Beyond the numbers:
Understanding potentially
avoidable deaths and the
evidence based approaches
to prevention
Professor Julie Quinlivan
University of Notre Dame Australia
University of Adelaide Women’s and Children’s Research Institute
Ramsay HealthCare, Joondalup Health Campus
Acknowledgements
• Members of the Perinatal and Maternal
Mortality Review Committee
• Chair, Professor Cynthia Farquhar
• Health Quality and Safety Commission New
Zealand.
Perinatal mortality
• Key associations
• Potentially
avoidable factors
• Evidence that may
guide a response
Associations with Ethnicity
• Maori and Pacific women
– Still birth
– Preterm birth
– Antepartum haemorrhage
– Sudden Unexpected Deaths in Infancy
• NZ European and non-Indian Asian women
– Neonatal deaths
– Hypertension and diabetes
Associations with
Socioeconomic Deprivation
Increased stillbirth
Increased neonatal death
Associations with Age
* Teenage mothers
– Stillbirth
– NND
– Preterm birth
* Older mothers (>40 years)
– Maternal medical conditions
– Congenital abnormalities
Associations with
Drug and Alcohol Use
• Smoking
– Data still incompletely reported (50%)
– 35-29% deaths compared to background rate of 14%
• Alcohol and marijuana
– Preterm birth
– Sudden unexpected deaths in infancy
Associations with
Overweight and Obesity
Associations
with
Twins and
multiple
pregnancy
Associations with
Family violence, Preterm birth
and Small for Gestational age
Potentially avoidable deaths
Perinatal related deaths (N=704)
Contributory factors
N
%
Present
192
27.3%
Absent
497
70.6%
Missing data
15
2.1%
Contributory factor present (N=192)
Potentially avoidable
N
%
Yes
124
17.6%
No
66
9.4%
Contributing factors present
but avoidability unknown
2
0.31%
Avoidable contributory factors
• Organizational
• Personnel
• Technology
• Environmental
• Barrier to care
Organizational factors (N=39)
Delay in procedure (eg C/S)
Delay in emergency response
Poor access to senior staff
Inadequate training/education
Lack of policies/protocols/guidelines
Inadequate staff numbers
Poor organization of staff
Other
8
5
4
4
3
3
2
10
Personnel factors (N=60)
Failure to follow recommended best
practice
Lack of knowledge and skills
Poor communication
Failure to seek help/supervision
Delayed response by staff
Other
21
12
7
5
4
11
Technology factors (N=5)
Essential equipment not available
Lack of maintenance of equipment
Malfunction/failure of equipment
Other
1
1
1
2
Environmental factors (N=19)
Geography
Other
14
5
Barriers to Care factors (N=149)
Lack of recognition of complexity or
seriousness of condition
Substance Use
Maternal mental illness
Family violence
Language barriers
Cultural barriers
Other
23
16
9
7
6
4
84
Barriers to Care - Other (N=84/124)
• No antenatal care
• Late booking with antenatal care
• Non-attendance with antenatal visits
• Not following advice or treatment
Staff education & behaviour
Staffing education/behaviour
(N=69/124)
• Lack of recognition of complexity or seriousness of
condition (N=23)
• Failure to follow recommended best practice (N=21)
• Knowledge and skills of staff were lacking (N=12)
• Failure to seek help/supervision (N=5)
• Inadequate training/education (N=5)
• Lack of policies/protocols/guidelines (N=3)
Discussion points
• Evidence based management
of teenage and older mothers
• Evidence base behind staff
training and behaviour in
obstetrics
• Evidence base behind non
engagement with care (talk 2)
The younger mother
– Stillbirth
– Preterm birth
– Neonatal death
What is the
evidence base
to improve
outcomes for
teenage
mothers?
The Quinlivan Triad of Care
1. Teenage antenatal clinics
2. Home visitation services
3. Postnatal re-engagement
in education or workforce
and parenting support
» Quinlivan JA. Community Paediatric Review 2008; 16: 5-6.
