National Maternity Monitoring Group...2013/04/11 · He works in public obstetric practice and privately in gynaecology and reproductive medicine. Dr Tait has been involved in a number

ANNUAL REPORT 2013

National MaternityMonitoring Group

2

DisclaimerThe purpose of this publication is to inform discussion and assist policy development. The opinions expressed in the publication do not necessarily reflect the official views of the Ministry of Health.

All care has been taken in the production of this publication. The data was deemed to be accurate at the time of release, but may be subject to slight changes over time as more information is received. It is advisable to check the current status of figures given here with the National Maternity Monitoring Group before quoting or using them in further analysis.

The National Maternity Monitoring Group makes no warranty, expressed or implied, nor assumes any legal liability or responsibility for the accuracy, correctness, completeness or use of the information or data in this publication. Further, the National Maternity Monitoring Group shall not be liable for any loss or damage arising directly or indirectly from the information or data presented in this publication.

The National Maternity Monitoring Group welcomes comments and suggestions about this publication.

Annual Report 2013 | National Maternity Monitoring Group 3

ContentsChair’s Introduction .................................................................................................................................................... 4

About the National Maternity Monitoring Group (NMMG) ......................................................................... 5

NMMG Members ......................................................................................................................................................... 6

The NMMG Work Programme for 2012/13 ......................................................................................................... 8

An Overview of NMMG Recommendations ...................................................................................................... 9

The First Annual Report of the National Maternity Monitoring Group .................................................10

Registration with a Lead Maternity Carer .........................................................................................................11

Preterm Births .............................................................................................................................................................14

The 2012 Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines) ..................................................................18

National Consistency in Provision of Maternal Mental Health Services ................................................21

Smoking amongst Pregnant Women .................................................................................................................25

The New Zealand Maternity Clinical Indicators ..............................................................................................28

Ministry of Health Report on Maternity ............................................................................................................30

District Health Board Maternity Quality and Safety Programme Strategic Plans ..............................31

District Health Board Maternity Quality and Safety Programme Annual Reports .............................33

The NMMG Going Forward ....................................................................................................................................35

Acknowledgements .................................................................................................................................................36

List of Definitions.......................................................................................................................................................43

List of Abbreviations ................................................................................................................................................44

4

Chair’s Introduction It has been a busy but rewarding first year of operation at the National Maternity Monitoring Group (NMMG). Overseeing New Zealand’s maternity system is no small task, but the dedication and enthusiasm shown by the team has ensured we have risen to the challenge.

As part of our work to assess the implementation of the New Zealand National Maternity Standards (2011), we have seen some fantastic examples of leading maternity care. But every member of the NMMG recognises that there are areas where improvements to the overall quality of maternity care can be made.

During our first year, we have chosen to tackle specific issues such as maternal mental health, timing of registration with a Lead Maternity Carer and smoking amongst pregnant women. We’ve also looked at more general themes such as the content of the Maternity Quality and Safety Programme Strategic Plans and Annual Reports produced by each district health board (DHB).

Whether we have been looking at specific issues or general themes, our work has led us to make recommendations to the Ministry of Health and the district health boards. In fact, these are more than simply recommendations. These are the things we believe must happen to ensure improvements continue to be made in the provision of maternity services.

There can be few jobs more important than ensuring that women and their babies, wherever they are in New Zealand, have a quality maternity service. It is with great pride that I present this first annual report on behalf of all the NMMG members.


The National Maternity Monitoring Group (NMMG) was established in 2012 by the New Zealand Ministry of Health. The Group’s remit is to oversee the maternity system in general and, more specifically, the implementation of the New Zealand National Maternity Standards (20111).

Ultimately, the NMMG acts as a strategic adviser to the Ministry of Health (the Ministry) on areas for improvement in the maternity sector. We provide a national overview of the quality and safety of New Zealand’s maternity services.

BackgroundThe NMMG was created as part of the Maternity Quality Initiative, which is made up of:

• A national Maternity Quality and Safety Programme, including maternity standards and clinical indicators;

• Revised Maternity Referral Guidelines, which set out processes for transfers of care, including in an emergency;

• Standardised, electronic maternity information management to improve communication and sharing of health information among health practitioners, and

• Improved maternity information systems and analysis so there is better reporting and monitoring of maternity services.

The New Zealand Maternity Standards, as part of the Maternity Quality and Safety Programme (MQSP), consist of three high-level strategic statements to guide the planning, funding, provision and monitoring of maternity services:

• Standard 1: Maternity services provide safe, high-quality services that are nationally consistent and achieve optimal health outcomes for mothers and babies;

• Standard 2: Maternity services ensure a woman-centred approach that acknowledges pregnancy and childbirth as a normal life stage, and

• Standard 3: All women have access to a nationally consistent, comprehensive range of maternity services that are funded and provided appropriately to ensure there are no financial barriers to access for eligible women.

These high-level statements are accompanied by specific audit criteria and measurements of these criteria. One of the criteria is that a National Maternity Monitoring Group (NMMG) be established to oversee the maternity system and the implementation of the National Maternity Standards.

The NMMG’s role is to provide advice to the Ministry on priorities for national improvement based on a number of key publications, and to provide advice to DHBs on priorities for local improvement. There are a number of more specific activities outlined in our Terms of Reference (please see Appendix One).

About the National Maternity Monitoring Group (NMMG)

1Ministry of Health. 2011. The New Zealand Maternity Standards. Wellington: Ministry of Health.

6

The NMMG consists of clinical sector experts and a consumer representative. Members have been brought together to represent different skill sets and expertise, covering areas such as midwifery, obstetrics, clinical research, primary care, obstetric anaesthesia, neonatal paediatrics and the perspective of service users. The members are:

Norma Campbell (Chair)Norma is a Midwifery Advisor - Quality and Sector liaison for the

New Zealand College of Midwives. She has been involved in a number of

expert advisory groups for maternity including developing and supporting the MQSP. She was the Chair of the National Breastfeeding Advisory Committee. Norma also practises as a casual core midwife at Lincoln Maternity Unit, Canterbury DHB.

Elaine Langton (Vice-Chair)Elaine is the Clinical Leader of Obstetric Anaesthesia at Capital and

Coast DHB, a member of the New Zealand Society of Anaesthetists and a

fellow of the Australian and New Zealand College of Anaesthetists. She has specialised in obstetric anaesthesia for more than twenty years and has represented obstetric anaesthesia on a number of maternity advisory groups. Dr Langton is currently involved in the Severe Acute Maternal Morbidity research project which is reviewing “near miss” maternity events.

Beverley Lawton (Ngati Porou)Beverley is a member of the Perinatal and Maternal Mortality

Review Committee (PMMRC) and the Director of the Women’s Health

Research Centre, Department of Primary Care and General Practice, University of Otago. She is a member of Te Ohu Rata O Aotearoa (Māori Medical Practitioners Association) and Te Akoranga a Maui (Māori faculty of RNZCGP). Dr Lawton is currently leading the Severe Acute Maternal Morbidity research project which is reviewing “near miss” maternity events.

Bronwyn Fleet (consumer representative)Mother of eight, Bronwyn Fleet has a

broad experience of maternity services from a personal and professional

perspective. She has given birth under midwifery and obstetric care, in hospital settings and at home. She has considerable experience as a childbirth educator and consumer representative for Parents Centre. She has also been a consumer representative for the Midwifery Standards Review and is a member of the Maternity Services Consumer Council. Bronwyn is Whakatōhea and currently living rurally on the outskirts of Rotorua. Bronwyn Fleet resigned on 30 June 2013 and has been replaced by Rosemary Swindells.

John TaitJohn is an obstetrician and the chair of the Royal Australian and New Zealand College of

Obstetricians and Gynaecologists - New Zealand Committee. He is also

the Executive Director Clinical, Surgery, Women and Children’s Directorate at Capital and Coast DHB. He works in public obstetric practice and privately in gynaecology and reproductive medicine. Dr Tait has been involved in a number of expert advisory groups including developing and supporting the MQSP.

Judith McAra-CouperJudith is chair of the Midwifery Council and a midwifery lecturer at

Auckland University of Technology. She is also a researcher and has

been involved in a number of research projects including maternal mental health, sustainability of midwifery practice and place of birth. Judith regularly works for the World Health Organisation in Bangladesh in Midwifery education. She has worked in Counties Manukau for many years and currently is a member of its Maternity Expert Advisory Group.

NMMG members


NMMG members

Margret NorrisMargret is the Midwifery Leader for Bay of Plenty DHB and co-chair of the Midlands Region Maternity

Action Group. She has had various roles in the Midwifery Profession as an

employed midwife working in the DHB and a lead maternity carer (LMC) midwife working in the rural areas, and continues to be a practising midwife.

Frank Bloomfield (co-opted member)Frank is a neonatal paediatrician at National Women’s Health. He is

currently President of the Perinatal Society of New Zealand, President-

Elect of the Perinatal Society of Australia and New Zealand and a corresponding member of the New Zealand Paediatric and Child Health Division Committee of the Royal Australasian College of Physicians. Frank also leads a large research group investigating perinatal care at the Liggins Institute, University of Auckland. He contributed to the Working Group on Maternity Standards.

Cynthia Farquhar (ex-officio)Cynthia is a professor of obstetrics and gynaecology and was until

recently the chair of Perinatal and Maternal Mortality Review Committee

(PMMRC). She is the Postgraduate Professor of Obstetrics and Gynaecology in the Department of Obstetrics and Gynaecology at Auckland University. She has national and international credibility in obstetrics and epidemiological research and analysis, and has led the development of several guidelines, including for the management of women with breech presentation, and vaginal birth after caesarean section. Cynthia Farquhar resigned on 30 June 2013 and has been replaced by Sue Belgrave.

Bronwen Pelvin (ex-offico)Bronwen is the Ministry of Health’s Senior Advisor Maternity Services.

