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Fifteenth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting Mortality and Morbidity 2020

28 Mar 2024



The Fifteenth Annual Report of the Perinatal and Maternal Mortality Review Committee | Te Pūrongo ā-Tau Tekau mā Rima o te Komiti Arotake Mate Pēpi, Mate Whaea Hoki aims to: 

  • provide epidemiological analysis of perinatal mortality from 2007 to 2020, maternal mortality from 2010 to 2020 and neonatal encephalopathy from 2010 to 2020
  • monitor and track trends and disparities to identify areas for improvement
  • stimulate discussion around appropriate areas for further research
  • provide information on outcomes by year and the appendix containing 2019 tables and figures can be used as a marker in time for future reference
  • focus on previous, critical recommendations that must be embedded into policies, protocols, consensus statements, guidelines and practices to reduce these deaths.

Documents included

At the bottom of this page you can find: 

  • The full fifteenth report, including the following appendices:
    • Appendix A: Reporting mortality and morbidity 2019 | Āpitihanga A: Te Tuku Pūrongo mō te Mate me te Whakamate 2019
    • Appendix B: Perinatal and Maternal Mortality Review Committee recommendations yet to be fully implemented (2007–2019) | Āpitihanga B: Ngā tohutohu a te Komiti Arotake mō Te Mate Pēpi, Mate Whaea Kāore anō kia Tino Whakaritea (2007–2019)
  • The executive summary and the key findings from the report
  • Methods and Definitions for Perinatal and Maternal Mortality Review Committee Reporting | Ngā Tikanga me ngā Kupu Whakamārama mō te Tuku Pūrongo a te Komiti Arotake Ira Tangata.

Key findings

Ethnic, deprivation and age inequities persist in all findings. The health system continues to fail: 

  • Māori
  • Pacific peoples
  • Indian populations
  • those aged under 20 years
  • those living in areas of high deprivation,

all of whom experience worse perinatal outcomes than those of New Zealand European ethnicity.

Neonatal encephalopathy rates remain static with no significant improvement. While it is recommended that all babies with moderate neonatal encephalopathy receive magnetic resonance imaging (MRI), this is not being achieved.

Wāhine Māori, Pacific women and women in higher deprivation areas suffer a disproportionate burden of maternal mortality. 

Increased risk of maternal mortality is correlated with women aged 40 years and over.

Wāhine Māori were 2.91 times more likely to die by suicide as a direct result of maternal mortality than women of New Zealand European ethnicity in the 2006–2020 period.