A first-time mother who paid hundreds of dollars to see a psychiatrist to prove mental health grounds for a caesarean section worries other women will miss out, amid a drive to bring down the number of surgeries.
"I would like to ensure other women have access to this procedure if it's the way they would like to give birth," the woman, whose boy was born in July, subsequently wrote to the DHB.
"I strongly believe if I hadn't had my obstetrician advocating for me and the resources to see a private psychiatrist (at a cost that is prohibitive for many people) I would have been faced with being rejected for this surgery, and robbed of the opportunity to deliver in the way I felt was safest."
The woman, who asked not to be named, released the letter - a similar one was sent to the Health Minister - after the Weekend Herald revealed growing tension at Auckland City Hospital over elective caesarean sections.
A caesarean section may be planned (elective) or unplanned (emergency), if complications develop and delivery needs to be quick.
Elective caesarean can be for a range of reasons, including having had the surgery previously, failed induction and the position of the baby, and now account for more than one in five births at the hospital.
Auckland DHB wants to rein in numbers, and has blocked more private obstetricians from using its facilities, because their patients are more likely to have a planned caesarean, and often live outside the DHB boundaries.
The 26 private specialists with existing access have had their requests put under more scrutiny, particularly earlier this year when Covid-19 threatened.
Some caesareans were declined, but later granted after the women saw psychiatrists to prove mental health grounds.
The woman who spoke to the Weekend Herald paid about $450 to see a psychiatrist, and the DHB booked her elective caesarean after their report, which strongly supported her decision, and "included details and experiences that were quite traumatic for me to re-live."
In her letter she praised the "compassionate, kind" staff, who ensured the surgery went well and helped her complication-free recovery.
"I urge you to reconsider how you are assessing people for elective caesarean sections, my birth has set me up for a positive postpartum experience and I hope that all women, regardless of their resources and LMC, will have access to this if they choose it in the future," she wrote.
There is a lack of private birthing facilities, and for decades women looked after by private obstetricians (at a cost of about $6000) have used Auckland DHB labour and birthing facilities, under "access agreements" with individual specialists.
For more than 12 months no new agreements have been granted - a "pause" while engagement is carried out with sector groups.
Recent DHB board meeting minutes noted, "women do not have the right to determine whether they can have a C-section or induction; this should be decided on the basis only of clinical need".
"The issue is that these women are receiving high-cost healthcare when there is no clinical reason for it," the minutes summarised.
"The DHB has limited resources and Auckland DHB provides the majority of services to people who cannot afford a private obstetrician. That means when the private obstetrician comes in and uses theatre capacity that theatre becomes unavailable to the rest of the Auckland population."
Auckland DHB chief executive Ailsa Claire said the situation where women saw psychiatrists to get C-sections "occurred during a time of heightened risk of a surge of Covid-19".
"In some instances where case reviews showed no clear clinical evidence, patients cared for by private obstetricians were able to provide psychological assessments that supported the clinical need for caesarean sections. Once this clinical need was established, these C-sections went ahead."
Royal Australian and New Zealand College of Obstetricians and Gynaecologists vice-president Dr John Tait declined to comment on the situation at Auckland DHB, but said the choice of how women give birth was influenced by funding - DHBs are only funded for caesarean sections that are medically required.
"The most important issue for maternity services in New Zealand is actually equity of access and outcomes for all women. It is vital that the focus is on improving outcomes for Māori, Pasifika and Indian women, and mothers under 20 years of age."
Giving birth at Auckland Hospital
• For "low-risk" women giving birth for the first time at Auckland Hospital in 2019, the caesarean rate for those using private obstetricians was more than 50 per cent, compared to a national average of about 21 per cent
• About half the patients cared for by private obstetricians at Auckland Hospital are NZ European, compared to 2 per cent Māori and 2 per cent Pacific. The rest are mostly Asian, "other European" and Indian.
• Women living outside the DHB's boundaries (mostly in West, North and South Auckland) who use such specialists give birth at Auckland City Hospital, and last year accounted for 325 of 1361 elective caesareans performed.