Indicator 17: Preterm birth - Ministry of Health NZ · Indicator 17: Preterm birth Indicator 17...

Indicator 17: Preterm birth

Indicator 17 Percentage of pre-term birth by DHB of domicile

11.0

10.0

9 .0

8.0

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0 .0

2009 2010 • 2011 2012 2013 • 2014 2015 • 2016

• West Coast DHB reporte

• considerable increase for this indicator, accentuated by a low percentage for 2015, com pared with t he two previous years.

Percentage of pre-term birth (New Zealand)

7.7

7.6 7.6

7.5 7.5

7.4 7.4

7 .ii. ········· .... ······ ······-···· 7.3

7.4 . ., ....... 1.a. ................................... .

7.3 7.3

7.1

7.0

2009 2010 2011 2012 2013 2014 2015 2016

Please note that the vertical axis commences at 7.0%

• The national data shows minor fluctuations but no sustained

35 NB• AS AT <?--"VY'2018, THE 2016 DATA IN THIS REPORT IS EMBARGOED. TREAT ACCORDINGLY.

Indicators 18 and 19: Small for gestational age at term

Indicator 18 Percentage of small babies at term (37-42 weeks' gestation), by OHS of residence

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3 .1

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2.8

2.6

2.4

2.2

2.0

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&.,a • 2013 • 2014 2015 • 2016

·""· ~=· • Whanganu1 DHB reported a considerable reduction compared to tH~prev1ous year.

•

Percentage of small babies at term (37-42 weeks' gestat ion) (New Zealand)

3.1 3.0 3.0

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Indicator 19 Percentage of small babies at t erm born at 4o-42 weeks' gestation, by DHB of residence

70.0 -.---------------------------------------------

60.0 1----------------------n-----------------------~

50.0 +-111-----------------------t

40.0

39.0

38.0

37.0

36.0

35.0

34.0

33.0

32.0

31.0

30.0

• 37

Percentage of small babies at term born at 40-42 weeks' gestation (New Zealand)

39.2 ' ................ ··· .'!~ :~

... "' 36.9, .. · ·

··'·

2013 2015 2016

For the second co. ecuit ive year there has been a decline in the percentage of sma ll babies at term born at 40-42 weeks' gestation by DHB . NB• AS AT <?--"VY'2018, THE 2016 DATA IN THIS REPORT IS EMBARGOED. TREAT ACCORDINGLY.

Indicator 20: Term babies requiring respiratory support

5 .0

Indicator 20 'l:ft_ ( _J Percentage of babies born at 37+ week's gestation requiring respiratory support, by D ~--4.~residence

4.5

4.0 - ,_ 3.5

3 .0

2 .S r

2.0 - - - '

1.5 - - _ ,

1.0 - - - ·~-~-·,..,- ·

0.5 ,_ - ,_ -

• Northland DHB stands out as having a co s~tently higher percentage of babies requiring respiratory support , with Capita l and Coast DH B a lso

Bs

•

•

38 NB• AS AT <?--"VY'2018, THE 2016 DATA IN THIS REPORT IS EMBARGOED. TREAT ACCORDINGLY.

2.5

2.0

1.5

1 .0

0.5

0 .0

•

39

Percentage of babies born at 37+ week's gestation requiring respiratory support

(New Zealand)

1.9 2.0 1.9

2013 2014 2015

1.0

With fou r years of reporting against this indicator, the national dat ind1 a es no change in the sma ll percentage of babies born at 37+ weeks gestation who require respiratory support.

NB• AS AT <?--"VY'2018, THE 2016 DATA IN THIS REPORT IS EMBARGOED. TREAT ACCORDINGLY.

