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.
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
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
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
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
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