VIEWPOINT

What does law reform mean for primary care practitioners in New Zealand? Emma Macfarlane, Michael Stitely, Helen Paterson

ABSTRACT New Zealand achieved a major sexual reproductive health and rights milestone when abortion ceased to be a crime. Introduction of the Abortion Legislation Act 2020 has significantly changed the way abortion care can be provided in New Zealand, with the potential to improve access, reduce inequities and transform the abortion experience for those people who choose to end their . The primary care sector stands to be a key player in the provision of first-trimester abortion care. However, with issues relating to funding, training and access to medications yet to be resolved, the health sector is not yet ready to provide best-practice abortion care within the new legislative framework.

n 23 March 2020 the Abortion Legis- abortion, reform, primary care, lation Act (AL) 2020 was passed into mid-level health providers. Any references law with the result that abortion in of papers identified through the literature O 1 New Zealand is no longer a crime. There is review that seemed relevant were located now scope for qualified health practitioners and considered for inclusion in the review. to provide abortion care that is evidence This review includes relevant New Zealand based, aimed at reducing inequities in ac- legislation and standards and international cess and more acceptable to pregnant people recommendations on provision of abortion and their whānau. However, in almost in primary care. The aim of this paper is to 12 months since the law reform, little has review the international literature to inform changed in the way that abortion services how optimal, first-trimester abortion care are configured, and we are yet to realise the can be provided in the primary care setting full extent of abortion care within a decrimi- post abortion law reform in Aotearoa nalised environment. New Zealand. A review of the literature was undertaken using the databases Medline and Google Background Scholar. The following key words were used: Abortion is one of the most common gynaecological procedures, and one in four women internationally will have an Figure 1: Key points of Abortion Law Reform in abortion in their lifetime.2 For the year New Zealand ending 2019 the general abortion rate in New Zealand was 13.5 per 1,000 • No statutory test for abortions <20 weeks women (pregnant people) aged 15–44, and gestation 19% of all known ended in • Abortions can be provided by a range of abortion.3 The term ‘woman’ is used by the health practitioners AL Act. We consider this to be inclusive of • Provision remains for conscientious objection transgender, gender-fluid, non-binary and • No requirement for licensed premises gender non-conforming people.

NZMJ 30 April 2021, Vol 134 No 1534 ISSN 1175-8716 © NZMA 91 www.nzma.org.nz/journal VIEWPOINT

