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Family planning is considered an important tool in averting maternal deaths and ensuring women’s reproductive needs are met.1 The need for family planning is supported by data which shows that an estimated 35% of all maternal deaths could be avoided if unintended births were prevented. Specifically, the WHO recommends that no unmet need for family planning should exist, meaning that women who do not wish to have any (more) children are able to access family planning methods.2 Reasons for non-use of modern contraceptive methods have been stated to be largely due to access issues.3,4 This view argues that if family planning methods were made more accessible then unmet need would decrease.

Access to family planning is considered a human rights issue.5 Along with health and wellbeing, lack of access to family planning has social and economic ramifications. Ensuring family planning accessibility warrants individuals with the opportunity to be in control of when to have or limit the number and timing of children, giving them the autonomy and self-preservation that is needed for the maintenance of good health. Given the financial challenges associated with supporting a growing family, being able to control family size can contribute to greater financial stability.6,7

Although access to family planning is considered more problematic in developing countries where resources are low, minority groups in developed countries experience disproportionately lower uptake of family planning services.8,9 Among Pacific populations in New Zealand, this is the case. In New Zealand, high teenage pregnancy and low use of contraception characterise Pacific reproductive behaviour.10,11 Despite these outcomes, little is known about Pacific women’s family planning unmet need and access. High national contraceptive prevalence estimates of 72.4% do not seem to reflect the Pacific experience.12 Furthermore, unmet need in New Zealand is reported to be 8.8%, low in comparison to other countries in the developed world.12

Thus, there seems to be a disconnect between the overall patterns of contraceptive use and unmet need and the reported experience of Pacific populations in New Zealand. The effects of teenage pregnancy and lack of contraceptive use found among Pacific groups can lead to long-term disability as a result of pregnancy and labour, and socio-economic deprivation as a result of teenage pregnancy.13,14 Therefore, lack of access and uptake of family planning not only has implications on the individual but on future generations.

Most studies in New Zealand of Pacific women’s reproductive health behaviour highlight the need for more understanding into social and cultural barriers to reproductive services, as most found cultural sensitivities and taboos to be barriers to access.15,16 Paterson’s study of a group of Pacific mothers found that due to cultural taboos and sensitivities, most women who did not plan their pregnancy were not aware of family planning and did not like discussing the topic.17

Given these findings, little has been done to try to capture behaviour involved with reproductive intentions and family planning use. Unmet need investigations give us that link and quantifies the proportion of women whose family planning needs are not being met. Furthermore, although previous studies of reproductive behaviour highlight the need for more understanding of socio-cultural factors associated with uptake, more research is needed to identify what these factors entail and how cultural barriers might change within the New Zealand context.

This study investigates the unmet need of a group of Pacific women, iTaukei or indigenous Fijian and the main barriers to health services. The study draws on the experience of iTaukei women in Fiji to provide insight into unmet need and access changes that might occur among iTaukei in New Zealand.

Methods

Design setting

Between 2012 and 2013, a cross-sectional survey of women’s family planning knowledge, attitudes and practice (KAP), unmet need and access was carried out in Fiji and New Zealand to investigate iTaukei women’s family planning behaviour. The data presented in this paper focuses on the unmet need and access data from the KAP study. Women who identified as being iTaukei and living in the five major cities of New Zealand—Auckland, Hamilton, Wellington, Christchurch and Dunedin, and in three suburbs in Suva—Samabula, Valelevu and Cunningham, were invited to participate in the study. Only women 18 years and above were included in the survey. If women were under the age of 18 or did not identify as being iTaukei, ie, they were Indian or another ethnic group, they were not included in the survey.

Sample

The sample size goal for the survey was 200 women in each country. This number was needed in order to obtain at least 163 completed questionnaires (ie, approximately 80% response rate) in each country which would allow the study 80% power to detect a statistically significant (p<0.05) difference of 15% between countries in the proportion of women who have used family planning, if this proportion was up to 40% in Fiji and higher in New Zealand.12,18 Multistage cluster sampling carried out in Fiji was based on household income and to ensure representativeness. Given the challenges with generating representative samples among minority groups and hard to reach groups in New Zealand, snowball sampling techniques were employed in New Zealand to get as many women involved in the study as we could. Women in New Zealand were recruited through community networks, social media and Pacific organisations.

Ethics

Ethical approval was granted by the Fiji National Health Research Council and the Human Ethics Committee of the University of Otago. Approval for working in communities in the Suva area was also granted by the Ministry of iTaukei affairs. Participants were provided with information sheets prior to filling in surveys. Questionnaires were self-administered to ensure privacy and confidentiality. Cultural protocols and sensitivities were observed with data collected by iTaukei researchers.

Survey questionnaire

To identify unmet need in the samples, the definition presented by Bradley et al (2012) was used to inform survey questions.19 These included women’s family planning use, pregnancy intentions and fecundity. Demographic, sexual and reproductive health surveys in the Pacific were also used to inform questions in the survey. To ascertain women’s experience with access, women were asked to indicate whether they found particular access factors, eg, cost, travel, spousal communication and health provider characteristics, to be problematic. The survey questionnaire was available in both the English and Fijian languages.

Analysis

Analysis of the survey data was carried out using Stata 13 statistical software. Data from each country was analysed separately to identify unmet need and access and then comparatively between countries to see if there were any differences in unmet need and access patterns. The Bradley et al (2012) definition was used as a framework to analyse unmet need in each country.19 Women who were not using family planning methods were classified as having an unmet need for spacing if they did not wish to have any (more) children in the next two years, while those who did not wish to have any more children in the future were classified as having an unmet need for limiting. Unmet need was only assessed among married women or women in a relationship.19

Women were asked to indicate whether the following access factors were problematic when accessing medical advice or treatment: knowing where to go, getting money to go, not having a facility nearby, having to find transport, not wanting to go alone, concern there may not be a female provider, talking to your husband/partner about it. Chi-square tests of statistical significance were used for comparison of unmet need and access factors between countries.

Results

Overall, 352 women filled in a survey questionnaire. A higher response rate was observed in Fiji as 212 women (out of the 220 approached) or 96% filled in a survey, while 140 (out of the 235 approached) or 60% filled a questionnaire in New Zealand. Overall, 249 (70%) women were either married or in a relationship and eligible to be included in the unmet need analysis. The mean age of women in New Zealand was 39 while in Fiji the average age of women was 36 years. Fifty-one percent of women in New Zealand had used a family planning method at the time of the survey. In Fiji, 58% of women had used a method. Among currently married women (or women in a relationship) in New Zealand, 26% had an unmet need for family planning. Of these, 25% had an unmet need for spacing while 75% for limiting (Table 1). In Fiji, 25% of women had an unmet need for family planning. Of these, a higher proportion had an unmet need for limiting (86%) compared with spacing (14%) (Table 1).

Table 1: Unmet need in Fiji and New Zealand among currently married women; n (%).*

*n is the number of women with an unmet need; % uses the total number of currently married women, including women in a relationship as the denominator.
†Missing information for limiting and spacing Fjii n=2, NZ n=1.
Note: p values were calculated using the Pearson chi-squared test.

