Concerns raised more than 20 years ago about inequities in New Zealand’s maternity services have still not being addressed, a new University of Otago study shows. The study, published recently in the international journal Midwifery, examined aspects of inequity in care from a 2014 Ministry of Health maternal satisfaction survey.

Study author, midwife and Professional Practice Fellow, Pauline Dawson says while the results of the Ministry survey reported 77 percent satisfaction from the 3801 women who took part, the Otago analysis revealed that satisfaction was not equitably distributed.

“Younger women, those from areas of high socio-economic deprivation, and remote rural women were most likely to be affected by dissatisfaction associated with physical access, cultural care, information provided and barriers to equity associated with additional costs of maternity care,” Ms Dawson says.

“More than 20 years ago, in a 1999 review of issues around access to maternity care, barriers were identified as contributing to inequitable maternity outcomes. Those barriers included the information given, cultural care as well as physically accessing maternity care.

“This article examines satisfaction data from 2014 and these same issues were still apparent. It is concerning that these remain sources of inequity in New Zealand 20 years after they were first identified as priorities to address.”

New Zealand’s maternity care system is unique in the world in that it is a predominately a midwifery workforce of lead maternity carers (LMC) funded by the Government. While women can choose to pay for a private obstetrician, that specialised care is also free if referred by an LMC for a medical indication.

The study showed cost was a factor in attending ante natal classes particularly for Pacific women and those who live semi-rurally, while women from higher deprivation areas, younger women and those who lived in remote rural areas were the least likely to pay for private specialist care.

“While the system is free for residents, the primary analysis of the 2014 satisfaction report showed that 71 per cent of women had paid for some part of their care, the largest proportion being for ultrasound services,” Ms Dawson says.

“Affordability is a significant barrier to some marginalised groups. If charges are being made for clinically indicated screening and testing it is possible that women at higher risk for poor outcomes are not getting the level of care that other women are.”

The availability of services was also an issue for women who lived rurally, she says.

“The distribution of health services and resources is based on population numbers so urban areas frequently have more services available than rural ones. This means access is often more costly in rural regions.”

The Ministry of Health survey had a poor response rate from Maori and Pacific women, and although weightings were applied in Otago’s analysis, it was likely that had more response from those populations being received, the reported 77 per cent satisfaction rate would be lower, Ms Dawson says.

“Extensive research has found a relationship between discrimination and racism and poor health outcomes in New Zealand.”

Ms Dawson says while the Ministry of Health has recognised the extra work and cost involved providing care to women with complex needs and rural women, and is reviewing the system, more engagement with those affected is paramount.

“On the basis of this study, urgent attention needs to be paid to removing sources of inequity within the health system and maternity care in particular.

“We need to engage with these communities and ask them what is important and how they would like the care provided, rather than a top-down approach. Some of the most marginalised groups were least satisfied and work needs to be done at a systemic and structural level.

“We need frank and honest consumer engagement and involvement in co-design of systems,” Ms Dawson says.


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