Making Pregnancy Safer November 2009
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Making Pregnancy Safer
November 2009
Before the PMMRC
•
NZ Maternity Reports 2000-2004–
Maternity and Newborn Information System
•
National Minimum Discharge •
Maternity claims
•
Birth and death certificates
Report on Maternity 2004
A brief introduction ....
•
The PMMRC was established in 2005 by the Minister of Health under the NZ Public Health and Disability Act 2000
•
The 10 members of the PMMRC are from midwifery, nursing, obstetrics, paediatrics, pathology, anaesthetics, consumers, as well as Māori
and Pacific communities
Presenter
Presentation Notes
The Perinatal and Maternal Mortality Review Committee (PMMRC) was set up in 2005 under the New Zealand Public Health and Disability Act 2000 The 10 members of the PMMRC were appointed by the Minister of Health. Committee members are from midwifery, nursing, obstetrics, paediatrics, pathology, anaesthetics, consumers, as well as Māori and Pacific communities
Purpose of the PMMRC
•
To review and report to the Minister of Health on perinatal and maternal deaths with a view to reducing the numbers
•
To support quality improvement through local local
perinatal and maternal mortality review
meetings
•
To develop strategic plans and methodologies to reduce morbidity and mortality
Purpose of Report•
To provide an accurate estimate of the absolute numbers of perinatal and maternal deaths in New Zealand
•
To describe risk factors for perinatal deaths •
To attempt to identify where maternity and neonatal services might best be focused in order to prevent perinatal and maternal deaths
•
To provide
a measure of the quality and safety of New Zealand maternity services
Data collection
•
Mother and Baby web-based forms are completed by clinical staff
•
The National and Local Coordinators ensure complete coverage of all deaths using Births, Deaths and Marriages and Discharge Dataset
•
At a local meeting, the PMMRC Local Coordinators and a multidisciplinary team review the death
•
Complete the PMMRC Classification using the PSANZ system for perinatal death (since 2006) and potentially avoidable factors (since 2009)
PMMRC reporting
•
In March 2009–
we reported on perinatal data for the second half of 2006
•
Today....–
we are reported on a full year of perinatal and
maternal data from 2007
Annual report 2007
•
First full report with 12 months data of 677 babies and 11 mothers who died–
38 tables
–
19 figures•
18 recommendations–
8 for the MOH
–
10 for clinicians and LMCs
Presenter
Presentation Notes
Explanation of the report/process and main findings
Births in New Zealand 1991-2007
Maternal mortality 2007•
11 maternal deaths–
5 direct
•
2 PET, PPH, PE, Peripartum
cardiomyopathy–
5 indirect
•
4 pre-existing, non obstetric sepsis–
1 unclassifiable
•
Maternal mortality rate 16.8 per 100,000 maternities –
2006 : 23 per 100,000 maternities
–
Not possible to comment on trends with only two years of data
Some perinatal definitions
Perinatal mortality in NZ 2007Number 2006
Rate *2007 Rate *
Total number of births (2007) 65,602 - -No. of fetal deaths (TOP & SB) 510 8.9 7.8No. of neonatal deaths < 28 days 167 3.4 2.6 No.of
perinatal deaths (fetal
deaths and early NND < 7 days)644 11.9 9.8
No.of
perinatal related deaths (fetal deaths and all NNDs
<28
days)
677 12.4 10.3
* Per 1000 babies born
Presenter
Presentation Notes
In New Zealand in 2007 , stillbirth was unexplained in 32 percent of deaths from 24 weeks of age and 41 percent of stillbirths at term. Sixty-nine percent of unexplained stillbirths from 24 weeks did not have a post mortem. The intrapartum stillbirth rate was 0.44/1000 in 2007. More than 80 percent of these babies were born at term and 80 percent were appropriately grown for gestational age. Only 41 percent had a post-mortem. International comparisons are difficult to make because of variations in the definition of intrapartum stillbirth. However, such deaths may be preventable. For this reason, the PMMRC are collecting prospective data from 2009 on potentially avoidable factors in perinatal death. In 2007 there were 10 neonatal deaths of healthy babies recorded that were associated with unsafe sleeping practices, including co-sleeping. Although the point estimates are slightly higher for Māori, Pacific and Indian babies than for other ethnicities, there were no significant differences in perinatal mortality by ethnicity in 2007. While this is reassuring, the number of deaths in each ethnic group is small, and the scarcity of the data may mask a significant association between ethnicity and perinatal related mortality. There is a statistically significant association between the deprivation index and perinatal related mortality, with a relative risk of perinatal related death of 1.5 (95 percent confidence interval 1.1–1.9) for babies born to mothers in the most deprived quintile compared to babies born to mothers in the least deprived quintile. In 2007, the perinatal mortality rate among mothers residing in Counties Manukau exceeded the national rate. This is not a new finding. Counties Manukau also reported a significantly higher perinatal mortality rate for the period 2000–2004 (NZHIS, 2007a). The proportion of babies optimally investigated (post-mortem or karyotype confirming diagnosis) following perinatal death in 2007 varied by ethnicity and by District Health Board (DHB) of residence. There is some uncertainty over exactly how many babies are born in New Zealand each year because of the current process for birth notification and registration. Unfortunately this means that exact rates of perinatal and maternal mortality cannot be calculated with complete accuracy. Lack of detailed information about all women who give birth in New Zealand restricts our ability to analyse the importance of potential predictors of perinatal death.