A midwife with more than 30 years of experience, Bronwen has worked

as a domiciliary midwife, a community-based LMC, a core midwife and a maternity manager. She worked as the national Midwifery Advisor for the New Zealand College of Midwives and was also the Professional Midwifery Advisor for Nelson Marlborough DHB before moving into her current role.

ONZL (Secretariat)ONZL provides secretariat and support services to the NMMG. It works across a range of sectors

including education, health, ICT and telecommunications. ONZL has

extensive experience working with New Zealand industry associations and government departments to deliver their organisational goals by providing board and governance support, meeting facilitation, analysis services, project management, finance management and administrative support.

8

1. Reviewing the timing of registration with a Lead Maternity Carer (LMC), particularly the proportion of women who do not register with an LMC before 14 weeks’ gestation;

2. Assessing preterm births, particularly the inconsistency in rates across New Zealand;

3. Investigating the regional implementation of the 2012 Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines), particularly in relation to emergency transport and retrieval;

4. Understanding national consistency in the provision of maternal mental health services;

5. Assessing statistics relating to smoking amongst pregnant women;

6. Reviewing and advising on the New Zealand Maternity Clinical Indicators;

7. Reviewing the Ministry of Health Annual Report on Maternity;

8. Assessing the district health board Maternity Quality and Safety Programme (MQSP) Strategic Plans;

9. Review of, and potentially providing expert advice on, the district health board Maternity Quality and Safety Programme (MQSP) Annual Reports, and

10. Production of an NMMG Annual Report.

In this, our first annual report, we outline our findings and recommendations relating to the work programme of 2012/13. A number of supporting documents can be found in the appendices, including a table illustrating the work programme (Appendix Two). A map of New Zealand DHBs can also be seen in Appendix Three.

The NMMG Work Programmefor 2012/13Taking into account our remit and Terms of Reference, the 12-month work programme with the Ministry of Health included the following:


An Overview of NMMG RecommendationsThere are a number of things that must happen to ensure improvements are made in the provision of maternity services in New Zealand. Below we have outlined those areas where we expect action from the Ministry of Health and district health boards:

• Timing of Registration with an LMC - we want to see new ways to encourage women to register in the first trimester. Access to services must improve;

• Preterm Births - more has to be done to monitor the incidence and causes of late preterm births. We expect to see more discussion of this issue over the next year;

• 2012 Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines) - we need more transparency, better communication and for DHBs to be using MQSP governance groups to monitor implementation of these;

• Maternal Mental Health Services – we will monitor access to maternal mental health services. DHBs need to improve accessibility for the community and primary maternity services;

• Maternal Smoking – general practitioners and LMCs must develop mechanisms to share information to integrate cessation services. DHBs must support this work across maternity services to deliver against the Ministry of Health’s ‘Better help for smokers to quit’ target;

• New Zealand Maternity Clinical Indicators - we want to see the introduction of seven new indicators and changes to definitions used by the Ministry from the 2012 report onwards. All DHBs are expected to comment on the Clinical Indicators data, and reasons for any variability, in their next MQSP Annual

Reports;

• Ministry of Health Annual Report on Maternity - this report is valuable and must be presented annually. We have recommended a number of areas for improvement;

• Maternity Quality and Safety Programme Strategic Plans - we expect DHBs to pay more attention to benchmarking regional progress against national priorities, and

• Maternity Quality and Safety Programme Annual Reports - we want better achievement of MQSP goals by DHBs and significantly improved engagement with consumers.

You can read more details of these recommendations in the appropriate sections of this annual report.

10

The First Annual Report ofthe National Maternity Monitoring GroupOver the following pages we outline our work over the year 2012/2013. We talk about our remit, findings and give areas for improvement. We have also shared examples of good practice and useful statistics. Further background information can be found in the appendices.


2Perinatal and Maternal Mortality Review Committee. 2012. Sixth Annual Report of the Perinatal and Maternal Mortality Review Committee. Wellington: Health Quality and Safety Commission

What we’ve doneWe assessed data from the National Maternity Collection (2012). We looked specifically at the number and percentage of women registered with an LMC by the end of the first trimester, where the year of delivery was 2011. The data was organised by DHB of domicile and was the most current data available at the time.

This data covered women who have an LMC registration reported and funded under Section 88 of the New Zealand Public Health and Disability Act 2000. Women who receive their primary maternity care from DHB funded maternity teams were not included as data was not available from the Ministry of Health at the time of this analysis.

Once we had reviewed the data, we then wrote to each DHB asking them to provide information about how they currently:

• Encourage women to register with an LMC in their first trimester, particularly through the Maternity Quality and Safety Programme;

• Help women to engage with primary maternity services in the first trimester, and

• Work with their general practitioner (GP) community to support referrals between GPs and LMCs.

Our focus To investigate the timing of registration with Lead Maternity Carers (LMCs), paying particular attention to those women not registering before 12 weeks’ gestation. We selected a 12 week cut-off as this signifies the end of the first trimester. In addition, we wanted to explore how each DHB might improve the level of, and access to, LMC registration.

We chose this work stream to reflect a recommendation discussed in the Sixth Annual Report of the PMMRC2. On page six of that report, it was identified that:

”All women should commence maternity care before 10 weeks, which enables:

• Opportunity to offer screening for congenital abnormalities, sexually transmitted infections, family violence and maternal mental health, with referral as appropriate

• Education around nutrition, smoking, alcohol and drug use, and other at-risk behaviour

• Recognition of underlying medical conditions, with referral to secondary care as appropriate

• Identification of at-risk women (maternal age, obesity, maternal mental health problems, multiple pregnancy, socioeconomic deprivation, maternal medical conditions)”

Registration with a Lead Maternity Carer

12

DataNationally, only 63% of women registered with an LMC within the first trimester. The proportion of women registered with an LMC during their first trimester varied across DHBs, ranging from 42% to 74%.

DHB InitiativesWe found there were many different initiatives currently being used by individual DHBs to encourage women to register with an LMC during the first trimester. These included:

Investigation of the issue• Identifying which specific groups (separated by

age, ethnicity, location or parity) are registering late in their DHB, and

• Looking for barriers to registration with an LMC early in pregnancy, particularly if women are engaging with general practice care early.

Local level strategy• Using Governance Groups (developed as part of

their DHB’s MQSP) to discuss LMC registration and develop targeted local interventions.

Focus on midwifery• Reconfiguring midwifery services to improve

continuity of care, or integrating midwifery services with other primary care services.

Working with GPs• Raising awareness with GPs about the

importance of early registration with an LMC, and ways in which GPs can help increase earlier registration, and

• Looking at how to use technology to transfer clinical information electronically between GPs and LMCs.

Additional resources • Promoting the Find Your Midwife (http://www.

findyourmidwife.co.nz/) website which was a joint development between the Ministry and the New Zealand College of Midwives;

• Developing Maternity Resource Centres, which are drop-in information centres with strong links to local LMCs. These can be staffed by a midwife or a consumer. The Centres provide information about pregnancy to women and their families, and also make appointments with local LMCs, and

• Facilitating discussions between LMCs and those women with a higher risk of not booking in the first 12 weeks’ gestation. Helping women understand the benefits of early LMC contact.

The changes we expect to see1. DHBs must consider new ways to encourage women to register in the first trimester. 2. We expect each DHB to: • Consider their pregnant population more fully; • Reduce barriers and improve access to appropriate services, and • Support the use of the Find Your Midwife website in general practice.We will continue to monitor how DHBs improve this issue.

What we found

90%80%70%60%50%40%30%20%10%

0%

Perc

enta

ge

DHB of Domicile

Percentage of Women Registered with an LMC in the First Trimester, by DHB of Domicile, 2011

Nor

thla

nd

Wai

tem

ata

Auck

land

Coun

ties M

anuk

au

Wai

kato

Lake

s

Bay

of P

lent

y

Taira

whi

ti

Haw

ke’s

Bay

Tara

naki

Mid

Cent

ral

Wha

ngan

ui

Capi

tal a

nd C

oast

Hut

t Val

ley

Wai

rara

pa

Nel

son/

Mar

lbor

ough

Wes

t Coa

st

Cant

erbu

ry

Sout

h Ca

nter

bury

Sout

hern

Ove

rsea

s

Unk

now

n

Tota

l NZ


Nelson Marlborough DHBNelson Marlborough DHB has been actively pursuing a number of avenues to improve the timing of registration with an LMC. Work includes:

Using groups established under the MQSPNelson Marlborough DHB plans to use its MQSP governance group to identify barriers for women wanting to access primary maternity services in the area. The MQSP LMC group for Nelson Marlborough DHB will then work to tackle those barriers.

Health PathwaysThe Health Pathways website can be tailored to provide relevant information to health practitioners (often through Patient Management Systems) and is used in many DHBs. Nelson Marlborough DHB is in the process of establishing a Health Pathway called Antenatal First Consult.

This Pathway was developed after consultation with LMCs and GPs. It outlines roles and responsibilities for GPs and LMCs when a women presents in pregnancy. The aim of the Pathway is to share best practice, ensure referrals are timely, and support early registration with an LMC.

The Antenatal First Consult Pathway includes links to access local LMCs, other agencies and relevant resources. It will soon require GPs to complete an advance referral form providing relevant clinical information on registration with an LMC.

Electronic connectionTo improve maternity care and service interface, this DHB is currently working with local Primary Health Organisations to identify a secure way for LMCs to connect electronically with GPs.

Whanganui DHBAccess to informationIn order to engage consumers, Whanganui DHB are in the process of establishing a Maternity Resource Centre which will provide a drop-in service where women and their families can access maternity

information and support, including contacting of an LMC.

Provision of culturally appropriate servicesWhanganui DHB is also developing a Whānau Ora contract with a rural Māori provider to promote all pregnant women enrolling with an LMC by 10 weeks.

