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Audit of contributory factors and potentially avoidable
perinatal related deathsLynn Sadler, Epidemiologist, PMMRC
PMMRC Conference, 13 June 2017
Te Papa, Wellington
Introduction
All perinatal related deaths in NZ are reviewed locally at DHBs with a multidisciplinary process, using a standard tool, contributory factors identified, and deaths determined to be potentially avoidable or not
Introduction
Among potentially avoidable perinatal related deaths:
• The proportion where the main contributory factor was barriers to access and/or engagement with care factors was statistically significantly higher for Māori women than for NZE women
• The proportion where organisation and management, or personnel factors were the main CF was significantly lower for Māori women than for NZE women
Main contributory factor(s) in potentially avoidable perinatal related deaths by maternal ethnicity (2011-2012)
Introduction
Hypothesised that this may be due to information bias:
• In the face of more than one factor reviewers may be more likely to focus on the barriers for Māori mothers
• In the face of a non-specific factor, reviewers may be more likely to conceptualise it as a barrier than a personnel or organisation and management factor for a Māori mother
Aim
To determine whether there is ethnicity bias in the identification of contributory factors and potentially avoidable death in local review of perinatal deaths
• by independent review
• and blinding of ethnicity age and place of birth
Methods
• Cases were deaths in 2012 where the mother had identified as Māori or NZE and local review had determined the death as potentially avoidable
• Case summaries excluding identifiers of ethnicity, including age, DHB of care or residence and socioeconomic status
• Independent review committee was not told that all cases had been identified as potentially avoidable at local review
• Review used the PMMRC standardised tool and process
Primary death classification by ethnicityNew Zealand European
N=37
Māori
N=45 Chi-squared
Primary Perinatal Death Classification n % n % p
Congenital abnormality 1 3 0 0
Perinatal infection 1 3 3 7
Hypertension 0 0 2 4
Antepartum haemorrhage 2 5 3 7
Maternal conditions 4 11 4 9
Specific perinatal conditions 8 22 2 4
Hypoxic peripartum death 5 14 3 7
Fetal growth restriction 7 19 5 11
Spontaneous preterm 3 8 19 42
Unexplained antepartum death 5 14 3 7
No obstetric antecedent 1 3 1 2 0.03
Findings: Any contributing factor(s) by ethnicity at local review
0
20
40
60
80
100Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Any CF Org/ManPersonnel Barriers
Local review
p<0.001
p<0.001
p=0.009
Findings: Any contributing factor(s) by ethnicity and review
0
20
40
60
80
100Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Any CF Org/ManPersonnelBarriers Any CF Org/ManPersonnelBarriers
Local review Independent review
p=0.009
p<0.001
p<0.001 p<0.001
p<0.001
p=0.03
p=0.8
0
20
40
60
80
100Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
Māo
ri
NZE
PA Org/ManPersonnelBarriers
p=0.012
p<0.001
p<0.001
Findings: Main contributing factor(s) by ethnicity at local review
Findings: Potentially avoidable death and main contributing factor(s) by ethnicity and review
0
20
40
60
80
100Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
Māo
ri
NZ
E
PA Org/ManPersonnelBarriers PA Org/ManPersonnelBarriers
Local review Independent review
p=0.012p=0.07
p=0.002p<0.001
p<0.001
p<0.001
p=0.09
Any contributory factor: Organisation and management by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 56 8
Yes 12 6 0.5
NZ EuropeanNo 20 4
Yes 7 6 0.5
MāoriNo 36 4
Yes 5 0 1.0
Any contributory factor: Personnel by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 39 12
Yes 4 27 0.08
NZ EuropeanNo 9 6
Yes 2 20 0.2
MāoriNo 30 6
Yes 2 7 0.3
Any contributory factor: Barriers to access and/or engagement with care by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 24 3
Yes 4 51 1.0
NZ EuropeanNo 21 2
Yes 2 12 1.0
MāoriNo 3 1
Yes 2 39 1.0
Main contributory factor: Organisation and management by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 62 7
Yes 12 1 0.36
NZ EuropeanNo 22 5
Yes 9 1 0.42
MāoriNo 40 2
Yes 3 0 1
Main contributory factor: Personnel by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 42 15
Yes 5 20 0.04
NZ EuropeanNo 10 8
Yes 2 17 0.11
MāoriNo 32 7
Yes 3 3 0.34
Main contributory factor: Barriers by local and independent review
Independent review
Overall NZ European MāoriMcNemar
p=
Local review No Yes No Yes No Yes
OverallNo 26 5
Yes 16 35 0.03
NZ EuropeanNo 22 1
Yes 4 10 0.38
MāoriNo 4 4
Yes 12 25 0.08
Summary
• At independent blinded review the initial findings were confirmed
• At independent blinded review, deaths were assigned as potentially avoidable in 78% of cases.
• Non-significantly fewer deaths were identified as potentially avoidable among Māori at independent blinded review (71% M v 86% NZE, p=0.09)• this was due to a reduction in cases with barriers identified as potentially
avoidable (p=0.03 overall; p=0.08 among Māori)
• Significantly more personnel factors were identified as a main factor in potentially avoidable deaths (43% v 30%, p=0.04)
• There was no significant change in the number of barriers factors identified at independent review; but there was a significant reduction in barriers factors as a main factor in potentially avoidable deaths
Summary
Conclusions
• There is some evidence of ethnicity bias in the identification of barriers factors as a cause of potentially avoidable death in perinatal related deaths at local review
• There is evidence of reduced identification of personnel factors at local review
