Revealed: ‘Grave concerns’ over pressure on workers before baby deaths
Wednesday, 29 April 2026
Investigations after the deaths of babies shortly before or after birth have raised concerns over staffing pressure or issues. Nicholas Jones reports.
Staffing problems have been linked to the deaths of babies in New Zealand hospitals, a Stuff investigation has found.
The strain on workers before some of the tragedies was so great they couldn’t take breaks. Vital time was lost in some cases because of inadequate or broken equipment.
Stuff reviewed findings by the Coroner and Health & Disability Commissioner (HDC) for births in hospitals and maternity centres since 2016.
This revealed 11 cases where a baby was stillborn or died soon after birth, with subsequent investigations identifying staffing issues or pressure.
In another case, a woman died during a caesarean section that should have been done by a senior specialist, but wasn’t because none were available.
Staffing issues were also identified in five cases in which the babies survived, but had to be resuscitated and suffered lifelong injury and disability, including from brain damage and stroke.
“I am gravely concerned by the resourcing and systems issues highlighted during the course of this inquiry,” concluded a coroner, in a finding on the death of a newborn girl in 2021.
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She was born unresponsive because of a brain injury sustained about 18 hours before her birth, possibly from a compression of the umbilical cord, and died later that day.
The coroner found deficiencies in her care at Auckland Hospital meant she wasn’t delivered quickly enough, and she may have survived if born earlier, although her brain injury meant it was not possible to be sure about this. There were also issues with the availability of equipment.
“An acute shortage of midwives … meant there were not enough midwives available to provide care to the women who were in labour or to support the timely transfer of women from the assessment unit to the delivery unit,” the coroner said.
“The midwives on duty were short-staffed, working long hours in demanding roles, and unable to take any breaks.”
The numbers are highly likely an undercount - the HDC needs a complaint to be made and takes years to make findings, meaning cases from at least the past 2-3 years won’t have surfaced.
Coroner investigations can have a similar lag time, don't cover stillbirths and they are only notified about a minority of baby deaths.
Generally, no determination was made on whether staffing problems caused the deaths. Rather, they were identified as factors or possible factors (among others, like errors from individuals) in substandard care.
Cramped resuscitation area, inadequate equipment
Another case concerned the 2016 death of a baby boy at Middlemore Hospital, 12 hours after birth and from congenital pneumonia and sepsis, a potentially treatable condition.
A coroner determined there were multiple instances when his care should have been escalated, but wasn’t. All staff interviewed as part of the investigation stated that, despite a full roster, staffing was inadequate for how busy the wards were. Many of the night shift staff were so busy they missed meal breaks.
Staff lost considerable time trying to locate equipment such as heaters, a stethoscope and pulse oximeters. The neonatal resuscitation area was cramped, with no computer to access the electronic system.
“It is very hard to pass judgement on a system and the hard-working dedicated professionals who care for mothers and babies,” the coroner concluded. “It was clear there were multiple systemic issues on the birthing and assessment, and maternity wards over the period in question, including staffing, communication and documentation issues.”
At Hutt Hospital, a baby died at six days of age after suffering severe brain damage due to oxygen deprivation before birth.
An HDC decision was critical of an obstetrician for not ordering a C-section earlier on, but noted, “Hutt Valley DHB did not ensure that its staff were supported adequately to provide safe and appropriate care”.
A review by the hospital noted, “on the night in question the unit was very busy, there was a shortage of midwifery staff … there was not really a clear person in charge who could oversee and coordinate services efficiently”.
Patients diverted after hospital reaches capacity
In another case, a woman died during a planned C-section at Middlemore Hospital in 2018, after a haemorrhage and multiple cardiac arrests.
The senior surgeon during the caesarean was an obstetric fellow (in their last year of specialist training), who stepped in after staff sickness. An HDC investigation concluded a senior obstetrician should have been present, or the surgery delayed, given the woman’s risk factors. A blood fridge was also out of order, causing a roughly 10-minute delay.
After a 2018 case in which a baby died soon after birth at Christchurch Hospital, the HDC determined inadequate staffing had created an excessive workload, resulting in “delayed observations, a delayed diagnosis of failure to progress in labour, prolonged labour, and a delay in the C-section commencing”.
In 2021 a woman sought help because she couldn’t feel her baby moving. North Shore Hospital was at capacity, so she was diverted to Waitākere Hospital. After some monitoring, she was sent home and the next day it was confirmed her baby had died in utero.
