealand. Students gained an insight into the health needs of the communities and were encouraged to challenge their own attitudes, assumptions and thinking regarding the determinants of health and the importance of cultural factors in health and illness. The programme included both health needs assessment and cultural immersion. Students made visits with primary health care professionals and were also introduced to Maori history and cultural protocol, and participated in diverse activities ranging from the preparation of traditional medicines to performing their own songs in concert. CONCLUSIONS: The students evaluated the course extremely highly. Attachments of this sort provide an opportunity for students to appreciate how cultural values have an impact on health care, and how they also make the teaching and learning of topics such as community health needs analysis an enjoyable and dynamic experience.     

Analysis of Medicine Prices in New Zealand and 16 European Countries

ObjectiveTo compare prices of medicines, both originators and generics, in New Zealand and 16 European countries.MethodsEx-factory price data as of December 2012 from New Zealand and 16 European countries were compared for a basket of 14 medicines, most of which were at least partially funded by the state in the 17 countries. Five medicines had, at least in some countries, generic versions on the market whose prices were also analyzed. Medicine price data for the 16 European countries were provided by the Pharma Price Information service. New Zealand medicine prices were retrieved from the New Zealand Pharmaceutical Schedule. Unit prices converted into euro were compared at the ex-factory price level.ResultsFor the 14 medicines surveyed, considerable price differences at the ex-factory price level were identified. Within the European countries, prices in Greece, Portugal, the United Kingdom, and Spain ranked at the lower end, whereas prices in Switzerland, Germany, Denmark, and Sweden were at the upper end. The results for New Zealand compared with Europe were variable. New Zealand prices were found in the lowest quartile for five medicines and in the highest quartile for seven other products. Price differences between the originator products and generic versions ranged from 0% to 90% depending on the medicine and the country.ConclusionsMedicine prices varied considerably between European countries and New Zealand as well as among the European countries. These differences are likely to result from national pricing and reimbursement policies.     

Reduction in Organochlorine Levels in the Milk of New Zealand Women

In this study, the authors investigated whether measures taken to reduce exposures subsequent to 1988 led to detectable reductions in levels of persistent organochlorine compounds in milk samples of New Zealand women collected in 1998-1999. The procedures and selection criteria used in a 1987-1988 study were replicated. Participants (n = 53) completed a questionnaire and provided a milk sample, which the authors analyzed for polychlorinated dibenzo-p-dioxins and dibenzofurans, polychlorinated biphenyl congeners, and organochlorine pesticides. Levels of most compounds measured in this study declined approximately 70% from their 1987-1988 values. Levels were low, compared with those found in similar studies from other countries. These results provide evidence that exposure of New Zealand women to organochlorine substances has substantially declined, suggesting that policy measures to reduce exposures have been effective.     

Immediate placement of intrauterine devices after first and second trimester pregnancy termination

Background

We reviewed our experience with intrauterine device (IUD) placement after surgical abortion up to 20 weeks' gestation.

Study Design

Women presenting for elective abortion between January 2004 and March 2009 who requested an IUD were included in this retrospective review.

Results

Of 308 women requesting postabortion IUD placement, 221 (72%) planned insertion at the time of abortion (immediate group) and 87 (28%) planned insertion at their postoperative visit (interval group). IUDs were placed in 96% of the immediate group and in 23% of the interval group (212/221 vs. 20/87; p<.0001). Failure to return for placement was the most common reason for noninsertion in the interval group (60/87=69%). Follow-up information was obtained for 56% of patients and was documented a median of 137 days postabortion (range 3–1594 days). There was no difference in complication rates between groups. Expulsion rates were 3% and 0% in the immediate and interval groups, respectively (6/212 vs. 0/20; p=.4). Considering only those with documented follow-up after immediate insertion (119), there was a nonsignificant trend towards increased expulsion with placement after second vs. first trimester abortion (4/54=7% vs. 2/65=2%; p=.3). When analyzing the 172 subjects with documented follow-up, those planning immediate insertion were more likely to have an IUD in situ at the last contact than those planning later insertion (84/124=68% vs. 20/48=42%; p=.002).

Conclusion

Immediate postabortion IUD insertion is safe and effective. Given the low rate of return for interval insertion, immediate placement may be preferable.     