Good examples of promoting timely LMC registration

14

3Morris, J.M., Algert, C.S., Falster, M.O., Fod, J.B., Kinnear, A., Nicholl, M.C. & Roberts, C.L. 2012. Trends in planned early birth: a population-based study. American Journal of Obstetrics and Gynecology, 207 (186), ppe1-8. doi: 0002-9378/$36.004Boyle, E.M., Poulsen, G., Field, D.J., Kurinczuk, J.J., Alfirevic, Z. & Quigley, M.A. 2012. Effects of gestational age at birth on health outcomes at 3 and 5 years of age: population based cohort study. British Medical Journal, 344, e896. doi: 10.1136/bmj.e896. 5McLaurin, K.K., Hall, C.B., Jackson, E.A., Owens, O.V. & Mahadevia, P. J. 2009. Persistence of Morbidity and Cost Differences Between Late-Preterm and Term Infants During the First Year of Life. Pediatrics, 123(2), pp653-659. doi:10.1542/peds.2008-1439.

Our focus To investigate the consistency in the rate of preterm births across New Zealand. The reasons for variation, and ways to reduce preterm births, need to be explored in relation to service delivery. This priority reflects the NMMG’s role in overseeing the implementation of Standard 1 of the National Maternity Standards, particularly to ensure that maternity services achieve “optimal health outcomes for mothers and babies”.

We wanted to monitor late preterm births (births between 34 and 36 weeks’ gestation) because research has found that worldwide late preterm births are increasing. It is argued that this may be due to increases in planned birth i.e. when the risks to the mother or baby of continuing the pregnancy are perceived to outweigh the risk of early birth. This may be related to changes in obstetric decision-making .

However, late preterm births may have a number of consequences, including:

• Higher neonatal and maternal mortality and morbidity3;

• Long-term health effects on babies such as poorer neurodevelopmental and educational outcomes, more hospital admissions and increased general disease burden in childhood3,4,

• Late preterm birth is also associated with greater use of health resources 3,5.

The period from 34-36 weeks is the period when there is most benefit in prolonging the pregnancy. Because prolonging pregnancy results in better neonatal outcomes and less health resource use, with each week gained in gestational age 3 4 5, we decided to focus on this issue.

Preterm births


What we’ve doneWe assessed data from the National Maternity Collection and the Births, Deaths and Marriages Collection Live Birth Registrations. We looked specifically at the rate of preterm births per 100 births, from 2008 to 2011. Only live births were included.

We reviewed the data by DHB of mother’s domicile, and also by the number of completed weeks’ gestation. The data was split into the following ranges in order to assess the distribution of preterm births by gestation:

• Late preterm birth: birth between 34 and 36 completed weeks’ gestation;

• Moderate preterm birth: birth between 32 and 33 completed weeks’ gestation;

• Very preterm birth: birth between 28 and 31 completed weeks’ gestation, and

• Extremely preterm birth: birth before 28 weeks’ gestation.

We also analysed late preterm births, at 34, 35 and 36 weeks’ gestation, broken down by birthing facility. This data was available from 2008 to 2011.

The number of preterm births varied by DHB. Excluding births where the domicile of the mother was overseas or unknown, there was some variation in the total rates of live preterm births (less than 37 weeks’ gestation) per 100 live births (all gestations) between different DHBs from 2008 to 2011.

What we found

10

9

8

7

6

5

4

3

2

1

0

Rate

per

100

live

bir

ths

Nor

thla

nd

Wai

tem

ata

Auck

land

Coun

ties

Man

ukau

Wai

kato

Lake

s

Bay

of P

lent

y

Taira

whi

ti

Haw

ke’s

Bay

Tara

naki

Mid

Cent

ral

Wha

ngan

ui

Capi

tal a

nd

Coas

t

Hut

t Val

ley

Wai

rara

pa

Nel

son/

M

arlb

orou

gh

Wes

t Coa

st

Cant

erbu

ry

Sout

h Ca

nter

bury

Sout

hern

Tota

l NZ

DHB of domicile

2008 2009 2010 2011 Rate of Preterm Births (<37 Week’s Gestation) Per 100 Births, 2008-2011

16

Preterm births

10%

9%

8%

7%

6%

5%

4%

3%

2%

1%

0%

Perc

enta

ge

Nor

thla

nd

Wai

tem

ata

Auck

land

Coun

ties

Man

ukau

Wai

kato

Lake

s

Bay

of P

lent

y

Taira

whi

ti

Haw

ke’s

Bay

Tara

naki

Mid

Cent

ral

Wha

ngan

ui

Capi

tal a

nd

Coas

t

Hut

t Val

ley

Wai

rara

pa

Nel

son/

M

arlb

orou

gh

Wes

t Coa

st

Cant

erbu

ry

Sout

h Ca

nter

bury

Ota

go

Sout

hlan

d

DHB of domicile 34-36 32-33 28-31 under 28

When this information is split into ranges of weeks’ gestation, there was further variation by DHB, particularly in the range 34-36 weeks.

The data presented below shows the number of preterm births (less than 37 weeks’ gestation) as a percentage of total live births (all gestation) by DHB of domicile. Each bar showing preterm births as a percentage of total live births is then split by gestation range. Data is shown here for 2011.

Late preterm birthsGiven the variation in late preterm births (between 34-36 weeks’ gestation) between DHBs, we then looked at the rates of late preterm births in different birthing facilities in New Zealand.

Nationally, the rate of preterm deliveries from 34-36 weeks’ gestation at primary birthing facilities has decreased over the period 2008 to 2011. This suggests that timely access to secondary/tertiary facilities has improved over this period.

4.50

4.00

3.50

3.00

2.50

2.00

1.50

1.00

0.50

0.00Pre-

term

Del

iver

ies

(34-

36 w

eeks

’ ges

tatio

n) p

er 1

00 D

eliv

erie

s

Year 2008 2009 2010 2011

Preterm Births by Weeks’ Gestation Range, as a Percentage of Total Births, by DHB of Domicile, 2011

Rate of Preterm Deliveries in Primary Birthing Facilities (34-36 weeks’ gestation) Per 100 Deliveries, 2008-2011


We found that rates of preterm birth at 34 and 35 weeks’ gestation have remained fairly constant over the four year period. However, preterm births at 36 weeks’ gestation may be increasing. This may represent changes in planned or elective early births. More information over the next two years is needed to confirm this apparent trend.

The changes we expect to see1. All DHBs should audit preterm births in their region, particularly births at 34, 35 and 36

weeks.

2. Factors that can be changed may include elective or planned deliveries and the clinical reasons for these.

3. Every DHB should cover the subject of preterm births in its next MQSP Annual Report. This should include information about interventions that have occurred as a result of information contained in this NMMG report in relation to late preterm births.

We will continue to monitor this issue over the coming year.

Preterm births

We also found that there was significant variation in the rates of late preterm births per total live births at different birthing facilities around New Zealand. While this data is not shown here, it is available on request from the NMMG.

3

2.5

2

1.5

1

0.5

0

Rate

of b

irth

s pe

r 100

live

bir

ths

Weeks Gestation, by Year of Delivery

Rate of Late Preterm Births (34, 35 & 36 weeks’ gestation) Per 100 Births, 2008-2011

34 35 36

2008 2009 2010 2011 2008 2009 2010 2011 2008 2009 2010 2011

18

Our focus To investigate how the revised 2012 Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines)6 were enacted regionally, paying particular attention to emergency transport.

This investigation reflects the NMMG’s role in overseeing the implementation of Standard 3 of the National Maternity Standards, particularly that “all women have access to a nationally consistent, comprehensive range of maternity services”.

The general aim of the Referral Guidelines is to improve the safety and quality of maternity care by ensuring women are referred by their LMC to the most appropriate level of care for their particular condition. The Referral Guidelines were designed to enhance communication, collaboration and documentation between clinical providers.

The Referral Guidelines are intended to improve the national consistency in the referral process. Emergency transfer and transportation is an issue for some regions. Emergency transport refers to transport used in emergency situations, where a woman needs to be moved from the community to a DHB facility, or between DHB facilities. This is a new addition to the Referral Guidelines.

The 2012 Guidelines for Consultation with Obstetric and Related Medical Services(Referral Guidelines)

What we’ve doneWe wrote to each DHB asking them to provide information about how the Referral Guidelines were being implemented within maternity services in their district. We were particularly interested in looking at the implementation of guidelines around emergency transport.

After receiving responses from each DHB, we wrote to those who had not yet fully implemented the Referral Guidelines in their regions. We wanted to offer support to the DHBs and underline the importance of the Referral Guidelines, not just as a key part of the MQSP, but also as an important step

in ensuring the best health outcomes for mothers and babies.

6Ministry of Health. 2012. Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines). Wellington: Ministry of Health.


We noted that there has been some regional inconsistency in the implementation and effectiveness of the Referral Guidelines:

• In many DHBs, copies of the Referral Guidelines had been disseminated to DHB staff and LMCs working in the district.

• Most DHBs had held meetings with various health professionals involved in the maternity sector to discuss the updates to the Guidelines and promote awareness.

• Unfortunately, only a small number of DHBs plan to use the maternity clinical governance/steering groups developed as part of the MQSP to monitor the implementation of the Guidelines and develop local Emergency Transport Plans.

• Many DHBs noted that updates to these policies need to be completed in conjunction with St John and other ambulance services.

What we found

The changes we expect to see1. DHBs should be using MQSP governance groups to monitor the implementation of the

Referral Guidelines.

2. The Referral Guidelines should be communicated effectively to maternity consumers, making processes more transparent.

3. Updates to referral policies need to be completed in conjunction with St John and other ambulance services.

4. We want to see that DHBs are engaging with ambulance services to improve the emergency transport of women in labour.

20

Southern DHBSouthern DHB has worked hard to implement the revised Referral Guidelines, particularly in relation to emergency transport.