Unmet need characteristics

One fifth of the currently married women with a primary and/secondary qualification in New Zealand had an unmet need while about a third in Fiji with a primary or secondary school qualification had an unmet need for family planning (Table 2). Conversely, a higher proportion of women with a tertiary qualification in New Zealand had an unmet need (30%) compared with Fiji (18%). This difference however, was not statistically significant. The in-country differences between primary/secondary and tertiary qualification should be noted as well. In Fiji, more women with a primary/secondary qualification had an unmet need for family planning (31%) compared with women who had achieved a tertiary qualification (18%). In New Zealand, more women with a tertiary qualification had an unmet need (30%) compared to those who had a primary and/or secondary qualification (21%) (Table 2).

Table 2: Unmet need by characteristics in Fiji and New Zealand; n (%).*

*n is the number of women with an unmet need; % uses the total number of currently married women, including women in a relationship as the denominator in each categorical grouping.
Notes: P values calculated without missing numbers; calculations were carried out using Pearson chi-squared test.

Main barriers to accessing family planning services

Table 3 presents the findings from analyses involving access among women in both countries. About half of the women in Fiji found getting money to attend a health facility and concern there may not be a female provider to be problematic. Similarly in New Zealand, almost half of the women identified financial barriers to attending a health facility a problem (49%). The next most problematic factor appeared to be concern there may not be a female provider (36%). The proportion of women not having a health facility nearby was significantly different between countries. More women in Fiji (39%) had a problem with having facilities nearby compared to those in New Zealand (22%) (p=0.002) (Table 3). Similarly, more women in Fiji reported having problems with concerns about not having female providers compared with New Zealand (p=0.010). The number of women reporting having problems with talking to husbands about health issues was higher among women living in Fiji (31%) compared with New Zealand (16%) (p=0.004) (Table 3).

Table 3: Factors affecting women’s access to health services.

Note: p values were calculated using a Pearson chi-squared test, n (%).

Discussion

Unmet need

The unmet need among iTaukei women in New Zealand was 26%, about three times the national estimate of 8.8%.12 The difference between national figures and the figures found in the current study reflect the need for further investigation into minority Pacific groups in New Zealand and reflect similar patterns in other developed countries. In the US, minority women have been found to have lower contraceptive use rates compared to the national figures.20 In a study investigating ethnic variations in sexual activity and contraceptive use from a national cross-sectional survey in Britain, minority ethnic groups were found to have significantly lower contraceptive use rates compared to Caucasian women.21

Calculations in the current study referred to any family planning method that women might be using, therefore unmet need calculations accounted for traditional methods as well as modern contraceptive methods. Thus, unmet need for modern contraception may be greater among this population and given the low reliability of traditional methods, total unmet need may be higher as well. This is important to consider given how young the Pacific population is in New Zealand and the high rates of teenage pregnancy.10

Comparatively unmet need among iTaukei women in New Zealand was similar to proportions found in Fiji. This is important to consider in light of the different level of resources available in each country and their specific economic contexts. The unmet need in both countries was similar to those found in West Africa and higher than estimates in the developing world (12.8%).12

Most of the unmet need found in this study referred to limiting the number of children rather than spacing and is supported by other research which found women preferred to use family planning to limit rather than for spacing.19,22 The higher unmet need associated with limiting may be due to the age structures of the samples. Studies have found that as age increases and women have more children, unmet need for spacing decreases while unmet need for limiting increases.19 In the current study, given the older age structures of the sample, it is likely that women may have reached their ideal family size and did not want any more children.

The finding that unmet need among primary/secondary qualified women is higher compared with those with tertiary education is supported by the literature.19,23 Therefore, the higher unmet need found in New Zealand among those with tertiary education is interesting and reflects similar findings to those found in the Democratic Republic of Congo, Guinea, Mali and Niger, where unmet need was found to increase with women’s education. In these countries, researchers found that women with higher education were more likely to live in urban areas and were found to have similar levels of unmet need, compared with those who live in rural areas.19 It is likely that, in the current study, because women were recruited from the major urban cities, higher unmet need among this group maybe due to work commitments and costs associated with a higher standard of living in urban areas. Therefore, the extra costs of raising children and career commitments may be motivators for women to desire to limit having children. Access barriers such as cost and inconvenience (time) may further add to unmet need among this group.

Health service access

Cost and concern that there may not be a female provider were problematic among most women in both countries. For women in developing countries like Fiji, studies show cost to be a significant barrier.24,25 Given that over one third of the participants in Fiji found not having transport to be a problem, having facilities far away would provide further challenges for access. The longer the distance to the health facility, the higher the cost of travel, further burdening women and limiting their likelihood of accessing family planning services.26 Although transport and distances were not as problematic for New Zealand participants, costs of GP visit and commodities may be a burden for iTaukei women living in New Zealand. Research in New Zealand among Pacific populations have found cost to be a significant barrier in accessing health services.27,28 Given the relative availability of resources in New Zealand, questions regarding effectiveness and targeting of services is warranted. Accessing subsidised services, eg, family planning clinics, needs to be effectively promoted among those who may find seeing a primary health provider, eg, general practitioner, too expensive.

Concern there may not be a female provider is an important finding as it highlights sensitivities around privacy and cultural values and belief systems. These concerns show that women are likely to feel more comfortable having female providers over male providers, especially when it comes to reproduction and sexuality. This finding reiterates the concerns highlighted by other Pacific research around the need for more understanding into the cultural barriers associated with accessing health services and further highlights the relevance of traditional gender roles within the reproductive patient-provider relationship in New Zealand.17,29–30

Perhaps ensuring that primary health care practitioners are trained in providing services that are culturally sensitive and inclusive of the respect and sacredness that sexual and reproductive issues require may be needed to improve cultural awareness and competencies in service delivery. Jameson and colleagues (1999) found that Pacific women’s barriers to cervical screening included being apprehensive about cultural backgrounds, embarrassment and confidentiality. The study highlighted the lack of discussion of such topics in the family and the effect that this might have on health.15 For women to discuss family planning intentions or experiences, women need to be able to feel comfortable and trust their health practitioner. Understanding traditional gendered roles and the effect that this might have on women’s perception of male providers is important to consider among Pacific women and their ability to access services. Improving community education about the importance of such concerns to health practitioners and the steps the health system is taking to ensure women’s matters are respected and remain confidential will help improve relationships and trust with health providers, leading to greater accessibility of these services among Pacific women.

The findings in this study should be considered in light of its limitations. Unmet need was measured among married women or women in long-term relationships, and so therefore, did not account for the unmet need among women who may be single and sexually active. It is likely that the rate of unmet need maybe an underestimation of the true unmet need in this population. Furthermore, given that the sampling strategy employed in New Zealand was a snowball sample, the findings are limited to older women and may not reflect younger women’s unmet need. Therefore, further research is needed to investigate the unmet need and access barriers among younger women in both countries.