NATIONAL MATERNITY MONITORING GROUP

AGENDA

Meeting 22 on 17 May 2018

Venue: GC.2, Ministry of Health, 133 Moleswort h Street

(On arrival, collect your pre-printed name tag from the reception desk)

NMMG Attendees: Also in Attendance:

John Tait (Chair)

Judith McAra-Couper (Vice-Chair)

Jeanine Tamati-E lli ffe

Mary M atagi

Rachael McEw ing

Rose Swindells

Guests:

Leonie McCormack,

Deb Pittam

Frank Bloomfield

Sue Tutty

Rach,~g~rty, Capital & Coast DHB (R~es nt-at ive from DHB Planning & Funding S(.bg oup)

Bronwen Pelvin (ex-officio) ;.~(j

Apologies:

Sue Belgrave (ex-officio)

~~ 0

0 Light refreshments available on arr;~ 9.30am

9.00 am

~I

0'l>

~

Meeting begins

~ inutes from 22 November 2017 for approval - !Annex 1 U -Register of directorships and ro les

€'.orrespondence & other business

•

•

Letter from Dr Sue Belgrave, Chair PMMRC re recommendations from the PMMRC 12th Annual Report dated 20 April 2018 - IAnnex 2

Letter from MMWG re recommendations from t he MMWG Annual Report dated 16 April 2018 - !Annex 3

• Letter from M inistry of Health re National workshops: maternal mental health and place of birt h dated 29 March 2018 - !Annex 4

• Update from MMWG dated 7 November 2017 (not previously t abled) - r4nnex 5

• Progress report from Waikato DHB re external review of maternity services dated 22 February 2018 - !Annex B

• Progress report from M idCent ral DHB re external review of maternity services dated 26 February 2018 - !Annex 7l

Responsibility to lead discussion

Chair

9.30 am

lOam

llam

11.30 am

12pm

• Letter from Count ies Manukau DHB re NMMG work programme and progress re external review of maternit y services dated 15 January 2018 - 14nnex 8

• DHB Data Elective Caesarean Section, Induction (2009-2016) -r4nnex 9

• MMWG Quarterly Report to PMMRC dated 1 May 2018 (for noting) -r4nnex 1Q

Overview of matters discussed at meet ings with Hon Dr David Clark and Hon Julie Anne Genter

uest - Leonie McCormack, Manager, and Josette McAllister, Senior Advisor, Child and Family Programmes, M inistry of Health

Updates from the M inistry of Health

• DHB MQSP Crow n Funding Agreements

• DHB MQSP Annual Reports

• Growth Assessment Protocol (GAP)

• M idwifery Strategic Advisory Group (MSAG) Update on midw ifery workforce issues

• M idwifery experience research

• Maternity Ult rasound Advisory Group Recom

• Hypertension and pre-eclampsia guideline

• Update on the status of the Materna l Feta ~ fcine (M FM ) Network

Chair

Discussion on Northern Southland Healt Company Ltd submission t o Chair

Southern District Health Board re profo~ ow ngrade of Lumsden maternity

services. 14nnex 11 ~

(representative from DHB Chair

Chair, Maternal Child and Chair/

nvestigative priorities

a) Maternal menta l hea lt h

b) Place of birth c) Equit y of access

d) Workforce Connecting Sector Leadership

e) Connect with Government maternit y sector advisory groups to

support cohesive qua lit y improvement advice to the maternit y sector

f) Investigate culture of DHBs' workplaces to ensure maternity staff are

working in safe and supportive environment s

M onitoring Priorities

Andrew Simpson

Chair

2.45 pm

3.00 pm

3.30 pm

g) Review key sector reports (PMMRC Annual Report, Clinical Indicators

and MOH ROM)

h) Support ratification of national maternit y clinica l guidelines

i) Monitor implementation of DHBs MQSPs

Afternoon Tea

Confirm key points for briefing for Director General Next Meeting - Possible date Thursday, 30 August 2018

Meeting ends

For Information: Literature Research Scan - Influences on Womens' preferences regarding planned plac

r.4 ttachment 1 • Q

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Secretariat

NMMG Draft Minutes 22 February 2018 Page 1 of 25


MINUTES

MEETING 21 HELD ON 22 FEBRUARY 2018

VENUE: ALLEN + CLARKE OFFICES, 262 THORNDON QUAY, WELLINGTON

Present: Also in Attendance:

NMMG:

John Tait (Chair)

Judith McAra-Couper (Vice-Chair)

Mary Matagi

Rachael McEwing

Rose Swindells

Sue Tutty

Bronwen Pelvin (ex-officio)

Carolyn Hooper, Allen + Clarke

Jackie Harrison, Allen + Clarke

Leonie McCormack, Ministry of Health

Laura Warwick, Ministry of Health

Kass Jane, Ministry of Health

Josette McAllister

Apologies:

Deb Pittam

Frank Bloomfield

Jeanine Tamati-Elliffe

Sue Belgrave (ex-officio)

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The meeting opened at 9.39 am

1. MINUTES OF 22 NOVEMBER 2017

The National Maternity Monitoring Group (NMMG) reviewed the minutes from

22 November 2017. No changes were made, and the minutes were confirmed.

1.1. Register of Directorships and Roles

No changes were noted.