It has found that “the revised guidelines have been used as an oportunity to develop relationships with our St John colleagues both in urban and rural localities. It notes that this has led to greater understanding of the emergency transport process for DHB clinicians, LMCs and St John staff. It has also led to new transfer information forms to ensure effective communication occurs.

Furthermore, relationships between rural providers and local St John staff have been enhanced through encouraging LMCs to contact St John staff early in a ‘heads-up’ manner so St John can consider information such as driving hours and the location of volunteer staff. This helps reduce delays when a call is made to transfer patients.

Good example of referral guidelines implementation


Our focus To investigate the availability and provision of maternal mental health services provided by each DHB. To ensure appropriate services are available and that there is national consistency.

The availability and provision of mental health services to some women during and after pregnancy is essential to their safety and that of their babies. Women with existing mental health issues are at risk of escalation during the pregnancy and postnatal period. This is particularly true for women with a history of Bipolar disorder, psychosis or postnatal depression/severe depression7.

All DHBs are required, under the DHB Service Coverage Schedule, to provide perinatal and maternal health services by direct provision of specialist services. They need to do this either through trained staff in general adult mental health services or by access to regional specialist services. We wanted to look at how this aspect of the DHB Service Coverage Schedule is being implemented across the DHBs to ensure ease of access for women and families who experience mental health issues during or after pregnancy and to ensure women have access to the same high standard of care wherever they live.

We also wanted to review maternal mental health in light of recommendations made in the Sixth Annual Report of the PMMRC which encouraged those working in the maternity sector to screen women antenatally in order to identify women who are at increased risk of mental health illness, and recommended better integration of maternal mental health services into maternity services.

National Consistency in Provision of Maternal Mental Health Services

What we’ve doneWe wrote to each DHB asking about the maternal mental health services they provide, and whether there are waiting times to access these services.

We asked them to provide any information on the number of referrals from LMCs to primary mental health services in their area. The aim of this was to understand the level of integration between services.

To avoid duplication we also liaised with the Ministry to understand their current work on maternal mental health.

7Ministry of Health. 2011. 2012/2013 Service Coverage Schedule. Wellington: Ministry of Health.

22

DHB servicesSome DHBs had areas of good practice and some needed improvement. Our findings covered three key themes:

1) Mental health service provisionWe were encouraged by the range of mental health services available to pregnant women in New Zealand. Services provided include:

a) Community-based servicesThese services are not solely for pregnant women. However, in many DHBs, community-based mental health service providers are able to refer pregnant women to specialist maternal mental health teams. Other service providers are able to seek advice from specialist maternal mental health teams by telephone.

A number of programmes or additional services exist in regions to support pregnant and postnatal women.

These include:

• Support through vulnerable pregnant women groups;

• Assistance from parents in need groups;

• Plunket’s Postnatal Adjustment Programme provided in the South Island, and

• A Cognitive Behavioural Therapy group programme targeted at postnatal depression piloted in one area of Northland DHB. This is to be expanded to other areas of Northland.

b) Secondary-based specialist servicesMany DHBs have specialist maternal mental health services, which often provide support to primary and other secondary mental health services. The services provided across the regions range from specialist nurses who receive support from other secondary mental health services, to large specialist teams. Examples of different approaches include:

• Waikato DHB purchase additional specialist Kaupapa clinical and perinatal mental health services for the urban Hamilton area and surrounding areas;

• The Canterbury Mothers and Babies Unit Specialist Service is a South Island regional specialist service providing psychiatric treatment for pregnant women and parents with babies up to 12 months old (at the time of the referral). It provides inpatient, outpatient and day patient treatment for women who experience depression and other psychological and psychiatric difficulties during pregnancy, and after the birth of their babies, and

• Some DHBs currently have no specific maternal mental health services but provide secondary mental health services to which pregnant women can be referred. Out of these DHBs, some are currently developing specialist maternal mental health services. Others have access to specialist maternal mental health services through a “hub and spoke” model of service delivery.

c) Inpatient servicesOnly a small number of DHBs (Auckland, Counties Manukau and Canterbury) have the ability to deliver inpatient secondary maternal mental health services where mother and baby can be placed together.

What we found

National Consistency in Provision of Maternal Mental Health Services


Some DHBs have small areas separate to the main adult mental health wards which can be used by mothers and babies if required.

Canterbury DHB provides the largest and most comprehensive service of this kind in the country in its Mothers and Babies Unit. We note that surrounding DHBs have access to these inpatient services.

We note that the Government has allocated $18.2 million over 4 years to improve acute maternal mental health services. We have sought updates from the Ministry on work with DHBs to implement this funding, and will continue to do so.

d) EducationSome DHBs provide education programmes for mothers with a prior history of mental illness. For the most part, this is provided postnatally.

e) Alcohol and other drug servicesAuckland and Canterbury DHBs provide specialist regional services for pregnant women with alcohol or other drug addiction. Other DHBs have access to these services as necessary.

2) Waiting timesAlmost all of the DHBs stated that there are currently no waiting times for their service. For those where there were waiting times, the largest was the Canterbury Mothers and Babies Unit, with a four-month waiting time. Auckland DHB’s specialist maternal mental health team quoted a two to three month waiting time.

3) Referrals from LMCs to primary mental health servicesMany DHBs stated that they do not have access to the number of referrals from LMCs to primary mental health services. However, those that did have this information reported referrals from LMCs ranged from 14.3% to 24.5% of total referrals to primary mental health services.

The percentage of referrals from LMCs to specialist maternal mental health services ranged from 3% to 71% of total referrals to these services. This information shows significant variability in access to services for pregnant women.

The changes we expect to see1. We want all DHBs to promote access to services for women with maternal mental health

issues. This will require better linkages between these services and maternity care providers.

2. Knowledge of mental health services available to the maternity sector must improve.3. DHBs must provide the maternity sector in their area with clearer information on the

mental health services available and enable direct referrals.

24

Taranaki DHBTaranaki DHB is proposing to implement a comprehensive flowchart of perinatal mental health local referral pathways for practitioners. Within this pathway, a modified Edinburgh Postnatal Depression Scale will be used to assess patients.

Flowchart of ServicesTaranaki DHB has a very comprehensive perinatal mental health local referral pathway process map. A copy of this is included in Appendix Five. Please note that this process map is not yet complete.

Use of Edinburgh Postnatal Depression ScaleIn this process the modified Edinburgh Postnatal Depression Scale is used to screen for emotional difficulties.

Taranaki DHB has informed the NMMG that LMCs (and some other health professionals) in the area have been taught how to use the Edinburgh Scale. It was part of the in-service education programme for employed midwives and also forms part of the new staff orientation.

It is already customary practice for LMCs to use the modified Edinburgh Scale now and as such is building on usual practice.

Auckland DHBThe Auckland DHB newborn service aims to support the emotional wellbeing of parents who have a child in the Neonatal Intensive Care Unit (NICU). Staff refer parents to the service, which is provided by the Paediatric Consult Liaison (CL) Service at Starship Children’s Hospital but funded by the NICU.

Mothers or fathers with a baby in the unit are referred if it is felt that they might benefit from the CL team services. This may be for stress, grief, anxiety, mental illness reasons, or if there are concerns about the parent-infant attachment relationship. Most parents of extremely fragile or unwell infants are referred routinely.

The CL service then provides assessment, therapeutic intervention, and liaison with other relevant services including maternal mental health services, GPs, and outpatient infant mental health services. The team works very closely with the NICU staff, functioning as an integral part of the NICU multidisciplinary team, and contributes to staff training days. It also links to LMCs if appropriate. The funded 0.8 FTE for this work provides access to child psychotherapy, infant/adult psychiatry, and Māori mental health practitioners.

In 2012, the service received 155 new referrals and had a total of 578 patient contacts.

Good example of promoting maternal mental health


What we’ve doneWe assessed data from the National Maternity Collection (2012). We looked specifically at the rates of smoking amongst pregnant women at delivery and two weeks post-delivery, where the year of delivery was 2011. We reviewed the data by DHB of mother’s domicile to identify areas of national variation.

We were then briefed by the Ministry’s Tobacco Control team on the current interventions to support smoking cessation amongst pregnant women. We also discussed the maternity indicator of the ‘Better help for smokers to quit’ health target. This indicator was introduced in July 2012 and assesses:

“Progress towards 90 per cent of pregnant women who identify as smokers at the time of confirmation of pregnancy in general practice or booking with Lead Maternity Carer are offered advice and support to quit.”

We then wrote to each DHB strongly supporting the implementation of the target.

Our focus To investigate maternal smoking in New Zealand, review access to appropriate smoking cessation services, and provide information and recommendations to the Ministry in its drive to achieve the maternity indicator of its ‘Better help for smokers to quit’ health target.

Smoking during pregnancy leads to increased carbon monoxide concentration in the blood of both the mother and her baby. This reduces the oxygen and nourishment available to the baby and leads to higher rates of neonatal mortality, Sudden Unexplained Death in Infancy (SUDI), low birth weight and long term respiratory problems for the child8.

Smoking amongst Pregnant Women

8The Quit Group. 2004. Smoking and Pregnancy. Available from http://www.quit.org.nz/file/infoSheets/04SmokingAndPregnancy.pdf

26

DataNationally, the proportion of women who were using tobacco up until birth was 15%, and 14% of mothers nationally were still smoking at two weeks after birth.

However, the proportion of mothers smoking at both delivery and two weeks post-delivery differed significantly across DHBs. Excluding women overseas and those whose DHB of domicile is unknown, the percentage of mothers using tobacco up until birth ranged from 6% to 32%. The percentage of mothers who were smokers at two weeks after birth ranged from 4% to 32%.

Ministry of Health TargetWe found that the maternity indicator of the Ministry’s ‘Better help for smokers to quit’ health target only measures cessation services offered by LMCs but not those offered by other primary care services, such as general practitioners, on confirmation of pregnancy.