Evaluation of the New Zealand Heart Food Festival 1988-9

A nationwide program of labelling of food products with hearthealth logos commenced in New Zealand in September 1988 withan inaugural Heart Food Festival (HFF). Four independent-samplesurveys of approximately 1000 consumers in twenty supermarketsthroughout New Zealand were conducted in September (prior tothe HFF), October and November 1988, and in March 1989. The results show that there were statistically significant increasesin consumers' awareness of the HFF which were maintained untilthe end of the evaluation phase. There was a positive and enduringresponse to the heart health logos, for example, from Octoberonwards a quarter of shoppers bought products with the logo;30% of women shoppers indicated that the HFF program had influencedthem to change their diets and 25% of them reported in March1989 that they purposely sought food products with the logo.At the September baseline only 18% of consumers correctly interpretedthe meaning of the logo; in subsequent evaluations one-thirdof them could do so. Consumers' dietary concerns did not appear to change duringthe study; over half reported that reduced fat intake was amajor priority for them. The findings suggest that HFF programs may have considerableimpact on consumers' awareness and food-related behaviours.However, greater efforts are required to ensure adequate suppliesof in-store information materials and sales staff educationas well as more appropriate targetting of responsive groups(e.g. women and over 45 year olds) and less responsive groups(men and younger people).     

初产妇子痫前期发病风险与前次妊娠早孕期经过相关性的Meta分析

目的 荟萃分析研究前次妊娠早孕期经过对于初产妇子痫前期(Preeclampsia, PE)发病风险的影响。方法 通过检索Pubmed、Cochrane Library以及Embase数据库2021年前的相关研究,纳入涉及前次早期妊娠经过与PE发病风险的相关文献,从中筛选出11篇文献进行Meta分析。用固定效应模型分析PE发病风险,采用Begg’s检验和Egger检验分析发表偏倚。统计学软件采用STATA 15.0。结果 共11篇文献纳入Meta分析,均为回顾性研究即病例对照研究。结果显示,对于初产妇而言,前次正常妊娠早孕期经过可能降低PE的发病风险[比值比(odd ratio,OR)=0.86,95%置信区间(confidence interval,CI)=0.81-0.91,I²=47.4%],而既往自然流产史对于PE发病无保护作用(OR=1.00,95%CI=0.95-1.06,I²=29%)。无明显发表偏倚。结论 前次妊娠早孕期正常经过或可降低PE发病风险,即妊娠早期可能已经产生“记忆”,对未来的妊娠起到保护作用。     

Post abortion contraception and its effect on repeat abortions in Auckland, New Zealand

Background

Many misconceptions still prevail about the appropriateness of use of the intrauterine device (IUD), particularly for younger women. This study examines the factors associated with post abortion IUD use as compared to the combined oral contraceptive pill (COC). It then examines the effect of type of post abortion contraception with the likelihood of seeking subsequent abortions.

Study design

This prospective cohort study followed, for a period of 3 years, 1422 women who had a first trimester surgical abortion between November 2004 and January 2005 in Auckland's public abortion clinic.

Results

Compared to women who left the clinic with COC, those leaving with an IUD (OR 0.3) at baseline were less likely to return for a subsequent abortion. Among women who had not had a previous termination, younger women were less likely than older women to have had an IUD inserted post abortion. With every additional live birth, women were three times as likely to have left the abortion clinic with an IUD. Among women who had had a previous termination, age was no longer significantly associated with post abortion IUD insertion. However, parity was still significantly associated, as was having a negative sexually transmitted infection test.

Conclusions

Young and nulliparous women are less likely to use an IUD as a method of contraception following an abortion. However, those women who have an IUD inserted following an abortion are much less likely to return for a subsequent abortion. IUDs are a safe and effective method of contraception that are currently still underused among the younger population.     

Key opportunities for sodium reduction in New Zealand processed foods

Objective: To identify key opportunities for reformulation of processed foods that could best decrease population sodium intakes in New Zealand (NZ). Method: Relevant national literature and reports were used to identify major food groups contributing to population sodium intakes in NZ. Sodium content data for these food groups were collected from the Nutrition Information Panels of processed foods in one large supermarket. Key opportunities for reformulation were identified by comparing mean sodium content with 2012 targets from the United Kingdom (UK) Food Standards Agency (FSA) and mean sodium values from Australia and the UK. Results: Major contributors to NZ sodium intakes are: bread (26%), processed meats (10%), and sauces (6%). Mean (SD) sodium contents of these processed foods were: 447 (125) mg/100 g, 1,169 (444) mg/100 g, and 1,046 (1,235) mg/100 g, respectively. Food categories with the lowest percentage of products meeting corresponding FSA targets were: sausages/hot dogs and sliced meat (0%); salami/cured meat (2%); liquid meal‐based sauces (4%); and multigrain bread (14%). Mean sodium contents of NZ products were higher than for similar products in the UK. Key opportunities identified for sodium reduction were: white bread, sausages and hot dogs, and salami/cured meats. Conclusion: There is substantial scope to reduce the sodium content of NZ processed foods. Implications: This paper identifies three key opportunities for reformulation of processed foods that could produce substantial decreases in sodium intakes in NZ, and benefits to population health.