1.2. Action Points

Open action items were discussed:

Item 7 Calendar invites for NMMG Consumer Representatives to attend monthly

teleconferences with the DHB MQSP Coordinators: This is in progress but the dates

are yet to be scheduled for 2018.

Item 9 NMMG Annual Report: A final draft report was tabled for review and information.

Publication is expected at end of February 2018.

Item 11 Invitations to the Minister of Health and Director-General of Health to attend NMMG

meeting: Formal invites were sent on 2 February 2018. The Secretariat will

continue to liaise with the Minister’s office and Ministry regarding appointment

times.

The Ministry advised that the Hon Julie Anne Genter, Associate Minister of Health,

holds the womens’ health portfolio including maternity, noting the Minister of

Health remains responsible for funding.

The Chair provided an overview of issues raised by Anthony Hill, Health and

Disability Commissioner at a meeting held on 20 February 2018 including concern

at the number of complaints, workforce, training, and the lack of confidence

developing the in the maternity sector. Discussion was also held on the advantages

of the NMMG becoming more visible as a monitoring group.

Item 12 Liaison with DHB Planning and Funding Managers: An invitation was sent to DHB

Planning and Funding Managers to have a representative attend the February

NMMG meeting with a view to discussing the ongoing DHB/NMMG relationship.

No response was received.

Item 14 Invite the Chief Medical Officer to the meeting to discuss the Maternal Child and

Youth Health Leadership Group: Andrew Simpson was unable to attend the

February meeting due to other commitments. Discussion deferred to May meeting.

Item 15 Hypertension and pre-eclampsia guideline: The Ministry advised that the guideline

remains unpublished due to on-going discussion with the College of Midwives

(NZCOM) concerning implementation. The Ministry intends to publish the

guideline, if necessary noting the absence of ratification from the College of

Midwives. There is a meeting scheduled for the week of 26 February to progress

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this. This means there will be a delay in the planned follow-up with DHBs, which

will still take place six months after the guideline is published.

The Ministry advised a letter has been prepared for DHBs which includes a

practical guide to the implementation of the Hypertension and Pre-eclampsia

Guideline. This letter also notes that the NMMG will be monitoring progress in

implementing the Guideline.

Action point/s: Secretariat – Write to the Chair of the DHB Planning and Funding Managers

Group extending a further invitation for the May meeting..

2. CORRESPONDENCE AND OTHER BUSINESS

2.1. Letter from Counties Manukau DHB regarding progressing recommendations in

the 11th PMMRC Annual Report relating to MAT dataset

Counties Manukau DHB has written to the NMMG regarding progressing recommendations in the

11th PMMRC Annual Report relating to the MAT dataset The DHB highlighted difficulties in

providing the requested data and noted it would appreciate an updated report on the steps the

Ministry were taking toward solving the MCIS to MAT data integration issues.

Action point/s: Secretariat – Write to Counties Manukau DHB advising that the NMMG has

endorsed the PMMRC recommendations in correspondence to the Ministry

and is awaiting a response.

2.2. Letter from Auckland District Health Board regarding Maternal Fetal Medicine

Dr Audrey Long, Clinical Lead and Maternal Fetal Medicine (MFM) subspecialist, National

Women’s Health, has written to the Chair of the Maternal Fetal Medicine Governance Board

highlighting the ongoing critical shortage of MFM subspecialists across New Zealand. The letter

was copied to the NMMG and the New Zealand Committee of Royal Australian and New Zealand

College of Obstetricians and Gynaecologists (RANZCOG).

The NMMG noted the concerns raised by the Auckland District Health Board regarding the

ongoing critical shortage of MFM subspecialists across New Zealand.