The previous laws governing abortion The new law: there is no statutory in New Zealand were sections 182A–187A test for abortion before 20 weeks of the and sections 10–46 of the Contraception, Sterilisation and gestation Under the AL Act 2020, health-practitioner Abortion (CSA) Act 1977.4,5 With safe abor- approval is not required for an abortion tions readily available, the only rational before 20 weeks gestation.1 Under previous purpose for criminalising abortion is legislation, two certifying consultants had to deter, punish and place the rights of to agree that the person met the criteria for the fetus over the rights and autonomy having an abortion as specified by section of the pregnant person.6 New Zealand’s 187A of the Crimes Act.4 Most pregnant abortion laws were considered by some people less than 20 weeks had an abortion as a violation of human rights, and in on the grounds that continuing the preg- 2019 Abortion Law Reform Aotearoa New nancy posed a serious danger to life, or Zealand (ALRANZ) brought a case to the physical or mental health.4 The decision Office of Human Rights Proceedings. The to have an abortion was not the pregnant complaint was subsequently withdrawn person’s and there was the potential for an when the AL Act 2020 was passed, as the abortion request to be declined. Under the AL Act addressed the issues raised by AL Act, people less than 20 weeks pregnant ALRANZ.7 who seek an abortion can obtain an abortion 8 The intention of the AL Bill 2019 was to from a suitably qualified health practi- decriminalise abortion and bring the legal tioner.1 This means that up until 20 weeks’ framework for abortion in New Zealand gestation it is the pregnant person’s choice to in line with how other health services are have an abortion. For pregnant people over delivered, and in doing so treat abortion as 20 weeks, the suitably qualified health prac- a health issue rather than a criminal justice titioner must consult with another health 9 issue. Decriminalisation of abortion can practitioner, decide whether an abortion is be defined as not punishing anyone for clinically appropriate and “have regard to; providing or having an abortion, and not all relevant legal, professional, and ethical involving the criminal justice system in standards to which the qualified health prac- deciding who can have an abortion. Above titioner is subject; and the woman’s physical all it means treating abortion like any other health; and mental health; and overall well- 6 health procedure. being; and the gestational age of the fetus.”1 Implementation of the AL Act trans- This means that, once they have been ferred supervision of abortion services pregnant for more than 20 weeks, it is not from the Ministry of Justice to the Ministry solely the pregnant person’s choice to have of Health (MOH). The MOH is now respon- an abortion. The final decision remains with sible for ensuring that abortion care and the health practitioner. counselling are provided according to stan- dards published by the Director-General.1 Abortion care can be provided by a Currently, these are the Interim Standards range of health practitioners for Abortion Services in New Zealand The AL Act 2020 states that abortions (the ‘Interim Abortion Standards’), which, can be provided by a “qualified health published in April 2020, are an amended practitioner,” as defined by the Health 10 version of the 2018 Abortion Standards. Practitioners Competence Assurance Act.1 Abortion has been included in the draft However, what this actually means for prac- Health and Disability Services Standards titioners requires clarification. Review.11 The World Health Organization (WHO) Recently, the MOH released a report from advocates the shifting and sharing of district health boards (DHBs) on abortion abortion care from specialist providers service provision post abortion-law reform. to mid-level providers, such as registered The results identify issues relating to work- nurses, nurse practitioners and midwives. force development, training and the way in The WHO recommends that these health which services are delivered. These issues practitioners can safely provide EMA and continue to negatively impact on equitable aspiration abortion in the primary care access and timeliness of abortion care.12

NZMJ 30 April 2021, Vol 134 No 1534 ISSN 1175-8716 © NZMA 92 www.nzma.org.nz/journal VIEWPOINT

setting.13 The rationale for training mid-level pregnant people can be monitored as outpa- health providers in abortion care is to tients.16,17 EMA providers can be trained in increase access to abortion and reduce the manual as a back-up for burden of cost to the healthcare system, a failed EMA, and most EMA complications while not compromising on safety.14 can be safely managed in primary care.17 Health practitioners who are not abortion However, a few complications associated 17 providers can refer the pregnant person to with EMA require emergency referral. an abortion provider. However, section 13 Therefore it is important to have referral 14 of the AL Act 2020 states that provision of pathways in place to secondary care. abortion care is not contingent on a referral Primary health providers, particularly in from another health practitioner and that rural areas, have the potential to increase pregnant people can self-refer.1 access to EMA. Pregnant people living in rural or remote regions rely on primary What about conscientious objection? healthcare services to meet their basic Sections 14 and 15 of the Abortion health needs. Strengthening primary care Legislation Act 2020 maintains a health prac- is a way of reducing health inequities.17 titioner’s legal right to conscientiously object Furthermore, abortion may be more to provide or assist with abortion, sterili- acceptable when provided by a primary sation, contraception or advice regarding health practitioner. One study of pregnant pregnancy options.1 The key differences people attending either a primary care between the AL Act 2020 and the CSA Act university clinic or a free-standing abortion 1977 are that conscientious objectors must clinic found that most preferred to receive now disclose their stance as soon as possible early abortion care with their trusted and provide contact details of the closest primary provider. The authors suggest provider. However, if the conscientious integrating early abortion care into primary objection causes an unreasonable disruption care to improve access and health outcomes to the service, an employer can take steps, for people with an unintended pregnancy.18 including provision of less favourable terms The Interim Abortion Standards of employment, termination or retirement.1 recommend that people should not be It could be seen that the new legislation required to travel more than two hours does go some way in addressing the impact to access an abortion.10 Providing first-tri- of conscientious objection on abortion mester abortion in primary care may services. However, it is less likely to address significantly decrease the travel some people the impact in primary care where prac- presently undertake to have an abortion, titioners provide a range of services and and also allow for provision of EMA via whose patients may not be aware of their telemedicine. stance. Unless conscientious objectors are Under the previous law, administration of made to publically disclose their objection, abortion pills was defined as the abortion.19 there is always the potential for pregnant People were required to be observed taking people to be denied care. the medication on a licensed premise, and as the most effective regime is to take the Where abortions can be provided medications 36–48 hours apart, people had Before the introduction of the AL Act to return to the clinic for the second dose.15 2020, pregnant people were required to be Removing the requirement for abortion to referred to one of 27 licensed institutions.5 be provided on licensed premises makes The new legislation does not limit where self-managed abortion possible. abortions can be provided. Early abortion A recent Cochrane review shows that services provided in primary care are safe self-managed EMA is as effective as provid- 13 and effective. Early er-administered EMA and is acceptable to (EMA) involves taking two medications women.20 A self-managed EMA allows a 36–48 hours apart to end the pregnancy. The pregnant person to take the abortion pills recommended medications are at a time and place that suits them without 15 and . EMA is well suited to supervision. It also means that the person primary care as it does not require proce- can self-assess completion of the procedure dural training or technical facilities, and

