An overhaul of maternity services at the country's largest hospital could affect the thousands of women who use a private obstetrician or live outside Auckland DHB boundaries but choose to give birth there. Nicholas Jones reports.
New Zealand was in its first lockdown when the couple rushed to Auckland City Hospital emergency department, worried about her pregnancy.
The husband wasn't allowed to stay because of Covid-19 visitor precautions, and that night his wife called to confirm premature rupture of membranes.
Twenty-one weeks' gestation is below the typical limit of viability and the next morning doctors confirmed the couple had lost their daughter.
The husband, who asked not to be named to protect the privacy of his two young sons, had to wait at home during and after his wife's surgery - and was called hours later to learn she was in intensive care with a blood infection.
When he got to her bedside she was sedated, receiving dialysis and on a ventilator. The next morning, doctors began administering adrenaline and CPR.
"After 20 to 30 minutes, a doctor told me there was nothing more they could do to save my wife," the man later told the Weekend Herald. "I kissed and hugged her. I told her I loved her and would take care of our kids and her mum."
The April 25 death was one of four deaths of women during or soon after pregnancy at Auckland DHB last year.
That caused alarm - only one such maternal death had occurred in the previous three years, and officials launched a number of investigations.
The Weekend Herald has now obtained an internal report 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 extraordinary document 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.
Maternity services are set to be overhauled to try to eliminate that inequity - changes likely to affect thousands of women and families.
"The outcomes are telling us that something is not right," Deborah Pittam, Auckland DHB's director of midwifery, told the Weekend Herald.
"At some point, some people are getting a different deal to others. So we need to find out what it is that's contributing to that."
One focus is likely to be the thousands of women living outside DHB boundaries, mostly in West and South Auckland, who choose to give birth at Auckland City Hospital, contributing to the pressure on services linked by the DHB report to inequities.
Another is private obstetricians ordering elective caesareans that the DHB doesn't think are necessary, tying-up limited staff and theatre time.
Nothing has been proposed yet but any change to restrict numbers of outside women would be hugely controversial and pile pressure on Middlemore, North Shore and Waitākere Hospitals, whose maternity services are also strained.
And emails obtained by the Weekend Herald show private obstetricians have pushed back against moves to limit their numbers and scrutiny of c-section requests.
In an exclusive interview, Auckland DHB chair Pat Snedden, Pittam and Nicole Pihema, associate director of midwifery for Māori health and equity, say the hospital needs to take action.
"Nobody likes to have the kind of experience we had recently with multiple mortality in women's health," Snedden says.
Staff go above and beyond for patients, says Pittam, despite doing overtime to cover for "constant" short staffing.
"They work so hard and they do an amazing job. But I guess what I really want to know is whether or not every woman that 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 show us that there's a difference."
Capacity pressure from women not living locally
The maternity report is part of a wider push to eliminate decades-old inequity across the entire DHB within three years.
Women's health is one of the first areas under the microscope, alongside mental health, child health and cancer and blood services.
The revamp was planned before the maternal deaths, but investigations into those tragedies, and an ongoing, overarching review by a panel, including independent experts, will now be likely to inform the work, which is in early stages. Staff, patients, medical groups and unions and iwi have been asked for their views.
Nothing's been proposed, but the report identifies possible "focus areas", including reviewing the policy for providing hospital maternity services for women outside DHB boundaries.
Auckland Hospital is a tertiary centre, meaning women and babies needing highly specialised and technical care are sent from other areas and regions.
At present, other lower-risk women living outside the DHB boundaries, which stretch from Avondale to Mt Wellington and Ōtāhuhu, choose to give birth at the hospital.
They are mostly Pākehā or Asian, and account for about a third of births. Accounting for women going the other way, there's a net inflow of about 1000 women each year - a big number in a system struggling to find enough space and staff.
A decision by Auckland to limit or stop such demand from outside the district would create "flow-on disruptions" for other DHBs, the report recognises.
Counties Manukau, in particular, is contending with a growing population that needs complex pregnancy care, partly because of high obesity rates linked to poverty.
In December, a report warned that maternity services there were dealing with more complications such as gestational diabetes, in ageing facilities and with workforce shortages (which are nationwide).
Pittam says the number of women from outside the DHB boundaries "definitely does impact on how busy we are", with such women having higher rates of c-sections and other interventions.
"I think it's something we have to look at as part of this process and just find out what is driving it."
Tension with private specialists
Another focus is reducing the number of caesareans the hospital carries out, which is currently far above average national and international rates.
The hospital has identified private obstetricians as a reason, because women they look after are much more likely to have an elective c-section (planned in advance of labour, as opposed to emergency c-sections, done if complications develop and delivery needs to be quick), and often live outside DHB boundaries.
Private specialists say their patient profile helps explain the higher rate - often women who have medical conditions or complex history, a past traumatic birth or anxiety - and this isn't reflected in the data cited by the DHB.
However, hospital leaders believe too many operations are not medically justified, and ordered because of patient choice. Guidelines in other countries, including the UK, allow for such "maternal-request" caesareans, but the NZ Ministry of Health doesn't fund them.
Across Auckland, there is a lack of private birthing facilities and, for decades, private obstetricians - who charge about $6000 to look after women through pregnancy and birth - have been granted "access agreements" to use labour and birthing facilities at Auckland Hospital.
However, DHB executives are now questioning that arrangement, including because most patients cared for by the specialists are NZ European, with only a fraction Māori and Pacific.
ADHB chief executive Ailsa Claire told a November board meeting they had limited resources, meaning, "when the private obstetrician comes in and uses theatre capacity that theatre becomes unavailable to the rest of the Auckland population".
