Implementing an equity-focused model for early pregnancy care in general practice

Outline of the problem

Significant disparities exist in maternal health outcomes in Aotearoa New Zealand, with Māori and Pacific women experiencing higher rates of complications and poorer outcomes compared to non-Māori women.¹ These disparities are closely linked to barriers in accessing early pregnancy care, highlighting the importance of culturally responsive models to improve equity in outcomes.^2–4

Best Start usage is tracked and reported to participating practices to support monitoring and improvement. In the Whanganui district there is marked variability in the delivery of these early pregnancy assessments and resulting service inequities. This data was reviewed by the Primary Maternity Interface Group, a collaborative forum of general practitioners, midwives, iwi provider representatives, public health staff, and Te Whatu Ora Whanganui clinicians who meet regularly to address gaps and improve coordination across services. This group identified the need to strengthen early pregnancy care systems as a local priority. With support from the Health Research Council (HRC), a collaborative funding initiative was established to develop and implement a model of care designed to address these inequities.

The objective was to develop and implement an equity-focused model of care utilising the Best Start early pregnancy tool.⁵ Using best practice guidance,^6,7 this initiative aimed to provide comprehensive early pregnancy assessments that addressed clinical and social risks while embedding culturally safe and responsive practices.

Outline of the context

Whanganui is a semi-rural district in New Zealand. Māori comprise 28.5% of the population compared with 17.7% nationally,⁸ and experience relatively high levels of socioeconomic deprivation with 35.6% of data zones in the Whanganui District among the most deprived compared with 20% nationally (Quintile 5).⁹

In New Zealand, a shift from general practitioners (GPs) to midwives as primary providers of maternity care occurred in the early 1990s. This transition was initiated by the Nurses Amendment Act 1990 (NZ),¹⁰ which granted midwives the autonomy to practice independently without medical supervision. Subsequently, in 1996, the introduction of the Lead Maternity Carer (LMC) model allowed women to choose their primary maternity care provider – midwife, GP, or obstetrician – with midwives becoming the predominant choice.¹¹

These changes led to a significant decline in GP involvement in maternity care. By the late 1990s, midwives had become the primary providers for most pregnancies in New Zealand, with GPs largely stepping back from this role.¹² This evolution established New Zealand’s current maternity care model, characterised by midwife-led continuity of care. However, primary care guidance identifies roles for general practice including pre-conception information, confirming pregnancy, managing acute or long-term conditions, giving advice about medicines use, offering pertussis and influenza vaccinations, and providing ongoing postnatal support to the mother, infant, their partner, and family/whānau.⁶ Furthermore, in response to Māori health disparities, the National Hauora Coalition (NHC) has developed the Best Start early pregnancy assessment tool as part of its 20/40 Equity Generation programme, providing a nationally available resource for early pregnancy assessments.¹³ In Whanganui, the Primary Maternity Interface Group identified early pregnancy care as a key area for improvement, particularly seeking to address fragmented pathways, inconsistent documentation practices, and challenges in cross-sector communication.

Detail of the approach taken

An iterative, test-and-revise quality improvement approach¹⁴ was used to develop a model of care that responded to reported experiences and concerns. Collected through a series of hui (meetings), a kaupapa Māori approach (an indigenous methodology rooted in Māori principles, values, and worldviews) was used to identify and understand experiences and concerns from both hapū māmā (pregnant women) and their whānau (extended families).¹⁵ Insights from these hui were used to implement the Best Start model across four diverse primary care settings in the Whanganui district: a Very Low Cost Access (VLCA) clinic owned by a health network trust, an iwi-Māori health provider clinic, and two group general practices. This approach aligned with continuous quality improvement methodology and incorporated Total Quality Management (TQM) principles,¹⁶ enabling flexible, real-time adaptation based on both clinical experience and patient feedback.

The methodology was underpinned by kaupapa Māori principles¹⁵ to ensure culturally responsive engagement and uphold mana-enhancing practices. Co-design with māmā and whānau was prioritised, enabling reflection, adaptation, and service realignment at each stage. The overall intent was to develop embedded systems for delivering equity-focused care that could be sustained within everyday general practice workflows.

The project was structured into three inter-related modules:

Criteria, standards, and guidelines

The Best Start early pregnancy assessment tool, developed by the NHC,⁵ served as the central framework for clinical care delivery. The tool included prompts to guide best-practice care, such as:

The tool was originally informed by national guidelines, but was locally adapted in partnership with practitioners to ensure it reflected the realities of general practice. This made the standards both evidence-based and contextually realistic.

Measurement of the problem

Variability and gaps in early pregnancy care were assessed using complementary methods:

Together, these methods allowed triangulation of quantitative and qualitative data, providing a more comprehensive picture of current care processes and identifying clear areas for quality improvement.

Module 1: Hapū Māmā village

Module 2: Clinical Implementation

In the lead practice, 85% of pregnancies were identified and known to practices prior to 100 maternity services birth notifications, with the majority (84%) identified in the first trimester. Of all pregnancies identified, 79% were assessed using the Best Start tool (74% of Māori pregnancies and 85% of European pregnancies). While an equity gap remains, this represents an improvement for Māori: only 4% of Māori pregnancies in the region were assessed using Best Start in 2020/21, increasing to 19% in 2021/22, and reaching 27% in the project period 2022/23. These data suggest that while parity has not yet been achieved, access for Māori has markedly improved through the programme.

Systems changes within the practices included dedicated pregnancy task lists, protected appointment spaces, and warm handovers for referrals. These recommendations were shared with the other research practices, and a Best Start implementation list was developed. A brief version of the tool was developed for opportunistic use during time-pressured clinical presentations. The most common clinical issues identified and referrals made were for mental health concerns and for smoking cessation. Training needs were identified, and an educational package was developed. A full analysis of the clinical implementation module is available.¹⁷

Module 3: Wrap-around Services

Mental health issues were the most common reason for referral, with 18% of māmā referred for support, primarily managed within the practice by a health improvement practitioner (HIP). Smoking was identified in 21% of māmā, most stopped without formal intervention, and the small number agreeing to referral did not attend stop smoking services. A gap in community resources, particularly for māmā without whānau support, was identified. Best Start provider feedback recommended the development of a community service directory as the initial stage of improving access to wrap-around services for māmā.

The model of care

The Best Start model developed through this project incorporated the NHC early pregnancy assessment tool to proactively identify health risks and social concerns during early pregnancy. It was supported by clinical governance and a commitment to continuous quality improvement, including regular audits. The model relied on early identification of pregnant patients and the provision of protected time for comprehensive checks. The structured recording tool guided clinical management and identified social risks. Key features of the developed model included early engagement with Best Start assessments, close collaboration with the wellbeing team (HIPs and health coaches as part of the integrated primary care team), active recall for pregnancy vaccinations, and coordinated care with midwives, including text or phone contacts when clinically indicated, and access to the Best Start report which was consent added to the shared access health clinical portal.

Strategies for quality improvement or change

Lessons learnt

Were benefits sustained?

At the time of reporting, the model had been implemented in all four participating practices in varying degrees. The VLCA and the iwi Māori clinics demonstrated the most complete integration. Ongoing monitoring and feedback from māmā who received the Best Start assessment are planned to further refine the model and support long-term sustainability.

Improving the maternity system and addressing pregnancy outcome inequities are known to be complex.¹⁸ A Best Start model of care has the capability to go beyond screening and risk identification and to draw on the resources within the primary care team. In the local context, continued support from the Primary Maternity Interface Group, the development of a shared community services directory, and emerging connections with kaupapa Māori wānanga programmes all offer promising avenues for embedding this model more widely.