Interventions to reduce maternal deaths in New Zealand
Professor Julie QuinlivanUniversity of Notre Dame Australia
University of Adelaide Women’s and Children’s Research InstituteRamsay HealthCare, Joondalup Health Campus
Acknowledgements• Perinatal and Maternal Mortality
Review Committee• Chair, Professor Cynthia Farquhar• Health Quality and Safety
Commission New Zealand.
Maternal deathsWhat 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 pointsStaff training in O&G (talk 1)
Evidence base behind non engagement with care
Domestic violenceMental 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