In conclusion, the study shows that in New Zealand, unmet need among iTaukei Pacific women is more prevalent than existing data show and has implications on other minority Pacific groups. Regardless of whether women lived in Fiji or New Zealand, financial and cultural barriers challenged women’s access to services. In New Zealand, better targeting of services is needed to ensure that minority groups like the iTaukei benefit from the greater availability of resources. Furthermore, addressing the financial and cultural barriers may lead to greater access of services and lower unmet need.

Summary

Abstract

Aim

The aim of the study was to identify unmet need and family planning access among indigenous Fijian or iTaukei women living in New Zealand and Fiji.

Method

A cross-sectional survey was undertaken between 2012-2013 in five major cities in New Zealand: Auckland, Hamilton, Wellington, Christchurch and Dunedin; and in three suburbs in Fiji. Women who did not want any (more) children but were not using any form of contraception were defined as having an unmet need. Access experiences involving cost and health provider interactions were assessed.

Results

Unmet need in New Zealand was 26% and similar to the unmet need found in Fiji (25%). Cost and concern over not being seen by a female provider were the most problematic access factors for women.

Conclusion

There is a need for better monitoring and targeting of family planning services among minority Pacific groups, as the unmet need found in New Zealand was three times the national estimate overall and similar to the rate found in Fiji. Cost remains a problem among women trying to access family planning services. Gendered traditional roles in sexual and reproductive health maybe an area from which more understanding into cultural sensitivities and challenges may be achieved.

Author Information

Radilaite Cammock, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland; Peter Herbison, Preventive and Social Medicine, University of Otago, Dunedin; Sarah Lovell, School of Health Sciences, University of Canterbury, Christchurch;-Patricia Priest, Preventive and Social Medicine, University of Otago, Dunedin.

Acknowledgements

Correspondence

Dr Radilaite Cammock, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland.

Correspondence Email

radilaite.cammock@aut.ac.nz

Competing Interests

Dr Cammock and Dr Priest report grants from New Zealand Health Research Council during the conduct of the study.

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  2. Singh S, Darroch J. Adding it Up: Costs and Benefits of Contraceptive Services - Estimates for 2012. New York: Guttmacher Institute and United Nations Population Fund (UNFPA). 2012.
  3. Casterline J, Sathar Z, ul Haque M. Obstacles to contraceptive use in Pakistan: a study in Punjab. Studies in Family Planning. 2001; 32(2):95–110.
  4. McIntosh J, Tsikitas L, Dennis A. Low-income women’s access to contraception after health care reform in Massachusetts. Journal of the American Pharmacists Association. 2012; 52(3):349–357.
  5. Newman K, Feldman-Jacobs C. Family Planning and Human Rights – What’s the connection and why is it important, Population Reference Bureau. 2015.
  6. Greenhalgh S, Winckler E. Governing China’s Population: From Leninist to Neoliberal Biopolitics. Stanford: Stanford University Press. 2005.
  7. Mason K. Explaining Fertitlity Transitions. Demography. 1997; 34(4):443–454.
  8. Dehlendorf C, Rodriguez MI, Levy K, et al. Disparities in family planning. American Journal of Obstetrics and Gynecology. 2010; 202(3):214–220.
  9. Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006; 38:90–96.
  10. National Institute of Demographic and Economic Analysis, University of Waikato. Current Trends for Teenage Births in New Zealand. 2015.
  11. Paterson J, Tukuitonga C, Abbott M, et al. Pacific Islands Families: First Two Years of Life Study - design and methodology. N Z Med J. 2006; 119:U1814.
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  16. Lovell S, Kearns RA, Friesen W. Sociocultural barriers to cervical screening in South Auckland, New Zealand. Social Science & Medicine. 2007; 65(1):138–150.
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Family planning is considered an important tool in averting maternal deaths and ensuring women’s reproductive needs are met.1 The need for family planning is supported by data which shows that an estimated 35% of all maternal deaths could be avoided if unintended births were prevented. Specifically, the WHO recommends that no unmet need for family planning should exist, meaning that women who do not wish to have any (more) children are able to access family planning methods.2 Reasons for non-use of modern contraceptive methods have been stated to be largely due to access issues.3,4 This view argues that if family planning methods were made more accessible then unmet need would decrease.

Access to family planning is considered a human rights issue.5 Along with health and wellbeing, lack of access to family planning has social and economic ramifications. Ensuring family planning accessibility warrants individuals with the opportunity to be in control of when to have or limit the number and timing of children, giving them the autonomy and self-preservation that is needed for the maintenance of good health. Given the financial challenges associated with supporting a growing family, being able to control family size can contribute to greater financial stability.6,7

Although access to family planning is considered more problematic in developing countries where resources are low, minority groups in developed countries experience disproportionately lower uptake of family planning services.8,9 Among Pacific populations in New Zealand, this is the case. In New Zealand, high teenage pregnancy and low use of contraception characterise Pacific reproductive behaviour.10,11 Despite these outcomes, little is known about Pacific women’s family planning unmet need and access. High national contraceptive prevalence estimates of 72.4% do not seem to reflect the Pacific experience.12 Furthermore, unmet need in New Zealand is reported to be 8.8%, low in comparison to other countries in the developed world.12

Thus, there seems to be a disconnect between the overall patterns of contraceptive use and unmet need and the reported experience of Pacific populations in New Zealand. The effects of teenage pregnancy and lack of contraceptive use found among Pacific groups can lead to long-term disability as a result of pregnancy and labour, and socio-economic deprivation as a result of teenage pregnancy.13,14 Therefore, lack of access and uptake of family planning not only has implications on the individual but on future generations.

Most studies in New Zealand of Pacific women’s reproductive health behaviour highlight the need for more understanding into social and cultural barriers to reproductive services, as most found cultural sensitivities and taboos to be barriers to access.15,16 Paterson’s study of a group of Pacific mothers found that due to cultural taboos and sensitivities, most women who did not plan their pregnancy were not aware of family planning and did not like discussing the topic.17

Given these findings, little has been done to try to capture behaviour involved with reproductive intentions and family planning use. Unmet need investigations give us that link and quantifies the proportion of women whose family planning needs are not being met. Furthermore, although previous studies of reproductive behaviour highlight the need for more understanding of socio-cultural factors associated with uptake, more research is needed to identify what these factors entail and how cultural barriers might change within the New Zealand context.

This study investigates the unmet need of a group of Pacific women, iTaukei or indigenous Fijian and the main barriers to health services. The study draws on the experience of iTaukei women in Fiji to provide insight into unmet need and access changes that might occur among iTaukei in New Zealand.

Methods

Design setting

Between 2012 and 2013, a cross-sectional survey of women’s family planning knowledge, attitudes and practice (KAP), unmet need and access was carried out in Fiji and New Zealand to investigate iTaukei women’s family planning behaviour. The data presented in this paper focuses on the unmet need and access data from the KAP study. Women who identified as being iTaukei and living in the five major cities of New Zealand—Auckland, Hamilton, Wellington, Christchurch and Dunedin, and in three suburbs in Suva—Samabula, Valelevu and Cunningham, were invited to participate in the study. Only women 18 years and above were included in the survey. If women were under the age of 18 or did not identify as being iTaukei, ie, they were Indian or another ethnic group, they were not included in the survey.