NZMJ 30 April 2021, Vol 134 No 1534 ISSN 1175-8716 © NZMA 93 www.nzma.org.nz/journal VIEWPOINT

by using appropriate pregnancy test kits support to new providers.23 Specialist and symptom checklists.20 The aim of self- obstetricians in Nepal provided training, managed abortion is to increase access and oversight and support to the mid-level acceptability, and it has the potential to health providers who subsequently reduce demand on health services.20 The provided abortion care in the commu- role of the primary care clinician in self- nities.22 Specialist providers will always managed EMA is to provide assessment, be needed to provide emergency care, and information and advice to the pregnant although their roles in abortion care will person on how to take the medication be different, they will remain crucial to correctly, how they can self-assess progress the provision of safe and effective abortion and how they can access help and infor- care.23 20 mation as needed. Perhaps the most important factor in the success of expanding health-worker roles by What is required for successful task shifting is their willingness to provide implementation of abortion into abortion care. Willingness is influenced by primary care? a number of factors, such as personal views Clinicians should receive training on abortion, the method of abortion they are and support to competently provide asked to perform, gestation of the fetus and safe abortion care. Primary care should health-provider perceptions of their roles also have tool kits, which could include as preservers of life. One way that has been assessment templates, clinical deci- shown to be successful in increasing will- sion-making support tools and information ingness to provide abortion care is through 24 and summary-of-care templates, in case the values-clarification workshops. pregnant person presents acutely to another It will be important for health regulatory health provider.16 bodies to ensure that abortion care is clearly 23 Prior to the repeal of the Eighth included in appropriate scopes of practice. Amendment, Ireland essentially did not The Midwifery Council of New Zealand has provide abortions, and subsequent to provided a clear statement that abortion the repeal, practitioners in primary and is within the midwifery scope of practice. secondary care needed to rapidly acquire Midwives, as authorised prescribers, can the skills to provide the service. The prescribe the medications required for government was criticised for its lack of abortion and, with appropriate training, support and leadership.21 Nepal’s success in can perform surgical abortion to the extent 25 making safe, legal abortion widely available allowed by their scope. has been attributed to a number of factors, Essential to provision of EMA is the ability including commitment and leadership by to provide the required medications with the Nepalese government and a compre- as few barriers as possible. Nurses often hensive approach to implementation of provide medications under standing orders abortion services. Abortion programmes as per the Medicines (Standing Orders) and policies were based on international Regulations 2002, whereby non-prescribers evidence for best-practice abortion care can administer or supply specific medi- and the training of mid-level providers to cations according to a written instruction increase the number of clinicians able to issued by an authorised practitioner, provide care to a wider geographical area.22 nurse practitioner or optometrist.26 In New Zealand currently does not have a practice, standing orders can pose a signif- primary care-based training programme icant amount of work for an organisation for abortion, but the New Zealand College to comply with the requirements of the of Sexual and Reproductive Health is legislation. A scenario exists for a non-pre- developing an online learning module for scriber who wishes to provide EMA but provision of EMA. lacks a supportive prescriber to administer For task shifting of abortion care to a standing order. One solution would be to non-specialist providers to occur we need develop a national standing order for miso- the support and leadership of our current prostol and mifepristone and a network of abortion providers, who will be crucial in supportive prescribers to administer the leading training and providing ongoing standing order. A further solution would