What we found

The changes we expect to see1. The Ministry should expand the maternity indicator of the ‘Better help for smokers to

quit’ target to include data from primary care providers (GPs and others). The sharing of information will help the integration of services, particularly between LMC and GPs, and monitoring of the success of intervention will be more effective.

2. Every DHB will work with all aspects of maternity services in its area and meet the Ministry’s target of “Progress towards 90 per cent of pregnant women who identify as smokers at the time of confirmation of pregnancy in general practice or booking with an LMC are offered advice and support to quit.”

3. DHBs must discuss this target with LMCs and general practice in any clinical governance groups that have been established as part of their DHB’s MQSP.

4. We expect each DHB to comment on this in its next MQSP Annual Report.

Smoking amongst Pregnant Women

35%

30%

25%

20%

15%

10%

5%

0%

Perc

enta

ge

DHB of domicile

Percentage Smoking at delivery Percentage Smoking at 2 weeks after birth

Percentage of Mothers Smoking at Delivery and Two Weeks After Birth in 2011, by DHB of Domicile

Auck

land

Coun

ties

Man

ukau

Wai

kato

Lake

s

Bay

of P

lent

y

Taira

whi

ti

Haw

ke’s

Bay

Tara

naki

Mid

Cent

ral

Wha

ngan

ui

Capi

tal a

nd

Coas

t

Hut

t Val

ley

Wai

rara

pa

Nel

son/

M

arlb

orou

gh

Wes

t Coa

st

Cant

erbu

ry

Sout

h Ca

nter

bury

Sout

hern

Ove

rsea

s

Unk

own

Tota

l NZ


Tairawhiti DHBTairawhiti DHB plan to implement a new initiative to improve smoking cessation among pregnant women. It will be extending education about how to provide smoking cessation advice to Sonographers within the district. This will provide a further way to offer cessation advice early in pregnancy for those women who decide to enter the screening pathway for Down Syndrome and other anomalies, and require an early scan as part of this. The aim of this initiative is to reduce smoking in pregnancy prior to 15 weeks’ gestation and increase early referrals to smoking cessation providers.

Good example of supporting maternal smoking cessation

28

9Ministry of Health. 2012. New Zealand Maternity Clinical Indicators 2010. Wellington: Ministry of Health.10Ministry of Health. 2012. New Zealand Maternity Clinical Indicators 2009. Wellington: Ministry of Health.11Ministry of Health. 2013. New Zealand Maternity Clinical Indicators 2011. Wellington: Ministry of Health.

Our focus To review and contribute advice to the Ministry on the New Zealand Maternity Clinical Indicators.

The indicators are a set of 12 clinically relevant issues which can be measured using available data collections. They consist of the following:

1. Standard primiparae who have a spontaneous vaginal birth;

2. Standard primiparae who undergo an instrumental vaginal birth;

3. Standard primiparae who undergo Caesarean section;

4. Standard primiparae who undergo induction of labour;

5. Standard primiparae with an intact lower genital tract (no 1st−4th-degree tear or episiotomy);

6. Standard primiparae undergoing episiotomy and no 3rd- or 4th-degree perineal tear;

7. Standard primiparae sustaining a 3rd- or 4th-degree perineal tear and no episiotomy;

8. Standard primiparae undergoing episiotomy and sustaining a 3rd- or 4th-degree perineal tear;

9. Women having a general anaesthetic for Caesarean section;

10. Women requiring a blood transfusion with Caesarean section;

11. Women requiring a blood transfusion with vaginal birth, and

12. Premature births (between 32 and 36 weeks’ gestation).

These indicators are a key part of the national MQSP, as they allow clinical data to be benchmarked at the national level using standardised definitions. The indicators were chosen by an expert working group established by the Ministry and build on previous work undertaken across Australasia. Reports discussing the Maternity Clinical Indicators have now been released for data from 2009, 2010 and 20119,10,11.

The NMMG monitored and reviewed the Maternity Clinical Indicators as a part of ensuring that Standard One of the National Maternity Standards is met, in that maternity services provide safe, high-quality services that are nationally consistent and achieve optimal health outcomes for mothers and babies.

The New Zealand MaternityClinical Indicators


What we’ve doneWe reviewed the current indicators and the value they provide to maternity services and consumers. After discussion with the Ministry, and to inform the next set of clinical indicators to be published, we suggested modifications and additions to the current indicators and data definitions.

The changes we expect to see1. We suggest the Ministry introduce to the current Maternity Clinical Indicators:

Additions to the current indicator set • Timing of first registration with LMC or DHB maternity services - to reflect the NMMG’s

work stream on this issue;

• Maternal tobacco use - to support the work of the maternity indicator in the ‘Better Help for Smokers to Quit’ target;

• Maternal Intensive Care Unit (ICU) and High Dependency Unit (HDU) admissions;

• Term babies (without congenital abnormality) transferred to Neonatal Intensive Care Units/Special Care Baby Units;

• Eclampsia;

• Small for Gestational Age (less than 10th percentile), and

• Vaginal Births After Caesarean (VBAC).

Modifications to the definition of standard primiparae in the Maternity Clinical Indicators

• Parity - include data on parity status from the registration claims submitted by LMCs under the Primary Maternity Services Notice (Section 88). Where parity status is not available from registration claims, use the previous method of estimating parity, and

• Gestation - match records of the mother to those of the baby or babies, and use gestation at birth (weeks) where available.

2. Now that a more comprehensive dataset is available, the Maternity Clinical Indicators data should be sourced from the National Maternity Collection for future reports to increase the scope and completeness of the data available.

3. The Ministry must consult with other maternity stakeholders before making any changes to the current New Zealand Maternity Clinical Indicators. This might include those who were initially involved in the development of the Maternity Clinical Indicators, the PMMRC and the respective health professional colleges.

4. We expect all DHBs to comment on their Clinical Indicators data, and reasons for any variability, in their next MQSP Annual Reports. This information should be shared with maternity consumers.

The NMMG will be able to see greater trends in the coming year once we have assessed the three years of data now available on the Maternity Clinical Indicators. We will ask for explanations from any DHBs who are outliers in the data, including their plans to understand why this has occurred and how they plan to address it.

30

Our focus To review the Ministry of Health Report on Maternity12 and give advice for future reports. We focused on this work stream as it is a key source of data for monitoring the standard of maternity services across New Zealand, and it is part of the NMMG’s Terms of Reference.

The Ministry of Health Report on Maternity presents health statistics on the pregnancy and childbirth of women who gave birth in New Zealand (to live-born or stillborn babies). The report uses data collected in the National Maternity Collection, hospital discharge data from the National Minimum Dataset, and information on primary community events from LMC claim forms. This report is statistical in nature and designed to inform debate.

Ministry of Health Report on Maternity

What we’ve doneThe NMMG reviewed the Ministry of Health Report on Maternity 2010. This was the first Report on Maternity since 2007 and we were pleased to see its reinstatement.

The changes we expect to see1. We want to see the Ministry continue to produce an Annual Report on

Maternity, and for its contents to be strengthened by:

• Reporting preterm births as a percentage of total deliveries, and

• Investigating other ways of classifying ethnicity - we noted that the category ‘Other’ included a number of diverse ethnic groups. We recognise that this is a commonly used way of classifying ethnicity, but we want the Ministry to explore different classification methods.

2. Each DHB must review its data and provide comment on the outcomes for women and their babies, and advise the work they have done as a result of this information in next year’s MQSP Annual Reports.

We look forward to reviewing the work of the DHBs in the next MQSP Annual Reports.

12Ministry of Health. 2012. Report on Maternity, 2010. Wellington: Ministry of Health.


Our focus To review the Strategic Plans produced as part of the Maternity Quality and Safety Programme in each DHB. This is an important focus for NMMG because these Strategic Plans identify how each DHB is going to ensure services are delivered in accordance with the New Zealand Maternity Standards at the local level. In particular, we wanted to direct DHB attention and resources to key priority areas.

District Health Board Maternity Quality and Safety Programme Strategic Plans

What we’ve doneWe reviewed the Ministry’s expectations for the development of MQSP Strategic Plans by DHBs.

The content of each DHB Strategic Plan for 2012 was then reviewed, paying particular attention to regional priorities. We also compared each Strategic Plan to national priority areas set by the Ministry and the work programme of the NMMG.

Where there was limited alignment between regional priorities and national priorities, we informed the relevant DHB about the gaps present in their Strategic Plan.

What we foundIn reviewing the Strategic Plans, the NMMG found that the following themes were apparent:

Governance • Many DHBs are developing governance structures, which include LMC and consumer representation at governance level.

Coordination • All DHBs will be employing or appointing dedicated resources to run the programme.

Consumer engagement • All DHBs are recruiting or have recruited consumers at various levels of the programme.

• Many DHBs are considering how best to communicate with consumers and consumer groups, such as through newsletters and websites.

• Many are also considering how to get consumer feedback through activities such as surveys, focus groups, or feedback forms.

Data monitoring and reporting • Many DHBs are reviewing how they collate and use data. This includes the use of local data and information from additional

sources such as the Health Round Table, NZ Maternity Clinical Indicators, MQSP Annual Reports, local KPIs and ‘dashboards’.

32

The changes we expect to see1. All DHBs should focus on national maternity priorities in their next MQSP. However, we

do understand that there will be local variations on the work each DHB carries out in relation to improving maternal quality and safety.

2. DHBs must improve engagement with maternity consumers in the coming year.

Strategic Plans are very important in delivering national priorities and improving local services. The NMMG will be monitoring the Strategic Plan process over the coming year.

Strengthening/bringing together current quality and safety actions• DHBs wish to integrate information from reviews such as the Mortality Review, Serious and Sentinel Event

Review, Clinical Case Review, and existing programmes such as SUDI Prevention Programmes.

Communication networks and information sharing• Most DHBs are trying to establish communication networks or build on existing networks within their

region.

• The aim of communication networks is to improve the sharing of clinical information between community and hospital-based clinicians, and the sharing of information with women and families.

