Midwives have complained that a lack of safe transfers from Central Otago and Queenstown to main centres is putting "women and babies at risk".
The New Zealand College of Midwives wrote to the Southern District Health Board last year on behalf of "extremely concerned" midwives.
"We are formally notifying you of the concerns of midwives in the region and the risk to the health and safety of the women, babies, and midwives."
Released to the Otago Daily Times under the Official Information Act, it highlights difficulties between hospital doctors - who call the shots - and midwives.
"There appears to be very poor understanding by the clinicians at Southern DHB ... of the logistics and safety challenges to the woman, her baby and her midwife when transferring to [hospital] from these remote rural settings.
"It is not just distance that is an issue for the midwives in this region but the lack of understanding, support, and help provided by the DHB to them during these transfers."
Hospital clinicians "sometimes minimise the transferring midwives' concerns", college chief executive Karen Guilliland's letter said. Ambulance transfers were often delayed, and there was insufficient medical support on the road.
Sometimes women had to change ambulance mid-journey. One Wanaka to Dunedin transfer involved four ambulances. If no ambulance was available, midwives had to use their own vehicles.
"The clinicians at the base hospital [in Dunedin or Invercargill] currently determine whether an air ambulance can be provided - it should be the clinician providing care directly to the women who determines the level of priority.
"It sometimes appears these decisions are made on a cost basis rather than a care required basis," the letter said.
Ms Guilliland's letter, which was also sent to the Ministry of Health, pointed to the area's significant population growth. Since the August letter, the parties had had a meeting to discuss the matter, the SDHB said in a statement this week.
"Representatives from Southern DHB and the New Zealand College of Midwives met in November and are working together with the wider sector involved to improve transfer and transport processes," the statement said.
Commissioner Kathy Grant's reply to Ms Guilliland was also released under the OIA.
New Zealand College of Midwives principal adviser Norma Campbell told the ODT yesterday there was now better communication between the parties.
"I guess, for us, we're keeping monitoring it because we want the momentum to continue. The college is keeping a watching brief."
Mrs Campbell said the board needed to consider moving more resources to areas to match population growth.
"They need to look at the whole district health board and where the population is now.
"If you can transport people with skiing accidents, why do midwives have such a problem transporting women and babies?"