Triad 1: Teenage antenatal clinic
“Teenage-specific antenatal clinics that have
comprehensive screening policies for infection
and psychosocial pathology are associated with
lower rates of preterm birth.”
» Quinlivan JA, Evans SF. BJOG 2004:111; 751-578.
Teenage antenatal clinic care
Care is provided by a multi-disciplinary team.
CPG includes:
– Screening for genital tract infection, anaemia and other
infections (dental, urine)
– Social work appraisals (housing, violence, income)
– Management plan for illegal drug use, smoking and alcohol
– An open hospital admission policy
– Direct linkage to Centrelink.
– Quinlivan JA, Evans SF. BJOG 2004:111; 751-578.
Teenage ANC and Preterm birth
Teenage antenatal clinics are associated with
reductions in:
– TPL
– PPPROM
– preterm birth
–
Quinlivan JA, Evans SF. BJOG 2004:111; 751-578.
Cost of a teenage clinic
Cost based
on N=70
No clinic
Teenage clinic
Cost of preterm $122,000
birth
$72,000
Cost of clinic
$0
$51,000
Total
$122,000
$123,000
Quinlivan JA. Teenage parents – improving their outcomes using evidence based medicine. Working towards closing the
gap on Aboriginal and Torres Strait Islander Children and Young People’s Health and Well Being Queensland Government,
Queensland Health. Brisbane May 2010.
Triad 2: Home visitation
Meta-analyses and surveys of over 3,000
studies show that nurse home visitation
consistently provide the most positive
outcomes for vulnerable mothers children
both in the short term and sustained over
time.
– Karoly LA, Greenwood PW et al. Investing in our children.: RAND
Corporation, Santa Monica, CA, 1998
Triad 3: Postnatal parenting
programs where childcare is
provided.
Findings of a systematic review, based upon 14
studies involving teenage mothers, found that
parenting programs can be effective in improving a
range of psychosocial and developmental outcomes
for teenage mothers and their children.
However, childcare is vital to program success.
Coren E et al, J Adol 2003.
The older mother
– Congenital anomalies
– Maternal chronic disease
» Loke AY, Poon CF. J Clin Nurs
2011; 20: 1141-50
What is the
evidence base
to improve
outcomes for
older
mothers?
Older age and
stillbirth
• Systematic review of 31 retrospective cohort and
6 case control studies found that greater
maternal age was associated with increased risk
of still birth.
• Relative risks vary from 1.20 to 4.53.
» Huang L et al. CMAJ 2008; 178: 165-172.
Older age a risk for many
adverse outcomes.
• Retrospective study of 45,033 women
• Significant linear association documented between
advanced maternal age and:
– IUGR, LBW, malformations, perinatal mortality.
– Most of the risk driven by
• chronic disease driven preterm birth and IUGR, and
• fetal malformations.
» Salem YS et al. Arch Gynecol Obstet 2011; 282: 755-9
Intrapartum anoxia a risk
• Retrospective cohort study of 1,043,002 women with singleton
term cephalic infants.
• Compared with women aged 25-34 years, women >35 years
had an increased risk of delivery related perinatal death at
term
– OR 2.20 95%CI 1.42-3.40
• Excess risk explained by intrapartum anoxia
– Primip OR 5.34 95%CI 2.34-12.20
– Multip 2.14 95%CI 0.99-4.60
» Pasupathy D et al J Epid Com Med 2011; 65: 241-5.
Managing Risk
• Excess fetal anomalies needs early advice of
options and screening
• Excess medical problems needs early
optimisation of conditions
• Excess anoxia in labour needs appropriate
birth plans
To address the evidence,
nulliparous women over 35
years of age and parous
women over 40 years of age
should have a first trimester
visit dedicated to discussing:
• Screening for prenatal
anomalies
• Screening for chronic
disease
• A realistic birth plan is
discussed.
Staff training and clinical guidelines
Clinical practice guidelines improve
patient care outcomes in obstetrics.
