Providing choice and expertise in sexual and reproductive health: for a nurse with a passion for sexual health and the needs of well women, there could be few better place to work than the Family Planning Association.

National nursing adviser with the Family Planning Association (FPA), Rose Stewart, can't imagine a better place to work. It's an organisation she has given a great deal to over the last 18 years, but one that has given her a great deal in return.

"I began my nursing career in Christchurch, graduating in the 1970s from Princess Margaret Hospital. Some years later I found myself working as a practice nurse in Porirua and realised I really wanted to work with people in a normalised, well setting, away from the illness model. A two-day FPA course in sexual and reproductive health set me off in a new direction--I realised this was where I really wanted to work." When Stewart began working for FPA in Wellington, she had one child. FPA was a good employer as she raised two more children and recovered from the stillbirth of twins at six-months. Three years ago, she began a master's programme through Massey University, Wellington, which she will finish this year. "Going back to study after such a long break has been just amazing. I have been challenged and politicised in a lot of my thinking, particularly around feminist and gender issues. I now see gender as a social construct. A black and white definition of gender excludes a lot of people."

A nationwide service

From its beginnings in the 1930s as the Sex Hygiene and Birth Regulation Society, FPA has grown into a nationwide service, employing 80 nurses and 40 doctors, many part-time workers raising families. The service has 15 health promotion and education centres, 32 outreach/ school clinics and 30 clinical centres providing non-judgemental, specialised professional services to people of all ages. It provides training for health professionals in contraception and sexual and reproductive health, including smear taking; training for non-clinical educators working in schools and the community; and provides policy advice to government. It advocates for comprehensive, age-appropriate sexuality education in schools and easier access to contraception for all New Zealanders.

FPA's International Development Unit--FPAID--is core-funded through international donors, and works to raise national, regional and international awareness of population and development issues, and to increase access to sexual and reproductive health information and services in the Pacific and Asia. To do this, FPAID works with local partners in developing countries and regional networks such as the Asia Pacific Alliance. The education service delivers sexuality education to schools and community groups.

"FPA offers expertise in sexual and reproductive health and a different model of service. Some people don't want to go to their own GP for advice in these areas and some GPs will refer patients to us for procedures like vasectomies and intrauterine contraceptive device (IUD) insertions. Our contract through the Ministry of Health enables us to provide free visits for those under 22 and subsidised visits for community service card holders, 22-24-year-olds and for people over 45."

Stewart would like to see mainstream health providers provide specialist sexual and reproductive health services, but, until that happens, FPA provides people with another choice. "There'll probably always be a need for FPA. We are an important service for young people, in particular, who see us as non-judgemental and confidential. They feel they can say anything to us. When we work with young people, we encourage them to delay intercourse, and talk to them about the risks of unsafe sex and how to reduce these risks. But we also acknowledge up front that sex is normal and fun--if you hit them with the risks straight off, they won't listen. You need to build relationships with young people to win their trust. We also encourage young people to talk to their parents, as the key to protecting kids from unsafe sexual behaviour is for them to be connected to their families, to their schools and community groups, and to have hobbies they enjoy. We are not alternatives to parents; we are safe adults for kids to talk to."

National nurse adviser role

Stewart has been FPA's national nurse adviser for just over a year. She combines her 14 hours a week in this job with 14 hours as a clinic nurse, enjoying the continuing contact with clients. The role, she says, is about representing nursing issues at the senior management level, including keeping the organisation up to date with nursing legislation and nursing trends. The role also involves some advocacy. "I project FPA as an organisation that employs nurses. Some people are not quite sure that an FPA nurse is a real nurse. It is important for me to make connections outside the organisation and to increase our collaborative efforts. Internally, I am interested in looking at the whole nursing structure and developing quality and standards." As part of her clinic work, Stewart used to run a school clinic in Wainuiomata once a week, but this work is now being done very ably by the lower Hutt Youth Health Service. One-stop-shop type youth services are a boon for young people, she says. School nurses in Wellington are also now well organised, with a great service being delivered to secondary school pupils in the Wellington region.

Dangers of complacency

Last year, at the Australasian Abortion Providers' Conference, Stewart experienced something of an epiphany--she now believes it is imperative people do not take their sexual and reproductive health rights for granted. "These rights were fought for during the Depression years by a small group of courageous New Zealand women who were concerned that so few women had access to information about birth control. In those days, women were considered traitors if they avoided getting pregnant. That history has been largely forgotten but could be repeated if we are not careful Abortion is part of the sexual and reproductive health picture and we have to talk about it. For me, it is an issue of social justice."

Stewart is personality concerned about the impact of United States' right wing policies and its present administration on how aid is distributed to developing countries. "Sexual and reproductive health services are missing out on assistance because of their link to abortion services. But between 60-70,000 women die from unsafe abortion in the world each year and safe services are desperately needed. The focus on the rights of the foetus, rather than on the rights of the mother, is leading to a backlash against women. Their rights are being undermined and challenged, thus reducing their humanity."

Abortion rates fatting

Stewart is encouraged there have been no abortion-related deaths in New Zealand since abortion was legalised in 1977. Before then, deaths from illegally obtained, underground abortion were common. She says that historically in New Zealand, and internationally today, women will get an abortion if they need it, one way or another. "Our abortion rates are high--between 18,000 and 19,000 a year--but they have been reducing in recent years. Last year, there were 680 fewer abortions than in the previous year and 980 fewer abortions than in 2003. The general abortion rate was 19.7 per 1000 women aged 15-44 years in 2005, down from 20.5 in 2004 and 21.0 in 2003. This is an encouraging trend. We want to get the rate down, but I personally would also Like to see our taw updated to reflect changes in abortion provision options.

"It is of great concern that only seven percent of abortions in New Zealand are done before eight weeks gestation. In the Netherlands, at least 70 percent are done before eight weeks. In many parts of Europe, medical or pill-induced miscarriages have been available since the 1980s, but this is available in only selected parts of New Zealand. Medical abortions, which mimic a natural miscarriage, are just as safe for women as surgical procedures. In fact, there can be fewer complications and it puts the decision firmly back with the woman, where it rightly belongs.

"Some women are forced to live very chaotic Eves and have Little control over when they have sex. Some are very fertile and others will be experiencing a Lot of family violence. We now ask a number of questions about family violence in our screening of all our clients and rarely have any negative feedback on these questions." Stewart is also concerned about the providers of abortion services, many of whom feel quite isolated in their practice and receive little support from colleagues. "In Ireland, many health practitioners want abortion services to be made available, but, at the same time, they don't want to deliver them themselves. There are double standards operating there, as in New Zealand."

Double standards and mixed messages

Double standards are also rife in societal attitudes towards sex and young people, Stewart believes. The view of guys as "studs" and girls as "sluts" still remains. "Most people say that young people are having sex far too young, yet our media is obsessed with the topic. Almost all television programmes contain sex information or involve sex in some way. Young people see sex depicted in the media as fun, romantic and free--they don't see people pulling out a condom before having sex or suffering the consequences of unprotected sex. Parents stilt don't talk about sex with their children and our sex education in schools is random and ad hoc. Our health syllabus requires primary and intermediate schools to consult with their communities about the course content, but what training do teachers have to do this consultation or teach the syllabus? Some schools are doing a great job, but it would be great to have more FPA educators available to provide this teaching." Stewart is on the nurse practitioner (NP) pathway but is not sure whether she will take the journey to its end. There is one FPA nurse who intends applying for NP status next year. However, FPA is still working through how best to use an NP within the organisation and following with interest the findings and recommendations of the Ministry of Health's Nurse Practitioner Employment and Development Working Party. "Employing an NP is not just about having expert clinical skills. There are also strong research, teaching and policy advocacy components to the role. We actively support the NP scheme, but I also believe more scope should be given to expert nurses who are not NPs but want to move the boundaries of their practice safely and use their skills to their full advantage."

Working under standing orders

As FPA nurses become more advanced in their practice, the restrictions on what contraceptives they can supply are Lifted. FPA nurses work under standing orders, enabling them to supply patients with a range of contraceptives. Those with the skills and training are also able to do pre-IUD checks, fit diaphragms and IUDs (an increasingly popular contraceptive choice once again), screen for sexually transmitted infections, conduct pre-vasectomy operation consultations, supply the emergency contraceptive pill and take smears. They enjoy a high degree of autonomy in their practice, have their own daily List of patients and receive good support from their medical colleagues.

"FPA is a fabulous place to work for a nurse who has a passion for sexual health and the needs of well women. We also follow in the footsteps of some wonderful role models, Like former medical director Margaret Sparrow who worked for FPA for nearly 34 years and former executive director Gill Greer, who is now director-general of the International Planned Parenthood Federation (IPPF), based in London. Her appointment shows just how well FPA is regarded internationally. Receiving IPPF accreditation for our excellent service provision recently is also a feather in FPA's cap."