Transcript Slide 1

Comment on the NZ 5th
Annual Perinatal & Maternal
Mortality Report 2009
Emphasis – international
perspectives and teenage
mums
Sue Kildea
Professor of Midwifery
Director, Midwifery Research Unit
Mater Medical Research Institute &
Australian Catholic University
Overview
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Focus on the mothers
International
Trans Tasman
New Zealand
Teenage mums
Why focus on the mothers?
• What had we lost?
• Harry and Emily had lost their mother at
the tender ages of three and six days old,
I had lost my best friend. My confidante.
My rock. My wife. My lover. My raison
d’eˆtre. My world.’
– Ben Palmer, 2008
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Palmer B. Friday’s Child: The Heartbreaking Story of a Mother’s Love and a Family’s
Loss. London: Virgin Books, 2008. 90 pp.
• If this Report helps to avert this tragedy
for women and families in the future, it will
have achieved its aim.
•
2011 Centre for Maternal and Child Enquiries, BJOG 118 (Suppl. 1), e1–e11
Why focus on the mothers?
Child deaths when a parent dies, per 1,000
International Context
• Every woman and baby counts…
Every year
• 350,000 women die
– pregnancy related condition
• 1 every 90 seconds
• 2 million newborns die in first 24
hrs of life
• 2.6 million stillbirths
• No universal access
– Education
– Skilled providers
Safe motherhood initiative
1987
– Nairobi Kenya
– All women deserve
access to a skilled
attendant
– Midwifery skills the single most
effective way to
reduce maternal
death
UN Millenium Development
Goals 2000-2015
Target 5: To reduce the maternal mortality
ratio by ¾, between 1990 and 2015
Target 5 - Progress
• This goal will not be reached
• Worldwide drop by 1/3
• 546,000 (1990) to 358,000 (2008) pa.
• <1/2 of what is needed
• Countries MMR>100
• On track 10/87
• Some - no progress
• Progress uneven
• Across and within countries
• ‘Global Call to Action’ 2010
Triple gap
• Competencies
• Coverage
• Access
• How many midwives are
‘we’ training?
• Are ‘we’ poaching?
Why women die…
What can
we learn
from the
UK?
MMR by age, UK, 2006-08
MMR - Partners
occupational group (UK)
Top 10 Recommendations
Service provision
•1. Pre-pregnancy counselling
•2. Professional interpretation services
•3. Communications and referrals
•4. Women with potentially serious medical conditions require
immediate & appropriate multidisciplinary specialist care
Quality of care
•5. Clinical skills and training (Back to Basics!)
•6. Specialist clinical care: identifying and managing very sick
women (early obstetric warning score)
•7. Systolic hypertension requires treatment
•8. Genital tract infection/sepsis
Clinical governance
•9. Serious Incident Reporting and Maternal Deaths
•10. Pathology: improve standard of maternal autopsy
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2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203
Trans Tasman
NZ - MM review
… a potted history
• 1950s - specific conditions (eclampsia, haem)
• 1959 - a maternal death review Prof L. Wright
• Next 10 yrs - more structure
• Maternal Mortality Research Act 1968; committee;
secretariat; assessors; requirements; payment; protection
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1990 - Maternal Deaths Assessment Committee
1993 - Different definitions to Aust & UK.
2000 - Public Health and Disability Act
2005 - Perinatal & MM Review Committee
2006 - Most perinatal deaths collated
2006 - MM Review Working Group
• national coordinator; network; systematic review; changing
professional attitude
• 2011……
Haslam A., Maternal mortality in New Zealand Vol 11 No 1 Autumn 2009 23
Estimates of number of maternal deaths,
lifetime risk, MMR, and range of
uncertainty (2005)
Country
Number of
maternal
deaths**
Lifetime risk of
maternal
death**: 1 in:
MMR** (maternal
deaths per 100 000
live births)
Range of
Range of
uncertainty uncertainty
lower
upper
Australia
Fiji
11
41
13 300
160
4
210
4
55
9
720
New
Zealand
Papua
New
Guinea
5
5 900
9
9
18
820
55
470
130
1 300
Solomon
Islands
34
100
220
65
580
United
Kingdom
51
8 200
8
8
15
WHO, 2007, Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank
Australia
• One of the “safest countries in
the world in which to give birth or
be born”
Improving maternity
services in Australia:
A discussion paper
from the Australian
Government.
Commonwealth of
Australia
2008. p.3.
Mothers dying in childbirth per
100,000
• Australian
Kildea, S., et al., ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health
outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health 10 (online), 2010. 1383.
Mothers dying in childbirth per
100,000
• Australian
• Malaysia
Kildea, S., et al., ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health
outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health 10 (online), 2010. 1383.
Mothers dying in childbirth per
100,000
• Australian
• Malaysia
• Sri Lanka & NZ - 2006-09
Kildea, S., et al., ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health
outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health 10 (online), 2010. 1383.
Could it be true?
Mothers dying in childbirth per
100,000
• Australian
• Malaysia
• Sri Lanka & NZ - 2006-09
• Aboriginal and Torres Strait Islander Australian
No national target for MMR
Kildea, S., et al., ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health
outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health 10 (online), 2010. 1383.
Australian report 03-05
• Media release ‘considerable drop in deaths’
• 65 deaths (03-05) vs 84 (20-02)
• Validation & ascertainment - not the same
Maternal Deaths
90
84
83
80
70
66
65
60
50
40
30
20
10
0
2000-02
2000-02 Validated
2003-05
2003-05 Not Validated
Maternal Mortality in
NZ & Australia
• Such a small number – does it
matter?
