The numbers of mothers and babies dying in pregnancy and childbirth across New Zealand has not budged in more than a decade.
Every year in Aotearoa New Zealand, about 650 babies and ten mothers die in pregnancy or shortly afterwards.
The 15th annual report of the Perinatal and Maternal Mortality Review Committee, released today, found this had not changed in 15 years, since 2007.
The report found ethnic, deprivation and age inequities persist and health system continued to fail Māori, Pasifika, Indian, those aged under 20 and those living in poorer areas.
In his introduction to the report, chairperson John Tait said he wanted to say deaths had reduced over time, "but I am saddened and frustrated to say this is not so".
"Aotearoa New Zealand continues to tolerate a health and welfare system that serves Pākehā better than anyone else, having been built around western values and bio-medical ideals."
While there was a reduction in perinatal mortality rates for babies with mothers of Indian ethnicity over the period 2011-2020, no other perinatal-related mortality ethnicity indices had improved.
The report also found there were worse outcomes for babies of Māori and Pacific mothers compared with those of New Zealand European.
The report's authors wanted "urgent prioritisation" to mandate cultural safety education for those working across the maternity sector and government agencies to address the impact of structural racism and socio-economic deprivation.
It also wanted Te Whatu Ora (Health New Zealand) to develop evidence-based solutions in consultation with young mothers and health practitioners to identify women who could more likely die from perinatal conditions.
In a statement, health and disability commissioner Morag McDowell said she had read the report and was "concerned about the lack of improvement over time".
"I also share their view that it is unacceptable that Māori, Pacific and Indian families, as well as babies born to mothers under the age of 20, experience worse perinatal outcomes.
"I was pleased to see that maternity services have been made a priority in the interim New Zealand Health Plan - Te Pae Tata, and note that this is an important opportunity to attend to some of these issues. I also acknowledge that the constraints on the system are complex and will take time to fix.
"However, I hold concerns about the pace of progress to date - fundamental issues remain unaddressed, and in the meantime significant harm continues to occur."
She also said the pace with which some of her organisation's recommendations around maternity care had been "frustratingly slow".
"For example, HDC (Health and Disability Commissioner) has made a number of recommendations to the sector around the need for mandatory multi-disciplinary fetal surveillance training, however, we have continued to observe that such training has not been consistently implemented."
In Te Pae Ora, the government's priorities included establishing maternal mental health, including pathways for bereavement and access to specialist mental health services, as well as improving access and consistency to neonatal retinal screening for premature babies.