Fetal Assessment and Wellbeing

Perinatal and Maternal Mortality in New Zealand: a midwifery perspective Norma Campbell, Midwifery Advisor Quality and Sector Liaison Chair National Maternity Monitoring Group

Mortality

Scope of Practice, Midwifery Council of New Zealand, 2010. “……The midwife understands, promotes and facilitates the physiological processes of pregnancy and childbirth, identifies complications that may arise in the mother and baby, accesses appropriate medical assistance, and implements emergency measures as necessary. When women require referral midwives provide midwifery care in collaboration with other health professionals……. In all settings, the midwife remains responsible and accountable for the care she provides.”

During the 2013 year 216 post-mortems were conducted. 41 cases (19 percent) revealed a different cause of death from that previously thought. Even if we think we know the reason that the baby died, we should request a post-mortem to be absolutely sure. The two biggest questions women have are ‘Did I do anything wrong?’ and ‘Is this going to happen again?’ Linda Penlington, member of PMMRC and SANDS Pg 24 Ninth Annual Report

Methodology

In 2013, the perinatal related mortality rate in New Zealand was 10/1000 births or one baby death for every 100 babies born. This was the lowest rate since the PMMRC started collecting data on baby deaths

The rate of stillbirth in New Zealand has dropped significantly since 2007

Significant reduction in the hypoxic peripartum perinatal related death rate

There has been a significant increase in the rate of terminations of pregnancy from 20 weeks since 2007.

Maori, Pacific and Indian mothers have higher risks of perinatal deaths than mothers of Other Asian and New Zealand European ethnicity for reasons other than having their first baby, smoking, obesity and socioeconomic deprivation, but it is not known why.

There has been an increase in the rate of perinatal death among teen mothers (mothers under 20 years old).

There are differences in perinatal related mortality rates according to the DHB area where mothers live.

Spontaneous preterm birth was a cause of perinatal death for almost 1000 babies from 2007 to 2013. It is the cause of death for 21 percent of perinatal deaths.

That all maternity care providers identify women with modifiable risk factors for perinatal related death and work individually and collectively to address these. Strategies to address modifiable risk factors include: a. improving uptake of periconceptual folate b. pre-pregnancy care for known medical disease such as diabetes c. access to antenatal care d. accurate height and weight measurement in pregnancy with advice on ideal weight gain e. prevention and appropriate management of multiple pregnancy f. smoking cessation g. antenatal recognition and management of fetal growth restriction h. prevention of preterm birth and management of threatened preterm labour i. following evidence-based recommendations for indications for induction of labour j. advice to women and appropriate management of decreased fetal movements. All DHBs should report the availability and uptake of relevant services in their annual clinical report to ensure that these strategies are embedded and to identify areas for improvements.

Key take home messages: Bleeding occurred at some time during pregnancy in 60% of women whose babies died from spontaneous pre term birth 34% of mothers whose babies died from spontaneous preterm birth were smokers Family Violence screening needs improving- is this true or is it as a result of poor data?

Women of Maori and Pacific ethnicity, women who smoke in pregnancy, women living in areas of high socioeconomic deprivation and women having their first birth are at increased risk of neonatal death of babies born at 20–27 weeks, independent of age and socioeconomic status. Women who smoke during pregnancy are also at increased risk of neonatal death of babies born from 28 weeks gestation, independent of ethnicity, socioeconomic deprivation, age, parity and BMI. A combination of risks means a higher risk of stillbirth or neonatal death as risks are independent of each other and so have a cumulative effect. Page 55. Ninth Annual PMMRC Report

District Health Boards which have significantly higher unadjusted rates or perinatal death than NZ data Counties Manukau- all perinatal mortality Northland- stillbirth and neonatal death rate Bay of Plenty- neonatal death rate

Maternity may only be about 1% of the health budget but it is clear that in some areas there is a need to now consider how to support the populations and also the health practitioners working in maternity in these DHBs and others who have similar populations.

Contributory Factors in Perinatal related deaths- 2009- 2013 Organisational/Management factors Personnel factors Barriers to access and/or engagement with care Ninth Annual Report, Page 87

Maternal mortality Pre- existing medical disease Amniotic fluid embolism 5.6 times higher in NZ than in the UK Maternal suicide 7 times higher in NZ than UK Maternal mortality ratio for Maori 2-3 times higher Postpartum sepsis Influenza

What is making the difference to our mortality rates? PMMRC Annual Meeting has become a focus in the maternity year Data about what is happening in maternity is accurate Robust professional relationships Education

National Maternity Monitoring Group

Maternity Quality Standards Maternity Quality Initiative Maternity Quality and safety Programme Sentinel event processes Reportable events Trigger tools National Minimum dataset Maternity Report Clinical Indicators PMMRC NE Group AMOSS - Maternal morbidity National processes