NZMJ 30 April 2021, Vol 134 No 1534 ISSN 1175-8716 © NZMA 94 www.nzma.org.nz/journal VIEWPOINT

be to ensure that the medications can be contracts to allow time for the Interim prescribed by all non-medical prescribers. Abortion Standards to be updated and the There are a range of non-medical establishment of national clinical guidelines. prescribers in New Zealand. Under the It is envisaged that these restrictions will interpretations of the Medicines Act 1981 then be removed, allowing access to funded authorised prescriber means “a nurse prac- EMA medications on PSO for all suitably 31 titioner; or an optometrist; or a practitioner; qualified prescribers. or a registered midwife; or a designated Currently, the brand of misoprostol prescriber,” where a “designated prescriber” imported into New Zealand is not approved is a registered health professional who has by Medsafe for use as an . undertaken further education and training Therefore, it is prescribed by authorised in order to be able to prescribe.27 Currently, prescribers only under Section 25 of the there appears to be confusion regarding Medicines Act 1981.27 Ongoing it will be whether a designated prescriber is an autho- important to gain clarification regarding rised prescriber or not. For example, in an the legal status of designated prescribers as overview of non-medical prescribing in New authorised prescribers and for mifepristone Zealand, designated prescribers are clearly to be added to the schedule of medicines distinguished from authorised prescribers.28 they can prescribe. Without this move, However, this is in contrast to the interpre- designated prescribers will be dependent tations section of the Medicines Act 1981, on standing orders, which may impact on which lists designated prescribers among equity of access to . 27 authorised prescribers. How abortion will be funded in primary There are two levels of registered care requires clarification. Presently the nurse (RN) designated prescribers in New Primary Maternity Services Notice Review Zealand: (1) prescribing in primary health 2021 specifically excludes funding of abortion and speciality teams, and (2) prescribing (termination of pregnancy). It also excludes in community health.29 RN prescribers in nurses from being maternity providers which primary health and specialty teams have poses a barrier to provision of autonomous undertaken further training, including a first trimester abortion care by nurses.32 Nursing Council approved postgraduate diploma in RN prescribing for long-term conditions. They can prescribe from a list of Figure 2: What is required for first trimester medications as per their area of practice and abortion to be provided in primary care. competency.30 The list includes misoprostol but not mifepristone. The second level of RN • Updated abortion standards prescribers, community prescribers, work • Appropriate training and support for within DHBs or other health organisations abortion providers and undergo a recertification programme • Access to EMA drugs on PSO in primary care to become prescribers. The medications list • Support for non-prescribers to provided EMA at this level of prescribing is more limited and does not include either misoprostol or mifepristone.29 A further way of reducing barriers to Conclusion One of the more pressing requirements EMA is for health practitioners to supply to providing safe abortion care in the the medications from a Practitioner Supply community is the provision of compre- Order (PSO). PHARMAC announced on 2 hensive and accessible training for health July 2020 that mifepristone and misoprostol practitioners. Unless there is adequate would be listed in Section B of the pharma- and appropriate funding for the primary ceutical schedule effective from1 August care sector, including for the training of 2020. This means that these medications midwives, nurses and nurse practitioners, can be supplied on PSO so that pregnant there will be no incentive to undertake the people are not required to go to a pharmacy training nor the provision of abortion care, for dispensing. However, this is currently with the result that access to safe abortion temporarily restricted to Family Planning will not be improved. Fundamental to equi- clinics and abortion providers with DHB table provision of EMA is access to funded