Board member Tama Davis agreed, saying, "these private planned interventions are using the resource of a public system that should be applied to those in greatest need. There is an equity aspect to this situation".
No new access agreements have been granted for more than 12 months.
The 26 specialists already with access have kept it, but their c-section requests have been put under more scrutiny, particularly last year when capacity was needed in case Covid-19 broke out. Some women ultimately got the surgery but only after seeing a psychiatrist to prove mental health reasons.
Emails show the crackdown has caused tension with private obstetricians, one of whom emailed Dr Rob Sherwin, director of women's health, in June, copying in lead clinicians at three private maternity practices.
In response, Sherwin said until there was a plan to reduce unwarranted treatment, the pause on new access agreements would continue, and "it would seem evident to me that a request to list a patient for surgery must include details of the clinical indication for the procedure; a number of caesarean section requests include no details other than 'maternal request'".
Another private specialist copied into the email chain replied all, "how very condescending!", and spoke of "walls of concern and frustration".
Those feelings could intensify - the maternity services report lists "reducing the high intervention rate" as a suggested focus.
"People will say, 'You are going to throw things up and down,'" Snedden says of the sensitivities. "We're not ... 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 ... we will take it all, and make an assessment of what needs to happen."
(A paper outlining proposals is expected to go to the board around the middle of the year).
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 - something expected to appeal to women who aren't comfortable being away from the hospital - and letting more women have the same midwife through not just antenatal and postnatal care, but birth as well.
Three of the maternal deaths occurred after the Covid outbreak put Auckland into a level 3 lockdown in March last year.
Pittam acknowledges the associated restrictions deepened the pain of some families, but says they didn't contribute to the care access or co-ordination problems.
"I think they are access issues that exist in our systems, and have existed forever."
The DHB says when things go wrong they are taken "extremely seriously", and women can be confident they and their babies will get high quality care.
However, data collected by the women's health service suggests poor experiences and inequities happen "at varying stages of the maternity journey" for Māori and Pacific women, the maternity report states, "along with some Asian and Indian women and their babies".
Some examples: perinatal mortality has decreased significantly for NZ Europeans, but not other ethnic groups. Māori women are more likely to give birth prematurely, and this gap is widening.
Those sorts of disparities plague the entire health system, and can't be blamed solely on wider social factors like poverty. A growing number of studies show Māori and Pacific people are less likely to be referred or accepted for treatment, and once in the system generally get less treatment.
DHBs, including Auckland, have attributed part of the problem to institutional racism, a term that describes how procedures or practices result in some groups being disadvantaged.
Confronting that can be uncomfortable, says Snedden, but changes to other services made a "profound" difference, without great cost.
That includes hiring "care navigators", nurses who are assigned to Māori and Pacific patients, to ensure they don't get sidelined by the system - securing an appointment or moving it to outside of work or childcare hours, for example.
The goal is to recognise how that helps, and eventually change systems so it happens for everyone who needs it, automatically.
More Māori and Pacific staff will be hired, "cultural competency" training will continue, and the success of working closely with iwi and Pacific groups during the pandemic - handing over more control and funding than ever before - expanded upon.
Even small steps like normalising the use of te reo Māori can make a big difference, says Pihema, who was the first Māori president of the College of Midwives, before taking her DHB role.
Her patients have exclaimed on the increasing and skilled use of te reo by TV and radio presenters and reporters, she says, "recognition of their culture that puts more emphasis on the fact that they're not invisible - and it is that invisibility stuff which is [what] we want to get rid of".
Last year the Weekend Herald revealed Auckland other DHBs were considering an unprecedented step to prioritise Māori and Pacific patients for certain elective surgeries, to ensure lockdown-driven backlogs didn't worsen inequity.
That's now happening through an "equity adjuster", confirms Snedden, a former chief Crown negotiator in the Office of Treaty Settlements.
"It is across a lot of services, and we are happy about it because it's actually making a difference."
Not everyone is supportive: such prioritisation is opposed by National and some elected board members and has been condemned by Act leader David Seymour.
However, the approach is spreading - Pharmac announced in January it would fund new diabetes drugs for all Māori and Pacific patients who haven't kept blood sugars under control, the first time the drug-buying agency has specifically included ethnicity as a criterion.
This week the Government confirmed elderly Māori and Pacific and those with long-term health conditions - and their wider whānau - would be prioritised for Covid-19 vaccination, with doses for that purpose given to Māori and Pacific health providers.
That's a "by Māori for Māori approach," says Associate Minister for Health Peeni Henare, although others have argued it doesn't go far enough, given studies show Māori and Pacific are at increased risk of infection, hospitalisation and death.
Momentum to eliminate health inequity is building, but is Auckland DHB's aim to do so in three years feasible?
"What will be achievable is to see whether it's working," says Pihema. "Three years is actually more than enough to see whether what we are doing is the right track."
A grandson never met
The DHB has completed individual reviews into the four maternal deaths, including Emerald Tai, who died with her 3-day-old son Tanatui at their home on March 16 last year.
The mother of seven died from sepsis from a post-birth infection. The baby, named after his father, also had sepsis but "unsafe sleeping" contributed to his death.
The DHB investigation found gaps in the system let Tai self-discharge with "early indications" of an infection to an address not listed with health-care providers, and case details weren't passed on to the community midwife.
"What has happened is unforgivable," said Tai's mother Susan Fa'amoe, who has set-up a Give a Little page to help her grandchildren.
"Tana has lost his soulmate and his baby and that broke a piece of him ... I have lost my daughter and my grandson, who I never got to meet."