Interventions to reduce maternal deaths in New Zealand

Professor Julie Quinlivan

University of Notre Dame Australia

University of Adelaide Women’s and Children’s Research Institute

Ramsay HealthCare, Joondalup Health Campus

Acknowledgements

• Perinatal and Maternal Mortality

Review Committee

• Chair, Professor Cynthia Farquhar

• Health Quality and Safety

Commission New Zealand.

Maternal

deaths

What are

potentially

avoidable factors ?

What evidence is

there to help?

C0incidential maternal deaths

• In the five years from 2006-2010 eight mothers died

of coincidental causes.

• All deaths occurred in the community.

• Six due to MVA

• One due to cancer

• One due to an accident

• Four deaths found to be potentially avoidable due to

not wearing a seat belt whilst a passenger in a motor

vehicle.

Risk Associations

• Fourth or higher order birth

• Overweight or obese

• Smoking, drug and alcohol abuse

• Age over 40 years

• Maori or Pacific mothers

• Domestic violence and mental illness

Potentially avoidable deaths

• 32% of all maternal deaths were

potentially avoidable deaths

Contributory factor present (N=57)

Contributing factor N %

Yes 30 53%

No 25 43%

Unknown 2 4%

Maternal deaths (N=57)

Potentially avoidable

N %

Yes 18 32%

No 37 65%

Missing data 2 4%

Avoidable contributory factors

• Organizational

• Personnel

• Technology

• Environmental

• Barrier to care

Organizational factors (N=18)

Lack of policies/protocols/guidelines

14

Poor education and training 6Poor communication 5Failure or delay in emergency response

4

Poor organization of staff 4Delay in procedure 3Poor access to senior staff 2Delayed access test result 1

Personnel factors (N=17)

Knowledge and skills of staff lacking

8

Lack recognition of seriousness of situation

8

Failure to communicate between staff

8

Delayed emergency response 5Failure to seek help/supervision 3Failure to follow best practice 2Other 9

Technology factors (N=1)

Lack of maintenance of equipment

1

Environmental factors (N=3)

Geography (long transfer) 3

Barriers to Care factors (N=21)

No or infrequent care or late booking

11

Lack recognition of seriousness of condition

8

Mental illness 5Substance use 4Family violence 3Other 7

Staffing education/behaviour

• Lack of policies/protocols/guidelines (N=14)

• Lack of recognition of complexity or seriousness of

condition (N=8)

• Knowledge and skills of staff were lacking (N=8)

• Inadequate training/education (N=6)

• Delayed emergency response by staff (N=5)

• Failure to seek help/supervision (N=3)

• Failure to follow recommended best practice (N=2)

Barriers to Care – Patient

• No or infrequent

antenatal care or late

booking

• Family violence

• Mental illness

Discussion points

Staff training in O&G (talk 1)

Evidence base behind non

engagement with care

Domestic violence

Mental illness

Why do patients

not engage

with care?

Patient engagement with care 1

• Travel – longer travel time to the

center associated with reduced number

of referrals for eligible women, but once

they attend, no difference in default

rates• Astell-Burt T, Flowerdew R, Boyle P, Dillon J. Soc Sci

Med 2012; 75(1): 240-7

Patient engagement with care 2

• Advice given – If patients are

uncomfortable or do not understand the

reasons behind advice given, they are

more likely to default from care than attend

and explain why they did not follow advice.• Cartwright B, Holloway D, Grace J et al. Obstet

Gynaecol 2012; 32(4): 357-61

Patient engagement with care 3

• Ethnicity – There are genuine ethnic

differences in attendance for care that

cannot be explained by simple

socioeconomic status, geography and

severity of illness• Bansal N, Bhopal RS, Steiner MF et al. Br J Cancer

2012; 106(8): 1361-6

Patient engagement with care 4

• Care giver advice - Incentives to attend

for care are greater levels of patient

knowledge, a sense of duty and fear. The main

disincentives to attend for care is the absence

of a strong recommendation that care is

beneficial by a healthcare provider.

