Connecting hapū māmā (pregnant women) early to a lead maternity carer: striving for equity using the Best Start-Pregnancy Tool

Keywords: health equity, infant health, maternal health, midwifery, Native Hawaiian or Other Pacific Islander, pregnancy, pregnancy trimester, pregnant women, primary health care.

In Aotearoa New Zealand, hapū māmā (pregnant women) are expected to select a lead maternity carer (LMC) to provide maternity care until 6 weeks’ postpartum. An LMC may be a midwife, general practitioner (GP), or obstetrician. The Perinatal and Maternal Mortality Review Committee (PMMRC) strongly recommends hapū māmā engage with an LMC before 10 weeks’ gestation to allow for timely screening and risk assessments, and education.¹ Support from an LMC early in pregnancy is critical for identifying and managing risk factors for perinatal and maternal mortality, and for optimising health outcomes for māmā and pēpi (mothers and babies). LMC midwifery care is most common in Aotearoa and is funded for all citizens;² however, barriers may exist for hapū māmā to connect with a midwife early in pregnancy, such as not knowing how to find a midwife, not being confident to contact a midwife, limited finances, and limited time.³ Māori hapū māmā are less likely than non-Māori hapū māmā to be registered with an LMC in the first trimester of pregnancy.⁴ The PMMRC has documented frequent barriers to the access and provision of care for Māori whānau (Māori families), which breach the health sector’s obligations to Te Tiriti o Waitangi.¹

Primary health care plays an essential role in connecting hapū māmā to LMCs early in pregnancy and achieving equity for Māori hapū māmā. The Generation 2040 Best Start Kōwae (modules) is an online tool funded by the Ministry of Health. The tool was recently developed from He Korowai Manaaki (Pregnancy Wraparound Care)⁵ as a pro-equity approach for use by primary care providers (PCPs) and LMCs, and is currently in an implementation phase.⁶ The Best Start Kōwae prompts a PCP to engage hapū māmā with an LMC from their first point of contact once a pregnancy is confirmed. The tool also guides an LMC to determine selected risk factors to the health of māmā and pēpi at three time points: early in pregnancy, during the second trimester, and 6 weeks postpartum. The first Kōwae: the Best Start-Pregnancy Tool prompts questions about physical and mental health, maternity and obstetric history, medications, housing, family violence, and smoking, drug, and alcohol use. If a hapū māmā does not connect with an LMC early in pregnancy, the first Kōwae can still be utilised at any time point.

The main aim of this study was to investigate the LMC plan (midwife, GP, or obstetrician) for hapū māmā at their first GP visit once a pregnancy is confirmed, including selected risk factors to maternal and perinatal health as documented in the first Kōwae. An ‘LMC plan’ is used because it is not confirmed whether hapū māmā became engaged with the anticipated LMC, which is outside the scope of this study. The secondary aim was to compare the LMC plan and selected risk factors between Māori and non-Māori hapū māmā. It was hypothesised that more Māori hapū māmā would present with risk factors to maternal and perinatal health than non-Māori hapū māmā. This study also explored the extent of data entry into the first Kōwae by PCPs.

This cross-sectional study was undertaken by a Māori research team as an audit and quality improvement-related activity of the first Kōwae: the Best Start-Pregnancy Tool (Health and Disability Ethics Committees reference: 20/CEN/275). The National Hauora Coalition anonymised the data for the research team. The authors underwent Privacy Training (Office of the Privacy Commissioner) and completion certificates were sent to the National Hauora Coalition before the research team accessed the anonymised data. Data had been entered from 27 November 2020 to 3 December 2021 by PCPs in Aotearoa New Zealand at the first point of contact with hapū māmā once a pregnancy is confirmed. If multiple ethnicities were reported, ethnicity was prioritised according to the Ministry of Health ethnicity data protocols.⁷ All questions in the Best Start-Pregnancy Tool were reviewed by the research team. Based on the research aims and hypothesis, consensus was reached on which data points to analyse. Data entries were reviewed for pregnancy status, woman’s response to pregnancy news, and missing data. Responses to mental health, housing, and family violence screening questions were recoded into binary data to indicate risk: yes or no (Supplementary File S1).

Gestation was estimated based on the date of data entry subtracted by the last menstrual period (LMP) and converted into weeks. Descriptive statistics and statistical analyses were performed using SPSS (Version 28; SPSS Inc., Chicago, IL, USA). Parametric tests were conducted based on the central limit theorem (n > 30).⁸ Continuous data (age, gestation, gravida, and parity) were compared between Māori and non-Māori groups using independent t-tests. For statistically significant differences (P < 0.05), effect sizes were calculated using Cohen’s d. Categorical data were reported as counts and percentages. Chi-squared tests were performed to assess the probability that differences between groups were due to chance; effect sizes were calculated using Cramer’s V.