New Zealand National Maternity Standards• Many DHBs plan to carry out a local audit against the New Zealand Maternity Standards.

Regional/sub-regional working • Some DHBs are looking at workforce development, shared clinical roles and regional planning.

Local priorities for quality improvement• Many DHBs have either set priorities in their Strategic Plans, or are currently developing action plans to

deliver on priority areas, such as workforce development.

We found that local priorities for quality improvement for some DHBs had limited alignment with national priorities or the NMMG’s areas of focus. For example, many DHBs did not mention the 2012 Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines) in their Strategic Plans. These Guidelines are of great importance to ensuring quality and safety. In addition, maternal mental health has been highlighted in the PMMRC recommendations for all DHBs to consider their services, but this area was not covered by some of MQSP Strategic Plans.

While all DHBs mentioned the New Zealand Maternity Clinical Indicators, only some identified further investigation or quality improvement actions arising from their DHB’s performance against the indicators.


What we foundWe were pleased to see the considerable work that each DHB has put into the MQSP over the past year. We reviewed the Annual Reports across a number of common themes:

Appointment of an MQSP coordinator• Almost all DHBs have now appointed an MQSP coordinator to oversee the implementation of this programme.

Establishment of governance groups• All DHBs have established a maternity clinical governance group in some form as part of the MQSP. However, some DHBs do

not have consumer representation on these groups.

Achievement of goals outlined in MQSP Strategic Plans• Most DHBs had partially achieved the goals set out in their MQSP Strategic Plans. The goals achieved generally focused around

establishment of clinical governance groups and consumer networks, and improved information sharing;

• Many DHBs had very high-level goals but failed to demonstrate how these goals would be measured;

• Often those DHBs which had not appointed an MQSP coordinator showed a lack of progress towards reaching MQSP goals, and

• The small number of DHBs who had achieved all the goals set out in their plans identified further work for the coming year which had flowed on from the achievement of set goals. They identified how these goals would be measured and their processes for this were transparent.

Our focus To review the Annual Reports produced as part of the Maternity Quality and Safety Programme in each DHB. Overview of the MQSP is one of the main roles of the NMMG, as part of ensuring the New Zealand Maternity Standards are met. We believe it is particularly important to give feedback to DHBs given that the MQSP is a new initiative.

District Health Board Maternity Quality and Safety Programme Annual Reports

What we’ve doneWe reviewed the Ministry’s guidance to DHBs on what was required of the MQSP Annual Reports. We then reviewed each DHB’s MQSP Annual Reports against criteria such as:

• Has the DHB achieved key goals set out in its first MQSP Strategic Plan?

• What discussion was there of national priorities?

• Do future priorities align with those identified by the NMMG?

34

Representation on DHB Quality Groups• Few DHBs outlined how quality improvement teams in the

DHB had been involved in the MQSP process. The DHBs who had considered how the MQSP would link with the wider DHB quality agenda also discussed establishing a relationship with other DHB quality teams.

Key DocumentsClinical Indicators• All DHBs had considered the Clinical Indicators. A number

had reviewed outcomes against the national Clinical Indicators and identified areas for further improvement.

Referral Guidelines• The majority of DHBs have implemented the Referral

Guidelines but some did not mention them.

Alignment with NMMG Priorities• Most DHBs had some alignment with the NMMG priorities;

• Many mentioned the number of women registering after the first trimester in their region. Very few identified ways to improve that number, and

• A small number of DHBs mentioned maternal mental health services as a future priority for their MQSP.

Identification of Future Priorities• Most DHBs identified future priorities for their MQSP in

2013/14. Some priorities were a continuation of the goals not reached in that year. Common new priorities included:

− Maternal mental health services − Ultrasound planning − Prioritisation of vulnerable pregnant women − Maternal and infant nutrition − Access to, and utilisation of, pregnancy and parenting

classes –particularly for rural, Māori, Pacific and young women

− SUDI − Breastfeeding − Utilisation of information systems or websites − Integration of primary and secondary/tertiary services.

• We were disconcerted to note that a small number of DHBs discussed very high-level concepts without mentioning specific deliverables or even why those priorities had been identified.

Consumer Engagement• It was disappointing to note that only just over half of

the DHBs had engaged a consumer representative to be involved with the MQSP. Additionally, of those who had, only a few have noted the provision of support for consumer representatives in the form of financial reimbursement or training, and

• It was encouraging to see that many DHBs have considered pathways for consumer feedback on services. However, this tended to be through paper forms or was sporadic in its coverage.

The changes we expect to seeWe expect that all DHBs will:

Manage the MQSP process• Be able to demonstrate how they are

working towards achieving the goals set out in their MQSP Strategic Plans;

• Make significant progress against their goals in 2013/14 given that this is the second year of the programme;

• Make goals more specific - they need to be measureable so they can be reported upon;

• Work more closely with wider DHB quality improvement teams;

• Reflect national priorities including those of the NMMG in future work.

Improve engagement with consumers• Have at least one, if not more,

consumer representatives on clinical governance groups and supply training to help them contribute effectively;

• Incorporate other ways to get consumer feedback into reporting systems, and

• Ensure that MQSP publications are accessible to consumers and that they are relevant and easy to read.

We are looking forward to seeing this feedback acted upon in the next year of the MQSP.


In 2012/13, the key areas of focus for the NMMG were:• Timing of registration with an LMC;

• Variation in preterm births, including those from 34-36 weeks’ gestation;

• The implementation of the 2012 Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines), particularly in relation to emergency transport and retrieval;

• National consistency in the provision of maternal mental health services, including integration with primary and maternity services;

• Smoking amongst pregnant women;

• The New Zealand Maternity Clinical Indicators;

• The Ministry of Health Annual Report on Maternity, and

• DHB MQSP Strategic Plans and Annual Reports.

We plan to continue our focus on these issues. Other potential areas of interest for the NMMG include:• The implementation of the postpartum haemorrhage (PPH) guideline;

• The impact that regionalisation of services will have on clinical leadership in maternity;

• Variation in the quality of and access to ultrasounds;

• Sentinel events, particularly processes around advocacy and debriefing for families, and

• Training for consumer representatives.

The work streams and work programme of the NMMG for 2013/14 will be finalised in August 2013.

The NMMG Going Forward

36

AcknowledgementsThe NMMG would like to thank the following groups and individuals for their contribution to our work this year:

• Those working at the Ministry of Health who have been involved in our work. Thank you for supporting an open and transparent working relationship with the NMMG;

• The Director-General of Health, for his on-going support, advice and commitment to a further three years of the NMMG;

• The Minister of Health, for his input into the direction and nature of our work, and

• Every DHB in New Zealand, for the commitment of staff involved in the Maternity Quality and Safety Programme. We value highly the palpable commitment we have seen, from the Chief Executives down, to ensuring that this work is undertaken well. We recognise that our requests for information this year may have increased your workload and your responsiveness to our communications has been appreciated.


Introduction1. This document sets out the: a) roles and responsibilities of the National Maternity

Monitoring Group;

b) work programme and reporting requirements; c) composition of the National Maternity Monitoring

Group, and

d) terms and conditions of appointment.

Background2. The New Zealand Maternity Standards (Ministry of Health

2011) consist of three high-level strategic statements to guide the planning, funding, provision and monitoring of maternity services:

a) Standard 1: Maternity services provide safe, high-quality services that are nationally consistent and achieve optimal health outcomes for mothers and babies;

b) Standard 2: Maternity services ensure a woman-centred approach that acknowledges pregnancy and childbirth as a normal life stage, and

c) Standard 3: All women have access to a nationally consistent, comprehensive range of maternity services that are funded and provided appropriately to ensure there are no financial barriers to access for eligible women.

3. These high-level statements are accompanied by specific audit criteria and measurements of these criteria. One of the criteria is that a National Monitoring Group be established to oversee the maternity system and the implementation of the Standards.

Role of the National Maternity Monitoring Group4. The role of the National Maternity Monitoring Group is to

oversee the New Zealand maternity system and to provide strategic advice to the Ministry of Health on priorities for improvement.

5. Standard 1 of the New Zealand Maternity Standards states: ‘a National Monitoring Group, consisting of a small number of clinical sector experts and consumer representatives … provides oversight and review of national maternity standards, analysis and reporting. The National Monitoring Group provides advice to the Ministry on priorities for national improvement based on the national maternity report, nationally standardised benchmarked data, the audited reports from DHB service specifications, Maternity Referral Guidelines, and the Primary Maternity Services Notice 2007’.

6. Standard 1 sets out audit criteria, applicable at the national level, to which the Ministry of Health and the professional colleges are accountable. These additionally inform the role of the National Maternity Monitoring Group.

7. The National Maternity Monitoring Group is not a decision making body. While it may provide recommendations to the Ministry of Health, responsibility for decision making and implementation rests with the Ministry of Health and/or other relevant participants in the maternity system.

Responsibilities and reporting requirements of the National Maternity Monitoring Group8. The National Maternity Monitoring Group will meet at

least four times per annum, and will undertake other communication as necessary to deliver the agreed work programme.

9. The National Maternity Monitoring Group is responsible for identifying priorities for action or investigation, and agreeing a 12 month work programme with the Ministry of Health.

10. The work programme may include but is not limited to: a) providing expert advice on data released through the

New Zealand Maternity Clinical Indicators, national maternity consumer surveys and the New Zealand Maternity Report, which are published from time to time by the Ministry of Health;

b) contributing to the review of the New Zealand Maternity Clinical Indicators at a minimum of three-year intervals and providing advice on the modification, addition or withdrawal of any indicators;

c) identifying priorities for national clinical guidelines/guidance for maternity including recommendations on best clinical practice, and providing advice on how these should be developed and implemented;

d) reviewing reports of the Perinatal and Maternal Mortality Review Committee (PMMRC), identifying the implications for the maternity system of the findings of the PMMRC and providing advice on system response to these findings;

e) reviewing and assessing the annual reports produced by each DHB as part of its Maternity Quality and Safety Programme, and

f ) reviewing and assessing other maternity reports produced or commissioned by the Ministry of Health, DHBs, professional colleges, consumer groups or other stakeholders as requested from time to time.