Selected Recommendations
•
For the Ministry of Health–
Improved systems for collection of birth data
•
Establishment of a National Perinatal Epidemiology Unit
•
Birth registrations to include some maternity data
•
Why? –
We now have a complete dataset about the babies who die but have little information about the rest.....
–
We need to improve the currency of the reports
–
Current system is fragmented
Presenter
Presentation Notes
Birth information In order to report on the quality of all aspects of NZ maternity services, a National Perinatal Epidemiology Unit should be established. Improve the current birth registration dataset by including critical maternity data (e.g. parity, smoking, major complications, mode of birth, previous obstetric history) Work towards legislation that enables Births Deaths and Marriages to accept NHI data and update the routine NHI dataset with regard to ethnicity. MOH continues to support and fund DHBs and LMCs in the process of collection of complete perinatal mortality statistics. Sudden Unexplained Deaths in Infancy (SUDI) MOH should prioritise the preparation and dissemination of a collaborative statement for parents and caregivers on risk factors and prevention of SUDI. National guidelines should be developed for safe sleeping arrangements for infants in post natal wards to improve ward safety and to model safe sleeping practices that may be followed after discharge. DHB Disparities Further research is warranted to understand the higher rates of perinatal mortality in the Counties Manukau and Northland regions. Lakes and Tairawhiti have socioeconomic and ethnic similarities to Counties Manukau and Northland, yet do not have such a high incidence of perinatal mortality; comparative analyses should therefore be undertaken. Early Booking Barriers to early booking should be collaboratively explored by the MOH, DHB, RANZCOG, RNZCGP and NZCOM with a view to increasing the number of women who book before ten weeks. A national media campaign should be considered. Access to perinatal postmortems The reasons for the differences in rates of “optimally” investigated perinatal deaths between the DHBs needs investigation. Hypertension in pregnancy Obstetric units should adopt the evidence based guideline recently developed on management of hypertension in pregnancy. Access to care Strategies to improve awareness and reduce barriers to accessing antenatal care for women who are isolated for social, cultural or language reasons should be developed. Seatbelts in pregnancy Public awareness of the importance of wearing a seat belt during pregnancy should be emphasised with the following advice on appropriate use: Three point seat belts should be worn throughout pregnancy with the lap strap placed as low as possible beneath the “bump” lying across the thighs with the diagonal shoulder strap above the “bump” lying between the breasts. Currently compiled from notification by hospitals or LMCs within 5 days of birth and then completed when parents register birth.zxcz The Working Group notes recent guidelines developed by a multidisciplinary group of the Society of Obstetric Medicine of Australia and New Zealand, available open-access through the Society’s website http://www.somanz.org/pdfs/somanz_guidelines_2008.pdf.
Variation across DHBs
• Recommendation for the MOH and DHBs: DHB disparities –
further research on higher rates
of PNM in different DHBs
should be undertakenWhy?