Almost one-fifth of data entries were removed from analysis (93/482). Some entries indicated pregnancies were discontinued (6/93) or termination was planned (3/93). The majority of removed entries were due to missing information about an LMC plan (74/93) or LMP (5/93). Gestation periods estimated at <3 weeks (5/93) were deemed erroneous and removed from the dataset due to reporting error.

Data from 389 hapū māmā across 11 District Health Boards (Table 1) were compared between Māori and non-Māori. Ethnicity was not reported for 11 hapū māmā. Demographic information is presented in Table 2. Māori hapū māmā were statistically significantly younger (M = 26.2 years, s.d. = 6.0) than non-Māori (M = 29.8 years, s.d. = 5.5; t(376) = −5.8, P < 0.001, d = 0.6). Gestation was registered significantly later for Māori hapū māmā (M = 11.5 weeks, s.d. = 7.9) than non-Māori (M = 9.0 weeks, s.d. = 5.7; t(376) = 3.5, P < 0.001, d = 0.4). Average gravida and parity were also slightly higher for Māori hapū māmā (gravida M = 2.7, s.d. = 2.0; parity M = 1.1, s.d. = 1.4) than non-Māori (gravida M = 2.0, s.d. = 1.4; parity M = 0.7, s.d. = 1.1; gravida: t(368) = 3.9, P < 0.001, d = 0.4; parity: t(351) = 3.2, P < 0.001, d = 0.4).

Table 1.  Distribution of data entries by District Health Board (DHB) in Aotearoa New Zealand.

Table 2.  Demographic information for hapū māmā.

Table 3 details the prompts in the Best Start-Pregnancy Tool to address the LMC plan; the majority of hapū māmā (356/389) indicated they would seek maternity care from a midwife. Out of the data entered (317/389), 71% of hapū māmā (224/317) had not chosen their midwife before their GP visit. One-third of entries (143/389) were missing about whether midwifery care information was provided to hāpū māmā.

Table 3.  The connection to LMCs for hapū māmā.

Significantly more Māori hapū māmā presented with risk factors to maternal and perinatal health related to smoking, vaping, alcohol intake, depression, anxiety, housing, and family violence (Table 4). For current smoking status, three-quarters of possible data entries were missing (293/389). Almost half of Māori hapū māmā lived with someone who smoked (53/115), compared to 16% of non-Māori (42/255); Chi-squared (2) = 36.5, P < 0.001.

Table 4.  Selected risk factors to maternal and perinatal health.

Half of data entries specified whether hapū māmā were experiencing problems in pregnancy (192/389). Medication reviews were documented for 58% of hapū māmā (227/389).

This retrospective study analysed 389 entries made by PCPs in an implementation phase of the first Kōwae: the Best Start-Pregnancy Tool. Findings highlight the pivotal role of primary health care in connecting hapū māmā to an LMC early in pregnancy.

After a confirmed pregnancy, some hapū māmā may directly contact an LMC before visiting a PCP. This dataset is limited to hapū māmā who did seek support from a PCP after a confirmed pregnancy. A minority of hapū māmā (29%) had engaged with a midwife before their first GP visit after a confirmed pregnancy. Although this proportion was similar for Māori and non-Māori, Māori hapū māmā presented at a significantly later gestational stage. The mean gestation for Māori hapū māmā also fell outside the recommended connection to an LMC before 10 weeks.¹ Since 2009, data from the National Maternity Collection show an ongoing trend that Māori hapū māmā and Pacific peoples have lower rates of registering with an LMC in the first trimester than other ethnicities.⁹ Even though some hapū māmā were in their second or third trimester, data entered into the First Kōwae were relevant for maternity care. The majority of hapū māmā planned for a midwife as their LMC.

In this small sample size, the hypothesis was confirmed; Māori hapū māmā were more likely to present with risk factors to maternal and perinatal health outcomes. Many of these risk factors are social determinants of health, which are detrimental to Māori due to colonisation.¹⁰ Māori hāpu māmā were significantly overrepresented as current smokers (28% of Māori vs 6% of non-Māori) and living with a smoker (45% of Māori vs 16% of non-Māori). The serious effects of smoking are well-documented, including stillbirth, low birth weight, and sudden infant death syndrome.¹¹ Some smokers may turn to vaping as an alternative in pregnancy, but the consequences remain to be understood.¹² For hapū māmā who reported as having vaped, seven were concurrent smokers (5/7 were Māori), three were ex-smokers and three did not smoke cigarettes. Data entries for smoking status were missing for 20 hapū māmā who vaped. Reported alcohol consumption was also higher for Māori hapū māmā (19%) than non-Māori (10%). Research suggests no amount of alcohol exposure is considered safe in pregnancy, risking adverse outcomes such as miscarriage and fetal alcohol spectrum disorder.^13,14

