Women wanting caesarean sections saw psychiatrists to prove mental health grounds for the surgery, as the country's largest hospital tries to bring down numbers.
Auckland City Hospital has one of the highest caesarean rates in the country, and hospital bosses have identified private obstetricians as a factor, because their patients are much more likely to have the surgery.
It has blocked any more of the specialists from using its services, and put caesarean section requests from those with existing access under greater scrutiny, particularly earlier this year when capacity was needed in-case Covid-19 broke out.
Some women ultimately got the surgery, but only after seeing a psychiatrist - a significant and costly step, and one that goes on their medical record.
The DHB has the backing of the College of Midwives, but Jenn Hooper, founder of Action to Improve Maternity, questioned the "obsession" with reducing caesarean rates, when long-term outcomes should be the focus.
"Women should be absolutely free to make whatever decision, in a fully informed way, that they want to make. Alongside their practitioner, whoever that is."
Elective caesareans (planned in advance of labour) accounted for more than one in five births at Auckland DHB last year - up from 15 per cent a decade earlier.
One reason identified by hospital management is patients who pay about $6000 for tailored, medical care and closer monitoring by a private obstetrician and their team.
Those in the public system get referred to an obstetrician if complications arise, but patients might deal with different doctors.
There is a lack of private birthing facilities, and for decades women looked after by private obstetricians have used Auckland DHB labour and birthing facilities, under "access agreements" with individual specialists.
For "low-risk" women giving birth for the first time at the 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, a paper recently presented to the DHB board noted.
About half the patients cared for by private obstetricians are NZ European, the report noted, compared to 2 per cent Māori and 2 per cent Pacific - groups at greater risk of problems like having premature or under-size babies.
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 caesarean performed.
"We currently enable private obstetricians to access our hospital services to provide private obstetric care. This provision of private care within a public hospital is relatively unique in New Zealand and not offered for other clinical specialties," Auckland DHB chief executive Ailsa Claire told the Weekend Herald in a statement.
"Our intervention rates do not reflect best care for mothers and babies and this is something that we are concerned about, as evidence shows when a woman can have a vaginal birth, the health of both mother and baby benefit."
The drive wasn't related to service capacity or the standard of patient care, Claire said.
Earlier this year Auckland and other DHBs cleared capacity for any Covid-19 cases, and planned caesarean were reviewed "to ensure clear clinical indications".
"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."
No new access agreements for private obstetricians have been granted for more than 12 months.
"I'd like to be very clear that at this stage we have not put a stop to anything," Claire said. "We have just paused providing access agreements to any more private obstetricians while we are undergoing an engagement process."
That would include partnering with iwi, she said, and working closely with patients, families, clinicians, midwives and private obstetricians.
There are currently 26 private obstetricians with access, who cannot meet demand; women must book before about six weeks' pregnant or risk missing out, and some are contacting private providers before an IVF transfer, or after a positive pregnancy test.
Midwives are also under high workloads. One South Auckland couple at eight weeks' pregnant spent last weekend contacting 30 midwives without success. Distressed, they decided to take out a loan to book with a private obstetrician, but the first three they rang were also booked out.
They eventually found a private obstetrician who fit them in, but the man's mother, a retired midwife, raised the alarm in letters to the Prime Minister and Women's Minister Jan Tinetti, saying, "this situation is causing me great alarm for the safety of both mother and baby".
Private specialists say their patient profile helps explain the higher caesarean rate - often women have medical conditions or complex history, a past traumatic birth or anxiety about their pregnancy. The cost can include private midwifery care.
Private obstetrician practices approached by the Weekend Herald declined to comment, one citing legal advice.
A Ministry of Health spokesperson said it was working with the DHB on the issue, "and acknowledges their efforts to further strengthen their triage processes across their maternity services and secondary care".
The ministry's position is, "no public funding is to be made available for non-clinically indicated elective caesarean sections".
"However, the ministry acknowledges that DHBs are responsible for the allocation of funding and the provision of services to their population," the spokesperson said.
Lesley Dixon, adviser for the College of Midwives, said it supported efforts to ensure caesarean were clinically necessary, and "significant variation" between DHBs indicates other factors were likely at play.
"Babies born by elective C-section - who have not been exposed to any labour - are more likely to experience breathing difficulties following birth and those born via emergency C-sections are more likely to experience difficulties establishing breastfeeding," she said.
"C-sections also have ongoing implications for women and babies' longer-term health, and for future pregnancies. In addition to this, C-sections are resource intensive for the health service and require a longer hospital stay."
The debate comes amid separate and unrelated investigations, after four women died during or soon after pregnancy this year, with three happening after level 3 restrictions began on March 23.
One maternal death was recorded in the previous three years.
Reviews into each case are being finalised, and an overarching review will then begin. Auckland DHB says all women had one-on-one care and the causes don't appear related, but it's crucial to identify any systemic problems.