182 Killing unborn child - Ministry of Justice€¦ · 182 Killing unborn child (1) Every one is liable to imprisonment for a term not exceeding 14 years who causes the death of any

Crimes Act 1961 Part 8 – Crimes Against The Person - Duties tending to the preservation of life - Homicide - Murder, manslaughter, etc. - Abortion - Assaults and injuries to the person - Female genital mutilation - Bigamy, feigned marriage - Abduction, kidnapping Abortion 182 Killing unborn child (1) Every one is liable to imprisonment for a term not exceeding 14 years who causes the death of any child that has not become a human being in such a manner that he would have been guilty of murder if the child had become a human being. (2) No one is guilty of any crime who before or during the birth of any child causes its death by means employed in good faith for the preservation of the life of the mother. 182A Miscarriage defined For the purposes of sections 183 to 187 of this Act the term miscarriage means— (a) The destruction or death of an embryo or fetus after implantation; or (b) The premature expulsion or removal of an embryo or fetus after implantation, otherwise than for the purpose of inducing the birth of a fetus believed to be viable or removing a fetus that has died.

183 Procuring abortion by any means (1) Every one is liable to imprisonment for a term not exceeding 14 years who, with intent to procure the miscarriage of any woman or girl, whether she is pregnant or not,— (a) Unlawfully administers to or causes to be taken by her any poison or any drug or any noxious thing; or (b) Unlawfully uses on her any instrument; or (c) Unlawfully uses on her any means other than any means referred to in paragraph (a) or paragraph (b) of this subsection. (2) The woman or girl shall not be charged as a party to an offence against this section. 184 Procuring abortion by other means (repealed) 185 Female procuring her own miscarriage (repealed) 186 Supplying means of procuring abortion Every one is liable to imprisonment for a term not exceeding 7 years who unlawfully supplies or procures any poison or any drug or any noxious thing, or any instrument or other thing, whether of a like nature or not, believing that it is intended to be unlawfully used to procure miscarriage. 187 Effectiveness of means used immaterial The provisions of sections 183 to 186 of this Act shall apply whether or not the poison, drug, thing, instrument, or means administered, taken, used, supplied, or procured was in fact capable of procuring miscarriage.

187A Meaning of “unlawfully” (1) For the purposes of sections 183 and 186 of this Act, any act specified in either of those sections is done unlawfully unless, in the case of a pregnancy of not more than 20 weeks' gestation, the person doing the act believes— (a) That the continuance of the pregnancy would result in serious danger (not being danger normally attendant upon childbirth) to the life, or to the physical or mental health, of the woman or girl; or (aa) That there is a substantial risk that the child, if born, would be so physically or mentally abnormal as to be seriously handicapped; or (b) That the pregnancy is the result of sexual intercourse between— (i) A parent and child; or

(ii) A brother and sister, whether of the whole blood or of the half blood; or (iii) A grandparent and grandchild; or (c) That the pregnancy is the result of sexual intercourse that constitutes an offence against section 131(1) of this Act; or (d) That the woman or girl is severely subnormal within the meaning of section 138(2) of this Act. (2) The following matters, while not in themselves grounds for any act specified in section 183 or section 186 of this Act, may be taken into account in determining for the purposes of subsection (1)(a) of this section, whether the continuance of the pregnancy would result in serious danger to her life or to her physical or mental health: (a) The age of the woman or girl concerned is near the beginning or the end of the usual child-bearing years: (b) The fact (where such is the case) that there are reasonable grounds for believing that the pregnancy is the result of [sexual violation]. (3) For the purposes of sections 183 and 186 of this Act, any act specified in either of those sections is done unlawfully unless, in the case of a pregnancy of more than 20 weeks' gestation, the person doing the act believes that the miscarriage is necessary to save the life of the woman or girl or to prevent serious permanent injury to her physical or mental health. (4) Where a medical practitioner, in pursuance of a certificate issued by 2 certifying consultants under section 33 of the Contraception, Sterilisation, and Abortion Act 1977, does any act specified in section 183 or section 186 of this Act, the doing of that act shall not be unlawful for the purposes of the section applicable unless it is proved that, at the time when he did that act, he did not believe it to be lawful in terms of subsection (1) or subsection (3) of this section, as the case may require.

Contraception, Sterilisation, and Abortion Act 1977 Contents Title 1 Short Title and commencement 2 Interpretation Contraception 3 Sale or disposal, etc., of contraceptives to children (Repealed) 4 Administering of contraceptives to mentally subnormal females 5 Supply of contraceptives to sexual violation complainants 6 Standards for manufacture of condoms Sterilisation 7 Consent to sterilisation operation 8 Reports on sterilisations 9 Conditions relating to sterility not to be attached to loans or

employment Abortion 10 Constitution of Abortion Supervisory Committee 11 Term of office of members of Supervisory Committee 12 Manner of appointments 13 Deputies of members 14 Functions and powers of Supervisory Committee 15 Supervisory Committee may appoint advisory and technical

committees 16 Supervisory Committee may co-opt specialist advice

17 Crown may provide services for Supervisory Committee 18 Restrictions on where abortions may be performed 19 Types and effect of licences 20 Applications for licences 21 Grant of licences 22 Issue of licences 23 Duration of licences 24 Renewal of licences 25 Cancellation of licences 26 Appeals on questions of law to High Court 27 Appeals against decisions of High Court 28 Supervisory Committee may state case for High Court 29 Abortions not to be performed unless authorised by 2 certifying

consultants 30 Supervisory Committee to set up and maintain list of certifying

consultants 31 Supervisory Committee to appoint or approve counselling services 32 Procedure where woman seeks abortion 33 Determination of case 33A Performance of abortion by other practitioner 34 Special provisions where patient mentally subnormal 35 Counselling 36 Certifying consultants to keep records and submit reports 37 Offences 38 Crimes Act 1961 not affected 39 Annual report

40 Protection of persons acting in good faith 41 Fees and travelling allowances 42 Costs of administration 43 Regulations 44 Female procuring her own miscarriage 45 Records of abortions to be forwarded to Supervisory Committee 46 Conscientious objection

Contraception, Sterilisation, and Abortion Act 1977 Public Act 1977 No 112 An Act to specify the circumstances in which contraceptives and information relating to contraception may be supplied and given to young persons, to define the circumstances under which sterilisations may be undertaken, and to provide for the circumstances and procedures under which abortions may be authorised after having full regard to the rights of the unborn child 1 Short Title and commencement (1) This Act may be cited as the Contraception, Sterilisation, and Abortion Act 1977. (2) Sections 11 to 17, 19 to 28, 30, 31, and 38 to 43 of this Act shall come into force on the 1st day of January 1978. (3) Sections 18, 29, and 32 to 37 of this Act shall come into force on the 1st day of April 1978. (4) Except as provided in subsection (2) or subsection (3) of this section, this Act shall come into force on the date on which it receives the Governor-General's assent. 2 Interpretation In this Act, unless the context otherwise requires,— abortion means a medical or surgical procedure carried out or to be carried out for the purpose of procuring— (a) The destruction or death of an embryo or fetus after implantation; or (b) The premature expulsion or removal of an embryo or fetus after implantation, otherwise than for the purpose of inducing the birth of a fetus believed to be viable or removing a fetus that has died: abortion law means every provision of— (a) Sections 10 to 46 of this Act; and (b) Sections 182 to 187A of the Crimes Act 1961: approved counselling service means any person or agency appointed or approved by the Supervisory Committee under section 31 of this Act: area health board: Definition repealed.

contraceptive means a substance or device or technique intended to prevent conception or implantation: family planning clinic: Definition repealed. holder, in relation to a licence issued under this Act, means,— (a) In the case of a [hospital] the person who is for the time being in charge of the hospital, whether or not that person was in charge of it when the licence was issued: (b) In the case of any other institution, the person who is for the time being in charge of the institution, whether or not that person was in charge of it when the licence was issued: hospital means a hospital care institution within the meaning of section 58(4) of the Health and Disability Services (Safety) Act 2001 Hospital Board: Definition repealed. institution means any hospital, clinic, or other premises in which it is proposed to perform abortions: licence means a licence issued under this Act: licensed institution means an institution in respect of which a licence is for the time being in force under this Act: medical practitioner means a health practitioner who is, or is deemed to be, registered with the Medical Council of New Zealand continued by section 114(1)(a) of the Health Practitioners Competence Assurance Act 2003 as a practitioner of the profession of medicine operating surgeon: Definition repealed. practising obstetrician or gynaecologist means a medical practitioner— (a) whose scope of practice includes obstetrics or gynaecology; or (b) who, in the opinion of the Supervisory Committee, is experienced in 1 or both of those branches of medicine private hospital: Definition repealed. Secretary, in relation to the Supervisory Committee, means the officer of the Ministry of Justice for the time being acting as Secretary of the Committee: scope of practice has the same meaning as in section 5(1) of the Health Practitioners Competence Assurance Act 2003 Supervisory Committee means the Abortion Supervisory Committee constituted under section 10 of this Act: woman's own doctor: Definition repealed

Abortion 10 Constitution of Abortion Supervisory Committee (1) For the purposes of this Act there shall be a committee, to be known as the Abortion Supervisory Committee. (2) The Supervisory Committee shall consist of 3 members, of whom 2 shall be medical practitioners. (3) Subject to section 12 of this Act, every member shall be appointed by the Governor-General on the recommendation of the House of Representatives, and one member shall be so appointed as Chairman of the Supervisory Committee. (4) The powers of the Supervisory Committee shall not be affected by any vacancy in its membership. 11 Term of office of members of Supervisory Committee (1) Subject to the succeeding provisions of this section, every member of the Supervisory Committee shall hold office for a term of 3 years, but may from time to time be reappointed. (2) Any member of the Supervisory Committee may resign his office at any time by written notice given to the Speaker of the House of Representatives, or to the Prime Minister if there is no Speaker or the Speaker is absent from New Zealand. (3) Any member of the Supervisory Committee may be removed from office at any time by the Governor-General upon an address from the House of Representatives for [inability to perform the functions of the office], bankruptcy, neglect of duty, or misconduct. (4) If any member of the Supervisory Committee dies, resigns, or is removed from office, the vacancy so created shall be filled in the manner in which the appointment to the vacant office was originally made, and every person appointed under this subsection shall hold office for the remainder of the term for which his predecessor was appointed. (5) Every member of the Supervisory Committee, unless he sooner vacates his office under subsection (2) or subsection (3) of this section, shall continue in office until his successor comes into office.

12 Manner of appointments (1) If any member of the Supervisory Committee dies, or resigns his office, or is removed from office, the vacancy thereby created shall be filled in accordance with this section. (2) If any such vacancy occurs at any time while Parliament is in session, it shall be filled by appointment by the Governor-General on the recommendation of the House of Representatives: Provided that if the vacancy occurs less than 2 months before the close of that session and no such recommendation is made in that session, the provisions of subsection (3) of this section shall apply as if the vacancy had occurred while Parliament was not in session. (3) If any such vacancy occurs at any time while Parliament is not in session, the following provisions shall apply: (a) The Governor-General in Council may appoint a person to fill the vacancy, and the person so appointed shall, unless his office sooner becomes vacant, hold office until his appointment is confirmed by the House of Representatives: (b) If the appointment is not so confirmed within 2 months after the commencement of the next ensuing session, the appointment shall lapse and there shall be deemed to be a further vacancy in the membership of the Supervisory Committee. 13 Deputies of members (1) In any case where any member of the Supervisory Committee is incapacitated by illness, absence, or other sufficient cause from performing the duties of his office, the Governor-General may appoint a person to act in the place of that member during his incapacity. (2) The power conferred by subsection (1) of this section shall be exercised only on a certificate signed by the Chairman of the Supervisory Committee to the effect that, in his opinion, the temporary appointment is necessary for the due conduct of the business of the Committee. (3) The provisions of section 12 of this Act shall apply, with any necessary modifications, to the temporary appointment of a member under this section as if the member were being appointed under that section to fill a vacancy. (4) Any person appointed under this section shall, while he acts as such, be deemed to be a member of the Supervisory Committee, and any person appointed in the place of the Chairman shall have all the powers of the Chairman. (5) No appointment of a person under this section and no acts done by him while acting as a member of the Supervisory Committee, and no acts

done by the Supervisory Committee while any person is acting as such, shall in any proceedings be questioned on the ground that the occasion for his appointment had not arisen or had ceased. 14 Functions and powers of Supervisory Committee (1) The Supervisory Committee shall have the following functions: (a) To keep under review all the provisions of the abortion law, and the operation and effect of those provisions in practice: (b) To receive, consider, grant, and refuse applications for licences or for the renewal of licences under this Act, and to revoke any such licence: (c) To prescribe standards in respect of facilities to be provided in licensed institutions for the performance of abortions: (d) To take all reasonable and practicable steps to ensure—

(i) That licensed institutions maintain adequate facilities for the performance of abortions; and

(ii) That all staff employed in licensed institutions in connection with the performance of abortions are competent: (e) To take all reasonable and practicable steps to ensure that sufficient and adequate facilities are available throughout New Zealand for counselling women who may seek advice in relation to abortion: (f) To recommend maximum fees that may be charged by any person in respect of the performance of an abortion in any licensed institution or class of licensed institutions, and maximum fees that may be charged by any licensed institution or class of licensed institutions for the performance of any services or the provision of any facilities in relation to any abortion: (g) To obtain, monitor, analyse, collate, and disseminate information relating to the performance of abortions in New Zealand: (h) To keep under review the procedure, prescribed by sections 32 and 33 of this Act, whereby it is to be determined in any case whether the performance of an abortion would be justified: (i) To take all reasonable and practicable steps to ensure that the administration of the abortion law is consistent throughout New Zealand, and to ensure the effective operation of this Act and the procedures thereunder: (j) from time to time to report to and advise the Minister of Health and any district health board established by or under the New Zealand Public Health and Disability Act 2000 on the establishment of clinics and centres, and the provision of related facilities and services, in respect of contraception and sterilisation: (k) To report annually to Parliament on the operation of the abortion law. (2) The Supervisory Committee shall have all such reasonable powers, rights, and authorities as may be necessary to enable it to carry out its functions.

15 Supervisory Committee may appoint advisory and technical

committees (1) The Supervisory Committee may from time to time appoint advisory committees, technical committees, and other committees to advise it on such matters as it may refer to them. (2) Every such committee may, in addition and on its own initiative, furnish to the Supervisory Committee reports on any matter in respect of which the members of the committee have special knowledge or experience. (3) Any person may be appointed to be a member of any such committee, notwithstanding that he is not a member of the Supervisory Committee. (4) Every such committee shall in all matters be subject to the control of the Supervisory Committee, and shall carry out all directions, general or special, of the Supervisory Committee in relation to the Supervisory Committee or its affairs. (5) Subject to the provisions of this Act, every committee appointed under this section may regulate its procedure in such manner as it thinks fit. 16 Supervisory Committee may co-opt specialist advice (1) The Supervisory Committee, and any advisory or technical committee appointed by the Supervisory Committee, may from time to time invite any person, or any officer employed in any Government department, or a representative of any organisation who, in its opinion, possesses expert knowledge or is otherwise able to assist it in connection with the exercise of its functions, to attend any of its meetings or to advise it on any matter with which it is concerned. (2) Any person attending a meeting under this section may, if invited, take part in any discussion at the meeting, but shall not participate in the determination of any question before the meeting. 17 Crown may provide services for Supervisory Committee (1) The Crown, acting through any department of State, may from time to time, at the request of the Supervisory Committee, execute any work or enter into arrangements for the execution or provision by the department for the Supervisory Committee of any work or service, or for the supply to the Supervisory Committee of any goods, stores, or equipment, on and subject to such terms and conditions as may be agreed.

(2) Without limiting subsection (1) of this section, the [chief executive of the Ministry of Justice]] shall from time to time, at the request of the Supervisory Committee, provide the Supervisory Committee with all such secretarial and clerical services as may be necessary or desirable to enable the Supervisory Committee to perform its functions efficiently. (2A) Repealed (3) Any hospital care operator (within the meaning of section 58(4) of the Health and Disability Services (Safety) Act 2001) may from time to time, at the request of the Supervisory Committee, execute any work or enter into any arrangements for the execution or provision by that operator for the Supervisory Committee of any work or service, or for the supply to the Supervisory Committee of any goods, stores, or equipment, on and subject to such terms and conditions as may be agreed. 18 Restrictions on where abortions may be performed (1) Subject to the provisions of this Act, no abortion shall be performed elsewhere than in an institution licensed for the purpose in accordance with this Act. (2) Subject to the provisions of this Act, no abortion shall be performed, after the pregnancy has subsisted for at least 12 weeks, elsewhere than in an institution in respect of which a full licence is for the time being in force under this Act. 19 Types and effect of licences (1) The Supervisory Committee may from time to time, in accordance with this Act, issue in respect of any institution— (a) A full licence; or (b) A limited licence. (2) A full licence shall authorise the holder to permit the performance of abortions in the institution to which the licence relates regardless of the length of time for which the pregnancy has been continuing. (3) A limited licence shall authorise the holder to permit the performance of abortions in the institution to which the licence relates only during the first 12 weeks of the pregnancy. 20 Applications for licences (1) An application for a licence may be made by— (a) in the case of a hospital, the person for the time being in charge of it; or

(b) Repealed (c) In the case of any other institution, the person for the time being in charge of the institution. (2) Every application shall— (a) Be addressed to the Supervisory Committee; and (b) Be in the prescribed form; and (c) State which type of licence is desired; and (d) Be accompanied by the prescribed fee. 21 Grant of licences (1) On receiving an application for a full licence in respect of any institution, the Supervisory Committee shall grant such a licence in respect of that institution only if it is satisfied— (a) That there are, in the institution, adequate facilities for the accommodation of patients for one or more nights; and (b) That there are, in the institution, adequate surgical and other facilities, and adequate and competent staff, for the safe performance of abortions; and (c) That there are, in the institution, adequate accommodation, surgical and other facilities, and competent staff to provide treatment and care of patients suffering complications arising while they are awaiting, undergoing, or recuperating from an abortion; and (d) That the person who will be the holder of the licence if the application is granted is a fit and proper person to hold such a licence; and (e) That adequate counselling services are available to women considering having an abortion in the institution, and are offered to such women whether or not they ultimately have an abortion. (2) On receiving an application for a limited licence in respect of any institution, the Supervisory Committee shall grant such a licence in respect of that institution only if it is satisfied— (a) There is a need for a or another licensed institution in the area in which the institution to which the application relates is situated; and (b) That there are, in the institution, adequate surgical and other facilities, and adequate and competent staff, for the safe performance of abortions; and (c) That adequate arrangements have been made with any other hospital or institution for the transfer of any patient suffering complications arising while she is awaiting, undergoing, or recuperating from an abortion to that other hospital or institution for treatment and care; and (d) That the person who will be the holder of the licence if the application is granted is a fit and proper person to hold such a licence; and

(e) That adequate counselling services are available to women considering having an abortion in the institution, and are offered to such women whether or not they ultimately have an abortion. (3) Notwithstanding anything in subsection (1) or subsection (2) of this section, on considering an application for a full licence, the Supervisory Committee may, with the consent of the applicant, grant a limited licence if it is satisfied in respect of the matters specified in subsection (2) of this section but is not satisfied in respect of the matters specified in subsection (1) of this section. (4) Subject to the provisions of sections 26 and 27 of this Act, the decision of the Supervisory Committee in respect of every application for a licence shall be final. (5) Where the Supervisory Committee refuses to grant an application for a licence, it shall, if requested to do so by the applicant, give to the applicant a written statement of its reasons for refusing the application. 22 Issue of licences Where the Supervisory Committee grants an application for a licence, it shall, on payment to it of the prescribed fee, issue to the applicant a full licence or, as the case may require, a limited licence in the prescribed form. 23 Duration of licences Subject to the provisions of section 24 of this Act, every licence shall, unless sooner cancelled under this Act, continue in force for one year commencing with the date of its issue, and shall then expire. 24 Renewal of licences (1) Every holder of a licence may from time to time apply to the Supervisory Committee for the renewal of the licence for a further period of one year. (2) Every such application shall be made not earlier than 3 months and not later than one month before the date of expiry of the licence, and shall be accompanied by the prescribed fee. (3) On receiving an application for the renewal of a licence, the Supervisory Committee shall grant the application unless it is satisfied— (a) That the institution no longer complies with the requirements of subsection (1) or (as the case may require) subsection (2) of section 21 of this Act; and (b) That the holder of the licence has not, during the currency of the licence, taken all reasonable and practicable steps to ensure that

the provisions of the abortion law were complied with in the institution. (4) Subject to the provisions of sections 26 and 27 of this Act, the decision of the Supervisory Committee in respect of every application for the renewal of a licence shall be final. (5) Where the Supervisory Committee refuses to grant an application for the renewal of a licence, it shall notify the applicant of its decision, and shall, if requested to do so by the applicant, give to the applicant a written statement of its reasons for refusing to renew the licence. (6) Where an application for the renewal of a licence is made in accordance with subsection (2) of this section but is not determined before the date on which the licence is due to expire, the licence shall continue in force until the application is determined. 25 Cancellation of licences (1) In any case where the Supervisory Committee believes, in respect of any licensed institution,— (a) That it no longer meets the requirements of subsection (1) or (as the case may require) subsection (2) of section 21 of this Act; or (b) That the holder of the licence has failed to take all reasonable and practicable steps to ensure that the provisions of the abortion law were complied with in the institution,— it may, by notice in writing addressed to the holder, call upon him to show cause why the licence should not be cancelled. (2) If, after considering any representations made to it and evidence put before it by the holder of the licence, and all such other matters as it considers relevant, the Supervisory Committee is satisfied of either of the matters specified in subsection (1) of this section, it may cancel the licence. (3) Where the Supervisory Committee cancels any licence, it shall notify the holder accordingly, and shall, if requested to do so by the holder, give to the holder a written statement of its reasons for cancelling the licence. 26 Appeals on questions of law to High Court (1) A person who is dissatisfied with a decision of the Supervisory Committee— (a) Refusing an application for the issue or renewal of a licence; or (b) Cancelling a licence,— as being erroneous in law, may appeal to the [High Court] by way of case stated for the opinion of the Court on a question of law only.

(2) Repealed by s3(4) of the Judicature Amendment Act 1991. (3) Within 28 days after the date of the determination or decision, the appellant shall lodge a notice of appeal with the Secretary. (4) Within 14 days after the lodging of the notice of appeal, or within such further time as the Chairman of the Supervisory Committee may in his discretion allow, the appellant shall state in writing and lodge with the Secretary a case setting out the facts and the grounds of the determination or decision and specifying the question of law on which the appeal is made. (5) As soon as practicable after the lodging of the case, the Secretary shall cause it to be submitted to the Chairman of the Supervisory Committee. (6) The Chairman shall, as soon as practicable, and after hearing the applicant if he considers it necessary to do so, settle the case, sign it, and cause it to be sent to the Secretary. The settling and signing of the case shall be deemed to be the statement of the case by the Supervisory Committee. (7) The Secretary shall send the signed case to the proper office of the High Court, and shall make a copy available to the appellant. (8) If, within 14 days after the filing of the notice of appeal, or within such further time as may be allowed, the appellant does not lodge a case pursuant to subsection (4) of this section, the Chairman of the Supervisory Committee may certify that the appeal has not been prosecuted. (9) The Court or a Judge thereof may in its or his discretion, on the application of the appellant or the intending appellant, extend any time prescribed or allowed under this section for the filing of a notice of appeal or the stating of any case. 27 Appeals against decisions of the High Court (1) If the appellant before the [High Court] is dissatisfied with any final determination of the Court in respect of the appeal as being erroneous in law, he may appeal to the Court of Appeal by way of case stated for the opinion of that Court on a question of law. (2) Within 14 days after the date of the determination or decision, the appellant shall file a notice of appeal with the Registrar of the [High Court] at Wellington. The appellant shall forthwith deliver or post a copy of the notice to the Secretary. (3) Within 14 days after the filing of the notice of appeal, or within such further time as the Judge before whom the proceedings were heard may in his discretion allow, the appellant shall state in writing and file with the Registrar a case setting out the facts and the grounds of the determination or decision and specifying the question of law on which the

appeal is made. The appellant shall forthwith deliver or post a copy of the case to the Secretary. (4) As soon as practicable after the filing of the case, the Registrar shall cause it to be submitted to the Judge before whom the proceedings were heard. (5) The Judge shall, as soon as practicable, and after hearing the parties if he considers it necessary to do so, settle the case, sign it, and cause it to be sent to the Registrar. The settling and signing of the case shall be deemed to be the statement of the case by the Court. (6) Where, since the date of the determination or decision, the Judge before whom the proceedings were heard has ceased to hold office as such or died or left New Zealand, or is incapable by reason of sickness or otherwise from acting as such, the case may be submitted to any Judge of the [High Court] and may be settled and signed by him. (7) The Registrar shall send the signed case to the Registrar of the Court of Appeal, and shall make a copy available to the appellant. (8) If within 14 days after the filing of the notice of appeal, or within such further time as may be allowed, the appellant does not file a case pursuant to subsection (3) of this section, the Judge may certify that the appeal has not been prosecuted. (9) The [High Court] or a Judge of that Court may in its or his discretion, on the application of the appellant or intending appellant, extend any time prescribed or allowed under this section for the filing of a notice of appeal or the stating of any case. (10) Subject to the foregoing provisions of this section, appeals under this section shall be heard in accordance with the rules of Court. 28 Supervisory Committee may state case for High Court (1) The Supervisory Committee may, of its own motion or on the application of any interested party, state a case for the opinion of the [High Court] on any question of law arising in any matter before the Supervisory Committee. (2) Repealed by s3(4) of the Judicature Amendment Act 1991. 29 Abortions not to be performed unless authorised by 2

certifying consultants Subject to the provisions of this Act, no abortion shall be performed unless and until it is authorised by 2 certifying consultants.

30 Supervisory Committee to set up and maintain list of

certifying consultants (1) The Supervisory Committee shall set up and maintain a list of medical practitioners (in this Act termed certifying consultants) who may be called upon to consider cases referred to them by any medical practitioner and determine, in accordance with section 33 of this Act, whether to authorise an abortion. (2) Before drawing up the list, the Supervisory Committee shall determine the minimum number of certifying consultants required to ensure, so far as possible, that every woman seeking an abortion has her case considered expeditiously, and shall make that number of appointments in accordance with this section. Thereafter, the Committee shall keep that number under review, and shall from time to time make such further appointments, or revoke such number of appointments, as it considers necessary to meet any change in the circumstances. (3) Having determined the number of appointments to be made, the Supervisory Committee shall consult with the New Zealand Medical Association, and may consult with any other professional or other body, before determining whom to appoint. (4) In making appointments to the list, the Supervisory Committee shall ensure that the following requirements are met: (a) At least one half of the total number of appointees shall be practising obstetricians or gynaecologists, and the list shall be marked in such a way as to indicate which of the appointees are so qualified: (b) There shall be a sufficient number of appointees practising in each area of New Zealand to ensure that every woman seeking an abortion can have her case considered without involving her in considerable travelling or other inconvenience. (5) In addition, in making such appointments, the Supervisory Committee shall have regard to the desirability of appointing medical practitioners whose assessment of cases coming before them will not be coloured by views in relation to abortion generally that are incompatible with the tenor of this Act. Without otherwise limiting the discretion of the Supervisory Committee in this regard, the following views shall be considered incompatible in that sense for the purposes of this subsection: (a) That an abortion should not be performed in any circumstances: (b) That the question of whether an abortion should or should not be performed in any case is entirely a matter for the woman and a doctor to decide.

(6) Every appointment to the list of certifying consultants shall be for a term of one year, but the Supervisory Committee may reappoint any practitioner on the expiry of his term. (7) The Supervisory Committee may at any time, at its discretion, revoke the appointment of any certifying consultant. 31 Supervisory Committee to appoint or approve counselling

services (1) For the purposes of this Act, the Supervisory Committee shall from time to time— (a) Appoint suitably qualified persons to provide counselling services for persons considering having an abortion; or (b) Approve any agency for the provision of such counselling services. (2) In appointing or approving persons or agencies for the provision of counselling services under this section, the Supervisory Committee shall have regard to the following matters: (a) Every counselling service should be directed by an experienced and professionally trained social worker: (b) That suitably trained lay counsellors may also be used where there are insufficient professional social workers: (c) Every counsellor should be thoroughly familiar with all relevant social services and agencies, and able to advise patients, or refer them to appropriate agencies for advice, on alternatives to abortion, such as adoption and solo parenthood. 32 Procedure where woman seeks abortion (1) Every medical practitioner (in this section referred to as the woman's own doctor) who is consulted by or in respect of a female who wishes to have an abortion shall, if requested to do so by or on behalf of that female, arrange for the case to be considered and dealt with in accordance with the succeeding provisions of this section and of section 33 of this Act (2) If, after considering the case, the woman's own doctor considers that it may be one to which any of paragraphs (a) to (d) of subsection (1), or (as the case may require) subsection (3), of section 187A of the Crimes Act 1961 applies, he shall comply with whichever of the following provisions is applicable, namely: (a) Where he does not propose to perform the abortion himself, he shall refer the case to another medical practitioner (in this section referred to as the operating surgeon) who may be willing to perform an abortion (in the event of it being authorised in accordance with this Act); or (b) Where he proposes to perform the abortion himself (in the event of it being authorised in accordance with this Act), he shall—

(i) If he is himself a certifying consultant, refer the case to one other certifying consultant (who shall be a practising obstetrician or gynaecologist if the woman's own doctor is not) with a request that he, together with the woman's own doctor, determine, in accordance with section 33 of this Act, whether or not to authorise the performance of an abortion; or

(ii) If he is not himself a certifying consultant, refer the case to 2 certifying consultants (of whom at least one shall be a practising obstetrician or gynaecologist) with a request that they determine, in accordance with section 33 of this Act, whether or not to authorise the performance of an abortion. (3) Where an operating surgeon to whom a case is referred under subsection (2)(a) of this section is satisfied, after considering the case, that it is one to which any of paragraphs (a) to (d) of subsection (1), or (as the case may require) subsection (3), of section 187A of the Crimes Act 1961 applies, he shall, if he is willing to perform the abortion, either— (a) If he is himself a certifying consultant, refer the case to one other certifying consultant (who shall be a practising obstetrician or gynaecologist if the operating surgeon is not, and who shall not be the woman's own doctor) with a request that he, together with the operating surgeon, determine, in accordance with section 33 of this Act, whether or not to authorise an abortion; or (b) If he is not himself a certifying consultant, refer the case to 2 certifying consultants (of whom at least one shall be a practising obstetrician or gynaecologist, and of whom one may be the woman's own doctor) with a request that they determine, in accordance with section 33 of this Act, whether or not to authorise the performance of an abortion. (4) Where any medical practitioner is required to refer any case to any other practitioner under this section, he shall refer it in accordance with the procedure for the time being prescribed by the Supervisory Committee. (5) As soon as practicable after a case is referred to him, each certifying consultant shall consider the case and shall, if requested to do so by the patient, interview her; and at any such interview she shall be entitled to be accompanied by her own doctor (if he agrees). (6) The woman's own doctor and the proposed operating surgeon shall be entitled (with the patient's consent) to make such representations and to adduce such medical or other reports concerning the case as he thinks fit to each certifying consultant. (7) Every certifying consultant may, in considering any case, with the consent of the patient, consult with any other person (whether or not a medical practitioner) as he thinks fit in order to assist him in his consideration of the case, but he shall not disclose the patient's identity without her consent.

(8) Notwithstanding anything in this section, or in section 33 of this Act, no certifying consultant shall be obliged to determine any case without first interviewing and examining the patient. 33 Determination of case (1) If, after considering the case, the certifying consultants are of the opinion that the case is one to which any of paragraphs (a) to (d) of subsection (1), or (as the case may require) subsection (3), of section 187A of the Crimes Act 1961 applies, they shall forthwith issue in accordance with subsection (5) of this section, a certificate in the prescribed form authorising the performance of an abortion. (2) If the certifying consultants are of the contrary opinion, they shall refuse to authorise the performance of an abortion. (3) If one of the certifying consultants is of the opinion that the case is one to which any of the said provisions applies and the other consultant is of the contrary opinion, they shall refer the case to another medical practitioner for his opinion, being a medical practitioner who is on the list of certifying consultants maintained under section 30(1) of this Act. (4) If that other medical practitioner is of the opinion that the case is one to which any of the said provisions applies, the certifying consultant who is of the same opinion shall issue, in accordance with subsection (5) of this section, a certificate in the prescribed form authorising the performance of an abortion. (5) Where 2 certifying consultants determine that they should authorise an abortion, they shall forward the said certificate to the holder of the licence in respect of the licensed institution in which the abortion is to be performed. (5A) Where the operating surgeon is not one of the certifying consultants issuing the certificate, he shall endorse on the certificate a statement that he is willing to perform an abortion on the patient to whom the certificate relates, but a failure to comply with this requirement shall not invalidate the certificate for the purposes of section 37(1)(b) of this Act or section 187A(4) of the Crimes Act 1961. (6) If, in respect of any case, any certifying consultant has not reached a decision within 14 days after it was referred to him, he shall advise the Supervisory Committee in writing of the matter, and of the reasons for the delay. 33A Performance of abortion by other practitioner

Nothing in section 32 or section 33 of this Act shall prohibit the performance of an abortion duly authorised in accordance with those sections by any medical practitioner who is not the operating surgeon within the meaning of section 32 of this Act. 34 Special provisions where patient mentally subnormal In any case where the patient lacks the capacity to consent, by reason of any mental incapacity, to an abortion, the persons charged, under section 33 of this Act, with determining whether to authorise the abortion shall, before determining the case, consult with a medical practitioner or other person believed by them to be qualified and experienced in the field and able to make an assessment of the patient's condition and the likely effect on it of the continuance of the pregnancy or an abortion. 35 Counselling When the certifying consultants have made a decision in any case (whether they have decided to authorise or to refuse to authorise the performance of an abortion), they shall (in consultation, where practicable, with the woman's own doctor) advise her of her right to seek counselling from any appropriate person or agency. 36 Certifying consultants to keep records and submit reports (1) Every certifying consultant shall keep such records and submit to the Supervisory Committee such reports relating to cases considered by him and the performance of his functions in relation to such cases as the Supervisory Committee may from time to time require. (2) No such report shall give the name or address of any patient. 37 Offences (1) Every person who— (a) Performs an abortion elsewhere than in a licensed institution; or (b) Performs an abortion otherwise than in pursuance of a certificate issued by 2 certifying consultants under section 33 of this Act,— commits an offence and is liable on summary conviction to imprisonment for a term not exceeding 6 months or a fine not exceeding $1,000. (2) Nothing in subsection (1) of this section shall apply to the performance of an abortion by a medical practitioner who believes that

abortion is immediately necessary to save the life of the patient or to prevent serious permanent injury to her physical or mental health. (3) It shall be a defence to a charge brought under subsection (1)(b) of this section if the defendant shows that he believed that a certificate had been issued in respect of the patient. 38 Crimes Act 1961 not affected Nothing in sections 11 to 37 of this Act shall limit or affect any of the provisions of the Crimes Act 1961. 39 Annual report Once in every year the Supervisory Committee shall prepare and submit to Parliament a report of its activities during the preceding 12 months. 40 Protection of persons acting in good faith No member of the Supervisory Committee, and no certifying consultant, shall be personally liable for any act done or omitted to be done by it or him in good faith in pursuance of the powers conferred on it or him by this Act. 41 Fees and travelling allowances (1) The Supervisory Committee is hereby declared to be a statutory Board within the meaning of the Fees and Travelling Allowances Act 1951. (2) There shall be paid to the members of the Supervisory Committee, and of every committee appointed by it, and to every person co-opted under section 16 of this Act by the Supervisory Committee or any committee appointed by it, and to every certifying consultant, out of money from time to time appropriated by Parliament for the purpose, remuneration by way of salary, fees, and allowances and travelling allowances and expenses, in accordance with the Fees and Travelling Allowances Act 1951, and the provisions of that Act shall apply accordingly as if, in the case of each such committee, the committee were a statutory Board within the meaning of that Act, and as if, in the case of every certifying consultant, he were a member of such a Board. 42 Costs of administration

(1) The costs of and incidental to the administration and operation of this Act shall be met out of money from time to time appropriated by Parliament for the purpose. (2) All fees from time to time payable under this Act shall be paid into a Departmental Bank Account. 43 Regulations The Governor-General may from time to time by Order in Council make regulations for all or any of the following purposes: (a) Prescribing forms to be used for the purposes of this Act: (b) Prescribing fees to be paid on applications under this Act: (c) Prescribing maximum fees that may be charged by any person or institution or class of persons or institutions in respect of the performance of abortions and the provision of services in respect thereof: (d) Providing for such other matters as are contemplated by or necessary for giving full effect to the provisions of this Act and for the due administration thereof. 44 Female procuring her own miscarriage (1) Every female commits an offence and is liable on summary conviction to a fine not exceeding $200 who, with intent to procure miscarriage, whether she is pregnant or not,— (a) Unlawfully administers to herself, or permits to be administered to her, any poison or any drug or any noxious thing; or (b) Unlawfully uses on herself, or permits to be used on her, any instrument; or (c) Unlawfully uses on herself, or permits to be used on her, any other means whatsoever. (2) For the purposes of subsection (1) of this section the term miscarriage means— (a) The destruction or death of an embryo or fetus after implantation; or (b) The premature expulsion or removal of an embryo or fetus after implantation, otherwise than for the purpose of inducing the birth of a fetus believed to be viable or removing a fetus that has died. (3) For the purpose of determining whether any act referred to in subsection (1) of this section is or is not done unlawfully the provisions of section 187A of the Crimes Act 1961, so far as they are applicable and with the necessary modifications, shall apply. (4) The provisions of subsection (1) of this section shall apply whether or not the poison, drug, thing, instrument, or means administered or used was in fact capable of procuring miscarriage.

45 Records of abortions to be forwarded to Supervisory

Committee (1) Without limiting anything in section 36 of this Act, every medical practitioner who performs an abortion, or any other medical or surgical procedure that could lead to or effect a subsequent unnatural miscarriage, shall make a record thereof and of the reasons therefor, and shall, within one month after performing the abortion or other procedure, forward a copy of the record to the Supervisory Committee. (2) No such record shall give the name or address of the patient. (3) The Hospitals Amendment Act 1975 is hereby repealed. 46 Conscientious objection (1) Notwithstanding anything in any other enactment, or any rule of law, or the terms of any oath or of any contract (whether of employment or otherwise), no medical practitioner, nurse, or other person shall be under any obligation— (a) To perform or assist in the performance of an abortion or any operation undertaken or to be undertaken for the purpose of rendering the patient sterile: (b) To fit or assist in the fitting, or supply or administer or assist in the supply or administering, of any contraceptive, or to offer or give any advice relating to contraception,— if he objects to doing so on grounds of conscience.

(2) It shall be unlawful for any employer— (a) To deny to any employee or prospective employee any employment, accommodation, goods, service, right, title, privilege, or benefit merely because that employee or prospective employee objects on grounds of conscience to do any act referred to in subsection (1) of this section; or (b) To make the provision or grant to any employee or prospective employee of any employment, accommodation, goods, service, right, title, privilege, or benefit conditional upon that other person doing or agreeing to do any thing referred to in that subsection. (3) Every person who suffers any loss by reason of any act or omission rendered unlawful by subsection (2) of this section shall be entitled to recover damages from the person responsible for the act or omission. (4) Nothing in this section limits or affects the provisions of section 5.

Care of Children Act 2004 Part 2 Guardianship and care of children Subpart 1 - Guardianship: Responsibility for children, and decisions about children Consent to medical procedures

38 Consent to abortion (1) If given by a female child (of whatever age), the following have the same effect as if

she were of full age: (a) a consent to the carrying out on her of any medical or surgical procedure for

the purpose of terminating her pregnancy by a person professionally qualified to carry it out; and

(b) a refusal to consent to the carrying out on her of any procedure of that kind.

All District Health Boards

SPECIALIST MEDICAL AND SURGICAL SERVICES

GYNAECOLOGY SERVICES

TIER TWO SERVICE SPECIFICTION

STATUS: It is compulsory to use this nationwide service specification when purchasing this service.

MANDATORY

Review History Date

First Published on NSFL 2003

Review of Tier Two Gynaecology Service (2003)

Amendments: updated service definition and termination of pregnancy content. Added purchase unit codes Non-contact First Specialist Assessment, Non-contact follow up and S00011, S30009, S30PRE, S30CANC, new PU Code for medical termination of pregnancy.

September 2014

Amendments: amended purchase units to align with purchase unit data dictionary July 2015

Amendment: updated wed links, minor formatting. September 2017

Consideration for next Service Specification Review

within five years

Note: Contact the Service Specification Programme Manager, National Health Board Business Unit, Ministry of Health to discuss proposed amendments to the service specifications and guidance in developing new or updating and revising existing service specifications.

Nationwide Service Framework Library website http://www.nsfl.health.govt.nz

Specialist Medical and Surgical Services, Gynaecology Services tier two service specification September 2017 Nationwide Service Framework 2

SPECIALIST MEDICAL AND SURGICAL SERVICES – GYNAECOLOGY SERVICES

TIER TWO SERVICE SPECIFICATION S00011, S00012, S30PRE, S30CANC, S30001, S30002, S30003, S30006, S30007, S30008,

S30009, S30010, S30011

This tier two service specification for Gynaecology Services (the Service) must be used in conjunction with the tier one Specialist Medical and Surgical Services and, as age appropriate, the tier one Services for Children and Young People service specifications.

Refer to relevant tier one service specifications for generic principles and requirements.

The Service is also linked to other services described in the following service specifications:

tier two Urology Services tier two Oncology Services tier two Radiotherapy Services tier two Assisted Reproductive Technology Services tier two Specialist Palliative Care Services tier one Community Health, Transitional and Support Services and its relevant tier two

service specifications tier one Maternity Services and its relevant tier two service specifications tier two Public Health Preventative Intervention service specification.

1. Service Definition

The Service provides access to assessment, management and treatment of gynaecological diseases and conditions, primarily those of the genital tract for females and includes reproductive medicine, management of early pregnancies with complications and termination of pregnancies (TOPs).

2. Exclusions

This Service will not duplicate services already contracted for by the Ministry of Health, Accident Compensation Corporation (ACC), or other Government departments and agencies or district health boards (DHBs), such as specified in: the National Cervical Screening Programme (NCSP) service specification, or the 2007 Maternity Services Notice Section 88 of the New Zealand Public Health and Disability Act 2000.

3. Service Users

Service Users are people who meet the Service’s eligibility criteria and require specialist gynaecological services to improve their health status.

4. Service Objectives

Refer to the generic service objectives listed in the tier one Specialist Medical and Surgical Services service specification, and as age appropriate, the tier one Services for Children and Young People service specifications.


5. Access

5.1 Entry Criteria

Access to the Service is only by referral from an appropriate health professional. Service Users will be eligible for the Service based on the clinical assessment of their health status risk. Service Providers will use the Electronic Gynaecology Surgery Clinical Prioritisation Tool1.

For women referred to the Service from the NCSP, see the document Guidelines for Cervical Screening in New Zealand (2008)2, and any subsequent updates:

Men may be referred to the Service as clinically appropriate.

Access to the TOP service is followed by an assessment of each individual’s specific and social circumstances. Females are eligible for a termination by the certification process3.

6. Service Components

6.1 Processes

The care of an individual and their family by a gynaecological service involves a complex sequence of relationships and events. The level of intervention will be dependent on the individual’s clinical condition and their desire for treatment, and the qualifications / training and experience of the clinical staff, and the level of clinical support.

The key components of the Service are:

6.1.1 Assessment, Diagnosis and Treatment

The Service is responsible for:

assessment, diagnosis, appropriate treatment and follow up of all Service Users undergoing treatment in line with accepted standards of clinical practice

provision of appropriate after hours care to Service Users undergoing day surgery, including arrangements for re-admission where required

follow up, re-admission and treatment of all Service Users in whom complications arise in the course of treatment by the Service (this may include appropriate referral to more intensive levels of care)

discharge planning including handover to the Service User’s general practitioner (GP) or primary health care provider

counselling services.

6.1.2 Education and Information


providing opinion and assistance to primary health care providers in managing their patients with gynaecological conditions, including informing women of the NCSP

provision of written information about the Service to Services Users and referrers referral to another speciality for an opinion and/or (shared) management of the

Service User.

1 The Gynaecology surgery tool (code 9065) was developed and endorsed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and is hosted on the National Prioritisation Platform, a log in required. (this tool is to be fully implemented by the end of 2014). A new sterilisation tool is currently being tested for validation and then endorsement in later 2014. 2 Refer to : http://www.nsu.govt.nz/files/NCSP/NCSP_Guidelines_ALL_small(1).pdf 3 TOP services are provided for females who meet the criteria provided by the Crimes Act 1961 Section 187A and the Contraception Sterilisation and Abortion Act 1977 Section 33.


6.1.3 Health Promotion and Disease Prevention


education and counselling of Service Users and / or caregiver concerning: - condition - specific health education - reducing the possibility of recurrence of acute conditions - acceptance and management of chronic conditions including the efficient and

appropriate use of medicines and equipment - self-care and self-management - prevention of further deterioration - personal remedial action related to lifestyle risk factors (e.g., stopping smoking,

weight control advice) - informing and educating women on HPV and screening for prevention of treatable

disease including NCSP communicable disease control activities, including:

- report communicable diseases as required by the Medical Officer of Health - contact tracing and treatment of likely affected /infected sexual contacts - infectious disease measures, including but not limited to, patient isolation.

6.2 Service Specific Deliverables

The level of the Service varies according to the Service User’s clinical condition, the qualification / training of medical / surgical staff, and the level of clinical support available.

The Service includes:

gynaecological surgery management of menstrual disorders endometriosis / pelvic pain services management of complications in early pregnancy basic fertility investigation and interpretation adjuvant urological services.

The Service may include, and / or be linked to other providers of, the following services:

Family Planning Service Sterilisation Services Termination of Pregnancy Services, including counselling services4.

In addition to the above, tertiary hospital Gynaecology Services will include the following and / or be linked to other providers of, the following services:

specialist micro-surgery gynaecological oncology colposcopy services uro-gynaecology reproductive endocrinology the NCSP.

6.3 Settings

The Services will be provided in a setting most appropriate for the delivery of the Services. Refer to the tier one Specialist Medical and Surgical Services service specification for settings information.

4 Note: The National Travel Assistance Scheme4 (NTA) applies to females travelling for terminations where these publicly funded secondary and tertiary services are not available locally


6.4 Key Inputs

This Service is provided by Gynaecologists, Registrars, other Medical Practitioners, Nurse Practitioners, Registered Nurses, and other nurses.

Procedural services such as: diagnostic services, operating theatres, pharmaceuticals, and the New Zealand Blood Service.

7. Service Linkages

The Service will be well integrated with other health services and ensure there is effective consultation, liaison and referral between services and sub-specialities that support seamless service delivery and continuity of care.

In addition to the service linkages in tier one Specialist Medical and Surgical services the Service is required to establish effective links and working arrangements with, but not limited to, the following service providers:

Assisted Reproductive Technology Service Providers Allied Health Services including: physiotherapy, social services, counselling services, sexual

dysfunctional therapists Consumer support groups Clinical Genetics Services Family Planning Services General Surgical, colorectal, and urological surgical services5 Pain Management Services Palliative Care Services Specialist Community Nurses Midwife / Lead Maternity Carers National Screening Unit screening programmes, NCSP Regional Services Independent

Service Providers and NCSP Laboratories New migrant and refugee services, as appropriate Primary Health Care Providers Public Health communicable diseases programmes, education and promotion services Regional Health Services e.g. Youth One Stop Shop Services Sexual Health Services Termination of Pregnancy services.

8. Quality Requirements

The Service must comply with the Provider Quality Standards described in the Operational Policy Framework (OPF) 6 or, as applicable, Crown Funding Agreement Variations, contracts or service level agreements.

Refer to the tier one Specialist Medical and Surgical Services service specification for generic requirements. In addition, the Service must comply with the following standards and guidelines:

Standards of Service Provision for Gynaecological Cancer Patients in New Zealand - Provisional

NCSP Policies and Standards and Guidelines for Cervical Screening in New Zealand (2008) and any subsequent updates

Objectives for the provision of Elective Services (Clarity, Timeliness, and Fairness) as outlined in Appendix One of tier one Specialist Medical and Surgical services, and within the OPF.

5 i.e. complex endo surgery, complex genito- urinary conditions, oophorectomy for braca, and follow up for gynaecology surveillance of endometrial problems associated with breast chemotherapy - tamoxifen 6 NSFL accountability documents: http://nsfl.health.govt.nz/accountability/operational-policy-framework-0


9. Purchase Unit Codes and Reporting Requirements

9.1 Purchase Units

Purchase unit (PU) codes are defined in the DHB and Ministry’s Nationwide Service Framework Purchase Unit Data Dictionary. The Service must comply with the requirements of national data collections. The following Purchase units may be used to purchase this Service.

PU Code PU Description

PU Definition Unit of Measure

S30PRE Gynaecology Preadmission visit

NOT PURCHASED; USE FOR REPORTING TO NNPAC FOR COUNTING ONLY. Preadmission visit for Gynaecology procedure paid for as part of CWD price

Attendance

S30CANC Gynaecology Cancelled Operation

NOT PURCHASED; USE FOR REPORTING TO NNPAC FOR COUNTING ONLY. Gynaecology cancelled case.

Attendance

S00011 Surgical non-contact First Specialist Assessment - Any health specialty

A review is undertaken by a Registered Medical Practitioner of Registrar level or above, or a Registered Nurse Practitioner, of patient records and any diagnostic test results from Primary to Secondary or Secondary to Tertiary. GP referral can come from tertiary and secondary referrals. The original referral should only be generated after a face to face contact by the referrer. A written plan of care is developed for the patient and provision of that plan and other necessary advice is sent to the referring clinician and the patient. The non-contact FSA does not include the triaging of referral letters. The patient should not be present during the assessment.

Written plan of care

S00012 Surgical non-contact Follow Up - Any health specialty

A review is undertaken by a Registered Medical Practitioner of Registrar level or above, or a Registered Nurse Practitioner, of patient records and any relevant diagnostic test results. The patient is not present during this follow up that should only be undertaken after an original face to face contact by the specialty. A written plan of care is developed for the patient and that plan and other necessary advice is sent to the referring clinician and the patient. The non-contact follow up PU code excludes the costs of diagnostic tests.

Written plan of care

S30001 Gynaecology - Inpatient Services (DRGs)

DRG WIESNZ Discharge. Additional Information is found in the NZ Casemix Framework for Publicly Funded Hospitals which gets updated every year.

Cost Weighted Discharge

S30002 Gynaecology 1st Attendance

First attendance to gynaecologist or medical officer at registrar level or above or nurse practitioner for specialist assessment.

Attendance

S30003 Gynaecology –Subsequent attendance

Follow-up attendances to gynaecologist or medical officer at registrar level or above or nurse practitioner. Excludes colposcopy and minor procedures.

Attendance

S30006 Surgical Termination of Pregnancy Surgical – 1st trimester

Non-acute Surgical Termination of Pregnancy (ToP) performed as an outpatient or elective day case during the first trimester of pregnancy up to 13 weeks. Includes specialist consultation.

Procedure

S30007 Tertiary Infertility Services

Assessments and work up for eligibility to access Fertility Services

Assessment

S30008 Gynaecology Minor Procedure – High Cost

Outpatient procedures where the purpose of the attendance is to receive the procedure and the patient is not admitted. Includes Mirena procedures. Excludes colposcopies and NCSP-20 purchases.

Procedure


PU Code PU Description

PU Definition Unit of Measure

S30009 Surgical Termination of Pregnancy Surgical – 2nd trimester

Non-acute Surgical Termination of Pregnancy (ToP) performed as an outpatient or elective day case during the second trimester of pregnancy up to 19 weeks. Includes obstetrics or gynaecology specialist consultation.

Procedure

S30010 Medical Termination of Pregnancy - treatment

Non-acute medical Termination of Pregnancy (ToP) performed as a non-surgical outpatient or elective day case

Treatment

S30011 Medical Termination of Pregnancy - FU

Follow up as part of a non-acute medical Termination of Pregnancy (ToP) performed as a non-surgical outpatient or elective day case.

Treatment

Unit of Measure7 Unity of Measure Definition

Assessment Number of assessments. Initial assessments and reassessments should be counted separately.

Attendance Number of attendances to a clinic/department/acute assessment unit or domiciliary.

Cost Weighted Discharge

A numerical measure representing the relative cost of treating a patient through to discharge

Procedure The number of individual operative/diagnostic/assessment procedures in the period (period is annual 1st July - 30th June).

Treatment Number of attendances for treatment.

Written plan of care Written plan of care provided by the specialist to the referring GP.

9.2 Reporting Requirements

Gynaecology Services providing TOP services must also comply with the reporting requirements of the Abortion Supervisory Committee.8

7 The Units of Measure are consistent with the Nationwide Service Framework Purchase Unit Data Dictionary www.nsfl.health.govt.nz/purchase-units 8 Abortion Services in New Zealand www.abortion.gen.nz/

JUNE 16

MEDICAL COUNCIL OF NEW ZEALAND

www.mcnz.org.nz

Level 6, 80 The Terrace, PO Box 10509, Wellington 6143, Tel 04 384 7635, 0800 286 801, Email [email protected]

Statement on telehealth Background1. This statement applies to doctors registered in New Zealand and practising telehealth in New Zealand and/or overseas; as

well as doctors who are overseas and provide health services through telehealth to patients in New Zealand.

2. Most doctors already use some form of information and communications technology when providing care, and this has become an integral part of medicine. Telehealth can help patients in isolated locations receive necessary care, provide patients with more convenient access to care, allow for more comprehensive delivery of services after-hours and allow for more efficient use of precious health resources. Telehealth is particularly useful when it is incorporated into an existing system for providing patient care.

3. In using telehealth, you should be aware of its limits and ensure that you do not attempt to provide a service which puts patient safety at risk.

4. In particular, you need to be aware of the inherent risks in providing treatment1 when a physical examination of the patient is not possible.

5. As a doctor, if you provide care to New Zealand-based patients via telehealth, the Council holds the view that you are practising medicine within New Zealand and you should therefore be registered with the Council.2,3. When practising telehealth, you will be subject to the same requirements as doctors registered in and practising in New Zealand. These include the Medical Council’s competence, conduct and health procedures and the complaints resolution processes of the office of the Health and Disability Commissioner. The Council will also notify the appropriate regulatory authorities in other countries if concerns have been raised about your practice.

6. You are also reminded that the New Zealand Code of Health and Disability Services Consumers’ Rights establishes the rights of patients and places corresponding obligations on doctors with respect to telehealth, as they do with all other forms of health care. This includes but is not limited to informing patients about the provision of telehealth services, explaining clearly your specialty or scope of practice, and seeking the patient’s consent before the telehealth service is provided.

1 For the purpose of this statement, “treating” and “treatment” covers all aspects of the practice of medicine, as outlined the Council’s Definition of the practice of medicine, including: assessing; diagnosing; reporting; giving advice; signing certificates; and prescribing medicines.

2 If you are based in New Zealand and provide telehealth services to patients in New Zealand, you must be registered with the Council and have a valid practising certificate. See also clause 18 of this statement for Council’s position with regard to registration where the doctor is in New Zealand but only provides services to patients in another country at the time of treatment.

3 An exception to this rule is when a doctor located overseas is asked by a responsible New Zealand registered doctor to provide an opinion in relation to a patient under the care and/or clinical responsibility of that New Zealand registered doctor. In such cases, the doctor located overseas does not have to be registered to practise in New Zealand. Where input from the overseas-based doctor is likely to be ongoing rather than one-off, it is recommended that the overseas-based doctor have a robust contractual relationship with the New Zealand body, which creates or enables an effective mechanism for dealing with performance and service provision concerns. If you are located in another country and report by telehealth on diagnostic procedures performed in New Zealand or provide treatment to New Zealand-based patients then you should contact the Council to discuss our expectations around registration, recertification and mechanisms to protect public health and safety. Doctors located in another country who provide teleradiology services to New Zealand-based patients should also refer to the Council’s Special purpose (teleradiology) registration requirements on https://www.mcnz.org.nz/get-registered/scopes-of-practice/special-purpose-scope/special-purpose-teleradiology-registration/

Definitions

7. Council has defined the following terms as: In-person: Where the doctor and patient are physically present in the same consultation room.4

Telehealth: the use of information and video conferencing technologies, to deliver health services to a patient and/or transmit health information regarding that patient between two or more locations at least one of which is within New Zealand.

Video consultation: Where the doctor and patient use information and video conferencing technologies to communicate with each other and visual and audio information are exchanged in real time but the doctor and patient are not physically present in the same consultation room. Video consultations can be conducted between a doctor and patient in the presence of their general practitioner or other health practitioner or it can be conducted with no medical support at the patient’s end.

Providing care

8. Any device, software or service you use for the purposes of telehealth should be secure and fit for purpose, and must preserve the quality of the information or image being transmitted.

9. If you treat a patient, you are responsible for gathering and assessing the information used to form a diagnosis, irrespective of its source. If you receive a referral which does not contain the information required to make a fair assessment, Council expects that you will request the relevant information or return the referral to the referrer with a request for more specific information.

10. Council expects that the treatment you provide to a patient in another location meets the same required standards as care provided in an in-person consultation. This includes standards relating to patient selection, identification, cultural competence, assessment, diagnosis, consent, maintaining the patient’s privacy and confidentiality,5 updating the patient’s clinical records and communicating with the patient’s relevant primary care provider in a timely manner (unless the patient expressly states that the details of the telehealth consultation are not to be shared with their primary care provider), and follow-up6. If, because of the limits of technology, you are unable to provide a service to the same standard as an in-person consultation then you must advise the patient of this.

11. It is particularly important that you consider whether a physical examination would add critical information before providing treatment to a patient or before referring the patient to another health practitioner for services including diagnostic imaging and pathology testing. If a physical examination is likely to add critical information, then you should not proceed until a physical examination can be arranged. In some circumstances, it may be reasonable to ask another practitioner in the patient’s locality to conduct a physical examination on your behalf. In those instances, it is important that you obtain the patient’s consent for that arrangement, communicate your request clearly to the other practitioner, and are available to answer any queries that the other practitioner might have.

4 While the consultation room is commonly used in many clinical settings, there are a number of specialties such as radiology where the patient and doctor may not be in the same room and the doctor may delegate the responsibility for examining or attending to the patient to another health practitioner. What is important in such a situation is that the doctor is proximate, available and can be called upon if clinically necessary in line with best practice for that particular discipline or specialty.

5 See also the section on ‘Privacy and confidentiality’ on page 11 of the Royal Australasian College of Physicians’ Telehealth: Guidelines and practical tips.

6 In February 2001, a charge was laid before the British General Medical Council after a doctor prescribed Xenical and Viagra to a patient over the internet. In its judgment, the Professional Conduct Committee noted that it “did not consider that the standard of care given to patients or the prescribing practice of a doctor should be different, whether through the internet or otherwise.” The doctor was suspended from practice for three months. In a separate case, heard by the GMC in 2009, a Fitness to Practise panel imposed conditions on a doctor who prescribed a range of medicines to patients over the internet. In this case, the panel dismissed several allegations and noted that the level of communication was sufficient to obtain a safe history with respect to some conditions, and also noted the need to ensure appropriate monitoring. However, several other charges were proven, and the doctor’s online consultation was found to be inadequate in one case because the format did not allow him to appropriately inform patients of the risks and benefits of treatment or ensure their consent. In addition, his prescribing was described as “inappropriate, irresponsible and not in the best interests of … patients” because the format of one consultation did not allow him to consider alternative diagnoses and because he did not advise the patient’s general practitioner of the treatment prescribed.

12. Specific distance medical services have been demonstrated to provide safe and effective care and are the subject of College approved clinical guidelines. Such guidelines may place additional requirements on your practice7.

13. If you work with or receive reports from telehealth providers, you should ensure that the above standards are followed and must notify that telehealth provider, their management and /or other appropriate reporting channels if you have concerns about the quality of care being provided.

Prescribing 8

14. There are legal restrictions on issuing prescriptions.9 Issuing prescriptions by electronic means only does not meet the current New Zealand legislative standards. In particular it is noted that:

� Under regulation 39 of the Medicines Regulations 1984 no doctor is permitted to prescribe medication to an individual unless it is for the treatment of a patient under his or her care.

� Prescriptions must be legibly and indelibly printed and personally signed by the prescriber with his or her usual signature (not a facsimile or other stamp). Therefore those issued only by email or other electronic means do not meet current New Zealand legislative standards under regulations 40-41 of the Medicines Regulations.

15. You may issue a prescription, including repeat prescriptions, only when you:

� have adequate knowledge of the patient’s health obtained by gathering and considering the patient’s relevant medical history and all other relevant clinical information (preferably including the patient’s full clinical record)10

� are satisfied that the medicines or treatment are in the patient’s best interests

� update the patient’s clinical records. If you are not the patient’s usual doctor, you must ensure that information about any prescriptions you issue are provided to the patient’s regular doctor.

7 In particular the Royal Australian and New Zealand College of Radiologists’ position statement on teleradiology should be the first point of reference for those involved in teleradiology.

8 See also Council’s statement on Good prescribing practice.9 In 2001, the Auckland District Court convicted a doctor who had been involved in the internet sale of prescription medications and sentenced

him to a term of imprisonment for the following offences under the Medicines Act 1981 (Police v Roy Christopher Simpson, Auckland District Court, 17 October 2001):

− Selling by retail a prescription medicine other than under a prescription given by a medical practitioner or designated prescriber. − Selling by retail a prescription medicine without being a pharmacist or other authorised person. − Publishing or causing to be published a medical advertisement that was likely to mislead any person with regard to the use and/or effect of

that medicine and which failed to give sufficient information on precautions, contraindications and side effects required by regulation 8 of the Medicines Regulations 1984.

− Publishing or causing to be published a medical advertisement that failed to make statements required by regulation 8 of the Medical Regulations 1984 to be made in an advertisement relating to medicines of that description, kind or class. A finding of the Hamilton District Court and affirmed in the High Court (Ministry of Health v Ink Electronic Media Ltd and others, Hamilton District Court 12 December 2003) and Ministry of Health v Ink Electronic Media Ltd and others (High Court, 18 August 2004) looked at another case of internet prescribing and considered the meaning of “under his or her care” in section 39 of the Medicines Regulations. The Court held that as a minimum there must be:

− Some information given about the patient to the doctor. − An acknowledgement by the patient that the doctor is his or her medical adviser for this purpose. − The doctor accepts responsibility for treating the patient for the condition referred to.10 In an emergency, responding to the acuity of the patient will be a matter of priority and this may result in prescribing without adequate

information about the patient’s medical history. It is important that all medicines prescribed in an emergency are documented in the patient’s clinical records.

16. Before prescribing any medicine for the first time to a patient, Council expects you to have an in-person consultation with that patient. If this is not possible because of exceptional circumstances,11 consider a video consultation with the patient12 or discuss the patient’s treatment with another New Zealand registered health practitioner who can verify the patient’s physical data and identity. When these options are not possible or practical, it may be reasonable practice to:

� complete a prescription for a patient if you are providing cover for an absent colleague or are discharging a patient from hospital and have reviewed the patient’s notes.

� renew a prescription of a patient you, or a colleague in the same practice, have seen previously, following a review of its appropriateness for the patient. When the prescription has potentially serious adverse effects, you should regularly assess the patient.

� complete a prescription when you have a relevant history and there is an urgent clinical need to prescribe, provided that you inform the patient’s regular doctor as soon as possible13.

You must give careful consideration before prescribing any medication with a risk of addiction or misuse or psychotropic medication, and ensure that there are robust systems in place to manage the care of these patients. It is never appropriate to prescribe medicines with a risk of addiction or misuse, or psychotropic medication, for the first time to a patient who has not been appropriately assessed in person.

17. Where an electronic system is used for any aspect of prescribing, it must comply with relevant standards pertaining to electronic prescribing in the location where the prescription will be filled.14

Providing care to a patient located outside New Zealand

18. If you are in New Zealand and only provide telehealth services to patients who are located in another country, then you are not required to be registered with the Council. However, you may be subject to the jurisdiction where your patient is located, and it would be sensible to familiarise yourself with the requirements of that country.

19. When providing care from New Zealand to patients in another country, then you remain subject to New Zealand law in areas such as prescribing and you may be subject to other legal obligations, requirements or liabilities in the location where your patient is. You may also be subject to the jurisdiction of authorities in your patient’s home country, and may be liable if you assist patients to contravene that country’s laws or regulations, for example, any importation and possession requirements. You should seek legal advice in that country if necessary.

20. If you are registered with the Council and provide telehealth services to patients overseas, Council will apply its standards (rather than the standards applicable in the location where your patient is) in relation to your conduct and fitness to practise medicine.

11 Examples of exceptional circumstances include the urgency of the clinical situation or the unavailability of a doctor. It is good practice to document in the patient’s clinical notes, the mode of the consultation and the reasons for not conducting an in-person consultation before prescribing any medication for the first time to a patient.

12 If you conduct a video consultation, you must take extra care to ensure that a physical examination of the patient is not necessary. If in the course of a video consultation it becomes clear that a physical examination is required, you must inform the patient and arrange for a physical examination. In instances where the physical examination is to be conducted by another health practitioner, you must ensure that you outline clearly what follow-up is required.

13 For example, when a public health physician prescribes prophylactic medicines for family members of a patient, after that patient has been diagnosed with a serious communicable disease.

14 See also regulations 41(a) and (b) of the Medicines Regulations 1984, and clause 37 of Good prescribing practice which states that a prescription written in New Zealand has no validity overseas.

Related resources � Doctors and health related commercial organisations

� Use of the internet and electronic communication

� Good prescribing practice

� You and your doctor

� The New Zealand Code of Health and Disability Services Consumers’ Rights

� College of Intensive Care Medicine of Australia and New Zealand’s Guidelines on the use of telemedicine in intensive care

� Royal Australasian College of Physicians’ Telehealth: Guidelines and practical tips

� Royal Australian College of General Practitioners and Australasian College for Emergency Medicine’s Guidelines for interprofessional collaboration between general practitioners and other medical specialists providing video consultations

� Royal Australasian College of Surgeons’ position paper on Telemonitoring and teleassessment of live surgery

� Royal Australian & New Zealand College of Psychiatrists’ Professional practice standards and guides for telepsychiatry

June 2016

This statement is scheduled for review by June 2021. Legislative changes may make this statement obsolete before this review date. The contents of this statement supersede any inconsistencies in earlier versions of the statement.

COLE’S MEDICAL PRACTICE IN NEW ZEALAND 2013 83

CHAPTER 8 THE uSE Of INTERPRETERS

DiversityIncreasing numbers of New Zealand residents are born overseas — since 1996 the percentage has increased from 17 percent to 22 percent or nearly one in four people living in New Zealand. Between 2006 and 2026 the Asian, Māori and Pacific populations are all projected to grow faster than the New Zealand population overall,1 and net migration will become an increasingly significant contributor to population growth.2 The proportion of people from non-English speaking backgrounds is also increasing; people of Chinese origin are now the second most common group of migrants after those of English origin, and Chinese and Samoan are the most widely spoken languages in New Zealand after English and Māori. New Zealand’s immigrant population is disproportionately concentrated in the Auckland region. In 2006, over half (52 percent) of the overseas born population lived in Auckland, which was home to 32 percent of the country’s total population.

New Zealand has three official languages, English, Maori and New Zealand Sign Language (for which there are 24,000 users)3

Right to communicationRight 5 of the Health and Disability Commissioner’s Code of Rights, “Effective Communication”, includes a right to a competent interpreter.4 Without an interpreter many of the other “Patient Rights” are not available to a person with “limited English proficiency”(LEP).

Is any interpreter satisfactory?Accurate complete interpreting is a difficult professional job that requires significant training. In addition good interpreting is founded on trust; the patient must trust the interpreter to hold any information confidential and trust them to accurately interpret their communication, the doctor has to trust the interpreter to be accurate, and to signal if there is any doubt as to how a phrase should be translated. The further apart culturally two languages are the more likely that concepts do not translate. For example, there is no equivalent term to schizophrenia in Somali. It requires significant practice to be able to recall all that is said in English and then accurately translate it into another language.

It is common practice for clinicians to use ad hoc interpreters: family members, friends, bilingual colleagues to aid communication with LEP patients. Table 1 lists the important linguistic and ethical problems with this approach.



Table 1

Linguistic problems Ethical problemsAccuracy of interpreting, degree of English fluency

Confidentiality

Unfamiliarity with medical terms Difficulty with talking about sensitive matters Incomplete interpretation Role conflict (e.g. abusing husband interpreting

for abused wife)Adding in advice or opinion of interpreter Disrupting family dynamics; in particular the

use of young children as interpreters for their parents is unacceptable.

In judging the likelihood that a professional interpreter is needed, the following issues should be considered:

• Complexity of anticipated clinical content

• Language ability of the patient

• Language ability of available ad hoc interpreter

• Degree of ethical risk: e.g. is the patient vulnerable with mental health issues? Is the available ad hoc interpreter a child? does the available ad hoc interpreter have a position of power over the patient?

• Sensitivity of clinical content: e.g. gynaecology, family discord

• Legal need for informed consent

• Urgency of presentation: in emergency use the best available

• Wishes of the patient

• Ability to pay for an interpreter.

It is useful to think of there being a continuum in degree of need to use a professional interpreter.

For example looking at clinical complexity, at one end it is essential: e.g. explaining a new diagnosis of cancer, gaining informed consent for a major procedure. At the other end a family member may be satisfactory: doing a repeat prescription for hay fever medication.

Every doctor must have the ability to employ a professional interpreter if caring for a Limited English Proficiency patientIf a patient has LEP then there will be times when care cannot be provided without a professional interpreter.



Professional interpreter: telephone vs face to faceMany organisations prefer to use telephone interpreting, predominantly because of cost.

Table 2 contrasts the risks and benefits of telephone and face to face interpreting.

Table 2

Telephone interpreter Face to Face Interpreter

Benefits Anonymity of interpreter

Availability (for smaller language groups or at short notice)

Cheaper

Relative ease of communication including non verbal

Easier if needing to consult with a family group

Disadvantages/Risks Distancing effect of the phone

Possible background noise

Difficulty in gauging quality of interpreter

Lack of continuity (more likely)

Possible issues with confidentiality/comfort the patient and interpreter are socially acquainted or part of a small ethnic community

More costly

Organisational systems required to care for LEP patientsDoctors work in organisations and there are many things at a system level that will facilitate communication with LEP patients:

• Routine collection of ethnicity, preferred language and need for interpreter data on registration

• Organisational policy on use of interpreters

• Provision of a budget for employing interpreters

• Register kept of available interpreters

• Speaker phones available (telephone interpreters are commonly used and available)

• Staff training on managing LEP patients including reception staff

• Look at all communications from the organisation to patients through the eyes of an LEP patient: do any of them need translating?

• Patient safety Incident management system flagging when language barrier may have been a factor.



Skills required

Assessing English fluency

If the patient speaks no English it is easy to work out that you need an interpreter. It is rarely helpful to ask someone if they speak English. Better is to ask open ended questions, or ask the patient to repeat back in their own words what they have understood you to have said. Even if someone has sufficient English for conversation at work they may still have insufficient for discussing complex health issues.

Working with an interpreter

Organisations providing interpreter services all offer brief advice or training on how to work with an interpreter. Some basic points are:

• Speak as if you are talking to the patient (“how do you feel” not “how does she feel”)

• Sit in an equilateral triangle so patient doctor and interpreter can easily see each other

• Speak in small “chunks”. The longer you speak without a break for interpreting, the harder it is to interpret accurately

• Avoid colloquialisms and medical jargon. Jokes are often hard to explain and risk being misunderstood.

Communicating with deaf peoplePast prohibition of the use of sign language in schools means that there are significant numbers of deaf people with low levels of literacy. Written communication is not a suitable or reliable substitute for communicating with many deaf people. If you have deaf people in your practice there is a detailed guide on managing this at: http://www.odi.govt.nz/resources/guides-and-toolkits/working-with-nzsl-interpreters/index.html

Funding for interpretersAll public hospitals in New Zealand have policies and a budget for the use of interpreters, although anecdotally the budgets are constrained. Any public sector organisation can join “Language Line” (see below) which provides subsidised telephone interpreting. This includes PHOs. The three Auckland DHB’s have a fully funded primary care interpreting service. Many PHOs provide some funding through “Services to Improve Access” funding.

http://www.odi.govt.nz/resources/guides-and-toolkits/working-with-nzsl-interpreters/index.html

http://www.odi.govt.nz/resources/guides-and-toolkits/working-with-nzsl-interpreters/index.html



Availability of professional interpretersLanguage Line is a partially subsidised telephone interpreting service that is provided from the Office of Ethnic Affairs. http://www.ethnicaffairs.govt.nz/oeawebsite.nsf/wpg_url/language-line-Index. They provide interpreters in 43 languages, and are available Monday to Friday 9am—6pm and Saturday 9am—2pm.

Auckland has its Primary Health Interpreting Service http://watis.org.nz/info/Primaryservice.php available to primary health services in Auckland, Waitemata and Counties Manakau. The New Zealand Society of Interpreters and Translators keep a database of interpreters: http://www.nzsti.org

Interpreting New Zealand provides interpreters in 70 languages from Wellington and Christchurch, face to face, and by telephone to other regions. http://www.interpret.org.nz

Uptake of professional interpreters is poorTwo New Zealand studies document that the use of interpreters is inadequate and clinical harm is likely to be happening as a result of impaired communication.5, 6 Cost can be a significant barrier to using professional interpreters. Doctors working for organisations who care for LEP patients where there is no budget for interpreters have a responsibility to lobby for funding to be found.

However even if the service is free there can be a low uptake. This has particularly been noted in Australia where despite a comprehensive free interpreting service uptake is significantly lower than anticipated.7

The main identified barriers to uptake identified were training of clinical staff and particularly training and attitudes of reception staff.8 A toolkit has been developed for use in primary care in New Zealand to address this need.9

SummaryNew Zealand has an increasingly diverse population with significant numbers of people who are not English proficient, particularly in the Auckland region. It is not possible to provide good care for an LEP patient without an interpreter, and there are some situations where a professional interpreter is essential. Current use of interpreters in New Zealand is such that it is very likely that LEP patients are being exposed to increased clinical risk. Attention to the systems in which doctors work as well as the skills and knowledge of clinicians is needed to improve this problem.

http://www.ethnicaffairs.govt.nz/oeawebsite.nsf/wpg_url/language-line-Index

http://watis.org.nz/info/Primaryservice.php

http://www.nzsti.org

http://www.interpret.org.nz



References

1. Statistics New Zealand 2006. Quick Stats about culture and identity. In: Statistics New Zealand. Wellington: NZ Government;.

2. Ministry of Social Development 2010. The Social Report 2010. Available from: http://socialreport.msd.govt.nz/people/people-born-overseas.html.

3. Statistics New Zealand 2006. Quick stats about culture and identity (2006 Census Data): Languages Spoken. Available from: http://stats.co.nz/Census/2006CensusHomePage/QuickStats/quickstats-about-a-subject/culture-and-identity/languages-spoken.aspx.

4. Health and Disability Commissioner 2009. The Code of Health and Disability Services Consumers’ Rights. [cited 2009 27/7/09]; available from: http://www.hdc.org.nz/theact/theact-thecode.

5. Gray B, Hilder J, Donaldson H 2011. Why do we not use trained interpreters for all patients with limited English proficiency? Is there a place for using family members? Australian Journal of Primary Health; 17(3): 240—9.

6. Gray B, Stanley J, Stubbe M, Hilder J 2011. Communication Difficulties with Limited English Proficiency patients — clinician perceptions of clinical risk and patterns of use of interpreters. NZ Med J.; 124 (1342).

7. Phillips CB, Travaglia J 2011. Low levels of uptake of free interpreters by Australian doctors in private practice: secondary analysis of national data. Australian health review : a publication of the Australian Hospital Association; 35(4): 475—9.

8. Huang Y- T Phillips C 2009. Telephone interpreters in general practice: bridging the barriers to their use. Aust Fam Physician; 38(6): 443—6.

9. Gray B, Hilder J, Stubbe M 2012. How to use interpreters in general practice: the development of a New Zealand toolkit. Journal of Primary Health Care; 3: 18.

http://socialreport.msd.govt.nz/people/people-born-overseas.html

http://stats.co.nz/Census/2006CensusHomePage/QuickStats/quickstats-about-a-subject/culture-and-identity/languages-spoken.aspx

http://stats.co.nz/Census/2006CensusHomePage/QuickStats/quickstats-about-a-subject/culture-and-identity/languages-spoken.aspx

http://www.hdc.org.nz/theact/theact-thecode

THE MEANING OF WORDS USED AT AN ABORTION SERVICE

ABORTION

Abortion is the ending of pregnancy by removing a fetus or embryo before it can survive outside the

uterus.

ANAEMIA

Anaemia occurs when you have a low level of red blood cells in your blood (low haemoglobin). Iron

deficiency anaemia is the most common type of anaemia, caused by insufficient iron to support the

normal production of red blood cells.

ANAESTHESIA

Anaesthesia is a state of temporary induced loss of sensation or awareness. It may be local or general.

General anaesthesia involves loss of consciousness while local anaesthesia involves only a specific part

of the body and you remain awake.

BACTERIAL VAGINOSIS

Bacterial vaginosis (BV) is a disorder of the vagina caused by excessive growth of bacteria. Common

symptoms include increased vaginal discharge that often smells like fish. The discharge is usually white

or grey in colour. Many women with BV have no symptoms. It is caused by an imbalance of the

naturally occurring bacteria in the vagina.

BIMANUAL EXAMINATION

This is part of a pelvic examination which may be performed by a doctor, midwife or nurse. It involves

the examiner having two fingers of one hand inside the vagina and the palm of the other hand on the

lower abdomen. The clinician is able to feel the size, shape and position of the uterus and cervix. This

is normally done before a surgical abortion procedure is commenced.

BLOOD PRESSURE

Blood pressure (BP) is the pressure of circulating blood on the walls of blood vessels. Blood pressure

is usually expressed in terms of the systolic pressure (maximum during one heart beat) over diastolic

pressure (minimum in between two heart beats) and is measured in millimetres of mercury (mmHg).

Normal blood pressure is between 90/60 and 140/90.

BLOOD TRANSFUSION

Blood transfusion is the process of receiving blood or blood products into one's circulation through a

vein. Transfusions are used for various medical conditions to replace lost components of the blood. A

blood transfusion is rarely required as a consequence of haemorrhage after a medical abortion. A

blood transfusion is very rarely required as a consequence of haemorrhage after a surgical abortion.

CERTIFYING CONSULTANT

A Certifying consultant is a doctor who is appointed by the Abortion Supervisory Committee under the

Contraception, Sterilisation and Abortion Act 1977. Certifying Consultants consider, in accordance

with section 33 of the Act, whether an abortion should be authorised.

CERVIX

The cervix (neck of the uterus) is the lower part of the uterus. The cervix is usually 2 to 3 cm long and

roughly cylindrical in shape, which changes during pregnancy. The narrow, central cervical canal runs

along its length, connecting the uterine cavity and the vagina. The opening into the uterus is called

the internal os, and the opening into the vagina is called the external os. The lower part of the cervix,

bulges into the top of the vagina.

CHLAMYDIA

Chlamydia is a sexually transmitted infection. It usually infects the cervix and urethra and is passed

from person to person during sex. If it is not treated it can cause infertility or an infection after

abortion. It is the most commonly diagnosed STI in Aotearoa New Zealand. It can be treated with

antibiotics. Sexual partners should also be treated at the same time.

COMPLICATION

A complication is an unfavourable consequence of a disease, a health condition or treatment. The risk

of a complication after a first trimester medical abortion is 5%. The risk of a complication after a first

trimester surgical abortion is 3%.

CONSCIOUS SEDATION

Conscious sedation is the administration of medicines given to help you relax and to block pain during

a medical procedure. You usually remain awake but may feel sleepy, a little dizzy and your memory of

the procedure may be affected.

Conscious sedation has the advantage over general anaesthetic in that you recover more quickly and

it is safer.

Examples of drugs used for sedation include fentanyl, midazolam and lorazepam. These drugs are

commonly used at the time of a surgical abortion.

You cannot drive until the day after conscious sedation.

CONTRACEPTION

Contraception, or birth control, is a term for the various methods used to prevent women from

becoming pregnant.

COUNSELLING

In the context of having an abortion, counselling is the provision of assistance by qualified

professionals who give advice and support and guidance for women making difficult decisions and

facing difficult situations. Counselling should be freely available when having an abortion, but may be

declined by those who do not want it.

COUNSELLOR

In Aotearoa New Zealand, Abortion Counsellors are usually qualified Social Workers, Counsellors or

Nurses with Counselling qualifications.

DILATION

In the context of having an abortion, cervical dilation refers to the opening of the cervical canal. In

first trimester surgical abortions, the doctor usually dilates the cervix to between 6mm and 10 mm

(1cm). This process is made safer and easier by taking misoprostol before the procedure.

DOCTOR

Registered Medical practitioner with the Medical Council of New Zealand. Under New Zealand Law,

only doctors can perform abortions.

EMA

Early Medical Abortion (up to 9 weeks from your last menstrual period ‐ about 7 weeks from when

you conceived)

EMBRYO

An embryo is an early stage of development of a multicellular organism. An embryo develops from

a zygote, the single cell resulting from the fertilization of the female egg cell by the male sperm cell.

The zygote possesses half the DNA of each of its two parents. The zygote will begin to divide

by mitosis to produce a multicellular organism. The result of this process is an embryo. The embryo

becomes a fetus at 8 weeks gestation.

FETAL DEVELOPMENT

2 WEEKS : Fertilisation occurs at 2 weeks gestation. (2 weeks after LMP)

3 WEEKS : Implantation occurs at 3 weeks gestation ‐ the hormone HCG is now detectable in the blood

4 WEEKS : Embryo is the size of a poppyseed

5 WEEKS : Embryo is the size of a sesame seed (looks like a tadpole)

6 WEEKS : Embryo is the size of a lentil (heart has started to beat)

7 WEEKS : Embryo is the size of a blueberry

8 WEEKS : Embryo is the size of kidney bean

9 WEEKS : Fetus is the size of a grape

10 WEEKS : Fetus is about 2.5cm long

11 WEEKS : Fetus is the size of a fig

12 WEEKS : Fetus is the size of a small lime (5cm)

FETUS

In human development, a fetus or foetus is a prenatal human between the embryonic state and birth

(8 weeks gestation to birth).

GESTATION

Gestation is the carrying of an embryo or fetus inside the female uterus.

Gestational age is a measure of the age of a pregnancy which is taken from the first day of the

woman's last menstrual period (LMP), or the age of gestation as estimated by an ultrasound scan.

Gestational age has traditionally been calculated from the LMP rather than by the day of fertilization

or conception because menstrual periods are usually noticed whereas it can be hard to figure out

when conception occurred. By definition, gestation by LMP will always be 2 weeks more than gestation

calculated from the date of conception.

GONORRHOEA

Gonorrhoea is a bacterial infection of the genitals, throat or rectum. Gonorrhoea can cause infertility

in both men and women or a pelvic infection after abortion. It can be treated with antibiotics. Both

partners should be treated at the same time.

HAEMOGLOBIN

A red protein responsible for transporting oxygen in the blood. Normal haemoglobin in the first

trimester of pregnancy is greater than 105g/L

HAEMORRHAGE

Bleeding, also known as haemorrhaging, is blood escaping from the circulatory system. There will

always be some blood loss at the time of an abortion. A haemorrhage requiring a blood transfusion

after abortion is rare.

HYSTERECTOMY

Surgical removal of the uterus. This is a very rare complication of an abortion. (less than 1/10,000)

IMPLANT

Also called the contraceptive implant or rods. The implant is a type of long‐acting

reversible contraception (LARC) which slowly releases a progestogen hormone. It can last 3‐5 years. It

is the most effective contraception available in Aotearoa New Zealand with a failure rate of 0.05%.

INCOMPLETE ABORTION

An incomplete abortion is an abortion that has left some pregnancy tissue behind. It is a common

complication in both medical (5% chance) and surgical (2% chance) abortion. The pregnancy has ended

— no fetus will develop, but your body has only expelled part of the tissue and products of pregnancy.

Treatment may include returning to the clinic and further suction procedure or medication.

INFECTION

An infection happens when a foreign organism enters a person's body and causes harm. In Aotearoa

New Zealand this is an uncommon complication after an abortion. It is most commonly seen as an

infection of the uterus (endometritis) or pelvis (PID‐ pelvic inflammatory disease). To reduce the risk

of an infection after your abortion it is recommended that you:

1. get your swabs done before the procedure to check for pre‐existing infection

2. take any antibiotics that are prescribed

3. use pads rather than tampons

4. avoid sex for about a week after the abortion.

IUD/IUCD

Intrauterine device or intrauterine contraceptive device. An IUD is a small, T‐shaped object that goes

inside your uterus. Other names for the IUD are coil or loop. There are two types of IUDs:

Copper IUD ‐ contains copper, a type of metal.

Hormonal IUD – contains the hormone progestogen (IUS).

IUDs are reliable forms of contraception with failure rates of less than 1%. They are a popular type of

LARC (long acting reversible contraception) and can be inserted at the time of a surgical abortion.

IUS

Intrauterine system or hormonal IUD. It is a small plastic T‐shaped device that slowly releases a

hormone, progestogen into the uterus. Two types of IUS are used in the NZ – Mirena and

Jaydess. The IUS is similar to the IUD (intrauterine device), but works in a slightly different way.

Progestogen thickens the mucus from the cervix, making it harder for sperm to move through it and

reach an egg. It also causes the womb lining to become thinner and less likely to accept a fertilised

egg. In some women, the IUS also stops the ovaries from releasing an egg (ovulation), but most women

will continue to ovulate. The IUS is very reliable with a failure rate of 0.2%.

IV LUER

Intravenous luer. This is a very small plastic tube put into your vein by a nurse or doctor. It is used to

give medication or fluids directly into your vein. When having a surgical abortion, you will be required

to have an IV luer.

LAPAROSCOPY

A surgical procedure in which a fibre‐optic instrument is inserted through the abdominal wall to view

the organs in the abdomen or permit surgery. Rarely women require laparoscopy if they have a uterine

perforation.

LAPAROTOMY

A surgical incision into the abdominal cavity, for diagnosis or in preparation for surgery. Very rarely,

women require laparotomy if they have a uterine perforation.

LARC

Long acting reversible contraception (IUD, IUS, Implant).

Long‐acting reversible contraceptives (LARC) are methods of birth control that provide effective

contraception for an extended period without requiring user action. They include intrauterine devices

(IUDs and IUSs) and subdermal contraceptive implants. LARC methods of contraception have perfect

use failure rates of 0.05 to 0.6% and typical use failure rates of 0.05 to 0.8%.

LOCAL ANAESTHETIC

Local anesthetic (LA) is a medication that causes reversible absence of pain sensation. The doctor

doing your surgical abortion will put local anaesthetic into your cervix. This will reduce your pain and

stop cervical pain but usually does not eliminate all discomfort because your uterus still has some

sensation.

MEDICAL ABORTION

Medical abortion uses pills rather than surgery to end a pregnancy.

MIDWIFE

In the context of abortion care a midwife may work with women to give them the necessary support,

care and advice during pregnancy and after their abortion. To practise as a midwife in New Zealand,

the midwife must have an annual practising certificate issued by the Midwifery Council of New

Zealand

MIFEPRISTONE

Also known as the ‘abortion pill’ or mifegyne. This is a steroidal anti‐progestogen used in conjunction

with misoprostol to induce medical abortion. It is taken orally.

MISOPROSTOL

Also known as Cytotec, this is a prostaglandin medication used widely in abortion care. In surgical

abortion it is used prior to the procedure to soften and dilate the cervix. In medical abortion , it is used

in conjunction with mifepristone. Misoprostol may be taken orally, vaginally, rectally, sublingually or

buccally. In abortion care the preferred routes of administration are buccally(in the cheek),

sublingually(under the tongue) and vaginally(at the top of the vagina).

MTOP

Medical termination of pregnancy or medical abortion. A medical abortion uses medication (usually

pills) rather than surgery to end the pregnancy.

NURSE

A Nurse is a professional within the health care sector who focusses on the care of individuals, families,

and communities so they may attain, maintain, or recover optimal health and quality of life. Anyone

who is practising as a nurse must hold a practising certificate with the Nursing Council of New Zealand.

PELVIS

In the context of abortion care, this refers to the female reproductive organs (vagina, uterus, fallopian

tubes, ovaries )

PREGNANCY

Pregnancy, also known as gestation or haputanga, is the time during which one or more offspring

develops inside a woman.

PRODUCTS OF CONCEPTION

Pregnancy tissue or POC. This includes the embryo or fetus and any placental tissue.

PROCEDURE

In the context of a surgical abortion, the procedure is the surgical operation performed by the doctor.

It usually takes about 15 minutes in the procedure room and involves administration of sedation and

local anaesthetic, vaginal examination, dilation of the cervix and suction to remove the embryo/fetus

and pregnancy tissue.

PULSE

Heart rate. It may be measured by arterial palpation of the heartbeat by fingertips or a machine (pulse

oximeter).

RUBELLA

Rubella, also known as German measles, is caused by a virus. It is usually a mild disease, but can result

in severe damage of an unborn baby when it occurs during pregnancy. For this reason, all women in

Aotearoa New Zealand of child bearing age should make sure they have Rubella immunity. Rubella

immunity is routinely tested when having antenatal blood tests. You can get a Rubella vaccine (MMR)

from your family doctor (GP).

SCAN

See ultrasound

SEDATION

See Conscious sedation

SOCIAL WORKER

Social workers provide advice and support, share knowledge and can assist with decision making for

those considering abortion. Social workers working in abortion care should hold an annual practicing

certificate and valid competence certificate.

SPECULUM

A vaginal speculum is a medical instrument which allows the doctor or nurse or midwife to view the

cervix. It is necessary to have a speculum placed in the vagina when having a surgical abortion.

STOP

Suction termination of pregnancy. Surgical abortion or Suction abortion.

SUCTION

Suction is the flow of a fluid into a partial vacuum. Suction is used during a surgical abortion to remove

the embryo or fetus via a plastic catheter.

SURGICAL ABORTION

First trimester (less than 13weeks 6days) surgical abortion uses vacuum aspiration or suction to end a

pregnancy and is usually done under sedation and local anaesthesia.

SWABS

A cotton swab (similar to a cotton bud) is used to wipe the cervix or vagina or urethra to test for

sexually transmitted infection, thrush or BV. It is recommended that women have swabs taken prior

to an abortion so that any infections can be treated.

TERMINATION OF PREGNANCY

Also known as TOP. See Abortion.

THE INJECTION

Also known as the jab or shot or depo provera. This is a hormonal form of contraception which lasts

12 weeks. It is an injection, usually into the thigh or bottom, which contains the hormone progestogen.

If taken perfectly (every 12 weeks) it has a failure rate of 0.2%. Typical use has a failure rate of 6%.

THE MINIPILL

The progestogen‐only birth control pill, commonly called the mini‐pill, is an oral contraceptive. If taken

perfectly, every day, it has a failure rate of 0.3%. Typical use has a failure rate of 9%.

THE PILL

Also called the COC or combined pill. This is an oral contraceptive which contains two hormones‐

estrogen and progestogen. Perfect use has a failure rate of 0.3% but typical use has a failure rate 9%.

TOP

Termination of pregnancy. See Abortion

TRICHOMONAS

Trichomoniasis (or “trich”) is a very common STI. It is caused by infection with a protozoan parasite

called Trichomonas vaginalis. Although symptoms of the disease vary, most people who have the

parasite cannot tell they are infected. It can be treated with antibiotics and both partners need to be

treated at the same time.

TRIMESTER

A period of three months ‐ a division of the duration of pregnancy.

First trimester is 0 to 3 months

Second trimester is 4‐6 months

Third trimester is 7‐9 months

ULTRASOUND

An ultrasound scan or scan is an ultrasound‐based diagnostic medical imaging technique used in pre‐

abortion care to measure the location and size of the pregnancy. Ultrasound is sound

waves with frequencies which are higher than those audible to humans.

UTERINE PERFORATION

In the context of having an abortion, a perforation is an uncommon complication where a hole is

accidentally made in the wall of the uterus. It may or may not require further treatment such as

transfer to another hospital, laparoscopy, laparotomy or blood transfusion.

UTERUS

The uterus or womb (te whare tangata) is a female reproductive organ where the embryo or fetus

grows. At the lower end of the uterus, the cervix opens into the vagina, while at the other end, the

fundus is connected to the fallopian tubes.

VAGINA

In women, the vagina is the fibromuscular, tubular part of the genital tract extending from the vulva

to the cervix.

VAGINAL EXAMINATION

Also called a pelvic examination. This is the physical examination of the external and internal

female pelvic organs. It includes a "bimanual examination". It is frequently used in gynaecology.

The examination can be uncomfortable or awkward but shouldn’t be painful.

ABORTION SUPERVISORY COMMITTEE

Standards of Practice for theProvision of Counselling

Counselling Advisory CommitteeApril 1998

2

FOREWORDIt is twenty years since the passing of the Contraception, Sterilisation, and Abortion Act,and over this time there has been a steady increase in New Zealand’s general abortionrate and an expansion of its use in different age and ethnic groups.It has also been a time of considerable change in the structure and provision of healthservices including a move towards the establishment of measurable standards ofcompetency for all health professionals.The importance of counselling in the provision of abortion services remains indisputableand is vital to the credibility and integrity of the service. The challenge now facing theprofession is the maintenance of high professional standards to ensure a quality servicewhich is not compromised by the financial constraints of current health policies.The original guidelines produced in 1979 have been a valuable resource but are nowoutdated. The Abortion Supervisory Committee decided those guidelines neededreviewing and asked the Counselling Advisory Committee to undertake the task. Thesestandards of practice are the result and we are grateful to the counselling advisors andprofessionals who assisted them.The Committee would like to thank all the social workers and counsellors who have overthe previous twenty years provided counselling for women considering an abortion, oftenworking within difficult work environments and at a personal cost to themselves.

Christine ForsterChairpersonAbortion Supervisory Committee

3

INTRODUCTIONThe Contraception, Sterilisation, and Abortion Act 1977 became law amid intense publicdebate and when attitudes towards abortion were extremely polarised. The requirementsof the Act regarding the provision of counselling are summarised in Appendix 1. Section21(1)(e) states that one of the requirements an institution must meet in order to be licensedis that adequate counselling services are available to women considering having anabortion ... and are offered to such women whether or not they ultimately have an abortion.

Section 15 gives the Supervisory Committee power to appoint advisory committees ... toadvise it on such matters as it may refer to them ...

In 1979, a Counselling Advisory Committee, committed to professional service delivery,was appointed and asked to draw up guidelines for counselling. These guidelines provideda useful and appropriate framework for social workers undertaking the counselling task, inoften difficult and threatening environments. They also assisted in getting servicesestablished and in developing professional models of practice.The models of practice adopted were strongly influenced by the developing feministtheoretical ideas of the time. These articulated empowerment and total care of women.Essentially they related to stand-alone clinics. Services established in large women’s andpublic hospitals presented different challenges. Those administering the hospitals were,at best, indifferent to the provision of abortion services and often openly hostile to thesocial workers and doctors offering services to women seeking abortion.In the intervening years, the surrounding context for social work and counselling has alteredalmost beyond recognition. The organisational environment requires quantification andoutput measurement. The educational and training environment has also changed: thereare now registered standards of competencies for counselling. Women, as consumers ofservices, are more aware of their entitlements and assertive about ensuring their rightsare respected and honoured.The development of social work and counselling as professions has led to greaterexpectations of competency, accountability and appropriate training. However, in thebroader political context, there is still ambivalence and ambiguity about abortion, which isreflected most pointedly in the inequalities of access.Within this context, women at a personal and relationship level continue to confront therange of dilemmas that an unintended pregnancy provokes in a climate that remainsambivalent, often hostile and critical of women who find themselves in this situation.

4

STATEMENT OF PURPOSEThese standards of practice conform to the requirements of the New Zealand statutes thatdetermine the circumstances which give women the right to request consideration fortermination of pregnancy and allow legal abortion to take place.The purpose of these standards is to:1. reflect the professional standards of social work and counselling that licence holders

should aim for in the clinics and institutions that provide counselling services to womenconsidering an abortion

2. state the overall concept and goals of counselling3. clarify the essential elements for the provision of a counselling service for women

seeking consideration for termination of pregnancy4. establish the areas of knowledge required by those providing decision-making

counselling to women faced with an unintended/unwanted/foetal abnormal pregnancy5. pull together the relevant standards for social work and counselling services and

set these in the context of abortion services, referring as appropriate to specialsituations and offering some guidance on resources available

6. remind all those involved in the provision of a counselling service that “choice doesnot exist as an abstract freedom” (Hadley: 1996), and that choice cannot bedisconnected from the realities of the social and political forces of our time, or thevision that a person holds for themselves at any given point in time. The client mustbe seen within the context she lives in, dreams about and desires

7. promote an expectation that the provision of counselling requires:• suitably qualified individuals who are informed, disciplined, skilled and committed

to enabling women to make informed decisions about their pregnancy• organisations that are committed to enabling women to make informed

decisions about their pregnancy.

PROFESSIONAL REQUIREMENTS FOR SOCIAL WORKERS/COUNSELLORS1. Qualifications and Training

Social workers and counsellors should have a recognised social servicesqualification:New Zealand Qualifications Authority, National Diploma Social Services (Level 6),Strand Counselling and Social Work. This is the present industry equivalent to theNew Zealand Council for Education and Training in the Social Services (NZCETSS)-B level qualification.or

5

Equivalent education and training that includes registered unit standards specifiedin appendix 2 obtained through an accredited provider or through registered industryassessor.orEquivalent overseas qualifications recognised by the industry training organisation(Te Kaiawhina Ahumahi) for practice in New Zealand.

2. Professional Membership

• The social worker/counsellor has full membership of a recognised professionalassociation that has a recognised code of ethics, established complaints proceduresand preferably indemnity insurance.

For example:• New Zealand Association of Social Workers• New Zealand Association of Counsellors• Te Whare Ki Tautoko

3. SupervisionThe social worker/counsellor is engaged in regular professional supervision to ensure• increased effectiveness• maintenance of accountability to the client and agency• development and maintenance of a professional identity and ethical practice.See Appendix 3 for the New Zealand Association of Social Workers policy statementon supervision.

6

4. Treaty of WaitangiThe social worker/counsellor demonstrates:

• support for the principles of partnership as embodied in the Treaty of Waitangi• commitment to a bicultural code of practice, as detailed in the New Zealand

Association of Social Workers Standards of Practice.For further information please contact:

New Zealand Association of Social Workers, P O Box 1072, Dunedin

7

AIMS, INTENTIONS AND GOALS OF COUNSELLINGCounselling is a process that:

• is founded on a purposeful working relationship with the client• exists to achieve certain goals and tasks with the client• involves exploration with the client of the realities of her situation• assists the client to identify thoughts and feelings about her situation• builds on a client’s abilities to act on decisions made• assists the client to develop problem-solving skills and to support herself in the

decisions made• supports a woman’s ability to make choices about her reproductive and sexual

health• provides relevant information that assists an informed decision-making process

Therefore the counselling process exists to achieve certain goals, and the counsellingrelationship exists to work toward this. The responsibility of the social worker/counsellor/service provider is to facilitate the development of an environment within which the clientcan work toward achieving their aims.There are guiding principles which are the same irrespective of the context within whichthe counselling service is being offered. The aim is for social workers/counsellors to knowthe areas of sameness and the areas of difference for the provision of counselling withinthe particular context in which they work:

• purpose built abortion facilities• regional areas that refer to major centres for abortion services• services located within major hospitals.

THE SPECIFIC KNOWLEDGE REQUIREDThere is a body of knowledge that must be acquired and integrated into the professionalfunctioning and identity of all those providing a counselling service:

• Adopton Act 1995• Contraception, Sterilisation, and Abortion Act 1977• Crimes Act 1961• Official Information Act 1982• Privacy Act 1993• Code of Health and Disability Services Consumers’ Rights 1996

8

• The various stages of the decision-making process - including pre-decisionand post-abortion counselling

• Pregnancy options - parenting, adopting, and abortion• Ability to conceptualise the nature of anxiety and fear and its function in the

decision-making process• Contraceptive choices• The abortion procedure/s, eg surgical termination of pregnancy, medical

termination of pregnancy, mid-trimester terminations• Cultural norms and practices related to the care, touch and respect of the human

body• Foetal development• Cultural practices concerning the disposal of human tissue• The availability and location of an abortion service to the client• The referral process for requesting consideration for a termination of pregnancy• Methods for working with significant loss and grief• Foetal abnormalities that may lead to abortion being considered as an option.• Risk-taking behaviour• Spiritual and religious beliefs and their influence on the ability to make, act on

and integrate decisions made• Methods of assessing suicide risk• The complexity of dynamics that can exist for women who face repeated

unintended pregnancies and terminations• The ‘contracts’ environment as determined by health policies and the implications

for access to services• Working knowledge of the social service resources of the community pertinent

to the client’s requirements• Client options and relevant social services depending on the outcome of the

consultations with the certifying consultants

OTHER AREAS OF KNOWLEDGE AND COMPETENCIES central to the professionalidentity and applicable to all social workers providing counselling

(a) Historical and philosophical knowledgeThe social worker/counsellor demonstrates knowledge and understanding of thehistory and philosophical principles for the provision of abortion services within NewZealand and the international context.

9

(b) AttitudeThe social worker/counsellor demonstrates:• belief in the uniqueness of each client and her situation• an ability to explore all pregnancy options free of negative or positive judgement.• an ability to explore the client’s system of beliefs about herself, her situation,

her relationships and her view of the world• respect for the client’s dignity and integrity• an ability to accept how the client perceives her situation.

(c) Theoretical frameworksThe social worker/counsellor demonstrates:• an ability to describe the theoretical framework/s that inform the helping

relationship• an understanding of the nature and function of a variety of social systems and

how these impact on women confronting the decision-making process• an ability to work with a wide range of people from different cultures• an understanding and application of a systemic approach as it applies to:

- an individual- a relationship- a family/whanau- an organisation- a cultural group/iwi/hapu

• an understanding and working knowledge of the different schools of thoughtthat promote understanding of the behaviour of an individual in a group situation,eg family, whanau, hospital environment, peer group.

(d) Ability to conceptualise the counselling sessionThe social worker/counsellor demonstrates ability to:• generate ideas about what makes an environment (physical and psychological)

conducive to the work of the counselling session• discuss the rationale of the interventions made and techniques utilised• work within time frames• reflect actively to the client her thoughts, feelings and emotions to assist a greater

clarity about herself, her situation and her abilities• work within a variety of settings, eg the interview room, the private home,

operating theatre, multi-disciplinary team

10

• observe, record and accurately report on sessions (verbally and in writing) whatis presented by the client

• communicate the assessment of the client’s situation to a range of otherprofessionals who may practise within different conceptual frameworks, egdoctors, psychologists, nurses

• appreciate areas of meaning as portrayed by the client and to value these tocreate an overview of her situation

• recognise and respond to other life concerns and events that impact on thedecision-making process such as:- substance abuse- sexual abuse- relationship violence- sexuality difficulties- resettlement- previous loss and grief

• relate all information gathered to a systemic model which perceives that allelements are dynamic and changing

• develop strategies for handling situations of conflict, eg:- role- intra-personal- inter- personal- organisational

• close a counselling session so that there is sufficient integration and closure forthe client

• make referrals to appropriate agencies and counselling services when required• make known the competence and integrity of the agency or counselling service

before the referral is actioned.

(e) Self awarenessThe social worker/counsellor demonstrates:• responsibility for her own actions through self-reflection, self-assessment and

evaluation• ability to acknowledge, accept and explore openly the judgements of others

through client feedback, peer review, and the supervision process

11

• ability to maintain an attitude of discovery to alternative views of life• ongoing commitment to the process of learning and a commitment to

professional development.

(f) Theories of communication and human developmentThe social worker/counsellor demonstrates a knowledge of current theories on:• communication patterns and processes• human growth and development• the development of the personality.

• The social worker/counsellor demonstrates an ability to recognise specific cultural,age and gender beliefs and behaviours that inform the foundations of a client’s viewof the world and shape their approach to the decision-making process, and theconnection these have to human growth and development.

(g) Clinical knowledge and its application to the counselling processThe social worker/counsellor demonstrates a basic knowledge of psychopathology.

(h) Public and Social PolicyThe social worker/counsellor demonstrates a current working knowledge of socialand public policies that impact on choices available to women and their ability to acton their decisions with confidence:

- Adoption Act 1955- Code of Health and Disability Services Consumers’ Rights 1996- New Zealand Income Support Services policies and procedures- Privacy Act 1993.

(i) Moral and ethical considerations related to the decision-making processThe social worker/counsellor demonstrates the ability to conceptualise:

• the ethical principles and standards of practice concerning the fields of socialwork and counselling as they apply to the decision-making process (seeAppendix 4).

• the difference between individually determined and socially determined moralprinciples and beliefs and their impact on the decision-making process.

12

Appendix 1

REQUIREMENTS OF THE CONTRACEPTION, STERILISATION, AND ABORTIONACT 1977 REGARDING THE PROVISIONS FOR COUNSELLING(a) Supervisory CommitteeThe Abortion Supervisory Committee set up under the Act to supervise the operation ofthe legislation is specifically charged with the duty of ensuring that sufficient and adequatefacilities are available throughout New Zealand for counselling women who may seek advicein relation to abortion (s.14(1)(e)).The Supervisory Committee is also required by s.31 of the Act to:

• Appoint suitably qualified persons to provide counselling services for personsconsidering having an abortion.

• Approve any agency for the provision of such counselling services.In appointing or approving persons or agencies for the provision of counselling servicesthe Supervisory Committee must have regard to the following:

• Every counselling service should be directed by an experienced andprofessionally trained social worker.

• Suitably trained lay counsellors may also be used where there are insufficientprofessional social workers.

• Every counsellor should be thoroughly familiar with all relevant social servicesand agencies, and able to advise patients, or refer them to appropriate agenciesfor advice, on alternatives to abortion, such as adoption and solo parenthood.

(b) Certifying ConsultantsCertifying consultants are given the power to authorise or refuse an abortion. By s.35 ofthe Act, they must, after authorising or refusing an abortion (in consultation, wherepracticable, with the woman’s own doctor) advise her of the right to seek counselling fromany appropriate person or agency.

(c) Licensed InstitutionsAbortions can be performed only at hospitals and clinics licensed by the SupervisoryCommittee. The form of application for a licence requires the applicant to state:

• The qualifications and experience of the persons to be employed as counsellors.

• The manner in which the counselling service is to be supervised, and by whom.

• Whether the counsellors are to be employed by the institution-if not by whom.

• The manner and procedures by which confidentiality and privacy are to beensured during counselling.

13

In deciding whether to grant a licence the Supervisory Committee must be satisfied thatadequate counselling services are available to women considering having an abortion inthe institution, and are offered to such women whether or not they ultimately have an abortion.If the institution fails to meet the requirements of the Act including the requirement relatingto counselling, the Supervisory Committee can take steps to cancel the licence (s.25).

14

Appendix 2

SPECIFIED SOCIAL SERVICES UNIT STANDARDS REGISTERED ON THENATIONAL QUALIFICATIONS FRAMEWORKProvide Social ServicesUnit 7912 Assess presenting needs of social service clientsUnit 7030 Negotiate service provision with users of the social servicesUnit 7937 Provide social services information for specific needsUnit 7948 Prepare and write social services reportsUnit 7928 Implement the Treaty of Waitangi in the social servicesUnit 7955 Engage in counselling with individuals in social service settingsUnit 7964 Facilitate empowerment of people experiencing oppression because of

genderUnit 7969 Facilitate empowerment of people who have experienced abuseUnit 7975 Identify and access social services in the community

Manage Social ServicesUnit 7916 Demonstrate knowledge of social service ethicsUnit 7917 Demonstrate self awareness in relation to Social Services workUnit 7944 Demonstrate knowledge of legal structures and laws governing social

services

15

Appendix 3

New Zealand Association of Social WorkersPolicy Statement on Supervision1. Preamble

Social work in Aotearoa New Zealand has become a profession with its own distinctivetradition and perspectives. While overseas countries have contributed much to thedevelopment of social work in the last twenty years there has been a growing desire tofind an indigenous expression of social work practice. The association has been inthe forefront in New Zealand of a search for a professional identity which puts emphasison empowerment, partnership and bi-culturalism.

These principles have been embodied in the Code of Ethics adopted in 1993.

2. Professional Social Work SupervisionSocial work supervision is concerned with the actions, function and oversight of socialworkers by a professional social worker colleague.The key components of supervision are concerned with the educational, administrationand supportive aspects of social work practice.The process of professional social work supervision involves the exchange of values,knowledge/experience and interactions in a particular field of practice. It is thus aconstellation of professional standards, knowledge, practice and commitment.Supervision is an interactional process which straddles management and practice.The role of supervisor is embedded within both the management system andprofessional practice system as a key element in each (1).As part of taking responsibility for his/her own professional development a social workermay seek a consulting relationship with a professional colleague to discuss difficultiesencountered in performing job related functions. Consultation is recognised as asupervision process (2).

3. Core Supervision and Special Fields of Social WorkWhile there is a general core for social work supervision which includes the roles andcommitment to the profession and its objectives and knowledge base, specialisedsupervision is necessary in most fields, e.g., Family work, Child Protection, CommunityDevelopment, Management, Education and Training, Maori and Pacific Island settings.

16

4. Forms of Supervision• Supervision/consultation within the agency.• Supervision/consultation on behalf of the agency by an external supervisor/

consultant/external supervision contracted by the worker and paid for by theagency.

• Independent practitioners will have as a supervisor/consultant either a colleaguein a share practice or one in external agency/practice.

Supervision can occur on an individual, group or collective (peer interaction) basis.

5. Expectations of a supervisee• Adherence to the NZASW Code of Ethics and Bi-cultural Code of Practice.• Commitment to an explicit contract with supervisor/consultant which is publicly

acknowledged by agency, client and other colleagues.• Regular participation with a supervisor/consultant in making the interaction one

that is goal directed, leading to educational, administrative, personal andprofessional development.

6. Expectations of Supervisor/Consultant• Has a commitment to the NZASW Code of Ethics and Bi-cultural Code of

Practice and is a member of NZASW.• Has been employed as a practitioner with experience and knowledge as a

supervisor/consultant.• Highly desirable to have undertaken training in social work supervision.• Has been recognised as social work supervisor/consultant by human service

organisations.• Has competence in a particular field of social work practice.

7. NZASW ExpectationsFor a member to be assessed as competent it is expected that-• In the first year of practice the member has a minimum of one hour social work

supervision per week.• During the following four years the member will be engaged in fortnightly social

work supervision.• Fully competent, experienced social workers will still be involved in a supervisory

arrangement that occurs at least monthly and which focuses on their work andtheir accountability. This may be collegial/consultative/peer supervision orindividual.

17

8. References

• Bunger M. and Wijnber JI (1988): “Supervision and Performance; ManagingProfessional Work in Human Service Organisations”.

• Kadushin, Alfred (1977): “Consultation in Social Work”.

NZASW June, 1995 (Printed with permission)

18

Appendix 4

Ethics and Ethical Decision-Making“Ethics refers to the systematic exploration of questions about how we should act inrelation to others” (Rhodes 1986)

Ethics is the study of:• an individual or group’s collective value and belief system and the study of the

principles and moral rules on which they are based• the decision-making involved in applying moral decisions to practical situations• the decision-making procedures specific to or appropriate in various contexts

and situations

Professional EthicsThe ultimate purpose of professional ethics is to analyse the issues and then decide howto act. Codes of Ethics provide statements of ethical principles and a public declarationof commitment to rules of professional conduct.

Ethics and AbortionAbortion raises issues at the heart of moral decision-making. Issues about life and deathare the central questions of ethics. This is reflected in the controversial history and currentsocial position of abortion in our society. “Morality cannot be separated from the socialconditions and concrete situations in which moral judgements take place” (Petchevsky1984:356).The politics and policies of abortion connecting as they do with the ethics of life and deathcreate unease. “But there is no balanced, universal ‘moral truth’ about abortion waitingto be discovered somewhere along the spectrum of views between flat-out feminism andthe Pope himself.” (Hadley 1996:55).Social workers working in this field need to:

• understand the range of moral issues that arise for women as they grapple withtheir decision

• be aware of the bases and processes of their own moral decision making.Ethical issues for the abortion counsellor in the context of their work are essentially nodifferent from the ethical decisions faced by social workers in other environments. Theydo however take on an additional sense of urgency that emanates from the social andpolitical perceptions of abortion in our society.

19

Ethical issues that arise in the counselling context include:1. Informed consentSocial workers will often be in the position of making an assessment on a woman’s abilityto fully know and understand what she is requesting, for example with a young teenager.Issues of importance

• Competence• Disclosure of information• Understanding of information• Voluntariness• Authorisation• Intellectual capacity• Literacy• Language• Culture

2. Self determination/paternalismDefinition

Self determination is based on the concept of autonomy, and refers to that condition inwhich personal behaviour emanates from a person’s own wishes, choices and decisions.It is part of the common endowment of humankind and is valued by social workers in botha positive and negative sense (Abramson 1985).Self determination is not an absolute principle but requires qualification and decision-making about where the limits should fall.• Do all clients have the capacity to exercise self determination?• Do any clients forfeit the right to freedom of choice because they have broken the

law?• Does self determination only apply when the decision outcome contributes to the

health of the client?• Should self determination be encouraged if the decision made harms either the client

or others?• Does self determination apply when social workers act as agents of the state and

require clients to take certain actions?• Does self determination apply when people lack the opportunity to exercise their

right to self determination? for example - immobility due to a lack of transport.

20

Two concepts that can help us decide that the person can choose freely and rationally

(a) To choose freely suggests that:• the action is voluntary and intentional• that the client is not under duress or undue influence or manipulation• the client is fully informed.

(b) To choose rationally and effectively suggests that:• the person knows that a decision is necessary and is aware of the

consequences of the alternatives• is aware of the alternatives and the consequences of the alternatives• has evaluated the alternatives and the consequences of the alternatives• has chosen a course of action based on an informed consent• has the resources to act on the decisions made.

Definition

Paternalism is a form of beneficence in which the helping person’s concepts of benefitsand harms differ from those of the client and the helper’s concepts prevail (Abramson1985).When is paternalism justified?• the person does not have the capacity to make an informed choice• the person is not considered mentally competent, rational or able to comprehend the

result of the decision-making• the person may be harmed unless there is intervention• others may be harmedAs the burden of proof lies with the social worker, social workers should ask if their actsare motivated by altruistic interest.

3. Confidentiality/privacyAbsolute and relative confidentiality

• Security of information is absolute when data learned or observed is never passedon to anyone in any form.

• The majority of social workers share information as part of the agency and thereforethis is relative confidentiality.

• Social workers recognise the tradition of seeking permission when revealinginformation outside the agency.

Confidentiality as a legal and ethical principle

• Confidentiality is both a legal and ethical principle.• The principle is a legal requirement.

21

• Confidentiality is also a principle in the NZASW Code of Ethics which makes a publicstatement about the principle and social workers’ obligations in respect of it.

• If confidentiality is cited as an ethical principle it implies a contractual relationshipbetween the social worker and the client and a relationship that is recognised by law.

The client has the right to know the parameters of the relationship. It is essential that thelimitations of any confidential information be discussed with clients at the outset of theinterview.Privacy

The provisions of the Privacy Act 1993 and the Official Information Act 1982 provide workingguidelines about the collection, use and dissemination of information disclosed by clients.All hospitals and clinics will have policy statements and procedures about the applicationof these Acts to service provision. Social workers should have an up to date workingknowledge of these policies.Unravelling ethical assumptions

To gain personal insight into the underlying ethical assumptions it is necessary for socialworkers/counsellors to ask themselves a series of questions.• What is the client’s point of view? As part of any ethical analysis it is important to

seek the client’s opinions and values and ask what approach they have tried to solvingthe problems.

• What is my perspective as a worker? This implies that social workers have anunderstanding of the kind of society they are trying to achieve, what it means to helpa client and what our personal beliefs and attitudes are.

• How should I handle the differences between my client and my own views? Given ourpluralistic society it is possible to expect that client views will differ from our own. Wewill need to be able to justify the position that we have taken to the client and theagency.

• What choice is required? The way a problem is posed often determines how theproblem will be solved. Ethical problems should be examined from a range of vantagepoints examining the assumptions underpinning each perspective.

• What are the alternative courses of action? This involves gathering data about thesituation and using one’s imagination to come up with alternatives.

• What options does each of these alternatives represent? In deciding on a course ofaction there needs to be an understanding of the general ethical position implicit inthe action.

• What are the legal/agency requirements, if any?• Are there any relevant cultural dimensions?

22

Problem Solving Model For Ethical Decision-Making

1. Step one:Clarify and define the nature of the problem, crisis or dilemma that requires adecision.

2. Step two:Assessment: identify key facts and values. What are the crucial facts of the case?What moral principles are at stake here? Whose moral principles are at stake?What are the implications of non-action?

3. Step three:Planning: what means do you use to reach your goal? How are alternative goalsevaluated/compared?

What is the aim of acting now? What are the objectives? What contingencies needto be taken into account? What/whose other interests are involved?

4. Step four:Implementation, the decision is a commitment to action. How to begin. What costsand benefits need to be weighed up? How do we monitor success or failure?

5. Step five:Evaluation with reference to aims and objectives. What means exist for debriefingand feedback? Have we used the right means to a good end? Review the pros andcons.

6. The Final Step:Apply the following test:Can you provide a reasonable ethical justification for the course of action taken?

(Adapted from Ian Thompson, Ethicist, Western Australia, cited in Fieldwork I: ResourceBook Flinders University of South Australia (1997)

23

Bibliography

Banks S 1995, Ethics and Values in Social Work , BASW UK

Bells S 1994, Reading, Writing and Re-writing the Prostitute Body, Indiana UniversityPress USA

Bennie G 1995, Social Work Supervision, An annotated bibliography

Brien Joanna & Fairbairn Ida 1996, Pregnancy and Abortion Counselling, RoutledgeLondon and New York

Combs Arthur W 1989, A Theory of Therapy: Guidelines for Counselling Practice,Sage Publishers

Ginsburg FO1989, Contested Lives: The Abortion Debate in a small AmericanCommunity, University of California Press, Berkeley

Hadley, Janet, 1996 : Abortion: Between Freedom and Necessity, Virago Press

Jones G 1991, Practical Medical Ethics, Oxford

Kane R.D.1994, Woman to Woman Encounters: Abortion Counselling in SocialWork in Action, eds M. Nash & R. Munford, Dunmore Press

Lowenberg F & Dolgoff R 1988, Ethical Decisions for Social Work Practice, FEPeacock Illnois

New Zealand Association of Counsellors, Code of Ethics (being revised 1998)

New Zealand Association of Social Workers, 1993 Competent Social Work Practice:A Handbook for members of NZASW

Singer P 1990, Applied Ethics, Oxford UK exp Chapt 4 Judith Jarvis

Other possible resource books:

A Colour Atlas of Life before Birth, England Marjorie 1990

Abortion: law, choice, and morality. Callahan Daniel 1970. MacMillan

Aborting Law: an Exploration of the Politics of Motherhood and Medicine. KelloughG 1996, University of Toronto Press

Abortion and Women’s Choice (Questions for Feminism Series). Petchesky R P1986, Verso, London

24

Abortion at work: ideology and practice in a feminist clinic. Simonds W 1996, RutgersUniversity Press

Abortion policies: a global review. United Nations Department of Economic and SocialDevelopment, 1992 New York

Abortion Politics. Jaffe F 1981, McGraw-Hill

Abortion Services and Health Changes. Federation of Women’s Health CouncilsAotearoa, 1992, Auckland (NZ) Federation of Women’s Health Councils of Aotearoa

Abortion: a positive decision. Lunneborg P, 1992, Bergin and Garvey

Abortion: The International Agenda. Feminist Review No 29 Spring, 1988

Beyond pro-life and pro-choice: moral diversity in the abortion debate. Rudy Kathy1996, Boston Beacon

Breaking the abortion deadlock: from choice to consent. McDonagh Eileen 1996,Oxford University Press

Contraception and Abortion from the Ancient world to the Renaissance. RiddleJohn M 1992, Cambridge, Harvard University Press

Creation and Abortion: a study in moral and legal philosophy. Kamm Frances 1992,Oxford University Press

Doctors of conscience: the struggle to provide abortion before and after Roe vsWade. Joffe Carole E 1995, Beacon Press

Fetal Positions: Individualism, Science, Visuality. Newman Karen 1997, CambridgeUniversity Press

Induced Abortion: A World review. Tietze Christopher 1986, 6th Edition, AllanGutmacher Institute

Life Before Birth: the moral and legal status of embryos and fetuses. SteinbockBonnie 1992, Oxford University Press

Life’s Dominion: an argument about abortion, euthanasia, and individual freedom.Dworkin Ronald 1994, Vintage Books

Liquid Life: abortion and Buddhism in Japan. La Fleur William R 1992, PrincetonUniversity

Marketing the menacin Fetus in Japan. Hardacre Helen 1997, University of CaliforniaPress

25

Our right to choose: toward a new ethic of abortion. Harrison Beverly Wildung 1983,Beacon Press

Prevalence of and attitudes to abortion among migrant women in Sydney. YusufFarhat 1995, Macquarie University

Psychiatric aspects of abortion. American Psychiatric Press, 1991

Psychotherapy with Women. Edited by Lawrence Marilyn and Maguire Marie 1997,MacMillan 1997

Religious violence and abortion. Blanchard Dallas 1993, University of Florida Press

Reproducing persons: issues in feminist bioethics. Purdy Laura M 1996, CornellUniversity

RU 486 Misconceptions, Myths and Morals. Klien R, Raymond JC and Dumble LJ1991, Spinifex AUS

Standing in the Sunshine. Coney S 1993, Penguin NZ

The abortion experience of some NZ women. Society for Research on Women in NZ1980, Auckland Society for Research on Women in NZ

The anti-abortion movement and the rise of the religious right: from polite to fieryprotest. Blanchard, Dallas A 1994, Maxwell Macmillan International

The Embryo Research Debate: Science and the Politics of Reproduction. MulkayMichael 1997, Cambridge University Press

We Women Decide, Women’s Experience of Seeking Abortion in Queensland,South Australia and Tasmania. 1985-1992. Dr Barbara Buttfield, Dr Lyndall Ryan, DrMargie Ripper, November 1994

Why I am an abortion Doctor. Poppema Suzanne T 1996, Prometheus Books

APPENDIX 9 SAMPLE GUIDELINE FOR PRODUCTS OF CONCEPTION COLLECTION FOR FORENSIC ANALYSIS This Sample Guideline is for POC collection for forensic analysis by ESR to identify the alleged offender in a sexual assault.

1. Ensure the woman has had the opportunity to discuss POC collection for forensic analysis with a counsellor/social worker and the Police.

2. The abortion service should appoint one person to liase between the Police and the Woman and the Abortion service (usually the Charge Nurse Manager or counsellor)

3. This counsellor/CNM should communicate closely with the Police Officer in charge of the case to confirm the date and time of the abortion procedure.

4. This counsellor/CNM should check that the Police Officer is aware of what they need to bring.

5. This counsellor/CNM should document in the clients notes what arrangements have been made for POC collection with the Police and document the Police Officers name and phone number.

6. The counsellor does not need to take a statement from the client as this is done by the Police but she must ascertain that the women is fully informed of her pregnancy decision options and right to make a Police complaint or not.

7. A specific consent to collect and release samples to Police needs to be signed- Police should be able to supply you with this consent.

8. For first trimester abortion, medical abortion is not suitable for forensic collection of POC.

9. The women should be aware that theDNA results may ultimately be made available to the Courts in the event of criminal proceedings.

10. The counsellor/CNM should liase with the Police to ensure they know to provide: (1) reference DNA kit for taking buccal swab from the patient (2) chilly bin or similar transport container (3) ice or chiller packs

11. Inform the Police of the date and time of the procedure 12. Ideally, schedule the women to be first on your surgical list 13. It is preferable but not mandatory that the Police Officer is present at the time of the

procedure 14. The Police Officer does not need to be in the operating room. 15. Collection of reference DNA : Before the abortion the surgeon or the Police Officer

should take the buccal swab – this swab also requires a chain of evidence form. 16. If the pregnancy is under 7 weeks, the surgeon should suck water through the suction

tubing to ensure all the tissue is obtained. 17. Equipment required :

(1) Plastic specimen container to be sealed with patient labels (2) If the POCs need to be examined by the surgeon- a new sieve is to be used. (3) The examination dish must be thoroughly washed prior to use to make sure there

is no possibility of tissue from previous procedures being present. (4) No transport medium required – no formalin to be used (5) Patient stickers to seal the container (6) Chain of evidence form (7) Consent form to release POC to Police

18. The surgeon must be able to verify that the specimen definitely came from the patient named and that there could not have been any opportunity for the specimen to be tampered with ie ‘chain of evidence’ was maintained

19. Specimens must be labelled with the patient’s label, including the date and time of the collection and the collectors name.

20. Specimens need to be in a sealed container with patient stickers placed over the lid 21. Stickers need to be signed by the surgeon, so that if the lid was removed, the stickers

would be torn and the signatures would not line up. 22. Each person in the chain of evidence needs to sign the chain of evidence form with

the date and time that they handed over custody of the specimen to the next person 23. The specimen must remain in the clinician’s sight at all times, or locked in the fridge

with the key held by the clinician, until signed over 24. Ideally the surgeon will hand the specimen container directly to the Police Officer

immediately after the procedure. 25. Keep a copy of the process and chain of evidence in the patients notes 26. For first trimester surgical abortion, provide all POCs (fetal tissue, placenta, sac,

endometrial tissue) 27. Transport and Storage: Place the POC container on ice or in a chilly bin or in a fridge.

The Police should provide the chillybin and transport the POCs to the ESR. 28. If immediate pick up is not possible, then the POCs should be placed in a secure

fridge with the key being the responsibility of the surgeon or the CNM– every person must sign the chain of evidence form

29. If a patient is undecided about making a complaint to the Police, she needs to be aware that the POCs cannot be stored indefinitely awaiting her decision. If she is unsure about pressing charges at the time of her procedure, speak to MEDSAC and your local Police for advice.

30. POCs cannot be transported to the ESR unless there is a Police investigation. 31. If the woman wants to take some of her POCs home the ESR require a minimum

sample size of 0.5cm to 1.0cm. the remainder of the POC can then be given to the woman.

about Sexual Health and STIs

Sexually Transmitted Infections

SUMMARY OF GUIDELINES 2017

July

201

7 Ed

itio

n

Sexually Transmitted Infections Education Foundation resources

HPV

Tollfree 0508 11 12 13

www.hpv.org.nz

Health professionals’ resources

1. Guidelines for the Management of Genital, Anal and Throat HPV Infection in New Zealand – 9th Edition 2017

Only available online at www.hpv.org.nz

2. Sexually Transmitted Infections – Summary of Guidelines 2017

Patient information pamphlets

1. Some Questions and Answers about HPV and Genital Warts

2. Cervical Smears and Human Papillomavirus Infection (HPV)

3. Preventing HPV Cancers by Vaccination: What Everyone Should Know

4. HPV and Men

5. HPV and Throat Cancer: Common Questions and Answers

HERPES

Tollfree 0508 11 12 13

www.herpes.org.nz

Health professionals’ resources

1. Guidelines for the Management of Genital Herpes in New Zealand – 12th Edition 2017

Only available online at www.herpes.org.nz

2. Sexually Transmitted Infections – Summary of Guidelines 2017

Patient information pamphlets

1. The Facts: A guide for people with Herpes Simplex

Includes – Genital Herpes – The Facts Herpes and Relationships Herpes and Pregnancy Facial Herpes

2. Herpes: Myth vs Facts

Website for youth with information about sexual health and sexually transmitted infections: www.justthefacts.co.nz

JUSTTHEFACTS.co.nz posters are available in A2, A3 and A4 sizes for display, in addition to wallet cards for consumers.

All the above resources are available free of charge from the Sexually Transmitted Infections Education FoundationPhone: 09 433 6526

Email: [email protected]

Helpline

Website

Resources

New Zealand Sexual Health Society (NZSHS) resources

Comprehensive STI Management Guidelines and Patient Information handouts are available on www.nzshs.org/guidelines

http://www.hpv.org.nz

www.hpv.org.nz

http://www.herpes.org.nz


www.justthefacts.co.nz

mailto:info%40stief.org.nz?subject=

www.nzshs.org/guidelines.html

1

Contents

3 GENITAL HERPES – SUMMARY OF GUIDELINES

8 Genital Herpes: Key Information to provide patients on diagnosis

9 GENITAL, ANAL AND THROAT HPV INFECTION – KEY INFORMATION SUMMARY

11 HPV: Key Information for Patients

12 NZSHS STI MANAGEMENT GUIDELINES – SUMMARIES 2017

Principles of Sexual Health Care

13 Sexual Health Check

14 Partner Notification/Contact Tracing – Management Summary

15 Partner Notification/Contact Tracing – Patient Information

Management of Sexual Health Conditions

16 Chlamydia – Management Summary

17 Chlamydia – Patient Information

18 Gonorrhoea – Management Summary

19 Gonorrhoea – Patient Information

20 Epididymo-orchitis – Management Summary

21 Epididymo-orchitis – Patient Information

22 Genital Skin Lesions (Non-Ulcerative) – Management Summary

23 Genital Ulcer Disease (GUD) – Management Summary

24 Pelvic Inflammatory Disease (PID) – Management Summary

25 Pelvic Inflammatory Disease (PID) – Patient Information

26 Syphilis – Management Summary

27 Syphilis – Patient Information

28 Trichomoniasis – Management Summary

29 Trichomoniasis – Patient Information

30 Urethritis in Males – Management Summary

31 Urethritis in Males – Patient Information

32 Vaginal Discharge – Management Summary

3

NEW ZEALAND HERPES FOUNDATION

Genital Herpes SUMMARY OF GUIDELINESTaken from: Guidelines for the Management of Genital Herpes in New Zealand 12th Edition - 2017

www.herpes.org.nz

The Ministry of Health supports the use of these clinical guidelines, developed by clinical experts and professional associations to guide clinical care.

Genital Herpes – Key Management Points• Genital herpes is under-recognised and under-treated. Minor lesions are common; any recurring localised anogenital

symptoms or lesions should be investigated as possible genital herpes.

• Oral antiviral treatment of the first clinical episode (without waiting for results) should always be offered, regardless of the time of symptom onset. The ‘72 hour’ herpes zoster rule does NOT apply to first episode genital herpes infection.

• Antiviral therapy of recurrent genital herpes may be suppressive or episodic.

• Some patients prefer suppressive antiviral therapy. It is often considered for those with frequent and/or severe recurrences or associated psychosocial morbidity. Adherence to suppressive treatment reduces but does not eliminate transmission.

• For those on episodic antiviral therapy, it is more effective when patients start therapy themselves at the first signs of a recurrence; this requires anticipatory prescribing (“pill-in-the-pocket” antibiotic prescription).

• Neonatal HSV infection needs specialist advice on management for women with a history of genital herpes and active lesions at term and especially in the high-risk situation of a first episode up to 6 weeks prior to delivery.

• Neonatal HSV infection is a rare, but potentially fatal, disease of babies, occurring within the first 4-6 weeks of life. Symptoms are non-specific and a high index of suspicion is required. Most neonatal HSV infections are acquired at birth, generally from mothers with an unrecognised first genital herpes infection acquired during pregnancy.

What’s new since 2015ValaciclovirThe special authority and Hospital Medicines List restriction was removed from 1 March 2016 (Pharmac). This is recommended first line treatment.

Treatment of first episode genital herpes • Oral valaciclovir 500mg bd for 7/7 or longer if new lesions appear during treatment or healing is incomplete.

• Immunocompromised patients consider valaciclovir 1g bd for 7 to 10 days.

• Alternative: oral aciclovir 400mg 3 times daily (8 hourly) for 7 days.

Treatment of recurrent genital herpesEpisodic Treatment• Oral valaciclovir 500mg bd for 3/7.

• Alternative: oral aciclovir 800mg 3 times daily for 2 days.

Prescribe enough tablets for patients to be able to self-initiate treatment at onset of symptoms.

Suppressive therapyOnly recommended for people with HSV confirmed on testing. Given daily to prevent recurrences and reduce asymptomatic shedding. Suggest prescribing for 12 months, followed by a break of 3 months to see if recurrences are still frequent and/or bothersome.

• Oral valaciclovir 500mg daily (increase to 500mg bd on individual basis of clinical presentation and/or having breakthrough recurrences on 500mg daily).

• Alternative: oral aciclovir 400mg twice daily.

Epidemiology• As many as one in five adults in New Zealand have genital herpes due to HSV-2, most will have asymptomatic or

unrecognised disease.

• Genital herpes due to HSV-1 (through oral to genital transmission) has also become common; HSV-1 is a frequent cause of primary genital herpes.

• The natural history of genital HSV-1 infection involves significantly fewer clinically apparent recurrences and less subclinical shedding than HSV-2.


4

Management of First Episode of Genital Herpes

a In cases of immunocompromised patients or herpes proctitis, refer to specialist.

b Specialist consultation is recommended for use of antivirals in pregnancy.

c Recommend early presentation for viral swab if recurrence.

Patient presents with first episode of genital herpes

Check symptom history, examine and take viral swab a

Immediate treatment ALL patients b

Offer referral to support system

• Oral valaciclovir 500 mg twice daily for 7 days

• Alternative: oral aciclovir 400 mg 3 times a day (8 hourly) for 5 to 7 days

If complications developing

consider referral to specialist

Provide patient information:• written information• Helpline tollfree 0508 11 12 13• Website www.herpes.org.nz• refer to sexual health clinic if appropriate

Suggest other treatment:• salt washes• topical anaesthetic creams• oral analgesics• oral fluids

Consider referral for specialised counselling

Answer further questions.Arrange appointment with partner if required.

Provide anticipatory “pill-in-the-pocket” episodic treatment – valaciclovir 500 mg

twice daily for 3 days (50 tablets)

Assess psychological status

Reassess in 5 to 7 days

Diagnosisnot excluded c

Virology confirmed

Diagnosis confirmed

YES

NO


5

Management of Recurrent Episodes of Genital Herpes

a In cases of immunocompromised patients or herpes proctitis, refer to specialist.

b Specialist consultation is recommended for use of antivirals in pregnancy.

c Recommend self-applied swab or early presentation for viral swab if recurrence.

d Increase to 500 mg BD on individual basis of clinical presentation and/or having breakthrough recurrences on 500mg daily.

Treat as appropriate

Refer for specialist

consultation

Other cause(s) of recurrent genital lesions

diagnosed c

Patient presents with recurrent episodes of genital herpes

Virology confirmed a

YES

YES

Offer further suppressive therapy

Offer referral to support system or sexual health clinic

if appropriate

Assess psychological

status

Treat as appropriate. Consider referral for specialist counselling

• Valaciclovir 500 mg twice daily for 3 days

• Alternative: oral aciclovir 800 mg 3 times daily for 2 days

Prescribe enough tablets for patient to self-initiate at onset of symptoms

Offer episodic therapy b

Offer episodic therapy b

Other psychological problems

unmasked

Provide patient information:• written information• Helpline tollfree 0508 11 12 13• Website www.herpes.org.nz

NO

Suppressive therapy required b

Oral antiviral for 1 year:• valaciclovir 500 mg daily

(see ‘d’ below right)• Aciclovir 400 mg bd

After 1 year discuss withdrawal for 3 months to monitor

recurrence pattern

Frequent/severe or problematic

in any way

Problematic recurrences

YES

NO

NO

YES

NO

NO


6

Management of women with suspected genital herpes in pregnancy (in consultation with a specialist)

* For first or second trimester acquisition, suppressive aciclovir or valaciclovir therapy can be used to treat symptomatic recurrences. From 36 weeks, treatment can be considered to reduce the chance of a recurrence at term and hence the need for caesarean section. Effects on the neonate have not been fully determined. However, aciclovir (and to a lesser extent valaciclovir, which is a pro-drug of aciclovir) has been widely used in pregnancy without reported adverse consequences. See full text for further information.

** SEM – skin, eye and/or mouth lesions only.

YES

Greater than 34 weeks or delivery less than 6 weeks following first clinical episode

Less than 34 weeks and greater than 6 weeks before delivery

Consider aciclovir or valaciclovir treatment from 36 weeks*

Genital ulcerationSuspected genital herpes

Previous genital herpes

Consider testing for syphilis on basis of history and clinical assessment

Treatment with oral aciclovir or valaciclovir on

clinical grounds

Treat with IV aciclovir or oral valaciclovir or aciclovir according

to clinical condition

Genital herpes confirmed on PCR testing

Stage of pregnancy

NO

Obtain type-specific serology to determine if

primary infection

Seronegativity

Recurrence at delivery

Manage as recurrent genital herpes

Deliver baby by elective caesarean

section

Deliver vaginally• If possible, avoid instrumental delivery/scalp clips• Mark history of HSV on chart• Educate parents on neonatal herpes

If baby inadvertently delivered vaginally or membranes ruptured

at greater than 4 hours

Take specimens for HSV PCR from baby immediately after delivery

Take blood and CSF for HSV PCR prior to starting

aciclovir treatment

Stop aciclovir if baby looking well

Take specimens for HSV PCR from baby after 24 hours

Aciclovir for 14 days in SEM** disease, 21 days in CNS or disseminated neonatal HSV

YES NO

Seropositivity

YES NO

Are results positive in baby

after 5 days?

Symptomatic and/or HSV/PCR positive

Educate parents on neonatal HSV disease

See management of recurrent genital herpes

Typical episode Atypical episode

Confirmed on PCR testing

YESNO

7

Management of women with history of genital herpes prior to pregnancy and women with first clinical episode greater than 6 weeks prior to delivery (in consultation with a specialist)

* For women with recurrences during pregnancy, suppressive aciclovir or valaciclovir therapy can be used to treat symptomatic recurrences. From 36 weeks treatment can be considered to reduce the chance of a recurrence at term and hence the need for caesarean section. Effects on the neonate have not been fully determined. However, aciclovir (and to a lesser extent valaciclovir, which is a pro-drug of aciclovir) has been widely used in pregnancy without reported adverse consequences. See full text for further information.

Take swabs from baby’s nasopharynx/mouth, conjunctiva,

umbilicus, rectum, plus urine. Swabs best deferred until

> 24 hours of age

Follow baby closely

Take blood and CSF for HSV PCR prior to starting

aciclovir treatment if indicated on clinical grounds

Deliver baby vaginally. Avoid routine use of

instruments

Offer delivery by caesarean section – the risk of transmission

is low but caesarean section is protective

History of recurrent herpes or clinical episodegreater than 6 weeks prior to delivery

Mark history of HSV infection on mother’s and baby’s charts*

Consider suppressive valaciclovir/aciclovir

greater than 36 weeks*

Are herpetic lesions present at

delivery?NOYES

History of recurrence

this pregnancyYES

NO

8

Key Information to provide patients on diagnosis – available on www.herpes.org.nz – 3 minute Patient (PowerPoint) Tool (under Health Professionals tab)

• Up to one in three people have genital herpes, but only 20% of them experience symptoms. (This includes genital herpes caused by both HSV-1 and HSV-2.)

• Most people (80%) who become infected with genital herpes will not have any symptoms, or have such mild symptoms that they will not be recognised or diagnosed as genital herpes. 75% of herpes is acquired from partners unaware they have it.

• For most people who experience symptoms, genital herpes is a sometimes-recurring ‘cold sore’ on the genitals. It does not affect your overall health or longevity of life.

• A small percentage of people who get genital herpes may experience problematic recurrences.

• There is effective oral anti-viral treatment available.

• People who experience a first episode of genital herpes will get better, lesions will heal and there will be no evidence of the initial lesions left.

• Most people who experience a first episode of HSV-2 will have recurrences, but they are generally milder than the first episode. HSV-1 tends to cause fewer recurrences than HSV-2.

• Getting genital herpes in a long-term relationship does not mean that the other partner has been unfaithful. However, a full sexual health screen may be reassuring.

• Where both partners in a long-term relationship have the virus, use of condoms is not necessary as they cannot reinfect each other.

• It is advisable to avoid sexual contact when lesions are present, as friction may delay healing.

• Oral to genital transmission of HSV-1 is very common through oral sex. This can happen when ‘cold sores’ are not causing symptoms.

• Genital herpes does not affect your fertility or stop you having children. Vaginal delivery is usual for most women with a history of genital herpes.

• Genital herpes does not stop you having sex.

• Anybody with genital herpes, whether they get symptoms or have never had symptoms, may shed the virus from time to time with no symptoms present.

• There is no evidence that genital herpes causes cancer of the cervix.

• Condoms reduce the risk of transmission. The use of condoms in a long-term relationship should be a matter of discussion between the individuals. It is advisable to avoid genital-to-genital contact, even with a condom, until any lesions are completely healed.

• Even if the virus is passed on, the most likely outcome is that the person will never experience symptoms.

• Ensure patients have access to the NZHF patient pamphlets and/or the HELPLINE TOLLFREE 0508 11 12 13 or visit www.herpes.org.nz



9

THE NEW ZEALAND HPV PROJECTKEY INFORMATION SUMMARY

Genital, Anal and Throat HPV InfectionTaken from: Guidelines for the Management of Genital, Anal and Throat HPV Infection in New Zealand 9th Edition - 2017

www.hpv.org.nz


What’s new – Changes since the 2015 Guidelines

9-valent vaccine (HPV9)9-valent vaccine (Gardasil 9 Seqirus/MSD) is registered for use in females 9-45 years and in males 9-26 years.

HPV9 is funded for both males and females aged 9-26 years (inclusive).

Those aged 9-14 years will get a two dose schedule and those aged 15-26 years will receive a three dose schedule.

Individuals who have received one or more prior doses of HPV4 may complete the vaccine course with HPV9.

HPV9 is available (but not funded) up to (and including) age 45 for females.

New patient information pamphletOne new patient information pamphlet is available from the HPV website – Preventing HPV Cancers by Vaccination: What Everyone Should Know (www.hpv.org.nz)

The NZ HPV Project produces excellent patient information resources which are available free of charge.

1. Some Questions and Answers about HPV and Genital Warts

2. Cervical Smears and Human Papillomavirus Infection (HPV)

3. Preventing HPV Cancers by Vaccination: What Everyone Should Know

4. HPV and Men

5 . HPV and Throat Cancer: Common Questions and Answers

HPV FAQs What are the consequences of HPV infection?• Most HPV infections are asymptomatic and of no consequence.

• HPV causes all anogenital warts – 90% of which are caused by non-oncogenic HPV 6 or 11.

• Persistent infection with oncogenic HPV types such as HPV 16 and 18 is responsible for a portion of intraepithelial neoplasia and cancers of the anogenital tract and oropharynx (cervical 100%, vaginal 90%, anal 80%, penile 50%, vulval 40%, oropharynx 26%).

• Although genital warts and genital tract cancers are declining, HPV-associated head and neck cancers and anal cancers are increasing – especially in men.

Does natural infection induce protective immunity?• Not always. Current evidence suggests that overall naturally acquired immunity is unlikely to be effective because of the

ability of the virus to evade the immune system. Previous infection does not necessarily create long term immune memory so does not prevent future re-infection with the same HPV type.

Does reactivation of latent HPV occur? • For most people HPV infection is transient and becomes undetectable by DNA testing within 6-12 months. HPV infection

can remain latent and may reactivate years later. It is not possible to detect HPV in its latent state so it is not possible to know whether in some cases the immune system has completely cleared the virus or whether the virus remains latent in an undetectable level.

Can asymptomatic people be tested for HPV?• There is no available test to determine the HPV status of a person.

• Current laboratory assays for HPV DNA detect only particular high risk types (in order to guide clinical management in cervical screening) so cannot be used as a screening test for ‘all HPV types’.



10

What are the important points to know about HPV associated anal cancer? • The incidence of anal cancer is increasing and the burden of disease is highest in men who have sex with men and

HIV positive MSM. There is no effective method (including anal cytology/smear) for screening for anal cancer. Annual digital anorectal examination (DARE) is recommended for HIV positive MSM who are aged 50 years or over (see www.ashm.org.au/hiv/management-hiv/anal-cancer). HPV vaccination is the most effective method of prevention.

What are the important points to know about HPV-associated oropharyngeal cancer? • Although oral cavity cancers associated with smoking and alcohol are decreasing, HPV-associated oropharyngeal cancer is

increasingly common – especially in men.

• In common with anogenital HPV-related disease, a viral aetiology for oropharyngeal cancer raises questions for the patient, their partner and health practitioners. There is no clinically apparent premalignant condition and no reliable laboratory screening test. Common concerns are how the virus is acquired, whether there have been sexual partners outside of the couple and how to manage an ongoing sexual relationship. It is important to emphasise that a diagnosis of HPV-related cancer does not necessarily imply multiple sexual partners or other partners outside the relationship. There is no need to alter sexual activity with a stable partner, as sharing of HPV would have occurred long before the clinical appearance of the cancer. Female partners are not known to be at higher risk of developing cancer (at any site) themselves, but should follow standard cervical screening guidelines. A useful guide to discussing these issues includes a printable patient information sheet.1 At the time of writing there is no clear evidence for transmission of HPV through kissing.

HPV Vaccines FAQs Can the vaccine be given to people who are already sexually active or already have HPV infection?• Yes. HPV vaccine can be offered to people who have HPV and would like to use the vaccine to reduce the risk of further

acquisition of new HPV or further disease. Vaccine protects against the HPV genotypes which a person has not previously encountered. Limited data in women shows that vaccination may help to prevent recurrence or reactivation of HPV infection.

• The decision to vaccinate older age groups or those already sexually active should be based on the individuals’ assessment of potential benefit and future risk as vaccine efficacy decreases with age.

Are the HPV vaccines interchangeable?• Yes. All HPV vaccines may be used interchangeably to complete a course.

Will cervical screening still be needed?• Yes. Irrespective of whether a woman has been vaccinated, routine cervical screening will need to continue for the

foreseeable future. This is because of possible prior infection with HPV types causing CIN, or new infection with other HPV types not covered by vaccination.

What if the vaccine is given to a pregnant woman?• While the vaccines are not specifically recommended for use in pregnancy, enquiring about possible pregnancy is

not required before vaccination. Completion of the vaccine course should be deferred if a woman is found to be pregnant. There are no safety concerns with the use of non-live vaccines in pregnant women and it is safe to use during breastfeeding.

Can the HPV vaccine be given with other vaccines?• Yes, HPV vaccine can be co-administered with other non-live and live vaccines.

Is the vaccine safe in patients who are on biologic agents?• Yes, as it is not a live vaccine.

How safe is the vaccine?• Very safe. HPV vaccine has an excellent safety profile and is well tolerated in all age groups. HPV vaccine is the most

monitored and researched vaccine in history. The HPV vaccine is no different from other routine vaccinations.

1. Fakhry C, D’Souza G. Discussing the diagnosis of HPV-OSCC: common questions and answers. Oral Oncol. 2013;49:863-71.

http://www.ashm.org.au/hiv/management-hiv/anal-cancer

11

HPV: Key Information for Patients

There is a balance to be reached between ‘over-normalising’ a diagnosis of a viral STI and failing to empathise with the potential psychological impact of a diagnosis. It is important to address any concerns generated by the individual by the proactive provision of information and education, e.g. handouts, directing the individual to reputable sources of information (www.hpv.org.nz) and referral to a sexual health specialist if required.

• Vaccination against HPV has been available for many years and everyone who is eligible should have it.

• 80% of unvaccinated adults will pick up HPV at some point in their life. In most people, it causes no symptoms (you won’t know you have it) so is therefore unavoidably shared mainly through sexual (including oral) skin-to-skin contact.

• In most people the virus is harmless and causes no symptoms and will not develop into warts, pre-cancer or cancer.

• In a few people, HPV causes genital warts which are harmless and different from the types of HPV that cause abnormal cells or cancer.

• In a few people, HPV can cause abnormal cells which can sometimes lead to cancers in both men and women, including cervical, vaginal, vulval, anal and head and neck cancers and penile cancers.

• Partners will inevitably share HPV. There is no way to know which partner it came from or how long ago. Having HPV does not mean that a person or his/her partner is having sex outside the relationship.

• There are treatments for genital warts and abnormal cells.

• There is no treatment to eliminate HPV itself. HPV is usually dealt with by your body’s immune system.

• HPV does not affect fertility.

• HPV does not stop you having a normal sex life.

• There is no HPV test to check HPV status. This means there is no test that can help answer the questions “Do I have HPV?”, “Does my partner have HPV?”, “Has my HPV gone?”, “Can I have the vaccine?”


12

NZSHS STI Management Guidelines – Summaries 2017

Taken from:

STI Management Guidelines for Use in Primary Care 2017

See: www.nzshs.org/guidelines

These STI Management Guidelines for Use in Primary Care have been produced by NZSHS.

Every effort has been taken to ensure that the information in these resources is correct at the time of publishing

(July 2017).

Further guideline information – www.nzshs.org/guidelines or phone a sexual health specialist.

NB: These guidelines have been written at a time of change in laboratory testing in New Zealand, with an increase in the use of nucleic acid amplification testing (NAAT) methodology.

This increases the sensitivity of testing and ability to use self-collected specimens. However, these advantages need to be balanced against decreased specificity and, for gonorrhoea, a concern about reduced culture for monitoring of antimicrobial sensitivities.

www.nzshs.org/guidelines


13

Sexual Health Check MANAGEMENT SUMMARY

PRINCIPLES OF SEXUAL HEALTH CARE

Recommended tests – FemalesAsymptomatic and/or opportunistic testing• Offer examination including speculum.• Vulvovaginal NAAT swab for chlamydia &

gonorrhoea testing (self-collected if not examined).

• Anorectal NAAT swab for chlamydia & gonorrhoea testing if patient has anal sex or anorectal symptoms (self-collected if not examined).

• Serology: Universal HIV and syphilis. • Targeted hepatitis B and C serology if hepatitis

B immune status unknown and risk factors present e.g. Maori, Pasifika, areas of high endemicity, IDU or incarceration www.hepatitisfoundation.org.nz/

SymptomaticExamination is required for clinical assessment if symptomatic of vaginal discharge, dysuria, lower abdominal pain, abnormal bleeding, anal pain or discharge, or a contact of gonorrhoea:• Examine the inguinal nodes, vulval and perianal

skin, vestibule and introitus.• Vulvovaginal NAAT swab for chlamydia &

gonorrhoea testing prior to speculum insertion.• Insert speculum and examine vagina and cervix.• Endocervical culture swab for gonorrhoea

(if gonorrhoea culture available).• High vaginal culture swab for candida & BV &

trichomoniasis (if NAAT for trichomoniasis not available).

• Anorectal NAAT swab for chlamydia & gonorrhoea testing if patient has anal sex or anorectal symptoms.

• Serology: Universal HIV and syphilis. • Targeted hepatitis B and C serology if hepatitis

B immune status unknown and risk factors present e.g. Maori, Pasifika, areas of high endemicity, IDU or incarceration www.hepatitisfoundation.org.nz/

Recommended tests – Men who have sex with women (MSW)Asymptomatic and/or opportunistic testing• Offer examination, as below.• First void urine for chlamydia & gonorrhoea NAAT testing (first 30ml),

preferably ≥1 hour after last void.• Serology: Universal HIV and syphilis.• Targeted hepatitis B and C serology if hepatitis B immune status unknown

and risk factors present e.g. Maori, Pasifika, areas of high endemicity, IDU or incarceration www.hepatitisfoundation.org.nz/

SymptomaticExamination is required for clinical assessment if symptomatic of urethral discharge, dysuria, testicular pain or swelling, anal pain or discharge or a contact of gonorrhoea.• Examine the genital and perianal skin, inguinal lymph nodes, penis,

scrotum, and testes.• Urethral culture swab for gonorrhoea (if gonorrhoea culture available)

followed by:• First void urine for chlamydia & gonorrhoea NAAT testing (first 30ml),

preferably ≥1 hour after last void.• Serology: Universal HIV and syphilis. • Targeted hepatitis B and C serology if hepatitis B immune status unknown

and risk factors present e.g. Maori, Pasifika, areas of high endemicity, IDU or incarceration www.hepatitisfoundation.org.nz/

Recommended tests – Men who have sex with men (MSM)All MSM should be tested at least once a year.• Extragenital (pharyngeal and anorectal) testing is required irrespective of

reported sexual practices or condom use.• Pharyngeal NAAT swab for chlamydia & gonorrhoea testing.• Anorectal NAAT swab for chlamydia & gonorrhoea testing (self-collected if

not examined).• First void urine for chlamydia & gonorrhoea NAAT testing (first 30ml),

preferably ≥1 hour after last void.• If anorectal symptoms refer or discuss with a sexual health specialist• Serology: Universal HIV, syphilis, hepatitis A and B (if hepatitis A and B

immune status unknown).• Targeted hepatitis C if HIV positive, IDU or incarceration.

MSM who fall into one or more categories below require testing up to 4 times a year:• Any unprotected anal sex• More than 10 sexual contacts in 6 months• Participate in group sex• Are HIV positive• Use of PrEP or PEP• Use recreational drugs during sex.

Test all sexually active persons < 30 years and anyone at risk. See Express STI Testing Questionnaire www.nzshs.org/guidelines.Be aware of the difference between a Nucleic Acid Amplification Test (NAAT) swab (e.g. PCR) and a culture swab.

Note: Most laboratories are automatically performing multiplex NAAT testing for chlamydia & gonorrhoea (+/-trichomoniasis). False positive gonorrhoea results are possible in low prevalence populations – see NZSHS Management of Gonorrhoea 2017, and Response to the Threat of Antimicrobial Resistance www.nzshs.org/guidelines.

The Ministry of Health supports the use of these clinical guidelines, developed by clinical experts and professional associations to guide clinical care.Further guideline information – www.nzshs.org/guidelines or phone a sexual health specialist.This STI Management Guideline Summary has been produced by NZSHS. Every effort has been taken to ensure that the information in this guideline is correct at the time of publishing (July 2017).

http://www.hepatitisfoundation.org.nz




http://www.nzshs.org/guidelines



14

MANAGEMENT SUMMARYPartner Notification/Contact Tracing

Identify who needs to be contacted based on routine sexual history• Ask about number of sexual contacts in past 3 months.• Are these contacts regular or casual? (Be mindful that the term partner may imply a relationship.)• Are they able to contact these people? (Notifying all contacts may not be possible, e.g. if there insufficient information or a threat of violence.)• The use of condoms does not affect the requirement for partner notification/contact tracing and treatment• Document number of contacts clearly in the notes – you may not be the one following-up partner notification• How many of these people does the patient have contact details for?• What contact details do they have for these people?

Explain the methods and offer choice

Introduce the reasons for partner notification/contact tracing as part of the STI treatment discussion• 1-2 Framing sentences and personalise it: – Contact/s need treatment to avoid reinfecting the patient. – Most people with an STI don’t have symptoms but could still have complications or pass the STI on. – The more times a person is re-infected the greater the risk of complications.

STI test resultsSexual contacts of chlamydia, gonorrhoea, trichomoniasis, syphilis, urethritis, PID and epididymo-orchitis need to be contacted and treated. Contact tracing is not required for genital warts or genital herpes. HIV, syphilis and gonorrhoea are automatic laboratory-notifiable infections under Infectious and Notifiable Diseases Regulations. Clinicians may receive a secure website link requesting additional anonymous information for national STI trend analysis. For all cases of syphilis and HIV refer or discuss with a sexual health specialist.

PATIENT REFERRAL(Patient informs sexual contact/s – preferred method if possible)

Discuss with client how they are going to notify contact/s• Face-to-face• Telephone • SMS/Social media• Treatment letter/s to be given to sexual contact/s, see

www.nzshs.org/guidelines• Email

Provide education, support and resources to assist patients, based on their chosen method:• Factsheets on infection and partner notification with

appropriate websites for further information.• Treatment letter/s to be given to sexual contact/s, see

www.nzshs.org/guidelines• Role play telling their sexual contact/s, if appropriate.

Follow-up (phone or in person) 1 week later• All notifiable contacts informed?• If unable to notify contacts, ask why and offer support and

appropriate resources.• Check no unprotected sex with untreated contacts – will need

re-treatment if re-exposed.• Advise retest for infection in 3 months.• Document in notes.

What is my role in Contact Tracing?When making an STI diagnosis it is the diagnosing clinician’s responsibility to initiate a discussion about contact tracing. As part of good clinical care this includes encouraging and supporting the patient in notifying their contacts.For more on difficult cases which may require public health action see the STI Notification Flow Chart www.nzshs.org/guidelines.

PROVIDER REFERRAL(Clinician informs sexual contact/s with patient consent.)

Note: Patient safety takes priority, if risk of violence then don’t notify contacts.Provider referral preferred if contact/s incarcerated or for repeated infections with doubt as to contact treatment.

Notify contacts anonymously• Advise they have been named as a contact of the specific

infection.• Do not give name of index client.• Advise them to attend for sexual health check and treatment.• Advise them where they can attend for this – GP, sexual health

or family planning clinic.

Consult with sexual health service if required• Contact details of New Zealand sexual health services located at

www.nzshs.org.

Obtain details of contact/s to be notified• Discuss confidentiality with index case, however explain that

contacts may be able to identify them.





http://www.nzshs.org


15

PATIENT INFORMATIONPartner Notification/Contact TracingWhat is partner notification?Partner notification is when you tell someone they have been in contact with an STI and advise them to get tested and treated for that STI, even if their test results are negative. This is also called contact tracing.

Why should we notify sexual contacts?• To avoid getting an STI back again from an untreated sexual contact.• The more times you get an STI, the higher the risk of getting serious problems in

the future.• It helps to stop the spread of STIs.• Unless they get tested, people often don’t know they have an STI and can spread

it to others without knowing.

Who do I need to contact?Usually anyone you have had sexual contact with (including oral, vaginal or anal sex) in the last 3 months, as advised by your doctor or nurse, even if you used condoms.

When should I do this?• As soon as possible after finding out that you have an STI.• Before you have sex with an untreated contact.

How am I going to do this?There are many ways of telling sexual contacts:• Face-to-face• On the telephone• SMS/Social media• Give them a treatment letter for sexual contacts• Give them an information sheet• Email

Things to think about when deciding how best to tell your sexual contact/s• How safe it is for you to tell your sexual contact/s. If you have concerns, please discuss this with your doctor or nurse.• What contact details you have for your sexual contact/s.• How you would like to be told yourself.

Many people prefer to inform people face-to-face and find that they have a positive response from their sexual contact/s.

Where can I go for help from a health professional?• GP/practice nurse • Local sexual health clinic • Family Planning

Remember• STIs are usually easy to test for and treat.• Most STIs are passed on by people who don’t know they have one, as they often don’t have any signs or symptoms.• Just because you were tested first doesn’t mean that you had the infection first.• Make sure you have the correct information (fact sheet or website) to answer any questions and correct any myths about the STI.• If you use a condom every time you have sex, you are much less likely to get an STI.

Important information• Partner notification/contact tracing

has health benefits to you as it can stop you getting re-infected.

• Many people don’t know they have an STI: notifying them can help them get treated.

• Partner notification/contact tracing helps stop the spread of STIs.

• Make sure the information that you pass on is correct. Health professionals can help you with this if you are unsure.

To download or print the patient information leaflet on partner notification, go to www.nzshs.org/guidelines


16

MANAGEMENT OF SEXUAL HEALTH CONDITIONS

Chlamydia MANAGEMENT SUMMARY

FOLLOW-UP• By phone or in person, 1 week later• No unprotected sex in the week post-treatment?• Completed/tolerated medication?• Notifiable contact/s informed?• Any risk of re-infection? Re-treatment necessary if re-exposed to untreated contact• Test of cure only needed if pregnant, extragenital infection or continuing symptoms• Diagnostic tests can detect traces of dead organisms – wait at least 5 weeks before retesting• Re-infection is common; offer repeat sexual health check in 3 months

PARTNER NOTIFICATION AND MANAGEMENT OF SEXUAL CONTACTS• Be clear about language: ‘partner’ implies relationship – all sexual contacts in the last 3 months should be notified• Contact/s should have a sexual health check and treatment for chlamydia with azithromycin 1g po stat, without waiting for test results• If contacts test positive for an STI refer to specific guideline www.nzshs.org/guidelines• Advise contact/s to abstain from sex or use condoms for 1 week from the start of treatment and until results of tests are available• Most choose to tell contact/s themselves, giving written information is helpful• Notifying all contacts may not be possible e.g. if there is insufficient information or a threat of violence

MANAGEMENT• Azithromycin 1g po stat (pregnancy category B1) – for asymptomatic urogenital infection• Doxycycline 100mg po twice daily for 7 days (NOT in pregnancy) – for symptomatic urethritis, rectal, pharyngeal or eye

infection, or if patient is on QT-prolonging medication (www.medsafe.govt.nz/profs/PUArticles/DrugInducedQTProlongation.htm)• If anorectal symptoms and a positive chlamydia test, refer or discuss with a sexual health specialist as LGV proctitis requires further testing and

doxycycline 100mg po twice daily for 21 days• Advise to abstain from sex or use condoms for 1 week from the start of treatment and until 1week after sexual contact/s have been treated

Treat immediately if high index of suspicion, e.g. symptoms and/or signs, or contact of index case.• Start treatment for patient and sexual contact/s, without waiting for lab results

RECOMMENDED TESTS• It is recommended to test for co-existing STIs (see Sexual Health Check guideline www.nzshs.org/guidelines)• Females: – A self-collected vulvovaginal NAAT swab if asymptomatic, examination declined and no other tests required – A vulvovaginal NAAT swab prior to a speculum examination and other STI swabs if symptomatic or needs examination – Additional anorectal NAAT swab as indicated based on sexual history – Note: A first void urine has lower sensitivity in females than cervical or vaginal swabs so is not specimen of choice• Males: – A first void urine (first 30ml), preferably ≥ 1 hour after last void• Men who have Sex with Men: – Additional pharyngeal and anorectal NAAT swabs irrespective of reported sexual practices or condom use, as asymptomatic pharyngeal

and rectal infection is common

TEST IF:• Sexually active under 30 years – OR more than 2 sexual contacts in last year – OR has had an STI in past 12 months – OR has a sexual contact with an STI• Pregnant• Increased risk of complications of an STI, e.g. pre-termination of pregnancy (TOP)• Signs or symptoms suggestive of chlamydia: – Females: Vaginal discharge / dysuria / lower abdominal pain/ abnormal bleeding / anal pain or discharge – Males: Urethral discharge / dysuria / testicular pain or swelling / anal pain or discharge• Requesting a sexual health check




http://www.medsafe.govt.nz/profs/PUArticles/DrugInducedQTProlongation.htm




17

What is chlamydia?Chlamydia is a common sexually transmitted infection (STI) that is easy to treat. It is quite easy to catch and can cause serious problems if you don’t get it treated. Untreated chlamydia infection can cause pelvic inflammatory disease and infertility in women, and testicle pain and swelling in men. It is very common in people aged less than 30.

How does someone get chlamydia?• By having sex or sexual contact with another person with chlamydia.• This includes oral, vaginal or anal sex and sex play or sharing toys.• The other person may not know they have the infection.• If you use a condom every time you have sex you are much less likely to get

chlamydia.• Chlamydia can also be passed from mother to baby during birth and may result

in an eye or lung infection in the baby.

How do I know if I have chlamydia?Many people don’t notice any symptoms. If they do, symptoms could be:

Females• There can be a discharge or fluid leaking from the vagina.• There can be pain when urinating or low tummy pain, especially during sex.• There can be unusual bleeding between periods or bleeding after sex.• Chlamydia can cause an unusual discharge or bleeding from the anus if there

has been anal sex.

Males• There can be soreness, an unusual discharge or itching in the opening at the end of the penis (urethra).• There can be pain when urinating.• There can be unusual discharge or bleeding from the anus if there has been any anal sex with males.• Very occasionally there can be pain or swelling in the testicles.

How do I get tested?You need to see your doctor or nurse or sexual health clinic for a check-up. If you want, take along someone you trust, for support.

If you have symptoms you will need to be examined by a doctor or nurse to find the cause.

• Females will need a swab from the vagina. An anal swab might be required if you have anal sex. You may be able to do the swab/s yourself.

• Males need a urine test. Throat and anal swabs might be required if you have sex with males. You may be able to do the swabs yourself.

It may be embarrassing, but it is better to get checked than to have untreated chlamydia.

How do I get treated?You will need to take some tablets – usually a single dose of an antibiotic cures chlamydia. Sometimes tablets may need to be taken for 2 weeks if the infection is more serious.

Important advice• Finish all the tablets you have been given, even if you feel better.• You need to tell anyone you have had sex with within the last 3 months to get a sexual health check and treatment for chlamydia

even if their tests are normal.• You should avoid sex for 1 week from the start of your treatment and until 1 week after your sexual contact/s have been treated.

If this is not possible always use a condom, including for oral sex, until your treatment and your sexual contact/s treatment has been completed.

• We recommend you have another sexual health check in 3 months in case you get the infection again.

Important information• Chlamydia is a common sexually

transmitted infection (STI) that is easy to treat with antibiotics.

• Many people with chlamydia don’t notice symptoms.

• You get chlamydia by having sexual contact with another person who has chlamydia.

• Testing: Females will need a swab from the vagina. Males need a urine test. Other tests might be required dependent on the type of sexual contact you have.

• You need to tell anyone you have had sex with with in the last 3 months to get a sexual health check and treatment for chlamydia.

• You should avoid sex or use condoms for 1 week from the start of your treatment and until 1 week after your sexual contact/s have been treated, so you don’t pass the infection on to someone else.

Chlamydia PATIENT INFORMATION

To download or print the patient information leaflet on chlamydia, go to www.nzshs.org/guidelines


18

Gonorrhoea MANAGEMENT SUMMARY

FOLLOW-UP• By phone or in person, 1 week later• No unprotected sex in the week post-treatment? • Completed/tolerated medication?• All notifiable contact/s informed?• Any risk of re-infection? Re-treatment necessary if re-exposed to untreated contact• Test of cure is only needed if symptoms don’t resolve or if pharyngeal infection. Re-test by culture in 3 days for genital gonorrhoea, or by NAAT in

3 weeks for pharyngeal infection• Reinfection is common; offer repeat sexual health check in 3 months

PARTNER NOTIFICATION AND MANAGEMENT OF SEXUAL CONTACTS• Be clear about language: ‘partner’ implies relationship – all sexual contacts in the last 3 months should be notified• Contact/s should have a sexual health check and treatment for gonorrhoea with ceftriaxone 500mg im stat (make up with 2ml lignocaine 1%

or as per data sheet) plus azithromycin 1 gram po stat, without waiting for test results• If contacts test positive for an STI refer to specific guideline www.nzshs.org/guidelines• Advise contacts to abstain from sex or use condoms for 1 week from the start of treatment and until results of tests are available• Most choose to tell contacts themselves; giving written information is helpful• Notifying all contacts may not be possible, e.g. if there is insufficient information or a threat of violence

MANAGEMENT• Treat immediately if high index of suspicion e.g. symptoms and/or signs, or contact of gonorrhoea• Ceftriaxone 500mg im stat (make up with 2ml lignocaine 1% or as per data sheet) PLUS azithromycin 1g po stat (pregnancy category B1) • If clinical PID or epididymo-orchitis, treat as per PID guideline www.nzshs.org/guidelines or Epididymo-orchitis guideline

www.nzshs.org/guidelines• Refer or discuss with a sexual health specialist if case has drug allergies or anti-microbial resistance is suspected or if anorectal symptoms or there

are concerns with QT-prolonging medication (www.medsafe.govt.nz/profs/PUArticles/DrugInducedQTProlongation.htm)• Advise to abstain from sex or use condoms for 1 week from the start of treatment and until 1 week after sexual contact/s have been treated

RECOMMENDED TESTS• It is recommended to test for co-existing STIs (see Sexual Health Check guideline www.nzshs.org/guidelines)• Asymptomatic Female (or examination declined): – A vulvo-vaginal NAAT swab either clinician-taken or self-taken – Additional anorectal NAAT swab as indicated based on sexual history• Symptomatic Female: – A speculum examination should be carried out. A vulvo-vaginal NAAT swab (prior to speculum insertion) plus an endocervical culture swab

for gonorrhoea (if gonorrhoea culture available) plus a high vaginal culture swab for testing for candida, BV & trichomoniasis (if NAAT for trichomoniasis not available)

– Additional anorectal NAAT swab as indicated based on sexual history• Symptomatic Male: – Take a urethral culture swab for gonorrhoea (if gonorrhoea culture available), followed by first-void urine for gonorrhoea NAAT testing

(first 30ml), preferably ≥1 hour after last void• Asymptomatic Male: – Men do not require screening for urethral gonorrhoea if asymptomatic but gonorrhoea testing may be done if a first-void urine specimen is

sent for chlamydia testing• Men who have Sex with Men: – Additional pharyngeal and anorectal NAAT swabs irrespective of reported sexual practices or condom use, as asymptomatic rectal and

pharyngeal infection is common

TEST IF:• Person is a sexual contact of gonorrhoea• Routine sexual health check in females• Pre-termination of pregnancy (TOP)• Pre-intrauterine device (IUD) insertion• Routine sexual health check in man who has sex with other men (MSM)• Signs or symptoms suggestive of gonorrhoea – Females: Vaginal discharge/dysuria/lower abdominal pain/abnormal bleeding/anal pain or discharge – Males: Urethral discharge/dysuria/testicular pain or swelling/anal pain or discharge






http://www.medsafe.govt.nz/profs/PUArticles/DrugInducedQTProlongation.htm




19

What is gonorrhoea?Gonorrhoea is an STI (a sexually transmitted infection) that is more common in people aged less than 30 years. Gonorrhoea is very easy to catch and also very easy to treat. It may cause serious problems if you don’t get it treated.

How does someone get gonorrhoea?• By having sex or sexual contact with another person with gonorrhoea.• This includes oral, vaginal or anal sex and sex play, particularly when saliva is

used as a lubricant.• The other person may not know they have the infection.• If you use a condom every time you have sex you are much less likely to

get gonorrhoea.• Gonorrhoea can also be passed from mother to baby during birth and may result

in an eye infection in the baby.

How do I know if I have gonorrhoea?Males with gonorrhoea in the penis are more likely to be symptomatic than females.

Many people don’t notice any symptoms. If they do, symptoms could be:

Females• There can be a discharge or fluid leaking from the vagina.• There can be pain when urinating or low tummy pain, especially during sex.• There can be unusual bleeding between periods or bleeding after sex.• Gonorrhoea can cause an unusual discharge or bleeding from the anus

if there has been anal sex.

Males• There can be soreness, an unusual discharge, or itching in the opening at the end of the penis (urethra). • There can be pain when urinating.• There can be unusual discharge or bleeding from the anus if there has been anal sex between males.• Very occasionally there can be pain or swelling in the testicles.

How do I get tested?You need to see your doctor, nurse or sexual health clinic for a check-up. If you want, take along someone you trust, for support.

If you have symptoms you will need to be examined by a doctor or nurse to find the cause.

• Females will need a swab test from the vagina. An anal swab might be required if you have had anal sex. You may be able to do the swab/s yourself.

• Males will need a urine test. Throat and anal swabs might be required if you have sex with males. You may be able to do the swabs yourself.

It may be embarrassing, but it is better to get checked than to have untreated gonorrhoea.

How do I get treated?You will need an injection and to take some tablets. A single dose of the right treatment usually cures gonorrhoea. You may need to take tablets for up to 2 weeks if the infection is more serious.

Important advice• Finish all the tablets you have been given, even if you feel better.• You need to tell anyone you have had sex with in the last 3 months to get a sexual health check and treatment for gonorrhoea,

even if their tests are normal.• You should avoid sex for 1 week from the start of your treatment and until 1 week after your sexual contact/s have been treated.

If this is not possible, always use a condom, including for oral sex, until your treatment and your sexual contact/s treatment has been completed.


Important information• Gonorrhoea is a sexually transmitted

infection (STI) that is easy to treat with antibiotics.

• Some people with gonorrhoea don’t notice symptoms.

• You can get gonorrhoea by having sexual contact with another person who has gonorrhoea.

• Testing: Females will need a swab from the vagina. Males need a urine test. Other tests might be required dependent on the type of sexual contact you have.

• You need to tell anyone you have had sex with with in the last 3 months to get a sexual health check and treatment for gonorrhoea..

• You should avoid sex or use condoms for 1 week from the start of your treatment and until 1 week after your sexual contact/s have been treated, so you don’t pass the infection onto someone else.

Gonorrhoea PATIENT INFORMATION

To download or print the patient information leaflet on gonorrhoea, go to www.nzshs.org/guidelines


20

Epididymo-orchitis MANAGEMENT SUMMARY

Take history – age, sexual history, previous catheterisation or urinary tract infection (UTI)? Examination – swollen scrotum, tender epididymis/testicle, urethral discharge? Tests – urethral culture swab for gonorrhoea (if gonorrhoea culture available) if urethral discharge, plus in all cases first void urine for chlamydia & gonorrhoea NAAT testing (first 30ml), preferably ≥1 hour after last void, and mid-stream urine for urine dipstick and culture for urinary pathogens

EXCLUDE TORSION

Symptoms and signs persist• Check compliance with treatment• Check no unprotected sex• Ensure partner notification complete• Review diagnosis• Consider alternative aetiologies• Consider testicular USS• Consider urology referral

Partner notification and management of sexual contactsIf STI cause suspected:• Be clear about language: ‘partner’ implies relationship• All sexual contacts in the last 3 months should be notified• Contact/s should have a sexual health check and treatment as an

epididymitis contact, with azithromycin 1g po stat, without waiting for test results

– If gonorrhoea suspected in index case, add ceftriaxone 500mg im stat

• If contacts test positive for an STI refer to specific guideline www.nzshs.org/guidelines

• Advise contacts to abstain from sex or use condoms for 1 week from the start of treatment and until results of tests are available

• Most choose to tell contacts themselves; giving written information is helpful

• Notifying all contacts may not be possible, e.g. if there is insufficient information or a threat of violence

• Consider renal tract ultra-sound scan (USS)• Referral to urology

Symptoms and signs resolved/significantly improved• Check compliance with treatment• Check sexual abstinence• Ensure partner notification/contact tracing complete

Discharge once symptoms and signs fully resolvedOffer repeat sexual health check in 3 months

MSU positive

Follow-up• Symptoms should be improving after 3 days• Arrange further review at 1 week• Check laboratory results

STI-associated epididymo-orchitis more likely if• < 35 years• > 1 sexual contact in past 12 months• Urethral discharge• Men who have sex with men (MSM)

Urinary pathogen-associated epididymo-orchitis more likely if• > 35 years• Low risk sexual history• Previous urological procedure or UTI• No urethral discharge• Positive urine dipstick for leucocytes + nitrites

Management of epididymo-orchitis likely due to any STI• Ceftriaxone 500mg im stat (make up with 2ml lignocaine 1%

or as per data sheet) plus doxycycline 100mg po twice daily for 14 days

• Advise to abstain from sex or use condoms for for 2 weeks after the start of treatment and until 1 week after all sexual contact/s have been treated

• Bed rest, scrotal support, analgesia

Management of epididymo-orchitis likely due to enteric or urinary organisms• Ciprofloxacin 500mg po bd 10 days (specialist approval may be

required)• Bed rest, scrotal support, analgesia




21

What is epididymo-orchitis?Epididymo-orchitis is an infection of the testicle and epididymis (tubes around the testicle).

How does someone get epididymo-orchitis?• Epididymo-orchitis is usually due to a sexually transmitted infection (STI) such

as chlamydia or gonorrhoea, which is caught from having unprotected sex with someone who has the STI. This can include oral, vaginal and anal sex, sex play or sharing sex toys.

• If you use a condom every time you have sex you are much less likely to get epididymo-orchitis.

• Sometimes epididymo-orchitis is due to a urinary infection – this is more common in men over 35.

• It can also be caused by a childhood infection known as mumps.

What are the symptoms?These can include:• Pain or swelling in the testicle or scrotum.• Discharge or fluid leaking from the penis, especially if it is due to chlamydia or

gonorrhoea.• Sometimes there may be pain passing urine.• Sudden severe pain in the testicle or scrotum can be due to a twisted testicle.

This is serious and you will need to see a doctor straight away.

What do I do if I think I have epididymo-orchitis?You should see a doctor urgently. You will need to have a sexual health check. You will need an examination and you will need to do a urine test. You may also need to have a swab taken from the penis.

How do I get treated?You will usually need an injection and a 2 week course of tablets. You will be advised to wear supportive underwear until it gets better. You may need painkillers such as paracetamol or ibuprofen to manage pain.

Important advice• Finish all the tablets you have been given, even if you feel better.• You should use a condom while on treatment, so you don’t pass the infection on to someone else.• You need to tell anyone you have had sex with in the last 3 months to get a sexual health check and treatment as a contact of

epididymo-orchitis even if their tests are normal.• You should avoid sex for 2 weeks from the start of your treatment and until 1 week after your sexual contact/s have been treated.



Important information• Epididymo-orchitis is an infection of

a male’s testicle and tubes.• It is usually caused by an STI, but can

sometimes be caused by a urinary infection or mumps.

• If you get pain or swelling in the testicle you need to see a doctor urgently.

• It is treated by antibiotics.• You need to tell anyone you have had

sex with in the last 3 months to get a sexual health check and treatment as a contact of epididymo-orchitis.

• You should avoid sex or use condoms for 2 weeks from the start of your treatment and until 1 week after your sexual contact/s have been treated, so you don’t pass the infection onto someone else.

Epididymo-orchitis PATIENT INFORMATION

To download or print the patient information leaflet on epididymo-orchitis, go to www.nzshs.org/guidelines


22

MANAGEMENT SUMMARYGenital Skin Lesions (Non-Ulcerative)

Patie

nt c

ompl

ains

of

gen

ital

ski

n lu

mp

(s)

/ b

um

p(s

)

Exam

inat

ion

Not

e th

e ap

pear

ance

and

loca

tion

of le

sion

s –

toge

ther

with

the

his

tory

, thi

s is

usu

ally

su

ffic

ient

to

mak

e a

diag

nosi

s.

Dis

cret

e lu

mps

or

bum

ps in

the

gen

ital r

egio

n m

ay b

e du

e to

nor

mal

ana

tom

ical

fin

ding

s, o

r m

ay b

e du

e to

a s

mal

l num

ber

of s

exua

lly t

rans

mis

sibl

e in

fect

ions

. Unu

sual

lesi

ons,

in

clud

ing

pigm

ente

d le

sion

s, s

houl

d be

refe

rred

for

a s

peci

alis

t op

inio

n be

fore

any

tre

atm

ent

occu

rs.

No

rmal

an

ato

mic

al

vari

ants

Mal

es•

Pear

ly p

enile

pap

ules

(c

oron

al p

apill

ae),

Ford

yce

glan

ds.

Fem

ales

• Ve

stib

ular

pa

pillo

mat

osis

, Fo

rdyc

e gl

ands

Gen

ital

war

tsEx

ophy

tic s

kin

lesi

ons

that

var

y in

siz

e/sh

ape

and

num

ber.

Mal

es•

Typi

cally

at

lead

ing

edge

of

prep

uce,

on

fren

ulum

, or

mor

e sp

orad

ical

ly in

cor

onal

sul

cus,

on

peni

le s

haft

. Le

ss f

requ

ently

on

scro

tum

or

in p

ubic

are

a or

per

iana

l.Fe

mal

es•

Usu

ally

vul

val (

ofte

n po

ster

iorly

), pe

rinea

l, or

per

iana

l.N

ote

: Les

ions

rese

mbl

ing

war

ts a

nd a

risin

g in

war

m m

oist

m

ucos

al s

ites

(e.g

. inn

er la

bial

, ana

l) –

excl

ud

e sy

ph

ilis

(Con

dylo

mat

a la

ta).

Mo

llusc

um

co

nta

gio

sum

• Sm

all d

ome-

shap

ed

lesi

ons

with

wax

y co

lour

, and

with

ce

ntra

l um

bilic

atio

n.

If la

rge

they

can

as

sum

e a

mor

e no

dula

ror

flesh

y ap

pear

ance

.•

Usu

ally

pub

ic,

peni

le, o

r vu

lval

lo

catio

n.

Scab

ies

no

du

les

• H

isto

ry o

f re

cent

/cur

rent

sca

bies

.•

‘Nod

ular

’ les

ions

mor

e co

mm

on

in m

ales

. Usu

al lo

catio

n: g

lans

pe

nis,

sha

ft o

r sc

rotu

m.

• Ty

pica

lly: 2

-10

mm

redd

ish

papu

lono

dula

r le

sion

s; v

ery

itchy

.

Man

agem

ent

• Re

assu

re p

atie

nt

that

the

lesi

ons

are

norm

al•

Off

er o

ppor

tuni

stic

ST

I scr

een

(see

Se

xual

Hea

lth

Che

ck g

uide

line

ww

w.n

zsh

s.o

rg/

gu

idel

ines

)•

If un

sure

of

findi

ngs,

ge

t a

seco

nd o

pini

on

Man

agem

ent

• Tr

eatm

ent

optio

ns –

see

Gen

ital W

arts

gui

delin

e

ww

w.n

zsh

s.o

rg/g

uid

elin

es.

• Pi

gmen

ted

or a

typi

cal l

esio

ns –

refe

r to

sex

ual h

ealth

sp

ecia

list.

• O

ffer

STI

scr

een

(see

Sex

ual H

ealth

Che

ck g

uide

line

w

ww

.nzs

hs.

org

/gu

idel

ines

)

Man

agem

ent

• W

ill re

solv

e w

ithou

t tr

eatm

ent,

but

may

ta

ke m

any

mon

ths.

• Tr

eat

with

cr

yoth

erap

y.•

Off

er S

TI s

cree

n (s

ee

Sexu

al H

ealth

Che

ck

guid

elin

e

ww

w.n

zsh

s.o

rg/

gu

idel

ines

)

Man

agem

ent

• C

heck

syp

hilis

ser

olog

y.•

Trea

t pa

tient

with

per

met

hrin

5%

lotio

n.•

Nod

ules

are

slo

w t

o re

solv

e –

use

topi

cal c

ortic

oste

roid

to

cont

rol

itch.

• Re

fer

to s

exua

l hea

lth s

peci

alis

t

if un

sure

of

diag

nosi

s or

lesi

ons

non-

resp

onsi

ve t

o to

pica

l tr

eatm

ent.

• O

ffer

STI

scr

een

(see

Sex

ual

Hea

lth C

heck

gui

delin

e

ww

w.n

zsh

s.o

rg/g

uid

elin

es)










23

Genital Ulcer Disease (GUD) MANAGEMENT SUMMARY

Are the lesions on examination• Multiple vesicles; or tender, shallow ulcerations; +/- inguinal adenopathy?

Patient complains of genital sore(s) / ulcer(s)

In New Zealand, GUD due to STI is largely confined to herpes simplex virus (either HSV-2 or HSV-1), or syphilis. Tropical causes of GUD such as chancroid or lymphogranuloma venereum are RARE. Consider if there has been an overseas sexual contact in an endemic region or with someone from a high-prevalence population group. Some ulcerative lesions are due to non-sexually acquired dermatological conditions. However, it is important to remember that most breaks in the genital skin are due to micro-trauma to the epidermis.

YESTests• Viral swab for herpes simplex virus (HSV) testing from the

base of the lesion (HSV PCR testing is the preferred test)• Syphilis serology should be routinely requested

NO• Larger typically solitary painless ulcers +/- unilateral non-

tender enarged rubbery lymph node is more typical of primary syphilis

• Other atypical lesions

Management• Valaciclovir 500mg po twice daily for 7 days OR• Aciclovir 400mg po 3 times daily for 7 days• +/- lignocaine gel and oral analgesia• +/- salt baths

Follow-up• Check HSV result and check for resolution of ulcers in 1 week• If HSV result positive, discuss diagnosis with patient• Partner notification is not necessary but diagnosis should be discussed with regular sexual contact/s• Offer full sexual health check if not already done (see Sexual Health Check guideline

www.nzshs.org/guidelines)• If HSV result negative and the lesions have resolved, then arrange to repeat the HSV test promptly if

problem recurs• Refer or discuss with a sexual health specialist if there are genital ulcers that are HSV-negative

and have not resolved

• Refer to or discuss with sexual health specialist for acute assessment

• DO NOT give oral or topical treatments prior to specialist assessment




24

Pelvic Inflammatory Disease (PID) MANAGEMENT SUMMARY

72 HOUR FOLLOW-UP FOR MODERATE/SEVERE PID• Repeat bimanual exam to assess resolution of signs and refer if not improved• No unprotected sex?• Tolerated medication?• Notifiable contacts informed?• Any risk of reinfection? Will need further treatment if re-exposed to untreated contact

1 TO 2 WEEK FOLLOW-UP FOR MILD PID (PHONE OR IN PERSON)• As above – bimanual where practical or where symptoms not improved• Re-infection is common; offer repeat sexual health check in 3 months

PARTNER NOTIFICATION AND MANAGEMENT OF SEXUAL CONTACTS• Be clear about language: ‘partner’ implies relationship – all sexual contacts in the last 3 months should be notified• Contact/s should have a sexual health check and if asymptomatic be treated for chlamydia with azithromycin 1g po stat, without waiting for

test results• If sexual contact/s has symptoms of urethritis (see Urethritis in Males guideline www.nzshs.org/guidelines)• If contacts test positive for an STI, refer to specific guideline www.nzshs.org/guidelines• Advise contacts to abstain from sex or use condoms for 1 week from the start of treatment and until results of tests are available• Most choose to tell contacts themselves; giving written information is helpful• Notifying all contacts may not be possible, e.g. if there is insufficient information or a threat of violence

RECOMMENDED TESTS – see Sexual Health Check Guideline www.nzshs.org/guidelines• Vulvovaginal NAAT swab for chlamydia & gonorrhoea testing prior to speculum insertion. Insert speculum, examine vagina and cervix.• Endocervical culture swab for gonorrhoea (if gonorrhoea culture available)• High vaginal culture swab for candida & BV & trichomoniasis (if NAAT for trichomoniasis not available)• Additional anorectal NAAT swab for chlamydia & gonorrhoea testing as indicated based on sexual history• Bimanual examination for pelvic masses or tenderness• Urine pregnancy test and urinalysis dipstick• Universal serology for HIV and syphilis• Targeted hepatitis B and C serology if hepatitis B status unknown and risk factors present• Full blood count (FBC) and C-reactive protein (CRP) in severe cases or diagnostic uncertainty• Vital signs: Temperature, pulse, blood pressure• Pain score: Mild PID = normal vital signs and pain score <5/10, moderate PID = normal vital signs and pain score ≥5/10

TEST IF• Woman at risk of STIs presents with lower abdominal/pelvic pain – see Express STI Testing Questionnaire www.nzshs.org/guidelines


SEVERITY ASSESSMENTPID IS SEVERE IF:• Acute abdomen• Pregnant• Fever, vomiting or systemically unwell• Intolerant of oral therapy• Clinical failure at reviewREFER • Severe PID• Ectopic pregnancy suspected• Severe drug allergies to usual regimen• Persistent or repeat PID where reinfection is excluded as Mycoplasma genitalium testing may be requiredMILD/MODERATE PID• Ceftriaxone 500mg im stat (make up with 2ml lignocaine 1% or as per data sheet) PLUS• Doxycycline 100mg po twice daily for 2 weeks PLUS• Metronidazole 400mg po twice daily for 2 weeks. (Metronidazole may be discontinued at review if not tolerated.)• For drug allergies refer to full guideline at www.nzshs.org/guidelines• Advise treatment may take time to work• Advise to abstain from sex until abdominal pain has settled and to use condoms for 2 weeks after initiation of treatment and until 1 week after

sexual contact/s have been treated

Treat immediately on the basis of symptoms of lower abdominal pain and EITHER uterine OR cervical OR adnexal tenderness.









25

What is pelvic inflammatory disease?PID is the name given to infection in or around a woman’s uterus (womb), fallopian tubes or ovaries. It is caused by bacteria spreading upwards into the uterus from the vagina or cervix (neck of the womb). It is commonly caused by sexually transmitted infections (STIs) such as chlamydia or gonorrhoea. Sometimes PID can occur after pelvic operations, a pregnancy, or in the first few weeks after an IUD is put in.

PID sometimes causes infertility (difficulty getting pregnant), ectopic pregnancy (a baby growing in a place outside the womb), or long term pelvic pain. These things are more likely to happen if the treatment is late, so it’s important to get treated straight away.

How does someone get PID?PID can develop after having sex or sexual contact with someone who has an STI.

PID is especially common if you are under 30 years old, have had a new sexual contact in the last 3 months, don’t always use condoms for sex, or if you’ve had an STI such as chlamydia or gonorrhoea.

You can prevent PID by using a condom every time you have sex, especially when you have sex with a new sexual contact.

How do I know if I have PID?In the early stages you might not notice anything wrong. Most women have mild symptoms such as:• Lower tummy pain or aching – a bit like a period pain.• Pain deep inside during sex.• Bleeding inbetween periods or after sex.• Abnormal vaginal discharge.

How do I get tested?It’s important to have a sexual health check if you have symptoms of PID. If you want, take along someone you trust, for support.

There is no one single test for PID. The doctor will rely on your symptoms and what is found on examination to decide if you have PID. Often the tests will not tell you the cause and you can still have PID even if the STI tests are negative.

How do I get treated?If your doctor thinks you might have PID you will get a 2 week course of antibiotic tablets and an injection.

Important advice• Finish all the tablets you have been given, even if you feel better and the tests are all normal.• You need to tell anyone you have had sex with within the last 3 months to get a sexual health check and treatment as a contact

of PID, even if their tests are normal. • You should avoid sex for 2 weeks from the start of your treatment and until 1 week after your sexual contact/s have been treated.


• The complications of PID get worse if you get it again, so preventing it by using condoms is important.• We recommend you have another sexual health check in 3 months in case you get an infection again.

Important information• PID is infection around a woman’s

uterus (womb), fallopian tubes or ovaries.

• It is commonly, but not always, caused by STIs such as chlamydia or gonorrhoea.

• Symptoms include abdominal (tummy) pain and abnormal bleeding or discharge.

• PID is treated with antibiotics. You should finish all the treatment you have been given.

• You need to tell anyone you have had sex with in the last 3 months to get a sexual health check and treatment as a contact of PID.

• You should avoid sex or use condoms for 2 weeks from the start of your treatment and until 1 week after your sexual contact/s have been treated, so you don’t pass the infection on to someone else.

Pelvic Inflammatory Disease (PID) PATIENT INFORMATION

To download or print the patient information leaflet on PID, go to www.nzshs.org/guidelines


26

Syphilis MANAGEMENT SUMMARY

FOLLOW-UPInfectious syphilis• Repeat serology at 3, 6 and 12 months• Serological cure is defined by consistent four-fold (2 dilutions) drop in RPR titre• Failure of RPR titre to decrease fourfold (2 dilutions) within 12 months indicates treatment failure – re-evaluation is necessary• A subsequent four-fold (2 dilution) rise in RPR titre is an indication of re-infection – re-evaluation is necessary

Late latent syphilis and tertiary syphilis (excluding neurosyphilis)• Repeat serology at 6 and 12 months to ensure remains serofast• Fourfold (2 dilutions) increase in titre indicates either treatment failure or re-infection – re-evaluation is necessary

PARTNER NOTIFICATION AND MANAGEMENT OF SEXUAL CONTACTS• Referral or discussion with a sexual health specialist or service is strongly recommended• Be clear about language: ‘partner’ implies relationship• All sexual contacts within the intervals below should be clinically and serologically evaluated

Infectious syphilis• Primary syphilis: 3 months plus duration of symptoms. Empiric treatment for syphilis is recommended, as serology may be negative• Secondary syphilis: 6 months plus duration of symptoms• Early latent syphilis and syphilis of unknown duration where RPR ≥ 1:32: 12 months

Late latent syphilis, syphilis of unknown duration with low RPR and tertiary syphilis• Serologic evaluation of current or last sexual contact and/or serologic evaluation of children if index case is female

MANAGEMENT• Advise to refrain from any sexual activity until assessed or discussed with a specialist service• Do not use/prescribe any topical agents or oral antibiotics for genital ulcers• Patients being treated for infectious syphilis should have syphilis serology repeated on the day treatment is commenced to provide an accurate

baseline for monitoring treatment• It is important that any intramuscular penicillin formulation used should be long-acting Bicillin LA (benzathine penicillin) 1.8g, as short-acting

formulations are insufficient for syphilis treatment. Treatment should ideally be given at a sexual health service.

RECOMMENDED TESTS• Syphilis serology – if clinical suspicion of infectious syphilis specify on laboratory form• HIV serology• Routine STI tests (see Sexual Health Check guideline www.nzshs.org/guidelines)• In MSM also request hepatitis A and B serology, unless known to be immune• In persons with a history of IDU, incarceration, or who use recreational drugs during sex, request hepatitis C serology

TEST IF• MSM (at least annually, but ideally with every sexual health check)• HIV positive (at least annually, but ideally with every sexual health check)• Routine antenatal screen; consider rescreening in later pregnancy if partner change• Routine immigration screen• A sexual contact of a person with syphilis• Routine sexual health check

Signs or symptoms of infectious syphilis:• Genital ulcers (see Genital Ulcer Disease summary www.nzshs.org/guidelines)• MSM with any genital symptoms or rash• Any rash affecting the palms of the hands or soles of the feet, or that is persistent or unexplained• Pyrexia of unknown origin, unexplained persistent lymphadenopathy, unexplained liver function disturbance, alopecia

Refer or discuss with a sexual health specialist if high index of suspicion of infectious syphilis (e.g. symptoms and/or signs, or contact of index case), or if pregnant.It is recommended to discuss all positive syphilis serology with a sexual health specialist.





27

What is syphilis?Syphilis is a sexually transmitted infection (STI). It is quite easy to catch and can cause serious problems if you don’t get it treated. It has been increasing in New Zealand particularly in men having sex with men (MSM). Having untreated syphilis increases your chances of catching HIV infection.

How does someone get syphilis?Syphilis is usually caught by having sexual contact with an infected person. This may include vaginal, anal or oral sex or just close skin-to-skin contact. The chances of catching syphilis are lower if you use condoms during sex. Syphilis can also be spread from mother to baby during pregnancy if the mother is infected. Syphilis can cause miscarriage or still-birth or infection in the baby if a pregnant woman is not treated.

How do I know if I have syphilis?• About 50% of people don’t have any symptoms and would not know

without having a blood test.• People without symptoms can still get problems later on if they are not

treated.• At the infectious stage people without symptoms can still pass the

infection to their sexual contacts.

What are the symptoms of syphilis?Early stages of syphilis (primary and secondary syphilis) are also called infectious syphilis.Primary syphilis• The first sign of syphilis is one or more sores on the penis, anus, mouth or cervix (neck of the womb).• The sore may not be seen easily at these sites and because it is often painless it may go unnoticed.• The sore will disappear on its own within a few weeks.• All genital sores must be examined by a doctor.Secondary syphilis• The most common symptom of secondary syphilis is a rash. • It may affect the palms of the hands or soles of the feet. It can be very mild or severe and will disappear on its own. • There may also be other symptoms such as mouth ulcers, headaches, swollen glands, fever, hair loss, tiredness, or warty growths

in the genitals or anus.If untreated, the symptoms of primary and secondary syphilis disappear, but you can remain infectious for up to 2 years.Late syphilis• If not treated, a small number of people will get late stage syphilis (or tertiary syphilis), which can cause damage to the heart,

brain, nerves, blood vessels, liver, bones and joints many years later.• People with late syphilis (latent and tertiary) are not infectious to sexual contacts.

How do I get tested?You need to see your doctor or nurse or sexual health clinic for a check-up. If you want, take along someone you trust, for support.

• Syphilis is usually diagnosed by a blood test. • The tests can take up to 3 months after you get the infection to become positive.• It may be negative if you test too soon, but treatment is usually recommended if you have had sexual contact with someone with

syphilis, even if the test is negative.• If you have symptoms, you may also need to have samples taken from the sores or body rash.• Syphilis is one of the routine blood tests in pregnant women.

How do I get treated?• You will need injections of an antibiotic called penicillin.• If you are allergic to penicillin other antibiotics will be used. • Proper treatment of the mother during pregnancy will prevent the baby being born with syphilis.• The blood tests can stay positive for months or years after the disease has been successfully treated, but this is

nothing to worry about and does not mean that you are still infectious.

Important advice• You must finish all the treatment to be cured.• If you have syphilis you will need to tell sexual contacts to get tested and treated.• The doctor or nurse will tell you how far back to notify sexual contacts – usually anyone in the last 3 to 6 months.• Do not have sex until any sores or rashes have completely gone away.• After treatment, follow-up blood tests are essential for at least one year to make sure cure is complete.• It is possible to get reinfected with syphilis again in the future, through sexual contact with someone who has syphilis.

Syphilis PATIENT INFORMATION

To download or print the patient information leaflet on syphilis, go to www.nzshs.org/guidelines

Important information• Syphilis is a sexually transmitted

infection that is easily treated with antibiotics.

• It is most commonly diagnosed in men who have sex with men, but heterosexual infections are increasing.

• Many people with syphilis don’t have symptoms.

• You get syphilis by having sexual contact, including oral sex, with another person with syphilis.

• Testing: You need a blood test, especially if you have a genital sore, a rash, or if you have had sexual contact with a person with syphilis.

• Condoms help prevent syphilis.• You should avoid sex until any sores

or rashes have completely gone.• You will need follow-up blood tests.


28

Trichomoniasis MANAGEMENT SUMMARY

FOLLOW-UP (PHONE OR IN PERSON) 1 WEEK LATER• Any unprotected sex in last week?• Completed/tolerated medication?• All notifiable contacts informed?• Any risk of re-infection? Re-treatment necessary if re-exposed to untreated contact• Check other STI test results and treat if positive (refer to specific guidelines www.nzshs.org/guidelines)• Test of cure only needed if symptoms don’t resolve• Refer suspected treatment failures to a sexual health specialist• Offer repeat sexual health check in 3 months

PARTNER NOTIFICATION AND MANAGEMENT OF SEXUAL CONTACTS• Be clear about language: ‘partner’ implies relationship – all sexual contacts in the last 3 months should be notified• Male contacts should be treated empirically as testing for trichomoniasis is not available outside specialist services• Contact/s should have a sexual health check and treatment for trichomoniasis, without waiting for test results• If contacts test positive for an STI, refer to specific guideline www.nzshs.org/guidelines• Advise contacts to abstain from sex or use condoms for 1 week from the start of treatment and until results of tests are available• Most choose to tell contacts themselves; giving written information is helpful• Notifying all contacts may not be possible, e.g. if there insufficient information or a threat of violence

MANAGEMENT• Metronidazole 2g po stat (pregnancy category B2) OR• Ornidazole 1.5g po stat (not recommended in pregnancy) OR• Metronidazole 400mg po twice daily for 7 days• Refer full guideline (www.nzshs.org/guidelines) if breastfeeding• Advise to abstain from sex or use condoms for 1 week from the start of treatment and until 1 week after sexual contact/s have been treated• Advise to abstain from alcohol for duration of treatment and for at least 24 hours after completion of treatment (72 hours for ornidazole)

RECOMMENDED TESTSTesting for trichomoniasis varies regionally with some laboratories offering NAAT (e.g. PCR) testing on the chlamydia & gonorrhoea swab• It is recommended to test for co-existing STIs (see Sexual Health Check guideline www.nzshs.org/guidelines)Female:• If NAAT available, vulvovaginal NAAT swab for trichomoniasis, chlamydia & gonorrhoea testing• If NAAT not available, high vaginal culture swab for testing for trichomoniasis plus vulvovaginal NAAT swab for chlamydia & gonorrhoea• Additional anorectal NAAT swab for chlamydia & gonorrhoea testing as indicated based on sexual historyAsymptomatic male contacts: • Full sexual health check (see Sexual Health Check guideline www.nzshs.org/guidelines) including first void urine (first 30ml), preferably

≥1 hour after last void for trichomoniasis testing by NAAT if available locally• Treat empirically for trichomoniasis• Male contacts with dysuria or discharge (see Urethritis in Males guideline www.nzshs.org/guidelines)Symptomatic male contacts: • See Urethritis in Men guideline www.nzshs.org/guidelines

TEST IF:• Female with vaginal and vulval symptoms• Female with evidence of vulvitis and/or vaginitis, “scalded skin” or napkin-distribution dermatitis on examination• Sexual contacts of trichomoniasis• Males with persistent urethritis

Treat immediately if trichomoniasis is clinically suspected or if a sexual contact of trichomoniasis.• Start treatment for patient and sexual contact/s, without waiting for lab results










29

What is trichomoniasis?Trichomoniasis is a sexually transmitted infection (STI).

How does someone get trichomoniasis?Trichomoniasis is passed on by having sex, sexual contact or sex play with another person with trichomoniasis. It can also be passed on by sharing sex toys, e.g. vibrators.

If you use a condom every time you have sex, you are much less likely to get trichomoniasis.

How do I know if have trichomoniasis?Symptoms may develop after sexual contact with someone else with the infection.Symptoms include:

Females• There can be a discharge or fluid leaking from the vagina.• There can be a bad smell or odour in the genital area.• You may feel itchy or sore in the genitals.• Many women have no symptoms.

Males• Most men do not have symptoms, however they can still pass trichomoniasis on.• Some men may have discharge or fluid leaking from the penis and/or pain when passing urine.

How do I get tested?• You need to see your doctor, nurse or sexual health clinic for a check-up. If you want, take along someone you trust, for support.• Females will need a swab from the vagina. An anal swab might be required if you have anal sex. You may be able to do the

swab/s yourself.• Trichomoniasis is difficult to test for in men, so men are usually just treated if they have had sex with someone with trichomoniasis

even if their tests are normal.• It may be embarrassing, but it is better to get checked than to have untreated trichomoniasis.

How do I get treated?A single dose of the right tablets usually cures it. The tablets sometimes make you feel a bit sick, but it helps if you take them with food. Don’t drink alcohol for 24 hours after taking the tablets as it will make you feel really sick.

Important advice• Finish all the tablets you have been given, even if you feel better.• You need to tell everyone you have had sex with in the last 3 months to get a sexual health check and treatment for

trichomoniasis.• You should avoid sex for 1 week from the start of your treatment and until 1 week after your sexual contact/s have been treated.



Important information• Trichomoniasis is an STI that is easy to

treat.• It is more common for females to

show symptoms than males.• However, males can still pass it on.• Women can get tested with a swab

from the vagina.• Men are usually just treated, but

should have a sexual health check.• You need to tell anyone you have had

sex with in the last 3 months to get a sexual health check and treatment for trichomoniasis.


Trichomoniasis PATIENT INFORMATION

To download or print the patient information leaflet on trichomoniasis, go to www.nzshs.org/guidelines


30

Urethritis in Males MANAGEMENT SUMMARY

Examination findings:• Profuse purulent penile discharge?

• If clinical epididymo-orchitis, see Epididymo-orchitis guideline www.nzshs.org/guidelines• Refer to full guideline at www.nzshs.org/guidelines for drug allergies, suspected anti-microbial resistance, known contact with Mycoplasma

genitalium or chlamydia and gonorrhoea co-infection• Advise to abstain from sex or use condoms for 1 week from the start of treatment and until 1 week after sexual contact/s have been treated• Reinfection is common; offer repeat sexual health check in 3 months

Recommended tests• Full sexual health check including serology (see Sexual Health Check guideline www.nzshs.org/guidelines)• Urethral culture swab for gonorrhoea (if gonorrhoea culture available) prior to urine test if discharge is present• First void urine for chlamydia & gonorrhoea NAAT testing (first 30ml), preferably ≥1 hour after last void

Patient complains of penile urethral discharge, discomfort, irritation or dysuria (without urge/frequency)

YESPresumptive gonorrhoeaOR if contact of gonorrhoea, treat with:• Ceftriaxone 500mg stat im (make up with 2ml lignocaine

1% or as per data sheet) AND azithromycin 1g po stat

NOTreat for non-gonococcal urethritis with:• Doxycycline 100mg po twice daily for 7 days

(recommended)* OR• Azithromycin 1g po stat (alternative)* Doxycycline is recommended because it has superior efficacy for symptomatic male urethritis and confirmed chlamydial urethritis, and azithromycin 1g is associated with resistance development in Mycoplasma genitalium. Azithromycin can be used as an alternative if compliance is a concern or doxycycline is contraindicated.

PARTNER NOTIFICATION AND MANAGEMENT OF SEXUAL CONTACTS• Be clear about language: ‘partner’ implies relationship – all sexual contacts in the last 3 months should be notified• Contact/s should have a sexual health check and treatment with doxycycline 100mg bd po 7 days or azithromycin 1g po stat, without waiting for

test results• If contacts test positive for an STI refer to specific guideline at www.nzshs.org/guidelines• Advise contacts to abstain from sex or use condoms for 1 week from the start of treatment and until results of tests are available• Most choose to tell contacts themselves; giving written information is helpful• Notifying all contacts may not be possible, e.g. if there is insufficient information or a threat of violence• Advise to use condoms or abstain from sex for 7 days after initiation of treatment and until results of tests are availableFOLLOW-UP• By phone or in person 1 week later • Check results. If gonorrhoea positive and untreated – treat with Ceftriaxone 500mg stat im (make up with 2ml lignocaine 1% or as per

data sheet) AND azithromycin 1g po stat• No unprotected sex for 1 week post-treatment? • Completed/tolerated medication?• All notifiable contacts informed?• Any risk of re-infection? Re-treatment necessary if re-exposed to untreated contact• Offer a repeat sexual health check in 3 months• If ≥2 weeks after treatment the patient complains of persistent or recurrent urethral symptoms discuss or refer to a sexual health specialist for

Mycoplasma genitalium testing







31

What is urethritis?Urethritis means an inflammation of a male’s urethra (the pee tube). It is often called NSU or NGU. It is usually due to a sexually transmitted infection (STI) such as chlamydia or gonorrhoea.

How does someone get urethritis?Urethritis can be caught by having vaginal, anal or oral sex without a condom, or sex play.

If you use a condom every time you have sex you are much less likely to get urethritis.

How do I know if I have urethritis?Symptoms can include:• Discharge leaking from the urethra.• Pain or discomfort when urinating.• Itching in the urethra.

How do I get tested?You need to see your doctor, nurse or sexual health clinic for a check-up. If you want, take along someone you trust, for suppport.

You will need to do a urine test, and you may need a swab test from the urethra. Throat and anal swabs might be required if you have sex with males. You may be able to do the swabs yourself.

It may be embarrassing, but it is better to get checked than to have untreated urethritis.

How do I get treated?Urethritis is usually treated with tablets. Sometimes you may need an injection.

Important advice• Finish all the tablets you have been given, even if you feel better.• You need to tell anyone you have had sex with in the last 3 months to get a sexual health check and treatment as a contact of

urethritis even if their tests are normal. • You should avoid sex for 1 week from the start of your treatment and until 1 week after all your sexual contact/s have been

treated. If this is not possible, always use a condom, including for oral sex, until your treatment and your sexual contact/s treatment has been completed.


Important information• Urethritis is an inflammation of the

urethra (the pee tube).• It is usually due to a sexually

transmitted infection (STI) such as chlamydia or gonorrhoea.

• Symptoms can include discharge, pain when urinating, or itching.

• It is treated with antibiotics.• You need to tell anyone you have had

sex with in the last 3 months to get a sexual health check and treatment as a contact of urethritis.


Urethritis in Males PATIENT INFORMATION

To download or print the patient information leaflet on urethritis in men, go to www.nzshs.org/guidelines


32

Vaginal Discharge MANAGEMENT SUMMARY

Patie

nt c

ompl

ains

of

vag

inal

dis

char

ge

+/-

itch

ing

/ s

ore

nes

s /

mal

od

ou

r.N

ote

: Als

o as

k ab

out

abn

orm

al b

leed

ing

/ p

elvi

c d

isco

mfo

rt /

dys

par

eun

ia. C

onsi

der

poss

ibili

ty o

f re

tain

ed t

amp

on

s /

fore

ign

bo

dy.

Follo

w-u

p•

Che

ck re

sults

and

reso

lutio

n of

sym

ptom

s.•

If po

sitiv

e re

sults

for

chl

amyd

ia, g

onor

rhoe

a or

tric

hom

onia

sis

– en

sure

app

ropr

iate

tre

atm

ent

and

part

ner

notif

icat

ion.

• If

neg

ativ

e re

sult

s an

d s

ymp

tom

s p

ersi

st –

co

nsu

lt w

ith

a s

exu

al h

ealt

h s

pec

ialis

t.

Vagi

nal d

isch

arge

can

aris

e fr

om e

ither

the

vag

ina

and/

or t

he c

ervi

x. It

is t

here

fore

impo

rtan

t to

vis

ual

ise

the

cerv

ix.

See

Sexu

al H

ealth

Che

ck g

uide

line

ww

w.n

zsh

s.o

rg/g

uid

elin

es.

Exam

inat

ion

fin

din

gs

• C

ervi

citis

– m

ucop

urul

ent

disc

harg

e on

cer

vix

or e

asily

indu

ced

blee

ding

.•

Bim

anua

l if

c/o

pelv

ic p

ain

(see

PID

gui

delin

e w

ww

.nzs

hs.

org

/gu

idel

ines

).•

Abn

orm

al c

ervi

x: R

efer

for

col

posc

opy.

Trea

tmen

t•

Pres

umpt

ive

chla

myd

ia +

/- g

on

orr

ho

ea.

• A

zith

rom

ycin

1g

stat

plu

s sp

ecifi

c tr

eatm

ent

for

gono

rrho

ea if

a c

onta

ct o

f go

norr

hoea

(s

ee G

onor

rhoe

a gu

idel

ine

ww

w.n

zsh

s.o

rg/

gu

idel

ines

).

Exam

inat

ion

fin

din

gs

• Vu

lviti

s/va

gini

tis.

• Th

ick

whi

te c

urd-

like

vagi

nal

disc

harg

e.

Trea

tmen

t•

Pres

umpt

ive

can

did

iasi

s.•

Topi

cal o

r or

al a

ntifu

ngal

su

ch a

s cl

otrim

azol

e or

flu

cona

zole

.

Exam

inat

ion

fin

din

gs

• O

ffen

sive

pur

ulen

t fr

othy

va

gina

l dis

char

ge +

/–

• Vu

lviti

s/va

gini

tis.

Trea

tmen

t•

Pres

umpt

ive

tric

ho

mo

nia

sis.

• M

etro

nida

zole

2g

po s

tat

or

met

roni

dazo

le 4

00m

g po

tw

ice

daily

for

7 d

ays

Exam

inat

ion

fin

din

gs

• N

O v

agin

itis

or v

ulvi

tis.

• Fi

shy

smel

ling

whi

te/g

rey

adhe

rent

vag

inal

dis

char

ge.

Trea

tmen

t•

Pres

umpt

ive

bac

teri

al

vag

ino

sis.

• M

etro

nida

zole

400

mg

twic

e da

ily f

or 7

day

s.

Rec

om

men

ded

tes

ts•

Vulv

ovag

inal

NA

AT

swab

for

chl

amyd

ia &

gon

orrh

oea

test

ing

prio

r to

spe

culu

m in

sert

ion.

• In

sert

spe

culu

m, e

xam

ine

vagi

na a

nd c

ervi

x.•

Endo

cerv

ical

cul

ture

sw

ab f

or g

onor

rhoe

a (if

gon

orrh

oea

cultu

re a

vaila

ble)

.•

Hig

h va

gina

l cul

ture

sw

abs

for

cand

ida

& B

V &

tric

hom

onia

sis

(if N

AA

T fo

r tr

icho

mon

iasi

s no

t av

aila

ble)

.•

Add

ition

al a

nore

ctal

NA

AT

swab

for

chl

amyd

ia &

gon

orrh

oea

test

ing

as in

dica

ted

base

d on

sex

ual h

isto

ry.







Members of the Joint Sexually Transmitted Infections Education Foundation and New Zealand Sexual Health Society Professional Advisory Board 2017

Sexual Health PhysiciansDr Min Lo (Editor in Chief, HPV Guidelines)

Dr Edward Coughlan

Dr Jeannie Oliphant

Dr Heather Young

Infectious Disease and Sexual Health PhysicianDr Massimo Giola

NZ Dermatological SocietyDr Darion Rowan

NZ Committee of the Royal Australian and New Zealand College of Obstetrics and GynaecologyDr Anne Robertson

Paediatric Society of New ZealandDr Lesley Voss

NZ College of General PractitionersDr Phil Jacobs

Dr Andrew Miller

NZ Society of Otolaryngology, Head and Neck SurgeryDr Julian White

Family PlanningDr Christine Roke

Immunisation Advisory Centre (IMAC)Dr Helen Petousis-Harris

Clinical MicrobiologistDr Arlo Upton

Infectious Disease PharmacistEamon Duffy

CounsellingClaire Hurst (Nurse Counsellor)

NursingGeorgina McPherson (NZ HPV Project)

MidwifeKaren Upton

Patient AdvocatePeter

Project Manager Hayley Samuel, PO Box 2437, Shortland Street, Auckland 1140

Tel: 09 433 6526 Email: [email protected]

New Zealand Sexual Health Society Guidelines Committee

Sexual Health PhysiciansDr Heather Young (Chair)

Dr Susan Bray

Dr Aideen Collins

Dr Rose Forster

Dr Massimo Giola

Dr Teena Mathew

Dr Jeannie Oliphant

Dr Anne Robertson

Dr Julia Scott

Project Co-ordinatorHayley Samuel


Supported by an educational grant from New Zealand District Health Boards

© 2017 Sexually Transmitted Infections Education Foundation


The New Zealand Sexual Health Society

www.nzshs.org

Sexually Transmitted Infections Education Foundation

Secretariat:PO Box 2437, Shortland Street, Auckland 1140, New Zealand

Phone: 09 433 6526Email: [email protected]

To order more copies of this publication, email [email protected]

[email protected] [email protected] [email protected] www.justthefacts.co.nz www.herpes.org.nz www.hpv.org.nz




mailto:info%40justthefacts.co.nz?subject=

mailto:info%40herpes.org.nz?subject=

mailto:info%40hpv.org.nz?subject=

http://www.justthefacts.co.nz



FSRH Guideline

Contraception After Pregnancy

January 2017 | FSRH

32

Copyright ©Faculty of Sexual & Reproductive Healthcare 2017

3. Contraception After Abortion 3.1 Discussion and provision of contraception after abortion The clinical guideline and the recommendations in this section focus on the discussion and provision of contraception to women who have recently had an abortion and complements the RCOG clinical guideline on The Care of Women Requesting Induced Abortion,13 which considers the care of women from the point of requesting induced abortion. 3.1.1 When should contraception after abortion be discussed/provided?

D Abortion service providers should give women requesting abortion opportunities to discuss contraception.

Whenever contraceptive counselling is provided, care should be taken to ensure women do not feel under pressure to choose a method of contraception.

The abortion assessment visit (when women attend to request an abortion) is an excellent opportunity for clinicians to discuss a woman’s future fertility intentions and

use of effective contraception after abortion.13 It is important that women are provided with information and counselling to help them make informed choices on suitable contraceptive methods after abortion.

Evidence level 4

However, two systematic reviews and meta-analyses23,124 showed that pre-abortion specialist contraceptive counselling alone did not influence effective contraceptive uptake or subsequent abortion.

Evidence level 1+

Studies from the UK125,126 reported that women value the opportunity to discuss contraception and to be offered their chosen method. One qualitative UK study126 reported that more than half of the 46 women interviewed wanted or were happy to address contraceptive needs at the pre-abortion assessment visit and suggested that it was an ‘obvious’ time to do so. However whenever contraceptive counselling is

provided, care should be taken to ensure women do not feel under pressure to choose a method of contraception.

Evidence level 3

After contraceptive discussion and counselling women need to be encouraged to make an informed choice and to reach a decision about their chosen method so that this can be initiated or planned for without delay.

Women should be informed about the effectiveness of the different contraceptive methods, including the superior effectiveness of long-acting reversible contraception (LARC), when choosing an appropriate method to use after abortion.

See Section 1.4.3

33


Click here to access a table that compares the percentage of women experiencing an unintended pregnancy during the first year of contraceptive use when the method is used ‘typically’ (which

includes both incorrect and inconsistent use) or ‘perfectly’ (correct and consistent use).

C Choice of contraception should be initiated at the time of abortion or soon after, as sexual activity and ovulation can resume very soon after abortion.

Women having an abortion should be provided with effective methods of contraception at the time of abortion or soon after since ovulation can resume very soon after abortion. Ovulation has been shown to occur within 1 month of first-trimester abortions in over 90% of women127–130 and has been reported to occur as early as 8 days after early medical abortion (EMA).131 Moreover, more than 50% of women have been reported to resume sexual activity within 2 weeks after abortion.132 If the immediate initiation of a woman’s chosen method is not appropriate or not preferred then a temporary (bridging) method should be offered until she can initiate her chosen method of contraception.

Evidence level 2+

Evidence from randomised controlled trials (RCTs) has shown that immediate initiation of contraception is associated with higher continuation rates and reduced risk of another unintended pregnancy (see Section 3.1.2).

Evidence level 1+

D Clinicians should adopt a person-centred approach when providing women with contraceptive counselling.

Clinicians who are giving advice to women about contraception after abortion should ensure that this information is timely, up-to-date and accurate.

D Comprehensive, unbiased and accurate information on contraceptive methods after abortion should be made available in different languages and in a range of formats including audio-visual.

See Section 1.4.4 Audio-visual formats can be useful in providing high-quality information about contraception in a non-judgemental way as part of routine care to women attending abortion services. Studies133,134 conducted in the UK have demonstrated that patient information provided via a digital video disk (DVD) was highly acceptable and informative to women attending abortion services.

Evidence level 2-

3.1.2 When can contraception be initiated after abortion?

B A woman’s chosen method of contraception should be initiated immediately after

abortion (medical and surgical).

34


B

Clinicians should be aware that insertion of intrauterine contraception (IUC) at the time of abortion is convenient and highly acceptable to women. This has been associated with high continuation rates and a reduced risk for another unintended pregnancy than when provision of IUC is delayed.

B

Clinicians should be aware that insertion of progestogen-only implants (IMP) at the time of abortion is convenient and highly acceptable to women. This has been associated with high continuation rates and a reduced risk for another unintended pregnancy than when provision of IMP is delayed.

See Section 3.2 Provision of highly effective contraceptive methods at the time of abortion has distinct advantages as (1) the woman is known not to be pregnant, (2) her motivation to use effective contraception may be high and (3) she is already accessing healthcare services. This is particularly relevant for methods such as the progestogen-only implant (IMP) and intrauterine contraception (IUC), which require the availability of a skilled clinician for insertion of the method. The provision of long-acting reversible contraception (LARC) at the same time as abortion is both convenient and highly acceptable to women who wish to initiate LARC methods, avoiding the need for an extra visit which has been identified as a barrier to the uptake of LARC after abortion.43,135 Studies have reported that up to 50% of women scheduled for IUC insertions 2–3 weeks after surgical or medical abortion did not return for their appointment.136–138

Evidence level 3

A Cochrane review139 showed that women were more likely to be ongoing IUC users at 6 months after surgical abortion if they had the device inserted immediately rather than given an appointment for insertion several weeks later. In addition, a RCT of immediate versus delayed insertion of IMP at medical abortion (1 hour after mifepristone administration) or 2–4 weeks later showed higher preference for immediate insertion, higher continuation rates of the IMP and fewer unintended pregnancies and abortion in the subsequent 6 months in the group randomised to immediate IMP.140

Evidence level 1+

3.1.3 Who should provide contraception to women after abortion?

Abortion service providers should be able to offer all methods of contraception, including LARC, to women before they are discharged from the service after abortion.

Abortion services should ensure that there are sufficient numbers of staff able to provide IUC or IMP so that women who choose these methods and are medically eligible can initiate them immediately after abortion.

35


Women who are unable to be provided with their chosen method of contraception should be informed about services where their chosen method can be accessed. A temporary (bridging) method should be offered until the chosen method can be initiated.

See Section 1.4.5

Abortion services should have agreed pathways of care to local specialist contraceptive services [e.g. community sexual and reproductive health (SRH) services] for women with complex medical conditions or needs which may require specialist contraceptive advice.

There should be agreed pathways of care to local services for women who may require additional non-medical care and support.

See Section 1.4.8 3.1.4 Which contraceptive methods are most effective in preventing another abortion?

A

Clinicians should be aware that women who choose to commence LARC immediately after abortion have a significantly reduced likelihood of undergoing another abortion within 2 years, compared with women provided with medium-acting, short-acting or no contraceptive methods.

The risk of a woman presenting for another abortion is strongly associated with the type of contraceptive method she uses after abortion. RCTs and observational studies138,141–148 from a number of countries have reported that women provided with LARC immediately after abortion have a significantly reduced likelihood of another abortion within the subsequent 2 years compared with women provided with medium-acting, short-acting or no methods. IUC is highly effective in preventing another abortion. In one RCT,141 751 women seeking first-trimester induced abortions were randomised into two groups. The intervention group (n=375) was provided with either the copper intrauterine device (Cu-IUD) or the levonorgestrel-releasing intrauterine system (LNG-IUS) immediately after surgical abortion (18.1%) or 2–4 weeks after medical abortion (81.9%). Women in the control group were prescribed oral contraceptives and advised to contact their primary healthcare unit for a follow-up visit and further contraceptive services according to national guidelines. At 1 year, the number of women requesting subsequent abortion was significantly lower in the intervention group than in the control group (5.4% vs 24%, p=0.038).

Evidence level 1++

36


Observational studies have also found that the risk of having another abortion was statistically lower in women who used IUC after abortion compared to those who used oral contraceptives (OC). An odds ratio (OR) of 0.05 (95% confidence interval (CI) 0.01–0.41) was reported in one study138 and an OR of 0.36 (95% CI 0.17–0.77) was reported in another study.147 In one study146 where women using IUC were compared to women using all other methods, the hazard ratio (HR) was 0.37 (95% CI 0.26–0.52). Compared to women using short-acting methods of contraception, the HR of subsequent abortion for women using the Cu-IUD and LNG-IUS were found to be 0.46 (95% CI 0.36–0.58) and 0.26 (95% CI 0.16–0.44), respectively. Observational studies138,145,148 have reported that women who choose to use IMP after abortion have also been shown to have a reduced likelihood of subsequent abortion. One UK study138 found that compared to women who used OC, the OR of women who used IMP after abortion having another abortion within 2 years was 0.06 (95% CI 0.02–0.23). Observational studies138,142,147 have yielded inconsistent findings regarding the initiation of depot medroxyprogesterone acetate (DMPA) immediately after abortion and the risk of subsequent abortion. For example, one observational study in the UK138 reported that compared to women using OC, women who used DMPA had a non-significant reduction in the likelihood of having another abortion within 2 years (OR 0.5, 95% CI 0.2–1.2). This may be because DMPA is a medium-acting method and requires greater user compliance for efficacy.

Evidence level 2++

3.1.5 Record keeping and obtaining valid consent

D Clinicians should clearly document the discussion and provision of contraception. Valid consent must be obtained before providing women with their chosen method.

See Section 1.4.7 3.2 Medical eligibility 3.2.1 Which methods of contraception are safe to use after abortion?

D Women should be advised that any method of contraception can be safely initiated immediately after an uncomplicated abortion.

D IUC should not be inserted in the presence of postabortion sepsis.

According to the evidence-based 2016 UK Medical Eligibility Criteria (UKMEC),18 all methods of contraception are safe to use by women who have had an uncomplicated abortion (see Table 6). IUC should not be inserted in the presence of postabortion sepsis. When supporting a woman to choose an effective and acceptable method of contraception after an abortion, consideration must be given to the woman’s personal

characteristics and other existing medical conditions.

Evidence level 4

37


Table 6: UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) categories applicable to a woman after an abortion13

Post-abortion Cu-IUD LNG-IUS IMP DMPA POP CHC

a) First trimester 1 1 1 1 1 1 b) Second trimester 2 2 1 1 1 1 c) Postabortion sepsis 4 4 1 1 1 1 CHC, combined hormonal contraception; Cu-IUD, copper intrauterine device; DMPA, depot medroxyprogesterone acetate (progestogen-only injectable); IMP, progestogen-only implant; LNG-IUS, levonorgestrel-releasing intrauterine system; POP, progestogen-only pill.

Definition of the UKMEC categories can be found here.

The RCOG guideline on The Care of Women Requesting Induced Abortion13

recommends that any chosen method of contraception may be initiated immediately after uncomplicated abortion. The World Health Organization guideline on Safe

Abortion: Technical and Policy Guidance for Health Systems149 states that for medical abortion, hormonal contraception can be started by the woman after taking the first pill of a medical abortion regimen, but confirmation that the abortion is complete should precede insertion of an IUC or sterilisation.

Evidence level 4

3.2.2 Is emergency contraception (EC) safe to use after abortion?

Emergency contraception (EC) is indicated for women who have had unprotected sexual intercourse (UPSI) from 5 days after abortion.

Women should be advised that any method of EC can be safely used after an uncomplicated abortion.

The guideline development group (GDG) recommends that emergency contraception (EC) is indicated for women who have had unprotected sexual intercourse (UPSI) from 5 days after abortion. All methods of EC including oral levonorgestrel emergency contraception (LNG-EC) 1.5 mg and ulipristal acetate emergency contraception (UPA-EC) 30 mg and the copper intrautreince device (Cu-IUD) can be safely used by women after an abortion.18 A Cu-IUD is the most effective form of EC. The pregnancy rate after Cu-IUD for EC is about 1 in 1000.59 The use of Cu-IUD for EC carries the same contraindications as use for regular contraception.18 3.2.3 Is additional contraception required after initiation of a method after abortion?

Women should be advised that additional contraceptive precautions (e.g. barrier methods/abstinence) are required if hormonal contraception is started 5 days or more after abortion. Additional contraceptive precaution is not required if contraception is initiated immediately or within 5 days of abortion.

38


Table 7: Requirements for abstinence or additional contraceptive precautions when a method of contraception (which the woman is medically eligible to use) is initiated after abortion

Methods of contraception the woman is medically eligible to use

Initiation <5 days after abortion

Initiation ≥5 day

after abortion Number of days of additional contraceptive

precautions required (days) Copper intrauterine device

None

None Levonorgestrel-releasing intrauterine system 7 Progestogen-only pill (traditional/desogestrel) 2 Progestogen-only implant or injectable 7 Combined hormonal contraception 7* *Except Qlaira® which requires 9 days of additional contraceptive precautions.

The GDG recommends that no additional contraception is necessary if contraception (for which the woman is medically eligible) is initiated immediately or within 5 days of abortion. However, if hormonal contraception is started 5 days or more after abortion, a woman is at risk of another pregnancy and thus additional contraceptive precautions (e.g. barrier methods/abstinence) are required (see Table 7). 3.3 Method-specific considerations 3.3.1 Intrauterine contraception (IUC)

A IUC can be safely used by women after an uncomplicated abortion. Women may be advised that they may benefit from reduced uterine bleeding when using levonorgestrel-releasing intrauterine system (LNG-IUS).

There is little evidence on the insertion of IUC on the same day as medical abortion (expulsion of pregnancy). Available evidence for same-day insertion relates to reports within observational studies.137 Most evidence for IUC insertion following medical abortion relates to insertion after several days have elapsed from expulsion.139,150 There is evidence from a Cochrane review139 and a systematic review151 that the insertion of IUC immediately after uncomplicated surgical abortion is safe and practical. A meta-analysis of three RCTs reported in a Cochrane review139 of 12 studies found that expulsion by 6 months was more likely in the group assigned to immediate insertion than in the group assigned to delayed insertion (RR 2.64, 95% CI 1.16–6.00) after surgical abortion. Ongoing use at 6 months was greater in the immediate insertion group compared to the delayed insertion group (RR 1.40, 95% CI 1.24–1.58). The analysis also showed a three-fold increase in risk of pregnancy in the delayed group compared with the immediate insertion group, although this was not statistically significant (RR 2.70, 95% CI 0.8–8.33). Risk of infection of the upper genital tract was similar for the two groups (OR 1, 95% CI 0.33–3.07).

Evidence level 1++

39


Similarly, a systematic review of 19 studies151 reported that IUC insertion immediately after surgical abortion is not associated with an increased risk of adverse outcomes compared with use of other contraceptive methods or with no IUC insertion after abortion. It also found no increased risk of adverse outcomes compared with IUC insertion at times other than immediately after abortion. IUC expulsion rates, while generally low, were higher in insertions performed after late first-trimester surgical abortions compared with those done after early first-trimester surgical abortions. Expulsion rates were also higher with IUC insertions performed after second-trimester surgical abortions compared with first-trimester surgical abortions. More recent RCTs not included in either systematic review reached the similar conclusion that immediate insertion of an IUC after abortion is safe.150,152,153

Evidence level 2++

There is some evidence that women who choose an LNG-IUS after surgical or medical abortion benefit from reduced menstrual blood loss.150,153 An RCT153 which compared bleeding patterns of women who had Cu-IUD or LNG-IUS inserted immediately after surgical abortion found that LNG-IUS users experienced a higher incidence of amenorrhoea and an increased number of spotting days throughout the follow-up period. At 6 months, 35/37 (94.5%) women who used Cu-IUD reported normal bleeding patterns and the other two women had heavy bleeding. Of 34 women who used LNG-IUS, 19 (55.9%) reported a normal bleeding pattern, four (11.7%) reported amenorrhoea, five (14.7%) reported spotting and five (14.7%) reported heavy bleeding. The other RCT150 which compared women randomised to early (5–9 days after mifepristone) or delayed (3–4 weeks after mifepristone) insertion of IUC reported no difference with regard to bleeding patterns between the two groups. The amount of postabortion bleeding was reduced in women with insertion of LNG-IUS compared to women with Cu-IUD.

Evidence level 1+

D With medical abortion, IUC can be inserted any time after expulsion of the pregnancy.

A With surgical abortion IUC, can be inserted immediately after evacuation of the uterine cavity.

Given that many women having EMA (less than 9 weeks’ gestation) go home to pass the

pregnancy, there is little published evidence on insertion of IUC on the same day of expulsion with medical abortion. There is also a lack of evidence on insertion of IUC after mid-trimester abortion. Given the demonstration that insertion of IUC within 1 week of mifepristone is as safe as delayed insertion (2–3 weeks later) and the safety of insertion of IUC in the immediate postpartum period, the GDG recommends that IUC can be safely inserted after medical abortion immediately after expulsion of the pregnancy.

40


If women choose to delay the insertion of IUC, the return visit for insertion should be scheduled as soon as possible since women are more likely to attend and less likely to have resumed intercourse, according to one RCT.150 There is no difference in complication rates between insertion conducted within 1 week of taking mifepristone or conducted 2–3 weeks later.150

Evidence level 1+

For women having EMA for whom successful abortion has not been confirmed (e.g. who go home to pass the pregnancy), exclusion of ongoing pregnancy is necessary before insertion of IUC. Whilst an ultrasound will reliably exclude ongoing pregnancy, the presence of ultrasonically visible but clinically unimportant clot/tissue can lead to unnecessary intervention. Clinicians should only make a decision to evacuate the uterus on clinical signs and symptoms of incomplete abortion. Alternative methods of excluding an ongoing pregnancy after medical abortion (up to 63 days) include use of a low-sensitivity urine pregnancy test [detection limit 1000 international units (IU) human chorionic gonadotrophin (hCG)] conducted at 2 weeks after misoprostol administration.154–157 The use of a high-sensitivity urinary pregnancy test (HSUP) (typically 10–25 IU hCG) after EMA to exclude ongoing pregnancy is limited, due to false-positive results from the residual low circulating levels of hCG in the weeks after EMA. If a HSUP is used at 1 month after EMA then approximately one-quarter of women will have a positive result.158 Multilevel urinary pregnancy tests that have a range of sensitivities for hCG have shown promise for excluding ongoing pregnancy from as early as Day 3 after medical abortion, but are not yet available for this purpose in the UK.159 Thus, for exclusion of ongoing pregnancy prior to 2 weeks after EMA, ultrasound examination is required.

Evidence level 1+

3.3.2 Progestogen-only contraception

B Progestogen-only contraception can be safely started at any time, including immediately, after medical or surgical abortion.

The UKMEC18 recommends that progestogen-only contraception can be safely started at any time after surgical or medical abortion. Observational studies160,161 suggest that women who have immediate insertion of IMP after abortion report insertion at this time to be highly acceptable. Women who have immediate insertion also have higher continuation rates after 1 year compared with women who have delayed placement of IMP.92,162–164

Evidence level 2+

B Women should be advised that IMP can be safely initiated at the time of mifepristone administration.

41


Progestogen-only contraception can be safely initiated at the time of administration of mifepristone. There has been a concern that commencing progestogen-only contraception at the same time as mifepristone (a progesterone receptor modulator) might reduce the efficacy of medical abortion due to competition at the progesterone receptor. One RCT165 from Mexico and the USA, which included 476 women undergoing EMA (9 weeks) randomised into receiving IMP either with mifepristone (Quickstart group, n=236) or after the abortion was complete (Afterstart group, n=240), showed no differences in success of the medical abortion. The study found that 3.9% and 3.8% of women in the Quickstart and Afterstart groups, respectively, had surgery to complete the abortion. The median days of bleeding was slightly but significantly higher in the Quickstart group than in the Afterstart group (12 vs 10, p=0.03). The incidence of heavy bleeding was nearly identical in both groups. The study also found that quick starting IMP enhanced patient satisfaction but found no evidence that it decreased unintended pregnancies 6 months later. A further randomised-controlled, equivalence trial140 from Sweden and the UK

included 538 women undergoing EMA (9 weeks) randomised to insertion of IMP 1 hour after mifepristone (immediate group, n=277) or at a follow-up 2–3 weeks later (delayed group, n=261). There was no significant difference in the efficacy of medical abortion in the immediate insertion group and the delayed insertion groups (94.2% vs 96.0%). However, a significantly (p<0.001) higher proportion of women in the immediate group received the IMP (98.9% insertion) compared to the delayed group (71.6% insertion). In addition, the study reported significantly fewer unintended pregnancies at 6 months in the immediate group compared to the delayed group (0.8% vs 3.8%, p=0·018). The study findings (which may be more relevant to the UK setting) suggest that IMP inserted on the day of mifepristone is safe, preferred by women, does not affect efficacy of medical abortion, but is associated with higher uptake and fewer subsequent unintended pregnancies than insertion several weeks later.

Evidence level 1+

B Women should be advised that there may be a slightly higher risk of continuing pregnancy (failed abortion) if DMPA is initiated at the time of mifepristone administration.

There is currently limited evidence on a possible impact of immediate initiation of DMPA on EMA. A recent RCT166 from Mexico and the USA, which included 461 women undergoing medical abortion (up to 75 days’ gestation) using a regimen of 200 mg mifepristone followed by 800 g misoprostol administered buccally 24–48 hours later at home. Women were randomised into receiving DMPA [150 mg intramuscular (IM)] either at the time of mifepristone administration (Quickstart group, n=220) or after the abortion (Afterstart group, n=226). The study showed no difference in need for surgical intervention between the groups. However, the study found that ongoing pregnancy rates were higher in the Quickstart group (8/220, 3.9%) compared to the Afterstart group (2/226, 0.9%). The difference was 2.7% (95% CI 0.4–5.6). The paper did not report the gestational age at treatment of those failures.

Evidence level 1+

42


The study also found that quick starting DMPA enhanced patient satisfaction and resulted in more women using the method in the short term (at 1 month) but no difference in use at 6 months. The study was designed and powered to examine needs for surgical intervention rather than ongoing pregnancy (which is less common). In addition, it is unknown whether similar findings would be observed with use of the subcutaneous SC

formulation (Sayana Press) at mifepristone since Sayana Press is a lower-dose (104 mg) preparation than the IM preparation (150 mg). Nevertheless, the GDG recommends that women should be advised that administration of DMPA (IM or SC) at the same time as mifepristone may be associated with a small increase in the risk of failure of EMA. Women who wish to start DMPA at time of mifepristone should be advised of the importance of confirming success of the procedure according to local clinic protocols. Women should be reminded that scant or absent bleeding may be due to failed medical abortion rather than hormonal method used. Under such circumstances, urgent medical review should be sought. There is no evidence of an adverse effect of mifepristone on the efficacy of ongoing contraception. Two RCTs167,168 that have examined the impact of the progesterone receptor modulator ulipristal acetate (UPA) which is licensed for EC, have shown no effect on contraceptive action (number of days of pill-taking required to induce ovarian quiescence or hostile cervical mucus) of either a desogestrel-containing progestogen–only pill (POP) or combined oral contraceptive (COC) pill when commenced the day following administration of UPA.

Evidence level 1+

Women should be advised that scant or absent bleeding should not be attributed to a hormonal method of contraception that has been initiated, but that it may be due to failed medical abortion. Under such circumstances, urgent medical review should be sought.

Given the association between progestogen-only contraceptive methods and amenorrhoea, there is concern that women with a failed EMA (ongoing pregnancy) might wrongly attribute the lack of bleeding post-procedure to the fact they are using progestogen-only contraception. Women who commence progestogen-only contraception at the time of EMA should be clearly instructed on the signs/symptoms of an ongoing pregnancy, which should prompt the need for medical review even before any scheduled follow-up or urine pregnancy testing. The symptoms and signs of an ongoing pregnancy after an abortion include:

Absent or scant bleeding Persisting symptoms of pregnancy such as nausea, breast tenderness, abdominal swelling Missed menstrual periods.

43


3.3.3 Combined hormonal contraception (CHC)

B Combined hormonal contraception (CHC) can be safely started immediately at any time after abortion.

A systematic review169 which included three RCTs and four cohort studies reported that the use of COC immediately after completion of surgical or medical abortion is safe. Two RCTs170,171 have shown that immediate use of COC does not affect the success rate of the abortion procedure. Limited evidence from RCT and observational studies suggests that the combined transvaginal ring (CVR)172 and the combined transdermal patch (patch)173,174 are also safe to commence immediately after abortion. The systematic review169 also reported that immediate COC use after first-trimester medical170,171,175 or surgical abortion176–178 did not increase side effects or prolong vaginal bleeding compared with use of a placebo, Cu-IUD, non-hormonal contraceptive method or delayed COC use. Initiating COC after first-trimester surgical abortion is associated with a small, statistically significant increase in coagulation parameters compared with intrauterine device (IUD) use;176 however, this is unlikely to be of clinical relevance.169

Evidence level 1+

3.3.4 Female sterilisation

D Female sterilisation is a safe option for permanent contraception after abortion.

Women should be advised that some LARC methods are as, or more, effective than female sterilisation and may confer non-contraceptive benefits. However, women should not feel pressured into choosing LARC over female sterilisation.

B

Tubal occlusion should ideally be performed after some time has elapsed after abortion. Women who request tubal occlusion to be performed at the time of abortion should be advised of the possible increased failure rate and risk of regret.

Few medical conditions would absolutely restrict an individual’s eligibility for female

sterilisation. Specific precautions may apply in certain circumstances as highlighted in the FSRH Clinical Guideline on Male and Female Sterilisation110 and the WHO Medical Eligibility Criteria (WHOMEC).107

Evidence level 4

All methods of contraception, including vasectomy (if appropriate), should be discussed with women requesting female sterilisation. Women should be made aware that some methods are as, or more, effective than female sterilisation and may confer non-contraceptive benefits such as reducing uterine bleeding with LNG-IUS use. However, it is important that women do not feel pressured into choosing LARC over female sterilisation.

44


Tubal occlusion

The available evidence regarding risks of complication and failure associated with abortion at the time of sterilisation is conflicting. The FSRH/RCOG guideline110 notes that although the addition of sterilisation to a procedure for abortion does not seem to increase the complication rate already associated with abortion,179 it has been argued that the complication rate associated with a combined procedure is higher than that associated with interval sterilisation.180 Studies181–185 comparing abortion combined with laparoscopic sterilisation versus laparoscopic sterilisation alone found no significant differences in the complication rate between the two procedures. Given that concurrent surgical abortion and laparoscopic tubal ligation are typically performed under general anaesthesia, it had been suggested that anaesthesia-related risk can be minimised by performing the two procedures together. An early casenote review study186 that compared failure rates of laparoscopic sterilisation with non-laparoscopic methods found that the pregnancy rate was double if sterilisation was combined with abortion. However a large case-control study187 failed to find any association between timing of the procedure and failure rate. The follow-up time was short and there were fewer suitable controls for the postabortion cases. Some studies reported no difference in regret rates188–191 between women who underwent laparoscopic sterilisation at the same time as abortion (predominately first-trimester) and those who underwent interval sterilisation. Conversely, other studies192,193 have reported an increased rate of regret when sterilisation was performed at the same time as the abortion.

Evidence level 2+

One RCT181 in which women were randomised to either undergo a combined abortion with laparoscopic sterilisation or an abortion with sterilisation as an interval procedure at least 6 weeks later reported that 32.8% of women did not return for their interval sterilisation. It is important to note that non-attendance does not necessarily indicate regret, but does suggest that some women may have changed their minds when they were able to reconsider their decision outside the stressful circumstances of an unintended pregnancy. This further emphasises the need for careful counselling when sterilisation is requested in association with pregnancy.

Evidence level 1+

Transcervical approaches There are no studies evaluating concurrent abortion and hysteroscopic tubal occlusion. The Essure® micro-insert manufacturer instructions for use194 list both childbirth and abortion of a second-trimester pregnancy within the previous 6 weeks as contraindications for insertion. A recent narrative review on contraception after abortion noted that the procedure could be reasonably and safely accomplished before 6 weeks after the procedure in a woman who is no longer bleeding and has had adequate endometrial preparation with POP, DMPA or the LNG-IUS.195

Evidence level 4

45


Clinicians should ensure that consent from the woman to conduct female sterilisation at the same time as surgical abortion is taken and documented in advance of the abortion.

The GDG considered that consent to conduct a sterilisation at the same time as surgical abortion should be taken and documented in advance of the procedure. This requires careful consideration, counselling and documentation. Removal of the fallopian tubes and ovarian cancer

There is epidemiological evidence suggesting bilateral salpingectomy may protect against developing high-grade serous ovarian cancer. It is postulated that this may be because some epithelial cancers may originate in tubal epithelium.120 The RCOG advises that women should be carefully counselled for removal of fallopian tubes, if their family is complete and they are undergoing pelvic surgery.121 This may be also relevant to women being sterilised after abortion. 3.3.5 Barrier methods

D Condoms (male and female) can be used by women after abortion.

D Women choosing to use a diaphragm should be advised to wait at least 6 weeks after second-trimester abortion because the size of diaphragm required may change as the uterus returns to normal size.

Condoms (male and female) can be used without restriction at any time by women after abortion.107 However, given their high failure rates (percentage of women experiencing an unintended pregnancy within the first year of use) with typical use, they are considered one of the least effective contraceptive methods.20 Diaphragms are considered unsuitable until 6 weeks after second-trimester abortion as the required size of diaphragm may change as the uterus returns to normal size.107 A different size diaphragm may be required for women who have used this method previously. Another method of contraception should be used until the woman is able to insert and remove a correctly fitted diaphragm.

Evidence level 4

3.3.6 Fertility awareness methods (FAM)

Fertility awareness methods (FAM) can be used by women after abortion. However, women should be advised that because FAM relies on the detection of the signs and symptoms of fertility and ovulation, its use may be difficult after abortion.

46


Women should be advised that fertility awareness methods (FAM) should be used carefully in order to ensure maximum effectiveness. The effectiveness of FAM can be improved when a combination of indicators are used and are taught by trained FAM practitioners.122 High failure rates are associated with typical use.20 Refer to FSRH guideline Fertility Awareness Methods for further guidance.123 Shortly after abortion, signs of fertility may be disrupted and extreme caution is required. Any calendar-based method should not be relied upon until one menstrual period has occurred.

Evidence level 4

3.4 Useful links and support group: Contraception after abortion

NHS Choices: Contraception guide NHS Choices: Pregnancy and baby The Family Planning Association (FPA) British Pregnancy Advisory Service (BPAS) Marie Stopes UK

http://www.nhs.uk/conditions/contraception-guide

http://www.nhs.uk/Conditions/pregnancy-and-baby

http://www.fpa.org.uk/

http://www.bpas.org/

http://www.mariestopes.org.uk/

ABOUT THE AUTHORS

DR ALISON KNOWLES

Certifying Consultant and Abortion Provider, Waikato

Chair Abortion Providers Group Aotearoa New Zealand

MB ChB 1989 Auckland

Bachelor of Medicine Bachelor of Surgery

University of Auckland, New Zealand

Diploma in Obstetrics


Member and Fellow of the Royal New Zealand College of General Practitioners

PROFESSOR PETER STONE

Certifying Consultant and Maternal Fetal Medicine Specialist, Auckland

Director of ISTAR*

MB ChB 1976 Auckland



Diploma in Obstetrics


MRCOG 1982

Member of the Royal College of Obstetricians and Gynaecologists

FRANZCOG 1988

Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists

DR JADE LE GRICE

Māori Consultant, Auckland

BA, BA (Hons), PhD (Auck)

Jade’s PhD investigated what reproduction means for Māori, casting a net around the wider

phenomenon to understand reproductive decisions, parenting, sexuality education, maternities and

abortion, as spheres of mutual influence. She is a lecturer at the University of Auckland.

GEORGE PARKER

Consumer Consultant, Auckland

George is a midwife with a Masters of Philosophy in Women and Gender Studies, currently

undertaking her PhD in Sociology at the University of Auckland on issues related to women’s health

care in Aotearoa New Zealand.

She has a special interest in women’s sexual and reproductive health, rights and justice.

DR SYLVIA ROSS

Certifying Consultant, Auckland

BBioMedSci, PGDipOMG, MBChB, O&G trainee


University of Otago, New Zealand

DR MICHELLE WISE

Certifying Consultant and Abortion Provider, Auckland

MD 1998 Toronto

Doctor of Medicine

University of Toronto, Canada

FRCS(C) 2003

Fellow of the Royal College of Surgeons of Canada

FRANZCOG 2012

Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists

DR CHRISTINE ROKE

Certifying Consultant, Auckland

National Medical Advisor

Kaitohutohu Hauora ā‐Motu, Family Planning

MB ChB 1968 Otago


University of Otago, New Zealand

Cert FPRH 1977

Certificate in Family Planning Reproductive Health

FACSHP 1997

Fellow of the Australasian College of Sexual Health Physicians

ASSOC PROFESSOR MIKE STITELY

Certifying Consultant and Abortion Provider, Dunedin

MD 1994 Pittsburgh

Doctor of Medicine University of Pittsburgh School of Medicine Pennsylvania

University of Pittsburgh, United States of America

Am Bd Cert Obst & Gynaec 2000

Certificate of the American Board of Obstetrics and Gynaecology

American Board of Obstetrics and Gynaecology, United States of America

DR SIMON SNOOK

Certifying Consultant and Abortion Provider, Wairarapa

Director of ISTAR*

MB ChB 1996 Birm


University of Birmingham, England

MRCGP 2002

Member of the Royal College of General Practitioners

FRNZCGP 2005

Fellow of the Royal New Zealand College of General Practitioners

CHRISSIE SYGROVE

Nurse, Auckland

Nurse and Midwife with extensive experience in Family Planning, Sexual Health and Abortion Care.

RGON, RM, PGDip AdvNsg, PGCert HSc, PGCert Prof Supv

NERGIS NARAYAN

Social Worker, Wellington

Registered Social Worker with extensive experience in pregnancy and abortion counselling and

support, Wellington

Masters Degree in Social Work (specialising in Family and Child Welfare) from the Tata School of

Social Sciences, Mumbai India.

DR DAVID BIVONA

Certifying Consultant and Abortion Provider, Wellington Laurea 1993 Di Palermo Laurea in Medicina e Chirugia Universita Degli Studi Di Palermo, Italy FRNZCGP 2013 Fellow of the Royal New Zealand College of General Practitioners *ISTAR is a charitable organisation involved in the supply of the abortion medication, mifepristone to Licensed Institutions in Aotearoa New Zealand. ISTAR also supplies Manual Vacuum Aspiration equipment to New Zealand clinicians. Any profits are used for the benefit of women’s health.

Documents

182 Killing unborn child - Ministry of Justice€¦ · 182 Killing unborn child (1) Every one is liable to imprisonment for a term not exceeding 14 years who causes the death of any