Sample

The sample size goal for the survey was 200 women in each country. This number was needed in order to obtain at least 163 completed questionnaires (ie, approximately 80% response rate) in each country which would allow the study 80% power to detect a statistically significant (p<0.05) difference of 15% between countries in the proportion of women who have used family planning, if this proportion was up to 40% in Fiji and higher in New Zealand.12,18 Multistage cluster sampling carried out in Fiji was based on household income and to ensure representativeness. Given the challenges with generating representative samples among minority groups and hard to reach groups in New Zealand, snowball sampling techniques were employed in New Zealand to get as many women involved in the study as we could. Women in New Zealand were recruited through community networks, social media and Pacific organisations.

Ethics

Ethical approval was granted by the Fiji National Health Research Council and the Human Ethics Committee of the University of Otago. Approval for working in communities in the Suva area was also granted by the Ministry of iTaukei affairs. Participants were provided with information sheets prior to filling in surveys. Questionnaires were self-administered to ensure privacy and confidentiality. Cultural protocols and sensitivities were observed with data collected by iTaukei researchers.

Survey questionnaire

To identify unmet need in the samples, the definition presented by Bradley et al (2012) was used to inform survey questions.19 These included women’s family planning use, pregnancy intentions and fecundity. Demographic, sexual and reproductive health surveys in the Pacific were also used to inform questions in the survey. To ascertain women’s experience with access, women were asked to indicate whether they found particular access factors, eg, cost, travel, spousal communication and health provider characteristics, to be problematic. The survey questionnaire was available in both the English and Fijian languages.

Analysis

Analysis of the survey data was carried out using Stata 13 statistical software. Data from each country was analysed separately to identify unmet need and access and then comparatively between countries to see if there were any differences in unmet need and access patterns. The Bradley et al (2012) definition was used as a framework to analyse unmet need in each country.19 Women who were not using family planning methods were classified as having an unmet need for spacing if they did not wish to have any (more) children in the next two years, while those who did not wish to have any more children in the future were classified as having an unmet need for limiting. Unmet need was only assessed among married women or women in a relationship.19

Women were asked to indicate whether the following access factors were problematic when accessing medical advice or treatment: knowing where to go, getting money to go, not having a facility nearby, having to find transport, not wanting to go alone, concern there may not be a female provider, talking to your husband/partner about it. Chi-square tests of statistical significance were used for comparison of unmet need and access factors between countries.

Results

Overall, 352 women filled in a survey questionnaire. A higher response rate was observed in Fiji as 212 women (out of the 220 approached) or 96% filled in a survey, while 140 (out of the 235 approached) or 60% filled a questionnaire in New Zealand. Overall, 249 (70%) women were either married or in a relationship and eligible to be included in the unmet need analysis. The mean age of women in New Zealand was 39 while in Fiji the average age of women was 36 years. Fifty-one percent of women in New Zealand had used a family planning method at the time of the survey. In Fiji, 58% of women had used a method. Among currently married women (or women in a relationship) in New Zealand, 26% had an unmet need for family planning. Of these, 25% had an unmet need for spacing while 75% for limiting (Table 1). In Fiji, 25% of women had an unmet need for family planning. Of these, a higher proportion had an unmet need for limiting (86%) compared with spacing (14%) (Table 1).

Table 1: Unmet need in Fiji and New Zealand among currently married women; n (%).*

*n is the number of women with an unmet need; % uses the total number of currently married women, including women in a relationship as the denominator.
†Missing information for limiting and spacing Fjii n=2, NZ n=1.
Note: p values were calculated using the Pearson chi-squared test.

Unmet need characteristics

One fifth of the currently married women with a primary and/secondary qualification in New Zealand had an unmet need while about a third in Fiji with a primary or secondary school qualification had an unmet need for family planning (Table 2). Conversely, a higher proportion of women with a tertiary qualification in New Zealand had an unmet need (30%) compared with Fiji (18%). This difference however, was not statistically significant. The in-country differences between primary/secondary and tertiary qualification should be noted as well. In Fiji, more women with a primary/secondary qualification had an unmet need for family planning (31%) compared with women who had achieved a tertiary qualification (18%). In New Zealand, more women with a tertiary qualification had an unmet need (30%) compared to those who had a primary and/or secondary qualification (21%) (Table 2).

Table 2: Unmet need by characteristics in Fiji and New Zealand; n (%).*

*n is the number of women with an unmet need; % uses the total number of currently married women, including women in a relationship as the denominator in each categorical grouping.
Notes: P values calculated without missing numbers; calculations were carried out using Pearson chi-squared test.

Main barriers to accessing family planning services

Table 3 presents the findings from analyses involving access among women in both countries. About half of the women in Fiji found getting money to attend a health facility and concern there may not be a female provider to be problematic. Similarly in New Zealand, almost half of the women identified financial barriers to attending a health facility a problem (49%). The next most problematic factor appeared to be concern there may not be a female provider (36%). The proportion of women not having a health facility nearby was significantly different between countries. More women in Fiji (39%) had a problem with having facilities nearby compared to those in New Zealand (22%) (p=0.002) (Table 3). Similarly, more women in Fiji reported having problems with concerns about not having female providers compared with New Zealand (p=0.010). The number of women reporting having problems with talking to husbands about health issues was higher among women living in Fiji (31%) compared with New Zealand (16%) (p=0.004) (Table 3).

Table 3: Factors affecting women’s access to health services.

Note: p values were calculated using a Pearson chi-squared test, n (%).

Discussion

Unmet need

The unmet need among iTaukei women in New Zealand was 26%, about three times the national estimate of 8.8%.12 The difference between national figures and the figures found in the current study reflect the need for further investigation into minority Pacific groups in New Zealand and reflect similar patterns in other developed countries. In the US, minority women have been found to have lower contraceptive use rates compared to the national figures.20 In a study investigating ethnic variations in sexual activity and contraceptive use from a national cross-sectional survey in Britain, minority ethnic groups were found to have significantly lower contraceptive use rates compared to Caucasian women.21

Calculations in the current study referred to any family planning method that women might be using, therefore unmet need calculations accounted for traditional methods as well as modern contraceptive methods. Thus, unmet need for modern contraception may be greater among this population and given the low reliability of traditional methods, total unmet need may be higher as well. This is important to consider given how young the Pacific population is in New Zealand and the high rates of teenage pregnancy.10

Comparatively unmet need among iTaukei women in New Zealand was similar to proportions found in Fiji. This is important to consider in light of the different level of resources available in each country and their specific economic contexts. The unmet need in both countries was similar to those found in West Africa and higher than estimates in the developing world (12.8%).12

Most of the unmet need found in this study referred to limiting the number of children rather than spacing and is supported by other research which found women preferred to use family planning to limit rather than for spacing.19,22 The higher unmet need associated with limiting may be due to the age structures of the samples. Studies have found that as age increases and women have more children, unmet need for spacing decreases while unmet need for limiting increases.19 In the current study, given the older age structures of the sample, it is likely that women may have reached their ideal family size and did not want any more children.