2.3. Letter from PMMRC Chair regarding recommendations from the PMMRC 11th

Annual Report

The PMMRC has written to the NMMG requesting feedback on the recommendation to develop a

national interdisciplinary clinical practice guideline on the indications and timing for induction

of labour, to guide clinicians to offer induction when appropriate. The NMMG noted the

development of a national interdisciplinary clinical practice guideline was underway for

submission to the Ministry.

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2.4. Letter from NZCOM regarding GROW Charts

The NZCOM has written to the Chair of the New Zealand Committee of RANZCOG highlighting

concerns regarding the GAP NZ education package required to enable the use of Gestation Related

Optimal Weight (GROW) charts. The letter was copied to the NMMG. The NMMG noted the

concerns raised by the NZCOM.

2.5. Quarterly update from Maternal Morbidity Working Group

The NMMG acknowledged the written update from the Maternal Morbidity Working Group

regarding the status of its current work programme.

3. UPDATES FROM THE MINISTRY OF HEALTH

Leonie McCormack, Laura Warwick, Kass Jane and Josette McAllister (Ministry of Health) joined the

meeting.

3.1. DHB MQSP Crown Funding Agreements

The Ministry advised that DHB Maternity Quality and Safety Programme (MQSP) Coordinators

had been provided with advice that the Ministry is unable to commit to funding prior to the

completion of the review of Ministry-wide funding priorities for 2018/19. The NMMG noted that

as a consequence of the inability to commit funding, there had been no action on the requests of

the NMMG in November 2017 that the Ministry sch dule meetings to discuss maternal mental

health, and barriers to women planning to give birth at primary birthing facilities.

The Ministry proposed that regional MQSP coordinator meetings be held in 2018 as an alternative

to the previous annual face-to-face meetings. This would provide opportunities for identifying

key areas of focus within regions. The NMMG noted advantages in linking areas of focus to NMMG

work plan priorities.

The NMMG noted there would be benefit in grouping DHBs who had similar populations when

developing areas of focus but did not provide advice on which DHBs should be grouped.

Action point/s: Secretariat – Draft a letter to the Ministry of Health outlining the benefits of

funding MQSP should a decision be made to no longer fund the MQSP.

3.2. Midwifery Strategic Advisory Group

The Ministry advised that a report developed by Health Workforce NZ on a whole of system look

at maternity had been discussed at the latest Midwifery Strategic Advisory Group meeting. Report

recommendations included:

• Support for third year midwifery students be increased including a financial grant to

offset costs of clinical placements.

• Australian new graduate midwives’ participation in the Midwifery First Year of Practice

Programme (MFYP) be paid for through Health Workforce NZ (not through the DHBs

where it is currently paid for), as under the current MFYP contract they are not funded as

they are not New Zealand citizens.

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• National and international campaigns be run to attract people into the midwifery

profession, and overseas midwives to New Zealand.

• Creating a locum service for LMCs to address the current workforce crisis.

The report will be presented to the Health Workforce NZ Board and Ministers seeking approval.

The Chair enquired whether TrendCare data was being collected to provide evidence of low or

unsafe staff levels. The Ministry advised that the Health Workforce NZ predictive model identified

that core DHB staffing was dropping and that attrition of new graduates as an issue. The

Midwifery Strategic Advisory Group discussed the limitations of TrendCare in maternity,

particularly relating to delivery suites. It noted that the predictive model had been adjusted to

differentiate between a person who was returning to the workforce following a per od not

working as a midwife as opposed to a new entry.

The Chair indicated the importance of communication regarding what was occurring in neonatal

wards and maternity, and the possible development of a transitional period which would increase

the amount of work for midwives.

Action point/s: Secretariat – Write to the Health Workforce NZ Board requesting an update

on its work on the midwifery workforce, and suggesting consideration be

given to co-opting a midwifery leader onto the Board.

3.3. Midwifery experience research

The Ministry tabled a research paper, “Risk of perinatal mortality in the first year of midwifery

practice in NZ: analysis of a retrospective national cohort” (presently embargoed) which has been

accepted for publication. A communications strategy, media response and key messages are being

developed by the Ministry to accompany the publication of the paper, with input being provided

by sector representatives. All parties will collaborate and coordinate response to the media about

the research and its findings.

Action point/s: Ministry – Write to the NMMG formally requesting advice on how to address

the research finding relating to new graduate midwives caring for higher risk

women; and the finding concerning high caseloads.

