The country's largest hospital is set to make major changes to maternity services, after admitting problems in the care of women who died during or soon after pregnancy.
Auckland DHB maternity services came under scrutiny after the deaths of four mothers last year. The Weekend Herald has now obtained an internal document that reveals "lack of access or co-ordination of care was a notable finding in three of the cases".
None of the women was Pākehā, and the report links their deaths to wider concerns about some mothers and babies, particularly Māori and Pacific, along with some Asian groups, not getting the care they need amid increasing capacity pressure.
Such disparities have plagued the entire health system for decades, and the DHB has now set an ambitious, organisation-wide target to achieve equity in three years.
Women's health has been chosen as first under the microscope, alongside mental health, child health and cancer and blood services.
The overhaul was planned before the four maternal deaths in 2020, but findings from those cases will now inform the review, which is in early stages, with staff, patients, iwi and medical groups and unions asked for input.
No changes have been put forward yet, but the document presented to the board lists possible "focus areas" to ease the capacity pressure linked to inequities, including:
• Reviewing the policy for providing secondary maternity services to women living outside DHB boundaries - mostly in West and South Auckland - who choose to give birth at Auckland Hospital. Such women account for about a third of all births, and any change of access would transfer pressure onto neighbouring hospitals, under strain themselves.
• Reducing the high elective caesarean section rate, which is above national and international benchmarks. Hospital leaders have identified private obstetricians as a factor, and have blocked giving access agreements to any more of the specialists, and put planned c-section requests under scrutiny - forcing some women to see psychiatrists to get evidence for the procedure on mental health grounds.
"The women's health service has been identified as a priority area for immediate focus on the board's strategic priority to achieve equity. Data collected by the women's health service suggest that Māori and Pacific women, along with some Asian and Indian women and their babies, experience inequitable outcomes and poor experiences at varying stages of their maternity journey," the maternity report states.
The Weekend Herald last year revealed the four maternal deaths, three of which happened after level 3 restrictions began on March 23.
One maternal death was recorded in the previous three years.
At the time, the DHB said all the women had one-on-one care and the causes didn't appear related, but an overarching review, which is ongoing, was ordered to identify any systemic problems.
The maternity document now reveals, "all four maternal deaths in 2020 involved non-European women and lack of access or co-ordination of care was a notable finding in three of the cases".
"The expert advisory review panel [doing the overarching review] have therefore been asked to ensure findings and recommendations from these reviews have adequately considered any possible structural inequities that may be contributing to disparities for some women."
The Weekend Herald interviewed Auckland DHB chair Pat Snedden, director of midwifery Deborah Pittam, and Nicole Pihema, associate director of midwifery for Māori health and equity, after receiving the report under the Official Information Act.
"Nobody likes to have the kind of experience we had recently with multiple mortality in women's health," said Snedden.
"The question we want to answer at the governance level is, are we doing the best thing for those women? Are we doing the best thing for the women in our own DHB boundaries? Have we got the right relationship between the public and the private services here?
"Issues like public and private, issues like rates of caesarean, issues like access to the services, all will be interrogated in this process. And everybody will be heard who wants to be heard."
Pittam conceded maternity could be a "busy and difficult" environment because of the increasing pressure on capacity, but said that wasn't unique to Auckland DHB.
"What I really want to know is whether or not every woman who walks in the door gets access to absolutely the same level of care and service. And I'm not sure of that.
"Not because I don't think people want to do the right thing, but because the outcomes that come out at the end show us that there's a difference."
A paper outlining proposals is expected to go to the board around the middle of the year. Action already agreed includes hiring more Māori and Pacific staff, along with "care navigators", who are assigned to Māori and Pacific patients to ensure they don't become sidelined by the system.
Other steps to increase primary birthing (when a low-risk woman has a natural birth, overseen by a midwife) include plans for a primary birth unit, in Auckland City Hospital but separate from the main birthing suite, and letting more women have the same midwife through not just antenatal and postnatal care, but birth as well.