Potentially Avoidable Deaths – what could obstetricians do better? Alec Ekeroma FRANZCOG FRCOG MBA Head, Pacific Women’s Health Research & Development Unit Department of Obstetrics & Gynaecology Member, of the PMMRC

Our 2009 stats… In 2009, the PNMR was 10.6 per 1000 births, The rate is comparable to Australia and the United Kingdom. The stillbirth rate in 2009 was 6.3 per 1000 births. 25% were unexplained – 35% had a post-mortem – 22% were not investigated.

In perspective million stillbirths a year - more than malaria and AIDS deaths combined 98 percent of all stillbirths in 2009 occurred in low- and middle-income countries – 70% in rural areas where midwives and doctors are often not on hand

The Lancet Series 2011, WHO estimations, NZ actual

Rates of Late Fetal Death by Mother's Ethnic Group, NZ Births Craig, Mantell, Ekeroma, Stewart, Mitchell, ANZJOG 2004

Ethnicity Maori and Pacific mothers – are more likely to have stillbirths and neonatal deaths compared to NZ European and non- Indian Asian mothers – higher rates of perinatal mortality compared to those with mixed ethnicities. – higher spontaneous preterm birth – Maori – antecedent: antepartum haemorrhage – Pacific – antecedent: hypertension

MMH Data

Socioeconomic Deprivation Higher rate of stillbirth and neonatal death among mothers in the most deprived socioeconomic quintile Spontaneous preterm birth and antepartum haemorrhage are associated with increasing socioeconomic deprivation.

PMMRC Report 2011

CMACE Report 2011

Age Teenage mothers are at higher risk of stillbirth and neonatal death compared to mothers aged 20–39 years (14.7/1000 compared to 10.3/1000). Mothers of 40 years and older are at increased risk of fetal loss. 50% of teenage mothers whose babies died from 2007 to 2009 were Maori. 45% of all teenage mothers whose babies died were smokers.

CMACE Report 2011

BMI and Stillbirths Univariate OR (95% CI) Multivariate * OR (95% CI) BMI (WHO criteria) Overweight Obese ≥ ( ) 2.1 ( ) 1.7 ( ) 2.1 ( ) BMI ethnic specific Overweight Obese 1.5 ( ) 1.9 ( ) 1.6 ( ) 1.8 ( ) Euro: 25/ 30 PP/Maori 26/32 Indian/Asian 23/27.5 *Adjusted for: Parity, age, ethnicity, BMI, marital status, smoking, Dep index illicit drugs Euro: 25/ 30 PP/Maori 26/32 Indian/Asian 23/27.5 Stacey, Mitchell, Thompson, Ekeroma, Zuccollo, Ekeroma, McCowan, ANZJOG 2011

Dr Brad Novak, CMDHB Public Health

PMMRC Report 2011

Potentially Avoidable Death A death is considered potentially avoidable if the absence of a contributory factor would have prevented the death. Contributory factors: – Organisational/management – Personnel – Technology, equipment, environment – Barriers to accessing/engaging with care – PMMRC Report 2011

Avoidable deaths Measure the quality, effectiveness and/or the accessibility of the health system. Broad indicator of possible concern but can rarely, if ever, confirm the presence and nature of a problem. Influenced by a range of factors - underlying prevalence of conditions in the community, environmental and socioeconomic factors and lifestyle choices. » Nolte E McKee M, Does Health Care Save Lives? Avoidable mortality revisited. 2004, The Nuffield Trust: London.

65 studies of avoidable deaths Inadequate treatment Inadequate diagnosis Delay of treatment Delay of diagnosis Inadequate treatment of complications Delayed recognition of complications Bad cooperation between different levels of carers Lack of prevention of complications Delay in seeking help Psychosocial factors – Westerling R, Studies of avoidable factors influencing death: a call for explicit criteria, Quality in Health Care 5:

PMMRC Report 2011

Potentially Avoidable Deaths in South Australia 680 pregnancies (2001–2005) resulting in perinatal death were compared to 86,623 live births. 270 cases (44.4%) have one or more avoidable maternal risk factors – 31 cases (5.1%) poor access to care – 68 cases (11.2%) were associated with deficiencies in professional care – 104 women (17.1%) presented too late for timely medical care: 85% of these did have a sufficient number of antenatal visits. De Lange T, Budge M, Heard A, et al. ANZJOG 2008