13Available at: http://www.moh.govt.nz/moh.nsf/indexmh/nz-maternity-standards

Appendix One: Terms of Reference for the National Maternity Monitoring Group

38

11. The National Maternity Monitoring Group may be asked to provide advice on any other matters related to the quality and safety of maternity care and services by the Ministry of Health from time to time.

12. The National Maternity Monitoring Group will produce an Annual Report by a date negotiated with the Ministry of Health detailing:

a) Work carried out, conclusions reached and recommendations made during the previous year, and

b) Its priorities and work programme for the following year.

Relationship of the National Maternity Monitoring Group to the Perinatal and Maternal Mortality Review Commission13. The Perinatal and Maternal Mortality Review Committee

(PMMRC) is a Mortality Review Committee, appointed under section 59E of the New Zealand Public Health and Disability Act 2000 by the Health Quality and Safety Commission.

14. The PMMRC considers maternal and perinatal mortality, and other morbidity as directed by the Minister in writing. It prepares an Annual Report, which includes its advice and recommendations.

15. In providing its advice, the National Maternity Monitoring Group will take account of the findings on maternal and perinatal mortality and morbidity by the PMMRC set out in its Annual Report.

16. Where the PMMRC recommends specific action by maternity system stakeholders, the National Maternity Monitoring Group will advise the Ministry on an appropriate response to these recommendations.

17. The National Maternity Monitoring Group will meet at least once annually with the PMMRC.

Composition of the National Maternity Monitoring Group18. The National Maternity Monitoring Group will have

a maximum of 7 members, not including ex-officio members from the Health Quality and Safety Commission and Ministry of Health.

19. Composition of the National Maternity Monitoring Group will balance requirements for: a) expertise necessary to analyse different sources

of information on the maternity system and make recommendations based on this analysis, and

b) perspectives of key stakeholders in the maternity system.

20. The National Maternity Monitoring Group will include the following skill sets or expertise: a) expertise in epidemiological research and analysis of

health data/statistics;

b) experience and expertise in midwifery care; c) experience and expertise in specialist medical

maternity care; d) expertise in Māori health, and e) expertise in Pacific health f ) experience and expertise in representing a consumer

perspective on maternity issues.

21. All members of the National Maternity Monitoring Group will have basic skills and confidence in working with and interpreting health data.

22. The Ministry will seek nominations from relevant organisations and professional colleges, including the Health Quality and Safety Commission. The Ministry reserves the right to appoint more than one member from an organisation or college or to appoint members not officially nominated by an organisation or college, in order to ensure the balance of skills and expertise outlined in 20 a) to f ).

23. Members of the National Maternity Monitoring Group will share a commitment to working collaboratively and constructively to oversee the national maternity system.

24. The National Maternity Monitoring Group may identify that additional skills or expertise in a particular field or specialty is required to deliver aspects of the agreed work programme. The National Maternity Monitoring Group may seek additional (co-opted) members to fill skill gaps. This will be done in agreement with the Director General of Health.

25. The role of a co-opted member is to provide advice on their defined subject area, when applicable to an aspect of the National Maternity Monitoring Group work programme. Co-opted members are not full members of the National Maternity Monitoring Group, and as such do not have voting or other rights of full members. There is to be only one co-opted member on the National Maternity Monitoring Group at a time. Co-option is time limited with the maximum term of one (1) year.

26. At least one representative of the Ministry of Health will attend meetings in an ex-officio capacity.

Term of the National Maternity Monitoring Group27. The National Maternity Monitoring Group will operate

until the end of June 2013 unless otherwise notified by the Director General of Health. Prior to June 2013 there will


be a review of whether the National Maternity Monitoring Group should remain under the jurisdiction of the Ministry of Health or of the Health Quality and Safety Commission.

Decision-making 28. Decisions within the National Maternity Monitoring Group

are to be made by consensus. Members are expected to work as far as is possible to achieve consensus. Dissenting views of members can be noted for the record.

Appointment process 29. The Director General of Health will appoint members to

the National Maternity Monitoring Group.

30. Membership of the National Maternity Monitoring Group will be for an initial period of one year.

31. A Chair and Vice Chair will be elected by the members of the National Maternity Monitoring Group for a term of one year.

32. Co-opted appointments may be proposed by the National Maternity Monitoring Group and will be made by the Director General of Health.

33. Any member of the National Maternity Monitoring Group may at any time resign as a member by advising the Ministry of Health in writing.

34. The Director General of Health may choose to fill vacancies should resignations occur.

Support for the National Maternity Monitoring Group 35. The Ministry of Health will arrange provision of the

secretariat function for the National Maternity Monitoring Group. This may be externally procured. This includes distribution of agendas and recording of the minutes. Agendas and any associated papers will be circulated at least five days prior to meetings. Minutes will be circulated no later than a fortnight following the meeting date.

Meeting arrangements 36. Meetings will normally be held in Wellington. Rooms and

refreshments will be provided for the meetings.

Payment of meeting fees and travel costs37. A fee of $325.00 (exclusive of GST) will be paid for

attendance at face-to-face meetings and is based upon a full day meeting including travel time. Other work carried out as part of the National Maternity Monitoring Group will be reimbursed on a pro rata basis at the rate of $325.00 per day (exclusive of GST).

38. Public servant/state servants/employees of Crown bodies are not paid for meetings of the National Maternity Monitoring Group. A public servant/state servant/employee of a Crown body should not retain both the fee and their ordinary pay where the duties of the outside organisation are undertaken during ordinary department or Crown body hours.

39. Payment of meeting and other fees will be in accordance with the latest Cabinet circular on fees and guidelines for appointments for statutory bodies, which can be found at: http://www.dpmc.govt.nz/cabinet/circulars/co09/5#PaymentBasis.

40. Travel to meetings and, if necessary, flights and accommodation will be arranged. Meal expenses (without alcohol) will also be paid, but other hotel charges including phone calls and items from the ‘mini bar’ will not be paid. Any additional travel expenses incurred will be reimbursed, including taxis, mileage (at the rate of $0.62 per km, GST not applicable) and parking. A valid receipt must accompany claims for expenses.

Conflicts of interest 41. Members of the National Maternity Monitoring Group

should document their conflicts of interests and identify any conflict of interest prior to a discussion of a particular issue. The National Maternity Monitoring Group will then decide what part the member may take in any relevant discussion, and will identify whether the conflict needs to be escalated to the Ministry of Health for consideration. Guidance can be found in the document ‘Conflict of Interest Protocol for Ministry of Health Advisory Committees’.

Confidentiality 42. The National Maternity Monitoring Group will maintain

confidentiality of agenda material, documents and other matters forwarded to them unless otherwise specified.

43. Members of the National Maternity Monitoring Group are not to represent themselves as agents of the Ministry of Health, and by reason of their membership of the National Maternity Monitoring Group, are not permitted to speak on behalf of the National Maternity Monitoring Group or the Ministry of Health.

44. If a member receives a media request or enquiry relating to the work of the National Maternity Monitoring Group, they must inform the Ministry of Health including the Ministry’s Health Communications Manager. Any media communication will be via the Ministry of Health.

40

Appendix Two: NMMG Year One Work Programme

July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July

2012 2013

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔ ✔ ✔ ✔ ✔ ✔

✔ ✔

✔ ✔ ✔ ✔ ✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

✔

Identify priorities for action or investigation

Review the DHB Maternity Quality and Safety Programme Strategic Plans, particularly in relation to the NMMG priorities

Review the New Zealand Maternity Clinical Indicators (for 2010)

Contribute to the review of the New Zealand Maternity Clinical Indicators (for 2011)

Timing of Registration with an LMC

Retrieve data

Communicate with DHBs

Provide recommendations

Preterm births

Retrieve data

Investigate data


Referral Guidelines

Retrieve data

Communicate with DHBs


Maternal Mental Health

Retrieve data

Consider data


Maternal Smoking

Retrieve data

Review data against Ministry targets


Reports

Review the Ministry of Health Annual Report on Maternity publication.

Review and assess the DHB MQSP Annual Reports, particularly in relation to each of the NMMG priorities

Produce a NMMG Annual Report


Appendix Three: Map of NZ DHBs

Ministry of Health. (2012). Location boundaries (map). Reprinted with permission from the Ministry of Health.

Reprinted with permission from Taranaki DHB. Please note that this is in draft form and still requires some refining.

Perina

tal M

ental H

ealth (PMH): Loc

al Referral P

athw

ay

Inform

wom

en re: scree

ning

for

emotiona

l difficulties

Complete PH

Q-‐3 / PHQ-‐9: i

f po

siti

ve

com

plet

e E

PDS

If im

med

iate risk of harm to self, infan

t or others ?P

olice or CYP

S, Crisis Te

am

or ED asap.

Furthe

r Assess

Repe

at E

PDS

Mot

her-‐

infa

nt in

tera

ctio

n

Inve

stigate

FBC,

U/E

, LFT

, TSH

, Cal

cium

B12

/fol

ate,

Glu

cose

,

? EC

G

Mod

erate de

pression

and

/or

anxiety disorder

(Q 3

-‐5 E

PDS-‐

anxi

ety)

EP

DS

13-‐1

4

Curren

tly men

tally

well b

ut

history of SMI o

r alread

y taking

psycho

trop

ic m

edication

Exclud

e or Treat

anae

mia

, thy

roid

dys

func

tion

, met

abol

ic

diso

rder

, vit

amin

def

icie

ncy,

vir

al in

fect

ions

E-‐m

ail c

onsu

lt: A

ttn:

Psy

chia

tris

t A

dvic

e Re

: Psy

chot

ropi

c pr

escr

ibin

g du

ring

pr

egna

ncy

or la

ctat

ion.

