School nurses handing out emergency contraceptive pills to teenage girls are among radical changes suggested to reduce the newborn and fetal death rate in South Auckland, which is 20 per cent above the national rate.
The suggestions by an independent review also include:
*State-funded financial incentives to encourage all women to book into antenatal care before the 10-week point in pregnancy.
*Improved access to ultrasound scanning to check, early in pregnancy, fetal size-for-age.
*State financial incentives for midwives who care for women with high needs, to help reduce South Auckland's chronic shortage of midwives.
*Better family planning services, because of links in national statistics between perinatal mortality and both teen pregnancy and having had four or more births.
*A medical abortion centre set up in the district, "mobile" contraceptive services, and after hours and "drop-in" contraceptive clinics.
The review was commissioned by the Counties Manukau District Health Board after it was found the area's fetus and baby death rate was more than 20 per cent above the national rate.
The figures cover the perinatal deaths - fetuses or babies from 20 weeks' gestation to 28 completed days after birth, or weighing at least 400g if gestation was unknown.
They include late abortions, which are mostly for congenital abnormalities.
More than half of the 8500 babies born a year to women living in Counties Manukau are from Maori or Pacific mothers or those who live in poor areas.
"If Counties Manukau District Health Board had the same perinatal mortality rate as the rest of New Zealand there would be approximately 27 fewer stillbirths and neonatal deaths in the district per year," the review panel says in its report, made public today.
There is some weak evidence that the district's elevated mortality rate is linked to Pacific ethnicity and poverty. However, the stronger explanation from several years of research is that it is largely explained by the underlying health and social risk factors of the population.
One researcher said: "It is not being Maori or Pacific that places you at higher risk. It is an increased odds of exposure to risk factors such as smoking, obesity, premature birth etc."
Maori women have high rates of smoking, and Pacific women have high rates of obesity.
Review panel chairman Professor Ron Paterson, the former Health and Disability Commissioner, said each death was a significant loss and brought immense grief to parents and whanau. Some were potentially avoidable.
"Decisive action is needed to address the underlying population health factors that contribute to perinatal [sickness] and mortality in Counties Manukau."
As well as more community-based family planning, to reduce clinic waiting times of up to six weeks, the panel wants the DHB's maternity service to routinely offer long-term contraception to women before they are discharged home.
More controversially, the panel suggests a medical abortion service should be set up in the district, as well as after hours and "drop-in" contraceptive clinics, and calls for more school nurses to be permitted to hand out emergency contraceptive pills to sexually active girls.
A source said clinics at some high schools provided contraceptives, but others didn't because of opposition from the senior management and board.
"Mobile" contraceptive services have also been recommended but the review did not suggest how this would work.
DHB staff, including the director of nursing, told the panel that Middlemore Hospital's maternity staffing levels were at times "unsafe" because of difficulties recruiting and retaining sufficient midwives, although gaps were largely filled with agency staff. Professor Paterson said this did not mean it was an unsafe facility: in fact the DHB's death rate during labour and birth was no different from other parts of the country.
DHB chairman Professor Gregor Coster, who commissioned the review, said the board was keen to implement its recommendations.
Chief executive Geraint Martin said he had appointed senior DHB official Margie Apa, a former deputy director-general of health, to oversee implementation of the recommendations.
The Health Ministry, when asked about extra funding for community midwives and family planning, said it would explore all funding options with the various parties and discuss family planning with the DHB.
from 20 weeks' gestation to 28 days after birth
13.1 per 1000 births
10.8 per 1000 births