3.4. Maternity Ultrasound Advisory Group recommendations

Sue Belgrave joined the meeting via teleconference.

Rachael McEwing advised that she recommended the Ministry form a multi-disciplinary group

work on the development guidelines for primary maternity ultrasounds. Discussions are

continuing.

3.5. New Zealand Maternal Fetal Medicine (MFM) Network

The Ministry advised that strategies for ongoing support to the MFM Network had been presented

to the Maternal Fetal Medicine Governance Board. These included:

• Short term – contracting for either a clinical lead or non-clinical lead with clinical support,

and

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• Medium term – applying for a national service improvement project to identify issues

regarding recruiting and maintaining specialist staff in the service.

Experienced MFM specialists not currently working in the field could also be used as resource. A

formal tendering process would be required to appoint a contracted lead which would likely take

about six months. The Governance Board was supportive of the recommendations, noting the

importance of placing an interim solution in place pending the implementation of the proposed

measures. A subgroup of the Board had been established to oversee the network. The Ministry

will liaise with DHB Chief Executives to obtain feedback on what had been proposed, noting it

would continue to progress the application for a national service improvement project in the

interim.

Leonie McCormack, Laura Warwick, Kass Jane and Josette McAllister departed the meeting.

4. LONG ACTING REMOVABLE CONTRACEPTIVES (LARC) UPDATE

Jo Elvidge (Ministry of Health) joined the meeting via video conference.

Jo provided an update on the Ministry’s LARC workstream (approval to proceed with the

workstream was granted in February 2018 following the submission of a detailed evaluation to

Treasury). Next steps included finalisation of the Funding Board procurement agreement,

recruitment, negotiations with DHBs, completion of a RFP for training, and the development of

postpartum contraception option national guidelines.

The NMMG discussed the benefits of developing credentialing criteria prior to the issue of

guidelines, noting the timeframe for the development of guidelines may possibly be 12-16

months. It would be valuable to obtain data on the percentage of women requesting removal,

timeframes, and the reasons why, to evaluate the efficiency of LARC. Jo advised that data collected

to date indicated that one-third of women requested removal due to increased bleeding.

Action point/s: Ministry – Liaise with PHARMAC to obtain further information on Mirena®

and report back to NMMG.

Jo and Sue left the meeting.

5. NATIONAL PERINATAL PATHOLOGY SERVICES CLINICAL NETWORK

The Chair spoke to a request received from Jane Potiki, Principal Advisor, National Services,

Electives and National Services, Ministry of Health seeking a representative from the NMMG to

join the National Perinatal Pathology Services Clinical Network which was being established to

provide multi-disciplinary leadership and oversight to implement the revised service model.

Judith McAra-Couper was nominated to represent NMMG.

Action point/s: Secretariat – Advise the Ministry of Health of Judith’s nomination to

represent NMMG on the National Perinatal Pathology Services Clinical

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6. MERAS MIDWIFERY SAFE STAFFING STANDARDS

Bronwen Pelvin introduced the Midwifery Employee Representation and Advisory Service

(MERAS) Midwifery Safe Staffing Standards, recommended by the Midwifery Strategy Advisory

Group to the NMMG for discussion and endorsement. The standards were initially developed as

a discussion document on midwifery staffing standards for maternity facilities. A second edition

developed following consultation with MERAS, NZCOM and DHB Midwifery Leaders. The scan be

used by DHBs as a staffing tool.

The NMMG:

1. endorsed (in principle) the MERAS Midwifery Safe Staffing Standards;

2. noted that the Ministry would provide a published version of the standards, and

3. noted the Standards would be sent to DHB Chief Executives and copied to the Midwifery

Strategy Advisory Group, Health Workforce New Zealand noting NMMG’s endorsement.

Action point/s: Ministry – Provide a published version of the standards to the NMMG as

soon as possible.

Secretariat – Send MERAS Midwifery Safe Staffing Standards to DHB Chief

Executives (copied to the Midwifery Strategic Advisory Group, MERAS,

NZCOM, and Andrew Simpson and Bronwen Pelvin, Ministry of Health).

7. NATIONAL CLINICAL INDICATORS AND CUSTOMISED BIRTHWEIGHT

CENTILES

Frank Bloomfield joined the meeting via teleconference for this item.