Significantly more Māori hapū māmā presented with mental health risk. Given the detrimental implications for māmā, pēpi, and whānau, early mental health screening is vital to promote immediate action, despite limited services available.¹⁵ In a study of hapū māmā in late pregnancy, more Māori māmā were affected by depression, anxiety, and life stress; however, non-Māori were more likely to seek help or be prescribed antidepressants for low mood.¹⁶ Maternal depression is associated with increased risk of preterm birth, low birth weight and intrauterine growth restriction.¹⁷ Suicide is the leading cause of maternal mortality in Aotearoa New Zealand and a growing inequity for Māori māmā.¹

Poor maternal mental health may be closely associated with experience of domestic violence.¹⁸ More Māori hapū māmā (13%) reported family violence concerns (Supplemental File S1) than non-Māori (4%). This disproportionate representation of Māori is well recognised and central to the recently launched National Strategy to eliminate family violence and sexual violence.¹⁹ The link between safety and well-being of māmā, pēpi, and whānau also relates to housing. In this study, 9% of Māori hapū māmā reported living in poor housing conditions, compared to 3% of non-Māori. A recent qualitative study of young Māori māmāunderlined the numerous health benefits of good-quality housing for Māori whānau, as well as the intrinsic rights for Māori, calling for a Tiriti o Waitangi compliant housing policy.²⁰ Māori health inequities stem from colonisation. Socio-political and health systems have failed to serve Māori; systemic and structural factors have caused devastating generational impacts on Māori health outcomes.²¹ Achieving maternal health equity requires transformative change at systemic and political levels.²²

The extent of data entry demonstrates strengths and weakness of how the Best Start-Pregnancy tool is being used clinically. The prevalence of missing data offers opportunities for further development of the tool, training for PCPs, and future data analysis that may inform health policies and initiatives to benefit hapū māmā and pēpi. The geographical distribution of data entries in the First Kōwae in Aotearoa New Zealand did not reflect the population size of cities or towns (Table 1). The Best Start-Pregnancy tool is yet to reach all PCPs due to the current implementation phase; therefore, there is a disproportionate distribution of data across DHBs.

Missing information about the LMC plan for hapū māmā (74/482) was the most common reason for removing data entries from analysis because the LMC plan was the main aim of this study. Ethnicity was unknown for 11 entries. Reporting ethnicity is important for measuring and monitoring Māori health inequities.²³ Although data were entered for most categories, substantial gaps were observed in some important categories. For example, it is unclear whether almost one-third of hapū māmā were provided midwifery information as data entries were missing. As hapū māmā may experience challenges seeking midwifery care,³ PCPs have an expectation to provide LMC information to mitigate these barriers. Regarding the selected risk factors to maternal and perinatal health, it is also unknown why data entry for smoking status had the highest rate of missing data (55% of data entries for Māori, 83% for non-Māori).

Results must be interpreted with caution given the small sample size; 58 659 births were recorded in Aotearoa New Zealand in 2021.²⁴ The potential utilisation of the Best Start Kōwae by DHB is presented in Table 1, which also demonstrates a limited capture of the South Island population during this implementation phase. There are many clinical parameters that improve quality care and address clinical risks. As the use of the Best Start Kōwae is in an early phase, factors explored in this study were limited by the research team. For example, the First Kōwae also captures whether aspirin, calcium, folic acid, and iodine were prescribed. It is expected there will be further examination of this tool in the future. Other limitations are linked to the retrospective nature of this study. The research team relied on data that had been entered into the Best Start Kōwae database. Gaps in the database were deemed missing data. It is unclear whether missing data entries indicated incompleteness or a negative response. The First Kōwae did not ask for gestational age; date of data entry, LMP, and estimated due date were prompted. Therefore, gestation was calculated based on the dates of data entry and LMP.

This study promotes the adoption of the Best Start Kōwae across primary healthcare services in Aotearoa New Zealand as a pro-equity approach. Findings demonstrate that many hapū māmā are yet to engage with an LMC by 10 weeks’ gestation, particularly Māori hapū māmā. More research is needed on systemic and structural factors that best support Māori hapū māmā accessing an LMC early in pregnancy. Prospective studies that benefit Māori whānau should utilise Kaupapa Māori methodology.

The Generation 2040 Best Start Kōwae is an accessible online tool, founded on equity for hapū māmā and pēpi. This study highlights the importance of screening for selected risk factors (primarily social determinants of health) in early pregnancy (<10 weeks’ gestation). Findings support the routine use of the Best Start-Pregnancy Tool by PCPs throughout Aotearoa New Zealand. Primary healthcare providers should prioritise support for Māori hapū māmā to engage with an LMC early in pregnancy.

Supplementary material is available online.

Data used to generate the results in this study are available by contacting the corresponding author.

The authors declare no conflicts of interest.

This research did not receive any specific funding. This study was conducted as part of a Kidz First Summer Studentship, organised by the Kidz First Māori Child Health Research Collaborative.