• Cartwright B, Holloway D, Grace J et al. Obstet Gynaecol

2012; 32(4): 357-61

Patient engagement with care 5

• Administrative factors –

women defaulting from care stated

that they were unaware of the

appointment date and time, were

confused about need to attend or

forgot the appointment.

• Wilkinson J, Daly M. J Prim Health Care 2012;

4(1): 39-44

Patient engagement with care 6

• Domestic violence and housing

instability– In multivariate analysis following

500+ women across three years, the only

independent variables associated with persistent

default and eventual loss to follow up in O&G clinics

were domestic violence and housing instability• Quinlivan J et al.. J Low Gen Tract Dis 2012; doi;

10.1097/LGT.Ob013e3182480c2e

• Collier R, Petersen RW, Quinlivan J Arch Wom Ment Health 2012

(in press); Paper to be presented at ASPOG ASM Melb August 2012

You need to know your

local factors for

disengagement with care.

Domestic violence and

mental illness

Domestic violence 1

• Common in the reproductive years

– NZ lifetime prevalence 33-39%

– Severe 19-23%

– Experienced annually 5%

• Women exposed to domestic violence present for

care

• Women do not mind being screened in healthcare

settings• Fanslow J, Robinson E. NZ Med J 2004; 117: 1206

• Violence Intervention program 2011

http//www.aut.ac.nz/_data/assets/pdf_file/0020/235640/ITRC-SUMMARY-FINAL-

2011-WEB.pdf

Domestic violence 2

• With the exception of psychopathic

domestic violence, the precipitating event is

frequently excessive use of alcohol and

drugs.

• Need to screen to identify

• Need to refer for intervention once identified• Quinlivan JA. Where should research now be focussed in domestic violence and alcohol.

International Journal of Substance Use. Commentary 2001; 6: 248-50.

Family Violence and NZ Maternal Deaths

Family violence data only

available in 40% of cases, but

where available, was involved

in 24% of cases

• Six of these eight women died

from suicide.

Family Violence and NZ Maternal Deaths

All District Health Boards

required to screen for

domestic abuse

However, only 82% of NZ

Hospitals monitor partner

abuse screening,

Only 22% of these achieve

screening rates >50%

Poor history taking

• There is poor history taking in relation to

mental illness in obstetric histories.

• Often bipolar disorders and major

psychotic disorders are mislabeled as

‘depression’

• Anxiety disorders are also missed» Chessick CA, Dimidjian Arch Womens Ment Health 2010; 13: 233-248

Screening tools

• Improve rates of disease detection.

• Need to rescreen in each pregnancy

as sufficient variation between

pregnancies to justify this.

• EPDS only screens for depression» La Porte LM, Kim JJ, Adams M et al. Am J Obstet Gynecol 2012; 206(3): 261-4

» Leddy MA, Lawrence H, Schulkin J Obstet Gynecol Surv 2011; 66(5): 316-23

Must be an entire program• Good history taking for mental illness and screening

tools

• A network of providers to accommodate screen positive

referrals

• 24/7 hotline appropriately staffed

• Midwifery and obstetrician education

• Centralized scoring and referral process

• Take care to ensure private providers implement policies

• Intensive therapy must be available for those identified

as requiring this input» Gordon TE, Cardone IA, Kim JJ. Obstet Gynecol 2006; 107(2 Pt1): 342-7

The Suicide profile• Based on a review of 46 published articles

on obstetric suicide.

• Risk factors:

– current or past history of psychiatric disorder,

young (<20 years), unmarried, unemployed,

unplanned pregnancy, illicit drug use, alcohol

use in pregnancy, low supports, previous

sexual or physical violence.» Gentile S, J Inj Violence Res 2011; 3(2): 90-7

You need to screen for domestic

violence and mental illness and act on the

findings