The NMMG discussed an email received from Lynn Sadler, Epidemiologist Women’s Health ADHB

regarding the decision by the maternity indicators group to use Intergrowth-21st centiles. The

email highlighted two questions which required to be discussed separately:

1. How the implementation of GAP could be monitored to measure effectiveness?

2. Were the INTERGROWTH standards the correct ones to use for the clinical indicator we

have?

The purpose of GAP is not to give incidence of SGA/FGR babies. The audit tool should measure

the increased detection of SGA/FGR babies. The introduction of GAP should be audited

appropriately as a clinical indicator to measure the incidence of SGA babies is not the appropriate

tool. Customised centile charts are an essential part of GAP. It would make sense that the audit

tools are used to measure the proportion of SGA/FGR babies born who had been detected

antenatally, not the incidence of SGA/FGR. Another measure could be stillbirth and/or perinatal

mortality in SGA/FGR babies, as reducing this is the ultimate goal of detecting SGA/FGR babies

in-utero. Concern was raised that the customised centile charts include BMI as one of the

calculations in the algorithm; however, BMI is not an accurate measure; and the algorithm that

sits behind the customised centile charts changes regularly. As New Zealand’s population

increases in size and algorithms are refined, the threshold for diagnosing SGA will change. To

enable comparison/benchmarking of New Zealand’s maternity service with others around the

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work, it would be beneficial to use a standard (not a chart) that was universal (i.e. WHO

standards).

Action point/s: Secretariat – Draft a response to Lynn Sadler on behalf of NMMG for review

by Frank Bloomfield.

Frank Bloomfield departed the meeting.

8. 2017/18 WORK PROGRAMME

Investigative priorities

8.1. Maternal mental health

The Ministry advised that the establishment of a National Maternity Mental Health Network as

recommended by the PMMRC is currently awaiting the outcome of the review of funding

priorities for 2018/19.

The NMMG discussed the Government’s Inquiry into Mental Health and Addiction and agreed to

write to Professor Ron Paterson, Chairperson of the Inquiry emphasising the importance of the

inclusion of maternal mental health in the inquiry. This letter should include reference to the

recommendation from the PMMRC relating to the coordination of mental health services, and a

request that the Inquiry consider the establishment of a subgroup to look at the mental health of

pregnant women in the postpartum period, including the access and appropriateness of services

available including Māori and Pasifika people and other groups in the community. responses. The

letter should also refer to the study undertaken by the Royal College of Obstetricians and

Gynaecologists in the UK in February 2017, entitled Maternal Mental Health – Womens Voices,

which highlighted maternal mental health problems cost the UK £8.1 billion each year.

The NMMG were advised that Allen + Clarke was providing support services to the Inquiry into

Mental Health and Addiction.

Action point/s: Secretariat – Write to the Dr Ron Patterson, Chair of the Inquiry into Mental

Health and Addiction, emphasising the importance of the inclusion of

maternal mental health in the Mental Health Inquiry and welcoming the

opportunity for representatives of the NMMG to meet with him to discuss.

8.2 Place of birth

The NMMG discussed the agreed actions to be undertaken in 2017/18 and encouraged the

Ministry to recommence the work to establish a group to investigate rural and primary birthing.

The NMMG discussed how to explore influencers that contribute to women’s preferences for

their planned place of birth. Professors and Associate Professors of Midwifery at Victoria and AUT

might be approached to suggest they consider the topic as a research proposal for a PhD student.

Prior to this, Allen + Clarke will undertake a rapid literature scan including New Zealand

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universities and published articles, and report back to NMMG prior to liaising with Victoria and

AUT.

Action point/s: Secretariat – Undertake a rapid literature scan on the subject of influencers

on women’s preferences regarding planned place of birth.

8.3. Equity of access

The NMMG discussed issues relating to equity of access, noting there is a push for equity of access,

not only for maternity, but across the wider health sector. Cultural responsiveness is important,

and the NMMG discussed specific examples of insensitivity towards Māori and Pasifika women.

Judith McAra-Couper noted the Midwifery Council of New Zealand was reviewing its guidelines

in this area.

Action point/s: Secretariat – write to the Medical Council of New Zealand, Midwifery

Council of New Zealand and DHB Chief Executives seeking clarification on

processes in place that ensured registered practitioners were competent in

cultural responsiveness.

