• Pauline Dawson, Chrys Jaye, Robin Gauld, and Jean Hay-Smith.
• Department of Women's and Children's Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand. Pauline.dawson@otago.ac.nz.
• Int J Equity Health. 2019 Oct 30; 18 (1): 168.

BackgroundThe purpose of this review was to examine the literature for themes of underlying social contributors to inequity in maternal health outcomes and experiences in the high resource setting of Aotearoa New Zealand. These 'causes of the causes' were explored and compared with the international context to identify similarities and New Zealand-specific differences.MethodA structured integrative review methodology was employed to enable a complex cross disciplinary analysis of data from a variety of published sources. This method enabled incorporation of diverse research methodologies and theoretical approaches found in the literature to form a unified overall of the topic.ResultsSix integrated factors - Physical Access, Political Context, Maternity Care System, Acceptability, Colonialism, and Cultural factors - were identified as barriers to equitable maternal health in Aotearoa New Zealand. The structure of the maternal health system in New Zealand, which includes free maternity care and a woman centred continuity of care structure, should help to ameliorate inequity in maternal health and yet does not appear to. A complex set of underlying structural and systemic factors, such as institutionalised racism, serve to act as barriers to equitable maternity outcomes and experiences. Initiatives that appear to be working are adapted to the local context and involve self-determination in research, clinical outreach and community programmes.ConclusionsThe combination of six social determinants identified in this review that contribute to maternal health inequity is specific to New Zealand, although individually these factors can be identified elsewhere; this creates a unique set of challenges in addressing inequity. Due to the specific social determinants in Aotearoa New Zealand, localised solutions have potential to further maternal health equity.

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