A doctor at Waitākere told HDC investigators that on the day the woman and two other patients from North Shore arrived, workload was already very high.
“The capacity of the medical staff at Waitākere Hospital was not taken into consideration,” an HDC decision noted. “The on-call obstetricians at North Shore Hospital and the Waitākere Hospital clinicians were not consulted or informed of the diversion order.”
There were also staffing issues at Tauranga Hospital in 2022, when a succession of failures preceded the death of Reuben Newlands, 22 hours after his birth.
His parents, Emma and Paul, went to the hospital in the morning because they couldn’t feel him moving. Electronic fetal monitoring showed an abnormal heart rate, but staff didn’t recognise the emergency situation, causing a delay of over five hours before his delivery via caesarean section.
Concern over staffing levels and capacity in the maternity and delivery suites that day triggered a code yellow and later orange alert. The maternity service had a deficit of nine full-time midwives.
“Reuben was a true fighter, and if he was given a fair chance by the maternity ward that day he certainly could have made it,” Emma told Stuff, in an interview published on Tuesday.
Health NZ: ‘Vast majority receive safe care’
On Wednesday, the NZ Nurses Organisation reacted to Stuff’s investigation, saying the cases detailed represented “a national and avoidable tragedy”.
'These whānau may have had different outcomes if these hospitals were safely and properly staffed,“ said NZNO Kaiwhakahaere and midwife Kerri Nuku.
'It is time for Te Whatu Ora to implement urgent safe midwife to patient, and nurse to patient ratios. Health care funding must be based on patient need not arbitrary budgets.
'These deaths are utter tragedies and every parent’s worst fear. The birth of a baby should be one of the happiest times in your life. My heart and condolences are with each and every whānau that lost a baby … the grief that these mothers endure is tragically life changing.'
Kiley Clark, Health NZ’s interim national chief midwife, said the organisation extended its sincere condolences to the families involved in the cases.
“We are deeply sorry for the distress caused and recognise the profound and long-lasting impact each death will continue to have.
“While adverse outcomes are rarely caused by a single issue, we acknowledge in these cases workforce pressure, skill mix, access to specialist oversight and theatre availability - in varying degrees - have been identified as contributing factors.
“These are complex, long‑standing challenges across the health system, particularly affecting some services after-hours and in smaller or rural settings, and were intensified during the pandemic.”
Clark said the cases highlighted by Stuff were not representative of maternity care overall, and “the vast majority of whānau continue to receive safe, high‑quality maternity care”.
“We have learnt from these findings and implemented changes to improve our service, including reforms focused on quality, safety, equity and sustainability of maternity services.”
There is still work to be done, Clark said, and strengthening workforce capacity, recruitment and retention was a priority, alongside support and training for staff.
“I would like to acknowledge our dedicated and experienced staff and thank them for their compassion and commitment to prioritising patient safety and quality of care every day.”
Doctors: staffing is inadequate
Dr Emma Jackson, the NZ vice-president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), which trains and accredits doctors in those specialities, says Aotearoa is a safe place to give birth, and cases like those highlighted by Stuff are uncommon.
However, when things go wrong “workforce pressures are often a contributing factor”.
“We do hear frustration and concern from our O&G doctors, who want to see women and whānau get the best possible care, but sometimes they feel they're unable to provide the care they'd like, in a quite constrained, under-resourced environment.”
Jackson says maternity is under pressure, not from birth rates - which are not rising significantly - but because women are having babies later in life, and more often have factors like diabetes, obesity or a history of fertility treatment, which makes them more likely to need intervention during their pregnancy or the birth of their baby.
“And all of that requires staffing and resourcing. That's where we're sometimes seeing that gap … as a college, we feel like the resourcing of obstetricians and midwives - and it's highlighted in the cases [identified by Stuff] - it hasn't really grown to match the complexity, and it's inconsistent around the country.
“Then you get situations where suddenly it gets extremely stretched, because it's a really busy day, more people are coming in, and you have no control, and then, occasionally, there will be a gap in care.”
RANZCOG hears from members “all the time” about shifts being too busy for even short breaks, Jackson says.
“We get told of the distress of staff, unable to get to the bathroom, unable to take a proper meal break, or they've been on since 8am and they don't have anything to eat until 5pm.
“I think that’s where there is sometimes a disconnect between policies and how things look on the books, and, if you’re working on the shop floor, how you actually see it.”
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