Ministry – request DHBs to provide evidence of their efforts to engage with,

and ensure equity of access to services for all consumers (particularly Māori,

Pasifika, Asian, Middle Eastern, Latin American and African women, women

with disabilities and young women) in their next MQSP reports.

Monitoring Priorities

8.4. Review key sector reports (PMMRC Annual Report, Clinical Indicators and MOH

ROM)

The NMMG discussed the tracking of results in future monitoring of DHB MQSP Annual Reports

to ascertain whether the results reflected the audits and improvements previously made. The

Ministry undertook to modify the MQSP programme from mid-2018 to define priorities that DHBs

would be required to report on.

Action point/s: Secretariat – Draft a letter to DHB MQSP Coordinators on how they intend

to implement the recommendations contained within the 12th PMMRC

Annual Report.

8.5. New Zealand Maternity Clinical Indicators Data

The NMMG discussed the paper identifying trends in the New Zealand Maternity Clinical

Indicators data (2009-2016) by DHBs. It was noted the paper was embargoed and was yet to be

published. It is important to develop commentary on what the key findings of the Maternity

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Clinical Indicators data highlight about the maternity system, and to identify priority areas

requiring research.

The NMMG noted a further analysis would be undertaken to highlight any substantial increase or

decrease in data over the period 2009-2016 for further examination.

Action point/s: Secretariat – Draft letters to Hutt Valley and West Coast DHBs regarding

maternity clinical indicators data.

Secretariat – Undertake further analysis to highlight any substantial

increase or decrease in maternity clinical indicators data over the period

2009-2016 for further examination.

9. KEY POINTS FOR BRIEFING FOR DIRECTOR-GENERAL HEALTH

The NMMG confirmed the following key points for inclusion in the briefing for the

Director-General Health:

• Concern at the lack of impact the NMMG has on the sector including the difficulty in

obtaining ongoing engagement with DHB General Managers Planning and Funding, and

receiving responses to correspondence sent to groups within the sector.

• Highlight risks relating to workforce and equity of access across the maternity spectrum.

• Support for the New Zealand maternity system as an integrated system that offers

continuity from primary through to tertiary care.

• Concern at the sustainability of the maternity system.

• The importance of a positive resolution of the co-design.

The raising of the priority of maternity and womens’ health in the profile of DHB service

provision would improve the health and wellbeing of women in New Zealand.

10. GENERAL BUSINESS

The NMMG asked that a request be made to the Ministry to provide analysis on how many DHBs

have reported their efforts to move elective caesarean sections to 39 weeks rather than 38 weeks.

Action point/s: Secretariat – Liaise with Simon Ross, Ministry of Health to request an

analysis on how many DHBs have reported efforts to move elective

caesarean sections to 39 weeks rather than 38 weeks.

Secretariat -Conduct a brief content search of MQSP Reports in this regard,

and report to the Chair.

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11. NEXT MEETING

The date for the next meeting will be set in May to coincide with the Clinical Indicators Expert

Working Group meeting to provide an opportunity for engagement.

Meeting Ends – 3.25 pm

The minutes were confirmed:

(Chair) Date

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INTERESTS, MATTERS ARISING AND CORRESPONDENCE REGISTER

As at February 2018

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NMMG - REGISTER OF DIRECTORSHIPS & ROLES................................................................................................................ ...... .. ........................... 14

NMMG FEBRUARY 2018 MEETING ACTION POINTS ..................................................................................................... ............................................. 18

CORRESPONDENCE SUMMARY –RECEIVED FROM 23 NOVEMBER 2017 – 22 FEBRUARY 2018 ........ .. ..... ............................................... 22

CORRESPONDENCE SUMMARY – SENT FROM 23 NOVEMBER 2017 – 22 FEBRUARY 2018 ......... .. .. ......................................................... 23

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R>rv Q) NMMG - REGISTER OF DIRECTORSHIPS AND ROLES ~"' This register ensures transparency by identifying NMMG members' other roles and responsibilities within org~Jons that have a mandate that could align, overlap or conflict with the NMMG, regardless of whether they are Directorships or otherwise. \