The finding that unmet need among primary/secondary qualified women is higher compared with those with tertiary education is supported by the literature.19,23 Therefore, the higher unmet need found in New Zealand among those with tertiary education is interesting and reflects similar findings to those found in the Democratic Republic of Congo, Guinea, Mali and Niger, where unmet need was found to increase with women’s education. In these countries, researchers found that women with higher education were more likely to live in urban areas and were found to have similar levels of unmet need, compared with those who live in rural areas.19 It is likely that, in the current study, because women were recruited from the major urban cities, higher unmet need among this group maybe due to work commitments and costs associated with a higher standard of living in urban areas. Therefore, the extra costs of raising children and career commitments may be motivators for women to desire to limit having children. Access barriers such as cost and inconvenience (time) may further add to unmet need among this group.

Health service access

Cost and concern that there may not be a female provider were problematic among most women in both countries. For women in developing countries like Fiji, studies show cost to be a significant barrier.24,25 Given that over one third of the participants in Fiji found not having transport to be a problem, having facilities far away would provide further challenges for access. The longer the distance to the health facility, the higher the cost of travel, further burdening women and limiting their likelihood of accessing family planning services.26 Although transport and distances were not as problematic for New Zealand participants, costs of GP visit and commodities may be a burden for iTaukei women living in New Zealand. Research in New Zealand among Pacific populations have found cost to be a significant barrier in accessing health services.27,28 Given the relative availability of resources in New Zealand, questions regarding effectiveness and targeting of services is warranted. Accessing subsidised services, eg, family planning clinics, needs to be effectively promoted among those who may find seeing a primary health provider, eg, general practitioner, too expensive.

Concern there may not be a female provider is an important finding as it highlights sensitivities around privacy and cultural values and belief systems. These concerns show that women are likely to feel more comfortable having female providers over male providers, especially when it comes to reproduction and sexuality. This finding reiterates the concerns highlighted by other Pacific research around the need for more understanding into the cultural barriers associated with accessing health services and further highlights the relevance of traditional gender roles within the reproductive patient-provider relationship in New Zealand.17,29–30

Perhaps ensuring that primary health care practitioners are trained in providing services that are culturally sensitive and inclusive of the respect and sacredness that sexual and reproductive issues require may be needed to improve cultural awareness and competencies in service delivery. Jameson and colleagues (1999) found that Pacific women’s barriers to cervical screening included being apprehensive about cultural backgrounds, embarrassment and confidentiality. The study highlighted the lack of discussion of such topics in the family and the effect that this might have on health.15 For women to discuss family planning intentions or experiences, women need to be able to feel comfortable and trust their health practitioner. Understanding traditional gendered roles and the effect that this might have on women’s perception of male providers is important to consider among Pacific women and their ability to access services. Improving community education about the importance of such concerns to health practitioners and the steps the health system is taking to ensure women’s matters are respected and remain confidential will help improve relationships and trust with health providers, leading to greater accessibility of these services among Pacific women.

The findings in this study should be considered in light of its limitations. Unmet need was measured among married women or women in long-term relationships, and so therefore, did not account for the unmet need among women who may be single and sexually active. It is likely that the rate of unmet need maybe an underestimation of the true unmet need in this population. Furthermore, given that the sampling strategy employed in New Zealand was a snowball sample, the findings are limited to older women and may not reflect younger women’s unmet need. Therefore, further research is needed to investigate the unmet need and access barriers among younger women in both countries.

In conclusion, the study shows that in New Zealand, unmet need among iTaukei Pacific women is more prevalent than existing data show and has implications on other minority Pacific groups. Regardless of whether women lived in Fiji or New Zealand, financial and cultural barriers challenged women’s access to services. In New Zealand, better targeting of services is needed to ensure that minority groups like the iTaukei benefit from the greater availability of resources. Furthermore, addressing the financial and cultural barriers may lead to greater access of services and lower unmet need.

Summary

Abstract

Aim

The aim of the study was to identify unmet need and family planning access among indigenous Fijian or iTaukei women living in New Zealand and Fiji.

Method

A cross-sectional survey was undertaken between 2012-2013 in five major cities in New Zealand: Auckland, Hamilton, Wellington, Christchurch and Dunedin; and in three suburbs in Fiji. Women who did not want any (more) children but were not using any form of contraception were defined as having an unmet need. Access experiences involving cost and health provider interactions were assessed.

Results

Unmet need in New Zealand was 26% and similar to the unmet need found in Fiji (25%). Cost and concern over not being seen by a female provider were the most problematic access factors for women.

Conclusion

There is a need for better monitoring and targeting of family planning services among minority Pacific groups, as the unmet need found in New Zealand was three times the national estimate overall and similar to the rate found in Fiji. Cost remains a problem among women trying to access family planning services. Gendered traditional roles in sexual and reproductive health maybe an area from which more understanding into cultural sensitivities and challenges may be achieved.

Author Information

Radilaite Cammock, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland; Peter Herbison, Preventive and Social Medicine, University of Otago, Dunedin; Sarah Lovell, School of Health Sciences, University of Canterbury, Christchurch;-Patricia Priest, Preventive and Social Medicine, University of Otago, Dunedin.

Acknowledgements

Correspondence

Dr Radilaite Cammock, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland.

Correspondence Email

radilaite.cammock@aut.ac.nz

Competing Interests

Dr Cammock and Dr Priest report grants from New Zealand Health Research Council during the conduct of the study.