NZMJ 30 April 2021, Vol 134 No 1534 ISSN 1175-8716 © NZMA 95 www.nzma.org.nz/journal VIEWPOINT

mifepristone and misoprostol by a range In passing the AL Act 2020, New Zealand of qualified health practitioners. We need achieved a major milestone in sexual and clarification regarding the legal status of reproductive health and human rights. With designated prescribers under the Medi- new legislative and regulatory frameworks, cines Act 1981 to prescribe misoprostol as health practitioners in primary care have a section 25 drug and, for misoprostol and the potential to be key players in shaping mifepristone to be added to the schedule of the future of abortion care. Further research medicines for both levels of RN designated is required to develop a framework for prescribing. Trained non-prescribers should provision of optimal first trimester abortion be supported to provide EMA via a national care in the primary sector in Aotearoa standing order. New Zealand.

Competing interests: Ms Macfarlane reports: I am a committee member of Abortion Providers Group Aotearoa New Zealand (APGANZ) and a member of The College of Sexual and Reproductive Health. I was actively involved in campaigning in support of abortion law reform. While undertak- ing this research I was the recipient of the University of Otago Dunbar Scholarship which paid for my PhD fees and a monthly stipend. Dr Paterson reports: I received professional fees from Southern and professional fees from Ministry of Justice, outside the submitted work; I was the Chair of Abortion Providers Group Aotearoa and a member of the committee, sat on the Ministry of Health Abortion Standards working group and presently act in an un-payed advisory role for the Ministry of Health abortion guidelines development. I am a member of The College of Sexual and Reproductive Health and have been funded to attend an educational conference by Bayer. I and Michael Stitely hold a contraception-related patent. Acknowledgements: This paper was written while the author Emma Macfarlane was the holder of the University of Otago, Dunbar Scholarship. Author information: Emma Macfarlane: Lecturer, Department of Women’s and Children’s Health, Otago Medical School, University of Otago, . Associate Professor Michael Stitely: Head of Department, Department of Women’s and Children’s Health, Otago Medical School, University of Otago, Dunedin. Dr Helen Paterson: Senior Lecturer, Department of Women’s and Children’s Health, Otago Medical School, University of Otago, Dunedin. Corresponding author: Emma Macfarlane, Department of Women’s and Children’s Health, Otago Medical School – Dunedin Campus, PO Box 56, Dunedin 9054, +64 3 470 9750 [email protected]. URL: www.nzma.org.nz/journal-articles/what-does-abortion-law-reform-mean-for-primary-care- practitioners-in-new-zealand

REFERENCES 1. Abortion Legislation Act 3. Stats NZ: Tatauranga from: http://www. 2020. Public Act. 2020 No Aotearoa. Abortion legislation.govt.nz/act/ 6. [Available from: http:// statistics: year ended public/1961/0043/149.0/ www.legislation.govt. December 2019 [Inter- DLM327382.html. nz/act/public/2020/0006/ net]. 2020 [cited 2020 5. Contraception, Sterilisa- latest/LMS237550.html. 26 Sep]. Available from: tion, and Abortion Act 2. Amnesty International. https://www.stats.govt. 1977. Public Act. 1977 Key facts on abortion nz/information-releases/ No 112. New Zealand [Internet]. 2020 [updated abortion-statistics-year-end- [Available from: http:// 4 Mar 2020; cited 2020 ed-december-2019. www.legislation.govt.nz/ 15 Aug]. Available from: 4. The Crimes Act 1961. act/public/1977/0112/10.0/ https://www.amnesty.org. Public Act. 1961. No 43. DLM17680.html. nz/key-facts-abortion. New Zealand [Available