Recommendations for South Australia Greater emphasis on the importance of – antenatal care and – educating women to recognise signs and symptoms that require professional assessment. Education of maternity care providers may benefit from a further focus on how to recognise and/or manage high-risk pregnancies. – De Lange T, Budge M, Heard A, et al. ANZJOG 2008

PMMRC Report 2011

Maternal mortality ratio The MMR for the four-year interval 2006–2009 is 19.2/100,000 maternities (95% confidence interval /100,000). Significantly higher than the ratio reported by the United Kingdom for the triennium 2006–2008 of 11.4/100,000 maternities. There were 14 maternal deaths in (9 in 2008, 11 in 2007, 15 in 2006).

PMMRC Report 2011

Causes of deaths The most frequent causes of maternal death in New Zealand in the years 2006–2009 were: – suicide (10 cases), – maternal pre-existing medical conditions (9 cases) – and amniotic fluid embolism (8 cases). Of the 14 deaths in 2009, four died of pandemic influenza (A) H1N1 infection.

Recommendations 2011 Report Early booking – all women should commence maternity care before 10 weeks, for the following reasons: – Opportunity to offer screening for congenital abnormalities, sexually transmitted infections, family violence, and maternal mental health; and to refer as appropriate – Education around nutrition (including appropriate weight gain), smoking, alcohol and drug use, and other at-risk behaviours – Recognition of underlying medical conditions with referral for secondary care as appropriate

Recommendations cont.. All LMCs should be aware that teenage mothers are at increased risk of stillbirth and neonatal death due to preterm birth, fetal growth restriction and perinatal infection. Maternity services for teenage mothers need to address the provision of services that specifically meet their needs, paying attention to: – smoking cessation, prevention of preterm birth (including smoking cessation, sexually transmitted infection screening and treatment, urinary tract infection screening and treatment) and screening for fetal growth restriction using regular fundal height measurement on customised growth charts

– providing appropriate antenatal education. Research on the best model of care for teenage pregnant mothers in New Zealand should be undertaken with a view to reducing stillbirth and neonatal death. Engagement with the Ministry of Education is required regarding appropriate education and maternity care in the school setting.

Avoidable perinatal related deaths Key stakeholders in provision of health and social services to women at risk (for eg, due to their age, ethnicity, or socioeconomic deprivation) should work together to identify existing research on: – reasons for barriers to accessing maternity care – interventions to address barriers to engagement with maternity care. Clinical services and clinicians have a responsibility to ensure the following:

– continuing education programmes which focus on knowledge and skills of personnel, including implementation and audit of best practice – local review of maternal and perinatal outcomes linked to quality improvement – policies and guidelines that are up-to-date, implemented and audited – a culture of teamwork including support, mentorship, supervision, communication and documentation – a culture of practice reflection on patient outcomes with a link to quality improvement – staffing arrangements that ensure timely access to specialist services.

Mental Health is important Regular monitoring and support is recommended for at least three months following delivery. At first contact with services women should be asked: – During the past month, have you often been bothered by feeling down, depressed or hopeless? – During the past month have you often been bothered by having little interest or pleasure in doing things?

Obstetric emergencies All staff involved in care of pregnant women should undertake regular multidisciplinary training in managing obstetric emergencies and in resuscitation, including appropriate use of peri-mortem caesarean section to facilitate adequate resuscitation of the mother.

Communication between services Pregnant women who are admitted to hospital for medical conditions not related to pregnancy need to have specific referral pathways for perinatal care

Family violence Family violence screening should be a routine part of maternity care and screening should be documented in clinical notes.

Pandemic influenza (A) H1N1 – Pregnant women should be immunised against influenza because they are at increased risk of severe outcomes – Pregnant women should consult their LMC or GP as soon as symptoms of an influenza-like illness develop or if other family members are unwell to allow: referral to hospital for assessment if there are symptoms of respiratory compromise due to influenza, that is, worsening shortness of breath, especially at rest, productive cough, pleuritic chest pain, haemopytsis prescription of antiviral medication.