  1. Cleland J, Bernstein S, Ezeh A, et al. Family planning: the unfinished agenda. The Lancet. 2006; 368(9549):1810–1827.
  2. Singh S, Darroch J. Adding it Up: Costs and Benefits of Contraceptive Services - Estimates for 2012. New York: Guttmacher Institute and United Nations Population Fund (UNFPA). 2012.
  3. Casterline J, Sathar Z, ul Haque M. Obstacles to contraceptive use in Pakistan: a study in Punjab. Studies in Family Planning. 2001; 32(2):95–110.
  4. McIntosh J, Tsikitas L, Dennis A. Low-income women’s access to contraception after health care reform in Massachusetts. Journal of the American Pharmacists Association. 2012; 52(3):349–357.
  5. Newman K, Feldman-Jacobs C. Family Planning and Human Rights – What’s the connection and why is it important, Population Reference Bureau. 2015.
  6. Greenhalgh S, Winckler E. Governing China’s Population: From Leninist to Neoliberal Biopolitics. Stanford: Stanford University Press. 2005.
  7. Mason K. Explaining Fertitlity Transitions. Demography. 1997; 34(4):443–454.
  8. Dehlendorf C, Rodriguez MI, Levy K, et al. Disparities in family planning. American Journal of Obstetrics and Gynecology. 2010; 202(3):214–220.
  9. Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006; 38:90–96.
  10. National Institute of Demographic and Economic Analysis, University of Waikato. Current Trends for Teenage Births in New Zealand. 2015.
  11. Paterson J, Tukuitonga C, Abbott M, et al. Pacific Islands Families: First Two Years of Life Study - design and methodology. N Z Med J. 2006; 119:U1814.
  12. Alkema L, Kantorova V, Menozzi C, et al. National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. The Lancet. 2006; 381.9878:1642–1652.
  13. WHO. The World Health Report 2005: Make Every Mother and Child Count. Geneva, Switzerland: World Health Organization. 2005.
  14. Christoffersen MN, Hussain MA. Teenage pregnancies: consequences of poverty, ethnic background and social conditions. Denmark: Social Forksnings Instituttet. 2008.
  15. Jameson A, Sligo F, Comrie M. Barriers to Pacific women’s use of cervical screening services. Australian and New Zealand Journal of Public Health. 1999; 23(1):89–92.
  16. Lovell S, Kearns RA, Friesen W. Sociocultural barriers to cervical screening in South Auckland, New Zealand. Social Science & Medicine. 2007; 65(1):138–150.
  17. Paterson J, Cowley ET, Percival T, et al. Pregnancy planning by mothers of Pacific infants recently delivered at Middlemore Hospital. The New Zealand Medical Journal. 2004; 117(1188).
  18. Fiji Ministry of Health. Tracking Progress in Maternal Child Survival, Case Study Report for Fiji. Suva: UNICEF and Ministry of Health. July 2013.
  19. Bradley S, Croft T, Fishel J, et al. Revising Unmet Need for Family Planning DHS Analytical Studies (Vol. No. 25). Calverton, Maryland, USA: ICF International. 2012
  20. Guttmacher Institue. Contraceptive use in the United States: Fact Sheet. New York. 2015.
  21. Saxena S, Copas AJ, Mercer C, et al. Ethnic variations in sexual activity and contraceptive use: national cross-sectional survey. Contraception. 2006; 74(3):224–233.
  22. Letamo G, Navaneetham K. Levels, trends and reasons for unmet need for family planning among married women in Botswana: a cross-sectional study. BMJ Open. 2015; 5(3).
  23. Ali A, Okud A. Factors affecting unmet need for family planning in Eastern Sudan. BMC Public Health. 2013; 13:102.
  24. Ciszewski RL, Harvey PD. The effect of price increases on contraceptive sales in Bangladesh. Journal of Biosocial Science. 1994; 26(1):25–35.
  25. Green RA. Empty pockets: Estimating the ability to pay for family planning. Paper presented at the annual meeting of the Population Association of America. Atlanta. 2002.
  26. Levin A, Caldwell B, Khuda B. Effect of price and access on contraceptive use. Social Science & Medicine. 1999; 49(1).
  27. Sopoaga F, Parkin L, Gray A. A Pacific population’s access to and use of health services in Dunedin. The New Zealand Medical Journal. 2012; 125(1364).
  28. Teevale T, Denny S, Percival T, et al. Pacific secondary school students’ access to primary health care in New Zealand. The New Zealand Medical Journal. 2013; 126(1375).
  29. Anae M. The Roles and Responsibilities of Some Samoan Men in Reproduction: Pacific Health Research Centre, University of Auckland. 2000.
  30. Asiasiga L. Abortion and Pacific Islands women. A pilot study for the New Zealand Family Planning Association Planning Association. Wellington: New Zealand Planning Association (NZFPA). 1994.

Contact diana@nzma.org.nz
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Family planning is considered an important tool in averting maternal deaths and ensuring women’s reproductive needs are met.1 The need for family planning is supported by data which shows that an estimated 35% of all maternal deaths could be avoided if unintended births were prevented. Specifically, the WHO recommends that no unmet need for family planning should exist, meaning that women who do not wish to have any (more) children are able to access family planning methods.2 Reasons for non-use of modern contraceptive methods have been stated to be largely due to access issues.3,4 This view argues that if family planning methods were made more accessible then unmet need would decrease.

Access to family planning is considered a human rights issue.5 Along with health and wellbeing, lack of access to family planning has social and economic ramifications. Ensuring family planning accessibility warrants individuals with the opportunity to be in control of when to have or limit the number and timing of children, giving them the autonomy and self-preservation that is needed for the maintenance of good health. Given the financial challenges associated with supporting a growing family, being able to control family size can contribute to greater financial stability.6,7

Although access to family planning is considered more problematic in developing countries where resources are low, minority groups in developed countries experience disproportionately lower uptake of family planning services.8,9 Among Pacific populations in New Zealand, this is the case. In New Zealand, high teenage pregnancy and low use of contraception characterise Pacific reproductive behaviour.10,11 Despite these outcomes, little is known about Pacific women’s family planning unmet need and access. High national contraceptive prevalence estimates of 72.4% do not seem to reflect the Pacific experience.12 Furthermore, unmet need in New Zealand is reported to be 8.8%, low in comparison to other countries in the developed world.12

Thus, there seems to be a disconnect between the overall patterns of contraceptive use and unmet need and the reported experience of Pacific populations in New Zealand. The effects of teenage pregnancy and lack of contraceptive use found among Pacific groups can lead to long-term disability as a result of pregnancy and labour, and socio-economic deprivation as a result of teenage pregnancy.13,14 Therefore, lack of access and uptake of family planning not only has implications on the individual but on future generations.

Most studies in New Zealand of Pacific women’s reproductive health behaviour highlight the need for more understanding into social and cultural barriers to reproductive services, as most found cultural sensitivities and taboos to be barriers to access.15,16 Paterson’s study of a group of Pacific mothers found that due to cultural taboos and sensitivities, most women who did not plan their pregnancy were not aware of family planning and did not like discussing the topic.17

Given these findings, little has been done to try to capture behaviour involved with reproductive intentions and family planning use. Unmet need investigations give us that link and quantifies the proportion of women whose family planning needs are not being met. Furthermore, although previous studies of reproductive behaviour highlight the need for more understanding of socio-cultural factors associated with uptake, more research is needed to identify what these factors entail and how cultural barriers might change within the New Zealand context.

This study investigates the unmet need of a group of Pacific women, iTaukei or indigenous Fijian and the main barriers to health services. The study draws on the experience of iTaukei women in Fiji to provide insight into unmet need and access changes that might occur among iTaukei in New Zealand.

Methods

Design setting

Between 2012 and 2013, a cross-sectional survey of women’s family planning knowledge, attitudes and practice (KAP), unmet need and access was carried out in Fiji and New Zealand to investigate iTaukei women’s family planning behaviour. The data presented in this paper focuses on the unmet need and access data from the KAP study. Women who identified as being iTaukei and living in the five major cities of New Zealand—Auckland, Hamilton, Wellington, Christchurch and Dunedin, and in three suburbs in Suva—Samabula, Valelevu and Cunningham, were invited to participate in the study. Only women 18 years and above were included in the survey. If women were under the age of 18 or did not identify as being iTaukei, ie, they were Indian or another ethnic group, they were not included in the survey.

Sample

The sample size goal for the survey was 200 women in each country. This number was needed in order to obtain at least 163 completed questionnaires (ie, approximately 80% response rate) in each country which would allow the study 80% power to detect a statistically significant (p<0.05) difference of 15% between countries in the proportion of women who have used family planning, if this proportion was up to 40% in Fiji and higher in New Zealand.12,18 Multistage cluster sampling carried out in Fiji was based on household income and to ensure representativeness. Given the challenges with generating representative samples among minority groups and hard to reach groups in New Zealand, snowball sampling techniques were employed in New Zealand to get as many women involved in the study as we could. Women in New Zealand were recruited through community networks, social media and Pacific organisations.

