National mortality review focus areas

Why this matters

Every year in New Zealand, around 10,000 deaths could be avoided with better prevention and health care. These deaths disproportionately affect Māori, Pacific peoples, rural communities, people with disabilities (tāngata whaikaha), those with chronic conditions, and people living in areas of high material deprivation. Many of these deaths are caused by conditions that are either preventable or treatable. We are missing many opportunities to prevent future deaths.

We are looking into deaths from cardiovascular disease (CVD), such as heart attacks and strokes, the leading cause of all deaths and a major reason that some populations have worse outcomes.

We also monitor Sudden Unexpected Deaths of Infants (SUDI), a major cause of preventable deaths of infants.

We continue to develop a long-standing programme monitoring perioperative deaths – deaths that occur during or in the month after an operation.

Our focus

• Improve access to quality treatments to avoid deaths from CVD treatable mortality. If the health system can improve access to and quality of care for CVD, we can make a real difference.
• Monitor and report on SUDI and perioperative deaths and support health care providers to action insights from experts, consumers and whānau.
• Highlight what is working well – and what isn’t – especially for populations experiencing early loss of life.  We look at the health system as whole, emphasizing the critical role of primary care, and factors outside the health sector.

Subject matter experts

• Dr Sue Crengle (Chair)
• Dr Nina Bevin
• Dr Dwayne Crombie
• Dr Anja Mizdrak
• Professor Tim Tenbensel
• Dr Jade Tamatea

Why this matters

The loss young lives is a tragedy, especially when it happens during pregnancy, delivery and in the first year.  The impact of these deaths is devastating for families and also impacts on health workers and the community.

Deaths of babies during pregnancy and in early infancy are less visible, but just as devastating.

For 16 years we have been reporting that Māori, Pacific and Indian pregnant people and their whānau face higher rates of maternal and perinatal deaths compared to New Zealand Europeans. These differences in outcomes have not been adequately addressed.

Suicide is a leading cause of maternal death, especially in the first year after birth, but it often goes unrecognised. People with disabilities (tāngata whaikaha), are also largely invisible in current data and reporting.

Our focus

• Improve access to timely information on maternal and perinatal deaths.
• Work with Māori, Pacific and Indian communities, experts and providers, to develop community-led solutions, especially around access to quality antenatal care.
• Include the voices and experiences of families to better understand avoidable deaths.
• Classify and publish annual updates on maternal mortality.
• Extend maternal mortality monitoring to include suicide deaths up to one year postpartum.

Resources

• Summary of Perinatal and Maternal Mortality Review Committee reports
• View all past publications of the Perinatal and Maternal Mortality Review Committee
• Information for parents and caregivers who have lost a baby or child

Why this matters

Family violence contributes to many types of avoidable deaths: perinatal deaths, maternal suicides, child and youth deaths, and more. Our recent report on femicide in New Zealand highlighted that family violence is often overlooked and showed the ongoing impact of gender-based violence, especially on Māori women and girls.  For example, from 2018–2022, there were on average 40 perinatal deaths linked to family violence each year, more than double the number of family violence homicides of women and girls. Our data systems don’t clearly show the role of family violence, which means we often miss chances to prevent deaths.

Family violence affecting the older people, disabled people and those with chronic conditions, is under reported and not well understood.

Our focus

• Work across sectors to better understand how family violence affects people with disabilities and those with chronic conditions – and how to monitor this.
• Conduct in-depth reviews and develop practical strategies to reduce family violence, especially for older people, disabled people  (tāngata whaikaha), and those with chronic conditions.
• Explore how family violence intersects with maternal and perinatal health to improve prevention and response.
• Share key findings from our Femicide Report to support action by partners like the New Zealand College of Midwives and Health New Zealand – Te Whatu Ora.

Subject matter experts

• Dr Nicola Atwool (Chair)
• Dianne Cooze
• Dr Moana Eruera
• Dr Michael Roguski
• Dr Armon Tamatea
• Sumudu Thode

Resources

• Summary of Family Violence Death Review Committee reports
• Historical Family Violence Death Review Committee submissions
• View all past publications of the Family Violence Death Review Committee

Why this matters

The death of a loved one has a profound impact on families, whānau, āiga and others with a close relationship to the deceased. When we understand how families experience avoidable deaths, we can improve how health and social systems respond – especially for those communities most affected.

Historically, health information has focused on individuals, communities or populations, not on families. To reduce avoidable deaths, we need to explore new approaches. In this work we put the experience of family and whānau at the centre, to find new ways to reduce avoidable deaths.  This will also help us understand the structural and intergenerational factors that affect health outcomes.

Our focus

• Review existing knowledge and whānau feedback from whānau across all focus areas.
• Identify where whānau voices are missing or underrepresented.
• Use these insights to inform policy and improve how we engage whānau in avoidable mortality reviews and health system response.

Child and youth mortality review

This work focused on the deaths of children and young people aged 28 days to 24 years.

• Summary of Child and Youth Mortality Review Committee reports
• View all past publications of the Child and Youth Mortality Review Committee

Suicide mortality review

From September 2013 to November 2023, the Ministry of Health contracted Health Quality & Safety Commission Te Tāhū Hauora to trial and then undertake suicide mortality review, an action contained in the New Zealand Suicide Prevention Action Plan 2013–16.

The Suicide Mortality Review Committee was established and supported from 2014 to 2022 to report on and undertake mortality reviews on aspects of deaths by suicide. Focus areas included rangatahi suicide and understanding deaths by suicide in the Asian population of New Zealand. 

• View all past reports of the Suicide Mortality Review Committee