Presenter
Presentation Notes
DHB disparities Further research on higher rates of PNM in different DHBs
Recommendations (cont.d)•
Intrapartum
stillbirths at term without
congenital abnormality need full investigation including a postmortem
Why?•
52 babies died during labour–
29 after 24 weeks without congenital abnormality
–
80% were at term–
Only 41% had a postmortem
–
50% were classified as hypoxic peripartum deaths
Presenter
Presentation Notes
Recommendations for Clinicians and Lead Maternity Carers (LMCs) Intrapartum stillbirths Intrapartum deaths of babies at term without obvious congenital abnormality need full investigation, including a post-mortem examination. Sudden Unexplained Deaths in Infancy (SUDI) LMCs should provide information to women and their family/whanau on SUDI prevention. This information should include the following: Encourage women to stop smoking in pregnancy and not allow anyone to smoke around their baby. Encourage breastfeeding. The recommended sleeping environment is having baby sleeping in a cot or bassinet near the parents’ bed, on their back on a firm surface positioned so blankets or bedding cannot accidentally cover their face. Co-sleeping is associated with an increased risk of SUDI. This risk is increased in the following circumstances: baby’s mother has smoked during pregnancy the adult in bed with the baby has been drinking alcohol or taking recreational or sedative drugs, is unwell or excessively tired. Socioeconomic disparities Identify mothers at risk due to social deprivation and provide them with care and support commensurate to their needs. Multiple Pregnancy All women with a multiple pregnancy should be offered an early specialist consultation, including ultrasound diagnosis of chorionicity prior to fourteen weeks gestation. Women with high risk monochorionic multiple pregnancies require fortnightly scans and specialist care. Advice is available through the newly established NZ Fetal Medicine Network. Antenatal care Encourage women to book with a LMC by 10 weeks gestation (to provide prenatal advice and screening and facilitate referral to specialist services if appropriate). Encourage women and their family/whanau to attend smoking cessation programmes. Bleeding in pregnancy Women who experience vaginal bleeding after twenty weeks gestation should have serial growth scans and be advised that there is an increased risk of spontaneous preterm birth.3 GROW Charts (Gestation Related Optimal Weight) In order to improve the detection and outcomes of SGA babies: GROW charts should be generated at booking. This is an opportunity to recognise previous SGA and therefore identify an important risk for the current pregnancy. Fundal height measurements should be plotted on the woman’s individualised growth chart. (www.gestation.net). All babies suspected to be SGA should have an ultrasound for growth and appropriate referral if SGA confirmed. Uptake of perinatal postmortems Provide information for families and clinicians, including distribution of the recently published Panui (Information) for Post Mortem Examination. Team approach to care Women with complex medical conditions require a team approach to care involving multiple disciplines often across more than one DHB. Identification of a key clinician would optimise coordination of care and communication in this setting. 18. Use of seatbelts in pregnancy LMCs should provide the following advice on the appropriate use of seat belts during pregnancy: Three point seat belts should be worn throughout pregnancy with the lap strap placed as low as possible beneath the “bump” lying across the thighs with the diagonal shoulder strap above the “bump” lying between the breasts. A similar recommendation was made in the PMMRC 2006 report.
Recommendations for LMCs
•
Sudden Unexplained Deaths in Infancy (SUDI) –
LMCs
should provide information to women and
their whanau
on SUDI prevention•
Stop smoking, encourage breast feeding, safe sleeping practice, discourage co-sleeping in babies at risk
Why?•
22 of 110 babies born after 24 weeks died at home and 10 of these were SUDI deaths
Recommendations (cont.d)
•
Bleeding in pregnancy after
20 weeks should have monthly serial growth scans and be advised that there is risk of spontaneous preterm births
Why?•
20% of stillbirths had bleeding after 20 weeks
•
32% of neonatal deaths had bleeding after 20 weeks
•
50% of these babies were growth restricted using customised birthweight
centiles.....
Recommendations (cont.d)
Use of seatbelts in pregnancy•
Three point seat belts should be worn throughout pregnancy with the lap strap placed as low as possible beneath the “bump”
lying
across the thighs with the diagonal shoulder strap above the “bump”
lying between the
breastsWhy? •
3 maternal deaths who were not wearing seatbelts (not included in the statistics as accidental)
Contributory and causal factors
From 2009: we are collecting information on each death on the following potentially avoidable factors:–
Organisational and management
–
Factors relating to personnel–
Technology and equipment
–
Environmental factors–
Factors relating to the woman and her family
Improving what we do?
•
Classifying potentially avoidable events means that we can look for areas where improvements in care could be made
•
Part of the quality improvement cycle–
Measurement of outcomes should lead to change...
What else have we been doing?
•
Established process for measuring neonatal encephalopathy –
Neonatal encephalopathy working group
•
Established process for measuring maternal morbitity–
AMOSS
•
Perinatal postmortems–
published a panui
on decisions about
perinatal postmortems–
Supported call for improved services
Today .....
•
Opportunity to reflect on the findings of the report
•
Hear from local and overseas obstetric and midwifery experts
•
Hear from NZ LMCs
and clinicians•
Take home some messages.....
Acknowledgements
•
Acknowledgements–
Vicki Masson, National Coordinator
–
Secretariat staff, MOH
–
Otago
Data Group
–
Members of the PMMRC
–
Local DHB coordinators
–
Clinicians everywhere
–
Lynn Sadler, Epidemiologist
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