Ethics

Ethical approval was granted by the Fiji National Health Research Council and the Human Ethics Committee of the University of Otago. Approval for working in communities in the Suva area was also granted by the Ministry of iTaukei affairs. Participants were provided with information sheets prior to filling in surveys. Questionnaires were self-administered to ensure privacy and confidentiality. Cultural protocols and sensitivities were observed with data collected by iTaukei researchers.

Survey questionnaire

To identify unmet need in the samples, the definition presented by Bradley et al (2012) was used to inform survey questions.19 These included women’s family planning use, pregnancy intentions and fecundity. Demographic, sexual and reproductive health surveys in the Pacific were also used to inform questions in the survey. To ascertain women’s experience with access, women were asked to indicate whether they found particular access factors, eg, cost, travel, spousal communication and health provider characteristics, to be problematic. The survey questionnaire was available in both the English and Fijian languages.

Analysis

Analysis of the survey data was carried out using Stata 13 statistical software. Data from each country was analysed separately to identify unmet need and access and then comparatively between countries to see if there were any differences in unmet need and access patterns. The Bradley et al (2012) definition was used as a framework to analyse unmet need in each country.19 Women who were not using family planning methods were classified as having an unmet need for spacing if they did not wish to have any (more) children in the next two years, while those who did not wish to have any more children in the future were classified as having an unmet need for limiting. Unmet need was only assessed among married women or women in a relationship.19

Women were asked to indicate whether the following access factors were problematic when accessing medical advice or treatment: knowing where to go, getting money to go, not having a facility nearby, having to find transport, not wanting to go alone, concern there may not be a female provider, talking to your husband/partner about it. Chi-square tests of statistical significance were used for comparison of unmet need and access factors between countries.

Results

Overall, 352 women filled in a survey questionnaire. A higher response rate was observed in Fiji as 212 women (out of the 220 approached) or 96% filled in a survey, while 140 (out of the 235 approached) or 60% filled a questionnaire in New Zealand. Overall, 249 (70%) women were either married or in a relationship and eligible to be included in the unmet need analysis. The mean age of women in New Zealand was 39 while in Fiji the average age of women was 36 years. Fifty-one percent of women in New Zealand had used a family planning method at the time of the survey. In Fiji, 58% of women had used a method. Among currently married women (or women in a relationship) in New Zealand, 26% had an unmet need for family planning. Of these, 25% had an unmet need for spacing while 75% for limiting (Table 1). In Fiji, 25% of women had an unmet need for family planning. Of these, a higher proportion had an unmet need for limiting (86%) compared with spacing (14%) (Table 1).

Table 1: Unmet need in Fiji and New Zealand among currently married women; n (%).*

*n is the number of women with an unmet need; % uses the total number of currently married women, including women in a relationship as the denominator.
†Missing information for limiting and spacing Fjii n=2, NZ n=1.
Note: p values were calculated using the Pearson chi-squared test.

Unmet need characteristics

One fifth of the currently married women with a primary and/secondary qualification in New Zealand had an unmet need while about a third in Fiji with a primary or secondary school qualification had an unmet need for family planning (Table 2). Conversely, a higher proportion of women with a tertiary qualification in New Zealand had an unmet need (30%) compared with Fiji (18%). This difference however, was not statistically significant. The in-country differences between primary/secondary and tertiary qualification should be noted as well. In Fiji, more women with a primary/secondary qualification had an unmet need for family planning (31%) compared with women who had achieved a tertiary qualification (18%). In New Zealand, more women with a tertiary qualification had an unmet need (30%) compared to those who had a primary and/or secondary qualification (21%) (Table 2).

Table 2: Unmet need by characteristics in Fiji and New Zealand; n (%).*

*n is the number of women with an unmet need; % uses the total number of currently married women, including women in a relationship as the denominator in each categorical grouping.
Notes: P values calculated without missing numbers; calculations were carried out using Pearson chi-squared test.

Main barriers to accessing family planning services

Table 3 presents the findings from analyses involving access among women in both countries. About half of the women in Fiji found getting money to attend a health facility and concern there may not be a female provider to be problematic. Similarly in New Zealand, almost half of the women identified financial barriers to attending a health facility a problem (49%). The next most problematic factor appeared to be concern there may not be a female provider (36%). The proportion of women not having a health facility nearby was significantly different between countries. More women in Fiji (39%) had a problem with having facilities nearby compared to those in New Zealand (22%) (p=0.002) (Table 3). Similarly, more women in Fiji reported having problems with concerns about not having female providers compared with New Zealand (p=0.010). The number of women reporting having problems with talking to husbands about health issues was higher among women living in Fiji (31%) compared with New Zealand (16%) (p=0.004) (Table 3).

Table 3: Factors affecting women’s access to health services.

Note: p values were calculated using a Pearson chi-squared test, n (%).

Discussion

Unmet need

The unmet need among iTaukei women in New Zealand was 26%, about three times the national estimate of 8.8%.12 The difference between national figures and the figures found in the current study reflect the need for further investigation into minority Pacific groups in New Zealand and reflect similar patterns in other developed countries. In the US, minority women have been found to have lower contraceptive use rates compared to the national figures.20 In a study investigating ethnic variations in sexual activity and contraceptive use from a national cross-sectional survey in Britain, minority ethnic groups were found to have significantly lower contraceptive use rates compared to Caucasian women.21

Calculations in the current study referred to any family planning method that women might be using, therefore unmet need calculations accounted for traditional methods as well as modern contraceptive methods. Thus, unmet need for modern contraception may be greater among this population and given the low reliability of traditional methods, total unmet need may be higher as well. This is important to consider given how young the Pacific population is in New Zealand and the high rates of teenage pregnancy.10

Comparatively unmet need among iTaukei women in New Zealand was similar to proportions found in Fiji. This is important to consider in light of the different level of resources available in each country and their specific economic contexts. The unmet need in both countries was similar to those found in West Africa and higher than estimates in the developing world (12.8%).12

Most of the unmet need found in this study referred to limiting the number of children rather than spacing and is supported by other research which found women preferred to use family planning to limit rather than for spacing.19,22 The higher unmet need associated with limiting may be due to the age structures of the samples. Studies have found that as age increases and women have more children, unmet need for spacing decreases while unmet need for limiting increases.19 In the current study, given the older age structures of the sample, it is likely that women may have reached their ideal family size and did not want any more children.

The finding that unmet need among primary/secondary qualified women is higher compared with those with tertiary education is supported by the literature.19,23 Therefore, the higher unmet need found in New Zealand among those with tertiary education is interesting and reflects similar findings to those found in the Democratic Republic of Congo, Guinea, Mali and Niger, where unmet need was found to increase with women’s education. In these countries, researchers found that women with higher education were more likely to live in urban areas and were found to have similar levels of unmet need, compared with those who live in rural areas.19 It is likely that, in the current study, because women were recruited from the major urban cities, higher unmet need among this group maybe due to work commitments and costs associated with a higher standard of living in urban areas. Therefore, the extra costs of raising children and career commitments may be motivators for women to desire to limit having children. Access barriers such as cost and inconvenience (time) may further add to unmet need among this group.

Health service access

Cost and concern that there may not be a female provider were problematic among most women in both countries. For women in developing countries like Fiji, studies show cost to be a significant barrier.24,25 Given that over one third of the participants in Fiji found not having transport to be a problem, having facilities far away would provide further challenges for access. The longer the distance to the health facility, the higher the cost of travel, further burdening women and limiting their likelihood of accessing family planning services.26 Although transport and distances were not as problematic for New Zealand participants, costs of GP visit and commodities may be a burden for iTaukei women living in New Zealand. Research in New Zealand among Pacific populations have found cost to be a significant barrier in accessing health services.27,28 Given the relative availability of resources in New Zealand, questions regarding effectiveness and targeting of services is warranted. Accessing subsidised services, eg, family planning clinics, needs to be effectively promoted among those who may find seeing a primary health provider, eg, general practitioner, too expensive.

Concern there may not be a female provider is an important finding as it highlights sensitivities around privacy and cultural values and belief systems. These concerns show that women are likely to feel more comfortable having female providers over male providers, especially when it comes to reproduction and sexuality. This finding reiterates the concerns highlighted by other Pacific research around the need for more understanding into the cultural barriers associated with accessing health services and further highlights the relevance of traditional gender roles within the reproductive patient-provider relationship in New Zealand.17,29–30

Perhaps ensuring that primary health care practitioners are trained in providing services that are culturally sensitive and inclusive of the respect and sacredness that sexual and reproductive issues require may be needed to improve cultural awareness and competencies in service delivery. Jameson and colleagues (1999) found that Pacific women’s barriers to cervical screening included being apprehensive about cultural backgrounds, embarrassment and confidentiality. The study highlighted the lack of discussion of such topics in the family and the effect that this might have on health.15 For women to discuss family planning intentions or experiences, women need to be able to feel comfortable and trust their health practitioner. Understanding traditional gendered roles and the effect that this might have on women’s perception of male providers is important to consider among Pacific women and their ability to access services. Improving community education about the importance of such concerns to health practitioners and the steps the health system is taking to ensure women’s matters are respected and remain confidential will help improve relationships and trust with health providers, leading to greater accessibility of these services among Pacific women.

The findings in this study should be considered in light of its limitations. Unmet need was measured among married women or women in long-term relationships, and so therefore, did not account for the unmet need among women who may be single and sexually active. It is likely that the rate of unmet need maybe an underestimation of the true unmet need in this population. Furthermore, given that the sampling strategy employed in New Zealand was a snowball sample, the findings are limited to older women and may not reflect younger women’s unmet need. Therefore, further research is needed to investigate the unmet need and access barriers among younger women in both countries.

In conclusion, the study shows that in New Zealand, unmet need among iTaukei Pacific women is more prevalent than existing data show and has implications on other minority Pacific groups. Regardless of whether women lived in Fiji or New Zealand, financial and cultural barriers challenged women’s access to services. In New Zealand, better targeting of services is needed to ensure that minority groups like the iTaukei benefit from the greater availability of resources. Furthermore, addressing the financial and cultural barriers may lead to greater access of services and lower unmet need.

Summary

Abstract

Aim

The aim of the study was to identify unmet need and family planning access among indigenous Fijian or iTaukei women living in New Zealand and Fiji.

Method

A cross-sectional survey was undertaken between 2012-2013 in five major cities in New Zealand: Auckland, Hamilton, Wellington, Christchurch and Dunedin; and in three suburbs in Fiji. Women who did not want any (more) children but were not using any form of contraception were defined as having an unmet need. Access experiences involving cost and health provider interactions were assessed.

Results

Unmet need in New Zealand was 26% and similar to the unmet need found in Fiji (25%). Cost and concern over not being seen by a female provider were the most problematic access factors for women.

Conclusion

There is a need for better monitoring and targeting of family planning services among minority Pacific groups, as the unmet need found in New Zealand was three times the national estimate overall and similar to the rate found in Fiji. Cost remains a problem among women trying to access family planning services. Gendered traditional roles in sexual and reproductive health maybe an area from which more understanding into cultural sensitivities and challenges may be achieved.

Author Information

Radilaite Cammock, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland; Peter Herbison, Preventive and Social Medicine, University of Otago, Dunedin; Sarah Lovell, School of Health Sciences, University of Canterbury, Christchurch;-Patricia Priest, Preventive and Social Medicine, University of Otago, Dunedin.

Acknowledgements

Correspondence

Dr Radilaite Cammock, School of Public Health and Psychosocial Studies, Auckland University of Technology, Auckland.

Correspondence Email

radilaite.cammock@aut.ac.nz

Competing Interests

Dr Cammock and Dr Priest report grants from New Zealand Health Research Council during the conduct of the study.

  1. Cleland J, Bernstein S, Ezeh A, et al. Family planning: the unfinished agenda. The Lancet. 2006; 368(9549):1810–1827.
  2. Singh S, Darroch J. Adding it Up: Costs and Benefits of Contraceptive Services - Estimates for 2012. New York: Guttmacher Institute and United Nations Population Fund (UNFPA). 2012.
  3. Casterline J, Sathar Z, ul Haque M. Obstacles to contraceptive use in Pakistan: a study in Punjab. Studies in Family Planning. 2001; 32(2):95–110.
  4. McIntosh J, Tsikitas L, Dennis A. Low-income women’s access to contraception after health care reform in Massachusetts. Journal of the American Pharmacists Association. 2012; 52(3):349–357.
  5. Newman K, Feldman-Jacobs C. Family Planning and Human Rights – What’s the connection and why is it important, Population Reference Bureau. 2015.
  6. Greenhalgh S, Winckler E. Governing China’s Population: From Leninist to Neoliberal Biopolitics. Stanford: Stanford University Press. 2005.
  7. Mason K. Explaining Fertitlity Transitions. Demography. 1997; 34(4):443–454.
  8. Dehlendorf C, Rodriguez MI, Levy K, et al. Disparities in family planning. American Journal of Obstetrics and Gynecology. 2010; 202(3):214–220.
  9. Finer L, Henshaw S. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspect Sex Reprod Health. 2006; 38:90–96.
  10. National Institute of Demographic and Economic Analysis, University of Waikato. Current Trends for Teenage Births in New Zealand. 2015.
  11. Paterson J, Tukuitonga C, Abbott M, et al. Pacific Islands Families: First Two Years of Life Study - design and methodology. N Z Med J. 2006; 119:U1814.
  12. Alkema L, Kantorova V, Menozzi C, et al. National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. The Lancet. 2006; 381.9878:1642–1652.
  13. WHO. The World Health Report 2005: Make Every Mother and Child Count. Geneva, Switzerland: World Health Organization. 2005.
  14. Christoffersen MN, Hussain MA. Teenage pregnancies: consequences of poverty, ethnic background and social conditions. Denmark: Social Forksnings Instituttet. 2008.
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