• Maternal mortality is often used as a
measure of a country’s overall health
and development status.
• Aust – no robust system for
monitoring and reporting
• A contributing factor ‘possibly
present’ or ‘certainly present’
– 48% Aust 2000-02; NZ 36% 2009)
Surveillance Cycle
The Maternal Mortality or Morbidity Surveillance Cycle
2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203; p.23
NZ – specific factors to
note
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Contributory factors – 36%
3 deaths potentially avoidable
A/H1N1 influenza - 4 deaths
AFE (induction) - 4 deaths
Suicide - 3 deaths
PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal Mortality
Review Committee: Reporting mortality 2009. p. 68
Contributing factors
Organisation / management
• Poor arrangements /access to seniors
• Inadequate education /training
• Lack of policies, protocols guidelines
• Delays / Inadequate systems /sharing information
Personnel
• Failure of communication
• Didn’t ask for help / recognise severity/ competence
Environment
• Distance accessing tertiary care
Barriers to accessing or engaging with care
• Substance use / Maternal mental illness
PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal Mortality
Review Committee: Reporting mortality 2009. p. 77
H1N1, UK, 1.4.09 – 13.1.10
• Pregnant women
– 4 x hospital admission; 7 x risk of ICU
admission
• 12 Maternal deaths
– + 1 Ireland
• All pregnant women advised:
– flu vaccine if not already received
A/H1N1/2009 (swine influenza) vaccine.
– Antiviral medication as appropriate
Oseltamivir (Tamiflu) and zanamivir (Relenza)
Modder,J., Review of Maternal Deaths in the United Kingdom related to A/H1N1
2009 Influenza, December 2010
Co-morbidities common
Problems
Slow diagnosis, false –ve swabs,
no management plan,
communication, anti vaccination
Teenage Pregnancy
Teenage pregnancy =
poorer outcomes
• Maternal
Anaemia, antepartum haemorrhage,
gestational hypertension, preeclampsia
• Neonatal
Small for gestational age (SGA),
preterm birth, intrauterine growth
restriction (IUGR), admission
neonatal intensive care unit (NICU),
stillbirth, neonatal death
Associated with…
• Stress
• Domestic violence
• Poor nutrition
• Unstable housing
• Lack of social support
• Drug use
• Smoking
• Depression and/or anxiety
Teenage births
1965 – 2008 in NZ
http://www.myd.govt.nz/policy-and-research/teenage-pregnancy.html
Distribution of perinatal deaths
by maternal age 2007-09
70
60
50
40
Termination of pregnancy
Stillbirth
30
Neonatal death
20
10
0
%
%
%
Maternal age <20
Maternal age 20-39
Maternal age >40
PMR
14.7
10.3
13.4
Per 1000
Adapted from: PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal
Mortality Review Committee: Reporting mortality 2009. p. 68
Young mums in NZ
• 7.8% births & 10.6% perinatal deaths
• 50% of teenage mums who lost
babies were Maori
• 45% highest deprivation quintile
• 50% were smokers
• Spontaneous pre-term birth, fetal
growth restriction and perinatal
infection more common causes in
teenagers than 20-39 yrs.
PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal Mortality
Review Committee: Reporting mortality 2009. p. 68
Adapted from: PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal Mortality
Review Committee: Reporting mortality 2009. p. 67
Maternity Care in NZ
• 75% of women now access a midwife
as a lead maternity carer (LMC)
• ‘Teen Pregnancy’ services
– Continuity antenatal and postnatal only
– Peer support and education programs
• Few LMCs who specialise in caring
for teenage pregnant women
• Problems with access to midwifery
care
– “Midwives turn away pregnant teens”
Standard Care
• May not be culturally safe, accessible
or appropriate
• Later gestation at booking
• Lower antenatal visit
attendance
• Higher number of
unscheduled reviews
• Lower ‘compliance’
with health advice
• Insufficient evidence of adequate quality to
recommend routine implementation of any of the
programs as a means of reducing infant mortality in
disadvantaged/vulnerable women. Several
interventions merit further more rigorous evaluation.
• Non-standard maternity care:
– some benefit and no known detriment
• Strong evidence Group ANC:
– increase ANC / BF & decrease preterm birth
• Young Women’s Clinic model may:
– increase ANC & decrease preterm birth
• Dearth of evidence MGP
A Known midwife
• No comparative studies of caseload
midwifery for teenagers
• Paucity of research on young
women’s experiences of having a
known midwife
• Audit of 375 teenage women in UK:
– 5% preterm birth
– 8% low birth weight
– 84% spontaneous birth
Pilot RCT
Interventions that may
help:
• Group antenatal care
• Peer support
• Enhanced payment to providers
who provide ‘enhanced’ care
– Ability to reduce caseload
• Home visiting
• Schools
• More research
is needed
References
• Family Care International Maternal Mortality
Fact Sheet
• Safe Motherhood Resource Guide
• Maternal Deaths in Australia 1997-99, 200002, 2003-05
• Why Mothers Die, UK, 2000-02
• NZ Perinatal Mortality Reports
• The State of the World‘s Midwifery Report
2011(sidebar photos and other facts)
• Thanks to Jyai Allen who assisted with this
presentation
Every mother counts
AND
every baby counts!
Thank you !!