NZMJ 30 April 2021, Vol 134 No 1534 ISSN 1175-8716 © NZMA 96 www.nzma.org.nz/journal VIEWPOINT

6. Berer M. Abortion law and 11 Dec]. Available from: 18. Logsdon MB, Handler A, policy around the world: https://www.google.com/ Godfrey EM. Women’s in search of decriminaliza- url?sa=t&rct=j&q=&es- preferences for the location tion. Health and human rc=s&source=web&c- of abortion services: a rights. 2017;19(1):13. d=&ved=2ahUKEw- pilot study in two Chicago 7. Abortion Law Reform iSu8C-y8ftAhVWxDgGHRe- clinics. Matern Child New Zealand [ALRANZ]. 3C7YQFjAAegQIARAC&ur Health J. 2012;16(1):212-6. ALRANZ’s complaint to the l=https%3A%2F%2F- 19. Ministry of Justice. Human Rights Commission www.health.govt. Standards of care for [Internet]. 2017 [cited nz%2Fsystem%2Ffiles%2F- woman requesting 2020 Aug 15]. Available documents%2Fpages%- abortion in Aotearoa from: http://alranz.org/ 2Fabortion-services-sum- New Zealand [Internet]. human-rights-complaint/. mary-dhb-quarterly-sur- 2018 [cited 2020 15 Aug]. vey-responses-dec20. 8. : Available from: https:// pdf&usg=AOvVaw1x-PE1w- Pāremata Aotearoa. www.justice.govt.nz/assets/ 9FzWUjwJEA7Fiwa. Abortion Legislation Bill Documents/Publications/ [Internet]. 2019 [cited 2020 13. World Health Organization Standards-of-Care-2018.pdf. 14 Aug]. Available from: DoRHaR. Safe abortion: 20. Gambir K, Kim C, Necastro https://www.parliament. technical and policy guid- KA, Ganatra B, Ngo TD. nz/en/pb/bills-and-laws/ ance for health systems Self‐administered versus bills-proposed-laws/ [Internet]: World Health provider‐administered document/BILL_89814/ Organisation; 2012 [cited medical abortion. Cochrane abortion-legislation-bill. 2020 25 April]. Available Database of Systematic from: https://apps.who.int/ 9. Te Aka Matua o te Ture: Reviews. 2020(3). iris/handle/10665/70914. Law Commission. Minis- 21. Taylor M, Spillane A, terial briefing: alternative 14. World Health Organization. Arulkumaran S. The approaches to abortion Health worker roles in Irish Journey: Removing law: ministerial brief providing safe abortion the shackles of abortion [Internet]. 2018 [cited 2020 care and post-abortion restrictions in Ireland. 15 Aug]. Available from: contraception [Internet]. Best Practice & Research https://www.lawcom. Geneva: World Health Clinical Obstetrics & govt.nz/abortion. Organisation; 2015 [cited Gynaecology. 2020;62:36-48. 2020 12 April]. Available 10. Ministry of Health: 22. Samandari G, Wolf M, from: https://www.who.int/ Manatū Hauora. Interim Basnett I, Hyman A, Ander- reproductivehealth/publi- Standards for Abortion sen K. Implementation of cations/unsafe_abortion/ Services in New Zealand legal abortion in Nepal: a abortion-task-shifting/en/. [Internet]. 2020 [cited model for rapid scale-up of 2020 15 April ]. Available 15. Istar Limited. Mifegyne high-quality care. Reprod from: https://www.health. 200mg tablets data sheet Health. 2012;9(1):7. 25 January 2021. [cited govt.nz/publication/ 23. Kim C, Sorhaindo A, 2021 23 Feb]. Available interim-standards-abor- Ganatra B. WHO guide- from: https://www.google. tion-services-new-zealand. lines and the role of the com/search?client=fire- 11. Hauora MoHM. Health physician in task sharing fox-b-d&q=medsafe+mife- and disability services in safe abortion care. pristone+data+sheet standards and review Best Pract Res Clin Obstet [Internet]. 2020 [202 16 16. Beaman J, Schillinger D. Gynaecol. 2020;63:56-66. Responding to Evolving December]. Available 24. Glenton C, Sorhaindo Abortion Regulations from: https://www. AM, Ganatra B, Lewin S. - The Critical Role of health.govt.nz/our-work/ Implementation consid- Primary Care. N Engl J regulation-health-and-dis- erations when expanding Med. 2019;380(18):e30. ability-system/ health worker roles to certification-health-care-ser- 17. Iyengar SD. Introducing include safe abortion care: vices/services-standards/ medical abortion within a five-country case study health-and-disability-ser- the primary health synthesis. BMC Public vices-standards-review. system: comparison with Health. 2017;17(1):730. other health interven- 12. Hauora MoHM. Abortion 25. Midwifery Council. tions and commodities. services: Summary of DHB The Midwifery scope Reprod Health Matters. quarterly survey responses of practice: Abortion 2005;13(26):13-9. [Internet]. 2020 [cited 2020 services (March 2020)