Santo S, Ayres-de-Campos O. Crr Opinion Obstet Gynecol 2012; 24(2): 84-8
Berglund A, Leferre-Cholay H, Bacci A et al. Acta Obstet Gynecol 2010; 89: 230-237
Strasser DC, Falconer JA, Stevens AB et al. Arch Phys Dis Rehab 2008; 89(1): 10-5
Clinical Practice Guidelines
Obstetric RCT
• Study across three hospitals to review impact of
clinical practice guidelines.
• High compliance rate with guidelines
• Improvements in all outcome measures for
pregnancy including reduction in PMR.
– Berglund A, Leferre-Cholay H, Bacci A et al. Acta Obstet Gynecol
2010; 89: 230-237
Clinical Practice Guidelines
Obstetric RCT
• “Improvements in health outcomes does not
require primarily expensive technology. Rather
staff must be trained and motivated to adhere to
evidence-based routines to prevent unnecessary
complications and treat the unavoidable ones.”
– Berglund A, Leferre-Cholay H, Bacci A et al. Acta Obstet Gynecol
2010; 89: 230-237
What is the evidence base behind
staff training and persuading staff
to follow clinical guidelines?
RCT trials data….
• Interactive computer based training is better than
lecture based training
–
Rosen J, Mulsant BH, Kollar M et al. J Am Med Dir Assoc 2002; 3(5): 291-6
• Multidisciplinary team based training with problem
solving and individual performance feedback is
better than education based training
–
Strasser DC, Falconer JA, Stevens AB et al. Arch Phys Med Rehab 2008; 89(1): 10-5.
• Setting examination benchmarks improves
performance in training
–
Santo S, Ayres-de-Campos O. Curr Opinion Obstet Gynecol 2012; 24(2): 84-8
In most areas of medicine
education and training change
clinician practice and improve
patients outcomes.
Does this hold true for
obstetrics?
Obstetrics appears to be different.
Systematic review of RCT
The systematic review of 33 studies concluded:
In obstetrics, educational strategies with medical
providers are generally ineffective;…
audit and feedback with personal reminders, local
leadership, and multifaceted strategies are generally
effective
» Chaillet N, Dube E, Dugas M et al. Obstet Gynecol 2006; 108: 1234-45
Interestingly
Most healthcare providers in obstetrics require
more than just education and training
They require
* Audit
* Personal Feedback
* Local leadership.
Audit with personalized feedback
Individual
*Can benchmark performance
Hospital/Healthcare authority
*Allows outliers to be identified
Role of local leadership
RCTs demonstrate that change in practice that
involves more than one category of staff (e.g.
doctors and midwives) requires strong and clear local
leadership to achieve acceptance and compliance
with routines.
» Smith H, Brown H, Hofmeyr GJ, Garner P. S African Med J. 2004: 94:
117-20
» Allery LA, Owen AO, Robling MR, BMJ 1997; 314: 840-7
» Rashidian A, Eccles MP, Russel I. Health Policy 2008; 85: 148-61.
Why? Maybe because bad
outcomes are rare, and…
• “Most doctors and nurses are convinced that their
traditional way of working is effective and good for
their patients”
• “It is important to provide not only new guidelines but
also in-depth understanding of the rationale for
change.”
– Berglund A, Leferre-Cholay H, Bacci A et al. Acta Obstet Gynecol 2010;
89: 230-237
Evidence-based medicine (EBM) and evidence-based
decision-making (EBDM) were intended to revolutionize
health care and health policy.
Thus far they have not.
The first step is to reconceive EBM and EBDM as habits of
mind rather than a toolbox and to recognize that the
Lewis S. J health Serv Res Policy 2007; 12(3): 166-72
“In the field of obstetric care, multifaceted
strategy based on audit and feedback and
facilitated by local opinion leaders is
recommended to effectively change
behaviors.”
Chaillet N, Dube E, Dugas M et al. Obstet gynecol 2006; 108: 1234-45
Why do
patients not
engage with
care?
Next talk!
Summary
• Excellent results.
• More work on managing the extremes of
reproductive age.
• More work on staff development in a format
that elicits positive behavioural change.
Thankyou