Social determinants and inequitable maternal and perinatal outcomes in Aotearoa New Zealand.

OBJECTIVES: Aotearoa New Zealand has demonstrable maternal and perinatal health inequity. We examined the relationships between adverse outcomes in a total population sample of births and a range of social determinant variables representing barriers to equity. METHODS: Using the Statistics New Zealand Integrated Data Infrastructure suite of linked administrative data sets, adverse maternal and perinatal outcomes (mortality and severe morbidity) were linked to socio-economic and health variables for 97% of births in New Zealand between 2003 and 2018 (~970,000 births). Variables included housing, economic, health, crime and family circumstances. Logistic regression examined the relationships between adverse outcomes and social determinants, adjusting for demographics (socio-economic deprivation, education, parity, age, rural/urban residence and ethnicity). RESULTS: Maori (adjusted odds ratio = 1.21, 95% confidence interval = 1.18-1.23) and Asian women (adjusted odds ratio 1.39, 95% confidence interval = 1.36-1.43) had poorer maternal or perinatal outcomes compared to New Zealand European/European women. High use of emergency department (adjusted odds ratio = 2.68, 95% confidence interval = 2.53-2.84), disability (adjusted odds ratio = 1.98, 95% confidence interval = 1.83-2.14) and lack of engagement with maternity care (adjusted odds ratio = 1.89, 95% confidence interval = 1.84-1.95) had the strongest relationship with poor outcomes. CONCLUSION: Maternal health inequity was strongly associated with a range of socio-economic and health determinants. While some of these factors can be targeted for interventions, the study highlights larger structural and systemic issues that affect maternal and perinatal health.

Do maternity services in New Zealand's public healthcare system deliver on equity? Findings from structural equation modelling of national maternal satisfaction survey data.

BACKGROUND: Birthing outcomes in New Zealand are demonstrably inequitable based on governmental reports and research. However, the last Ministry of Health maternal satisfaction survey in 2014 indicated that 77% of women were satisfied or very satisfied with care. This study used data from the maternal satisfaction survey to examine aspects of inequity in reported satisfaction with care. METHODS: Structural Equation Modelling (SEM) was used to infer latent variables of satisfaction with equity domains from responses to the satisfaction survey. Additional data (residential location and deprivation score), not used in the Ministry of Health primary analysis, were provided and included in this modelling. RESULTS: SEM showed 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/or barriers to equity associated with additional costs (all p<0.05). Financial burden of additional costs was also unevenly distributed. CONCLUSION: While these findings are congruent with other research on the association between social determinants and maternal satisfaction, it is concerning that they remain sources of inequity in New Zealand twenty years after they were first identified as priorities to address. 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.