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...
• 2.65 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
Stillbirth Rate
The Lancet Series 2011,
WHO estimations,
NZ actual
Singapore
Germany
USA
France
Australia
Ireland
UK
New Zealand
Cook Is
Tonga
Samoa
Tuvalu
Kiribati
Fiji
Vanuatu
Papua New Guinea
Nauru
0
2
4
6
8
10
12
14
16
18
20
Rates of Late Fetal Death by Mother's Ethnic
Group, NZ Births 1980-2001
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 nonIndian 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 2000-2005 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
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 25-29.9
Obese ≥30
1.7 (1.0-2.8)
2.1 (1.3-3.3)
1.7 (1.0-2.9)
2.1 (1.1-3.7)
BMI ethnic specific
Overweight
Obese
1.5 (0.9-2.4)
1.9 (1.3-3.1)
1.6 (1.0-2.7)
1.8 (1.0-3.1)
Euro: 25/ 30 PP/Maori 26/32 Indian/Asian 23/27.5
Euro:
25/ 30
Indian/Asian
23/27.5
*Adjusted
for:PP/Maori
Parity, age,26/32
ethnicity,
BMI, marital status,
smoking,
Dep index illicit drugs
Stacey, Mitchell, Thompson, Ekeroma, Zuccollo, Ekeroma, McCowan, ANZJOG 2011
Dr Brad Novak, CMDHB Public
Health
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
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•
•
•
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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, 1996. Studies of avoidable factors influencing death: a call for explicit criteria,
Quality in Health Care 5:159-165
PMMRC Report 2011
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
Maternal mortality ratio
• The MMR for the four-year interval 2006–2009 is
19.2/100,000 maternities (95% confidence interval
14.2-25.4/100,000).
• 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 2009. (9 in 2008,
11 in 2007, 15 in 2006).
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.
“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
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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, 2010.
• 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 2000.
• 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
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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