All Hea

lth Profession

als (m

idwife, W

ell C

hild Provide

rs, soc

ial w

orke

r, psych

olog

ist, obstetrician etc.) a

ssessing

a w

oman

during preg

nanc

y an

d up

to 1 ye

ar postnatally

have

the

opp

ortunity fo

r screen

ing for pe

rina

tal m

ental h

ealth prob

lems. This shou

ld occur at least on

ce in

the

ante an

d po

st-‐natal periods, p

referably tw

ice.

Mild

dep

ression an

d /or

anxiety

EPD

S 10

-‐12

Repe

at in

2-‐4

wee

ks

Mod

erate-‐Se

vere m

ental illn

ess

(SMI),Treatmen

t resistan

t de

pression

, bipolar disorde

r,

psycho

ses; Risk of harm to self ,

infant or othe

rs (>

14 E

PDS

& Q

10)

Prov

isiona

l Diagn

osis based

on clin

ical ju

dgem

ent, psych

osocial a

ssessm

ent an

d EP

DS

Rea

ssuran

ce, lifestyle adv

ice

PLUS Psycho

logical The

rapy

&

mon

itoring

Enga

ge p

artn

er (a

sses

s de

pres

sed?

) and

/or

fam

ily s

uppo

rt

Web

-‐bas

ed s

elf h

elp

e.g.

CBT

Re

fer

Coun

selli

ng v

ia v

ouch

er s

yste

m o

r Pr

ivat

e Th

erap

ist

for

evid

ence

– b

ased

ta

lkin

g th

erap

ies:

Bri

ef P

robl

em S

olvi

ng

Ther

apy

N

on d

irec

tive

cou

nsel

ling

Cogn

itiv

e be

havi

our

ther

apy

Inte

rper

sona

l The

rapy

Psycho

trop

ic m

edication

requ

ires

di

scus

sion

of i

ndiv

idua

l ris

ks &

ben

efit

s du

ring

pre

gnan

cy &

bre

astf

eedi

ng.

ww

w.m

othe

rsm

atte

r.co

.nz

Cons

ult

MIM

S; S

SRI’s

usu

ally

firs

t lin

e.

Low

dos

e in

itia

lly

M

anag

emen

t Plan

(w

omen

’s preferenc

es con

side

red)

Referral G

uide

C

oordinated

care & In

terprofessiona

l co

mmun

ication

Referral to Pe

rina

tal M

ental H

ealth

(PMH]

at D

HB

A

sses

smen

t &

tre

atm

ent

by m

ulti

-‐d

isci

plin

ary

team

incl

udin

g ac

cess

to

ka

upap

a M

aori

ser

vice

s; P

MH

bir

th

plan

, ris

k as

sess

men

t, r

elap

se

prev

enti

on +

/-‐ m

anag

emen

t pl

an.

Coor

dina

tion

& r

efer

ral t

o ot

her

ag

enci

es, f

amily

& c

are

coor

dina

tion

m

eeti

ngs

A

djus

tmen

t to

Par

enth

ood

Gro

up.

Resou

rces: E

dinb

urgh

Post Natal Dep

ression Scale (EPD

S) PHQ-‐3 or 9 MIM

S Internet access

Barrier to seeing

GP?

Furthe

r assessmen

t of m

othe

r an

d infant by GP

En

sure com

mun

ication is empa

thic, w

oman

& fa

mily

-‐ cen

tred

, non

-‐directive

Clinical ju

dgem

ent &

EPD

S score > 14

or risk factors

Refe

r PM

H &

sen

d a

copy

of r

efer

ral

to

GP

Consider Police or CYF

S if risks

Crisis Tea

m or E.D. referral

Urgen

t psychiatric assessmen

t &

In-‐patient Treatmen

t (S

tart

MH

A if

req

uire

d)

Clinical Assessm

ent

As

abov

e pl

us s

ympt

oms

of m

ood

diso

rder

, anx

iety

, PT

SD, E

atin

g di

sord

er, p

sych

oses

, bip

olar

dis

orde

r,

pers

onal

ity

Psycho

social risk factors

or con

cern re: m

othe

r-‐infant in

teraction

EPDS < 10

Rea

ssuran

ce, Lifestyle Adv

ice &

Mon

itor

Psyc

ho-‐e

duca

tion

, Exe

rcis

e (g

reen

pr

escr

ipti

on),

Sle

ep; N

utri

tion

; Sm

okin

g (N

RT);

Rel

axat

ion,

m

indf

ulne

ss, s

tres

s re

duct

ion;

pos

itiv

e ac

tivi

ties

; moo

d di

ary;

con

trac

epti

on

Refe

rral

oth

er a

genc

ies

for

pare

ntin

g,

rela

tion

ship

cou

nsel

ling

or s

uppo

rt

A&

D

Post

nata

l Sup

port

Gro

up

Psycho

ses or im

med

iate risk of

harm

to self, in

fant or othe

rs

Aus

tin

M-‐P

, Hig

het

N &

the

Gui

delin

es E

xper

t A

dvis

ory

Com

mit

tee

(201

1) C

linic

al P

ract

ice

guid

elin

es fo

r de

pres

sion

and

rel

ated

dis

orde

rs-‐a

nxie

ty, b

ipol

ar d

isor

der

& p

uerp

eral

psy

chos

is –

in t

he p

erin

atal

per

iod,

A g

uide

line

for

prim

ary

care

hea

lth

prof

essi

onal

s.

Mel

bour

ne: B

eyon

d Bl

ue: t

he n

atio

nal d

epre

ssio

n in

itia

tive

; NZG

G (2

008)

Iden

tific

atio

n of

com

mon

men

tal d

isor

ders

and

man

agem

ent

of d

epre

ssio

n in

Pri

mar

y Ca

re, E

vide

nce-‐

base

d be

st p

ract

ice

guid

elin

e; N

ICE

(200

7) g

uide

line

on c

linic

al m

anag

emen

t an

d se

rvic

e gu

idan

ce a

nten

atal

and

pos

tnat

al m

enta

l hea

lth,

Bri

tish

Psy

chol

ogic

al S

ocie

ty &

Roy

al C

olle

ge o

f Psy

chia

tris

ts. A

ckno

wle

dgem

ent

to

Dr

Jane

Alla

n &

Per

inat

al M

enta

l Hea

lth

Team

Tar

anak

i DH

B

Refe

renc

es

Ask: W

ould you

like

help?

Scor

e EP

DS

: Q

.10

If S

core

> 0 Assess Sa

fety

Score <

10

if un

ders

cori

ng r

efer

GP

+/-‐

PMH

Psycho

social Factors:

Iden

tify

age

ncy

&

refe

r Score 10

-‐12: R

epea

t 2/

52, s

uppo

rt, a

dvis

e G

P

Score: >

12:

GP

for

furt

her

asse

ssm

ent

Pre-‐

conc

epti

on p

sych

otro

pic

advi

ce b

y co

nsul

t or

ref

erra

l

App

endi

x Fo

ur:

Dra

ft T

aran

aki D

HB

Peri

nata

l M

enta

l Hea

lth L

ocal

Ref

erra

l Pat

hway


List of DefinitionsCaesarean section An operative birth through an abdominal incision.

Episiotomy An incision of the perineal tissue surrounding the vagina at the time of birth to facilitate delivery.

Parity Number of previous births a woman has had.

Postpartum Haemorrhage Excessive bleeding after birth that causes a woman to become unwell.

Primary health care The first-contact professional health care received in the community, usually from an LMC, GP or practice nurse.

Secondary health care Specialist care that you may be referred to by a primary healthcare professional. These services are usually hospital-based.

Standard primiparae A group of mothers considered to be clinically comparable and expected to require low levels of obstetric intervention.

Tertiary health care Highly specialised consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment.

Weeks’ gestation The term used to describe how far along the pregnancy is. It is measured from the first day of the woman’s last menstrual cycle to the current date.

44

List of Abbreviations

Data SourcesUsed

DHB District Health Board

GP General Practitioner

HDU High Dependency Unit

ICU Intensive Care Unit

LMC Lead Maternity Carer

MQSP Maternity Quality and Safety Programme

NICU Neonatal Intensive Care Unit

NMMG National Maternity Monitoring Group

PMMRC Perinatal and Maternal Mortality Review Committee

PPH Postpartum Haemorrhage

SUDI Sudden Unexplained Death in Infancy

VBAC Vaginal birth after caesarean

National Maternity Collection• Percentage of Women Registered with an LMC in the First Trimester, by DHB of Domicile,

2011 (p12)• Rate of Preterm Births (<37 Weeks Gestation) per 100 Births, 2008-2011 (p15) • Rate of Preterm Deliveries in Primary Birthing Facilities (34-36 weeks’ gestation) Per 100

Deliveries, 2008-2011 (p16)

The Ministry of Health’s National Maternity Collection includes data from hospital birth records and claims made by Lead Maternity Carers. This dataset includes hospital and home births. This dataset allocates year as year of registration with an LMC.

Births, Deaths and Marriages Collection Live Birth Registrations• Preterm Births by Weeks’ Gestation Range, as a Percentage of Total births, by DHB of

Domicile, 2011 (p16)• Rate of Late Preterm Births (34, 35 & 36 weeks’ gestation) Per 100 Births, 2008-2011 (p17)

Statistics New Zealand publish births based on figures collected by Births, Deaths and Marriages at the Department of Internal Affairs. This is New Zealand’s official record of births numbers. This dataset allocates year as year of birth.

46

Website: http://www.hiirc.org.nz/section/20254/maternity-quali-ty-and-safety/?tab=5973Email: [email protected]: +64 9 475 0201Fax: +64 9 479 4530

Postal Address: PO Box 302469North HarbourAuckland 0751New Zealand

If you have any enquiries about this report, or wish to contact the NMMG, please contact the NMMG Secretariat on: