Health and Disability Commissioner concerned by lack of progress in improving maternity care

The Health and Disability Commissioner is calling for urgent action to improve outcomes for whānau in the maternity system.

“I have read the latest report of the Perinatal and Maternal Mortality Review Committee with concern, and I echo their comments about the lack of improvement over time in regards to systemic issues within maternity care. I also share their view that it is unacceptable that Māori, Pacific and Indian families, as well as babies born to mothers under the age of 20, experience worse perinatal outcomes.

”The volume of complaints received by HDC about maternity care is small, however the profile of complaints is more serious than is seen for other services, and the frequency with which common issues recur is concerning. The outcomes for the whanāu involved can often be tragic and the harm caused can have life-long consequences.

“I was pleased to see that maternity services have been made a priority in the interim New Zealand Health Plan – Te Pae Tata, and note that this is an important opportunity to attend to some of these issues. I also acknowledge that the constraints on the system are complex and will take time to fix. However, I hold concerns about the pace of progress to date - fundamental issues remain unaddressed, and in the meantime significant harm continues to occur.”

Ms McDowell further commented “The pace with which some of HDC’s recommendations around maternity care have been implemented has, at times, been frustratingly slow. For example, HDC has made a number of recommendations to the sector around the need for mandatory multi-disciplinary fetal surveillance training, however, we have continued to observe that such training has not been consistently implemented.”

Ms McDowell said the common issues in complaints to HDC about maternity care included:

  • Cultural safety and inequities in care
  • Inadequate management and assessment of risk during labour, and in particular inadequate monitoring of the baby’s heart rate.
  • Lack of adherence to guidelines outlining when a specialist needs to be consulted by lead maternity care midwives
  • Inadequate assessment and management of the baby’s growth
  • Geographical disparities in access to and quality of care
  • Significant workforce issues
  • Inadequate informed consent processes and discussion of women’s options during pregnancy and labour.


HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

Established in 2005, the PMMRC is one of the Commission’s five mortality review committees initially established under the New Zealand Public Health and Disability Act 2000 (the Act), and now sits under the Pae Ora (Healthy Futures) Act 2022. 

The PMMRC reports on mortality trends in babies and mothers and serious morbidity from neonatal encephalopathy, in order to reduce these deaths and improve the quality and safety of Aotearoa New Zealand’s health care system. 



Key Points Summary

  • While the volume of complaints about maternity care is small (around 108 complaints a year), the profile of complaints is more serious than is seen for other services, and the frequency with which common issues recur is concerning.
  • The outcomes for the whanāu involved can often be tragic and the harm caused can have life-long consequences.
  • We have raised concerns about systemic issues in the maternity care system over a number of year and are concerned that fundamental issues are still not addressed. (see below)
  • There is an urgent need for action – harm is continuing in a system that is increasingly constrained.
  • We need an exploration of the wider system factors that shape how maternity services are provided, and ensuring a sustainable workforce must be a priority.
  • There are some quick wins – such as updating the Referral Guidelines and the roll-out of a nationally consistent bereavement pathway for whānau who have experienced loss in the perinatal period.

Our Actions

HDC has written to Te Whatu Ora outlining its concerns and calling for urgent action following the Perinatal and Maternal Mortality Review Committee findings.

Our recommendations are:

  • Cultural safety and inequities in care –complaint numbers about maternal deaths are small but all involved woman of non-European ethnicities. Complaints point to failures by providers to engage consumers and their whānau in their care in a culturally safe way.
  • Cardiotocography (CTG) monitoring/interpretation and inadequate assessment and management of risk by the multi-disciplinary team – one of the most common issues seen in the more serious complaints received by HDC. We have made several recommendations about mandatory multi-disciplinary fetal surveillance training but training still not consistently implemented.
  • Pace of change on updating Referral Guidelines for LMC midwives. Lack of adherence to the guidelines is one of the most common complaints received in our more serious complaints. These guidelines are a safety net for pregnant people especially when we are seeing more complex and acute presentations combined with workforce shortages. The guidelines have not been updated since 2017 – getting them updated is a matter of urgency.
  • Consistent use of GROW (gestation related optimal weight) charts for monitoring and assessing fetal growth. We understand progress has been made but we continue to see the consequences that use of out-dated methods can have on fetal well-being.
  • Access to theatres and staff afterhours - delayed emergency access to theatre, lack of theatre availability and a lack of specialist oversight after-hours. We are concerned about variation in care and geographical inequities in access to and quality of services. These complaints also highlight concerns about a lack of information provided to pregnant people about the availability of services and specialists after-hours at their DHB.
  • Staffing – capacity and capability – We are aware of the pressure the midwifery workforce is under and the capacity and skills mix of staff in obstetric units across New Zealand is a common contributing factor to the issues seen in complaints. We are now seeing a number of complaints raising concerns about the capacity of antenatal clinics across districts. Addressing workforce issues must be a priority to ensure that people using maternity services are receiving an appropriate standard of care.

We support:

  • Pae Ora legislating for a woman’s health strategy. We are in support of this, and acknowledge that this may also provide an opportunity to raise the profile of maternity care and further address some of the challenges we outline below.
  • Maternity and early years services being made a priority in the interim New Zealand Health Plan – Te Pae Tata – this will be important opportunity to address some of these issues identified.
  • HQSC’s position.

We are seeking:

  • An opportunity to discuss our concerns with Te Whatu Ora.