Avoidable Deaths… So the question.. What could or should obstetricians do better?

“The 3 Delays”.....in relation to getting the right Midwifery/Obstetric Care at the right time to prevent maternal death and disability 1.Delay in recognizing the problem &/or delays in deciding to seek care 2.Delay in getting to care 3.Delay in getting the right care when they have arrived at the health facility

Risk Factors advanced maternal age high pre-pregnancy body mass index (BMI) smoking fewer than 4 antenatal visits maternal ethnicity fetal growth restriction and low socio-economic status

Obstetricians Could… Advise Advocate Agitate On all levels and sectors political organisational community Inequality in health care provision and outcomes

Social Determinants of Health a holistic approach to collaboratively across all sectors to develop systems to reduce health inequalities. the most disadvantaged and marginalised are often the last in society to seek medical help. act on social determinants of health and to promote health throughout the population – Royal College of Physicians, Royal College of Physicians 2010

NZMA Stocktake: Actions done to address health inequities Social welfare policies implemented in part at least are pro-equity, including Working for Families and Whanau Ora. Intersectoral activities e.g. housing insulation, Before School Check and the National Immunisation register.

Actions done.. Many policies relevant to health include equity goals or purposes, including the Health Strategy, Cancer Control Strategy, Reducing Inequalities in Health Strategy, He Korowai Orange and Ala Mo’ui Māori health provider, and Māori development. The Treaty of Waitangi and Māori health has been enshrined in legislation in the NZPHA Increasing focus on the needs of Pacific and other peoples has grown in parallel with NZ’s multi-ethnic composition

Actions to be done... Equitable and fair fiscal and social welfare policy, including progressive taxation, comprehensive and fair social policy, and ensuring that everyone has a minimum income for healthy living. Maintain and enhance social cohesion, through ensuring all services are accessible by all. Maintaining and enhancing investment in early childhood, including the need to for there to be a visible leadership that champions child health and wellbeing.

Actions to be done... Health equity needs to be widely understood. It affects everyone. Everybody working in a service delivery occupation needs to be able to alter their practice to reduce health inequities. Ill-health prevention that addresses risk factors contributing to health inequities, including making NZ Smokefree by 2025, ensuring healthy food and stronger policies to tackle harmful alcohol consumption.

Actions to be done... Maintaining and enhancing Māori, Pacific and Asian policies and programmes, including health promotion, screening and health care services models that are culturally specific or tailored. Health equity research needs to continue and focus on ‘what works’, evaluating policies and programmes for equity impacts in processes and outcomes. Ensuring health services are equitable, including ensuring a strong equity focus in prioritisation of health resource allocation, quality improvement policies and programmes, and improved information systems. This means, among other things, transparent monitoring, smoothing out regional variations in access, and ongoing provider education and support. Blakely T, Simmers D, Sharpe N. NZMJ, 2011

Interventions that averts 99% of stillbirths Family Planning Periconceptional Folic acid and screening Reduction of malaria and syphilis Detection and management of hypertension and diabetes Detection and management of IUGR IOL at >41 weeks gestation Comprehensive emergency obstetric care – Systematic review of RCT and OS, Lancet 2011

Priority actions to reduce stillbirths Reduce inequity, intentionally designing policies and programmes to reach underserved women from poorer communities or ethnic minorities. Improve quality of care and use audit to link to change. Address lifestyle risk factors such as obesity, smoking, and advanced maternal age. Identify ways to reduce maternal overweight and obesity. An agreed set of investigations, combined with improved counselling is important for every stillbirth. – The Lancet 2011

Obstetricians Should…. Conduct Audit of all Near Misses – Maternal and Neonatal – Health outcomes might be a more meaningful point than process indicators – Near-miss more common than deaths, enabling more quantitative analysis – Near-miss less threatening than deaths – Survivors live to tell stories – incorporates a woman’s perception of care received

Obstetricians Should… Work and Learn in teams – Work closely with midwives and junior staff – Learn with midwives and junior staff Review current models of antenatal services – Strengthen LMC model – Accessible to women – Address needs of woman and family – Meaningful and appropriate

Promote Targeted interventions – Families at risk – Women with risk factors