NZMJ 30 April 2021, Vol 134 No 1534 ISSN 1175-8716 © NZMA 97 www.nzma.org.nz/journal VIEWPOINT

FAQs [Internet]. 2020 Zealand: an overview 2020 4 Aug]. Available [cited 2020 4 August]. of prescribing rights, from: https://gazette.govt. Available from: https:// service delivery models nz/notice/id/2017-gs2787. www.midwiferycouncil. and training. Therapeutic 31. PHARMAC. Modifying health.nz/midwives/ advances in drug safety. funded access to mife- practice-issues/midwifery- 2017;8(11):349-60. pristone and misoprostol scope-practice-abortion- 29. Nursing Council of New [Internet]. 2020 [cited 2020 services-march-2020-faqs. Zealand: Te Kaunihera 4 August ]. Available from: 26. Medicines (Standing Tapuhi o Aotearoa. Tūtohu https://www.pharmac. Order) Regulations 2002 Kua Rēhitatia: Registered govt.nz/news/notifica- New Zealand [Available Nurse Prescribing [Inter- tion-2020-07-02-mifepri- from: http://www.legisla- net]. [cited 2020 4 August]. stone/. tion.govt.nz/regulation/ Available from: https:// 32. Ministry of Health: public/2002/0373/10.0/ www.nursingcouncil. Manatū Hauora. Primary DLM170135.html. org.nz/Public/Nursing/ Maternity Services Notice: 27. Medicines Act 1981. Public Nurse_prescribing/ Draft For Consultation Act. 1981 No 118. New NCNZ/nursing-section/ [Internet]. 2020 [cited Zealand [Available from: Nurse_Prescribing.aspx. 2020 22 Sep]. Available http://www.legislation.govt. 30. New Zealand Gazette from: https://www.health. nz/act/public/1981/0118/ Te Kāhiti o Aotearoa. govt.nz/system/files/ latest/whole.html. Medicines (Designated documents/publications/ 28. Raghunandan R, Tordoff Prescriber) – Registered primary-maternity-ser- J, Smith A. Non-medical Nurses Prescribing in vices-notice-draft-con- prescribing in New Community Health Notice sultation-sep20.pdf. 2017 [Internet]. 2017 [cited

NZMJ 30 April 2021, Vol 134 No 1534 ISSN 1175-8716 © NZMA 98 www.nzma.org.nz/journal