1. Bronwen Pelvin (ex-officio) Ministry of Health

New Zealand College of Midwives

2. Deb Pittam Northland DHB

ACC

3 . Prof Frank Bloomfield

Auckland Dist rict Health Board

Manager and Midwifery leader

President

New Zealand delegate, Internat ional Confederation of Midwives

Taskforce looking at measures to reduce neonatal encephalopathy in New Zealand

Member

Member, Loca l Organising Committee, 2018 Congress

Professor

Director

Consultant Neonatal Paediat rician

Page 14 of 25

4. Jeanine Tamat i-Ellif fe

5. Dr John Tait {Chair)

National Intest inal Failure Service

National Pulse Oximetry Screening Programme for Crit ical

Congenit al Heart Disease Feasibility study

Perinatal Research Society {USA)

Maori 4 Kids Inc

Brainwave Trust Aotearoa

Manawa Titi' Ltd

ACC

~aterna l Morbidity Working Group

Waikato Mat ernity Services Taskforce

Chair, si;#"mittee

ommittee member I coordinator

Business Director/ Owner

Vice President

New Zealand Councilor

New Zealand Representative on AOFOG

Chief Medical Officer

Pr ivat e Obstetrician and Gynaecologist

Taskforce looking at measures to reduce neonat al encephalopathy in New Zealand

Co-Chair

Member

Page 15 of 25

Severe Acute Maternal Morbidity Preventable Review Co-invest igator

{SAMM)

6. Dr Judith McAra-Couper {Vice Auckland University ofTechnology

Chair) New Zealand College of Midwives

Midwifery Council

7. Mary Matagi New Zealand College of Midwives

ANIVA Pan-Pacific Nurses Association ~f ~e

8. Rachael McEwing

Member

Member

Specialist obstetric and gynaecology rad iologist

Specialist obstetric and gynaecology rad iologist

Member

Royal us~~n and New Zealand College of Radiologists Examiner

9 . Rosemary Swindells Consumer Representative on MQSP group

Facilitator

10. Dr Sue Belgrave (ex-otqcl'j~ PMMRC Chair

Page 16 of 25

... No. NMMG member Name of Organisation Position held / Role

11. Sue Tutty

Wartemata DHB

Waitemata DHB

Auckland DHB

ACC

Royal College of Obst etricians and Gynaecolo ist

Royal New Zealand College

Auckland faculty board

East Tamaki Hea lt hcare

Obstet r icia •

•

Obstft~~ and Gynaecologist in Ult rasound

aslgorce looking at measures to reduce neonat al encephalopathy in New Zealand

Fellow

Secretary

General Practit ioner

Member

GP Liaison

Page 17 of 25

NMMG FEBRUARY 2018 MEETING ACTION POINTS

Shaded items are completed

Post-meeting actions

1

2

3

4

5

Write to the Chair of the DHB Planning and Funding Managers GroyP eirt'encting a 22/02/18 fu rther invitation for the May meeting. \

Write to Counties Manukau DHB advising t he NMMG had endorsed the PMMRC 22/02/18 recommendations in correspondence to the Ministry and weFe awaiting a response.

Draft a letter to t he M inist ry outlining the berfefits of f unding MQSP should a 22/02/18

decision be made to no longer fund the Mo0 Write to t he Health Workforce NZ B ar requesting an update on their work being 22/02/18

undertaken in midwifery workfm:ce, and suggesting consideration be given to the

co-opting of a midwifery lea1' on the Board.

8/12/17 Ministry of

Health

Secretariat

Secretariat

Secretariat

Secretariat

Complete. Rachel

Haggerty attending

May meeting.

Complete.

Draft complete. On

hold pending outcome of funding.

Complete.

Page 18 of 25

6 Write to the NMMG formally requesting advice on how to address the research Ministry finding relating to new graduate midwives caring for higher risk women; and the finding concerning high caseloads.

7 Liaise with PHARMAC to obtain further information on Mirena® and report back to Ministry NMMG.

8 Advise the Ministry the NMMG have nominated Judith McAra-Couper to represent 22/02/18 Secretariat Complete. them on the National Perinatal Pathology Services Clinical Network.

9 Provide a published version of the MERAS Midwifery Safe Staffing St andards to the 22/02/18 Ministry Complete. NMMG as soon as possible.

10 Send MERAS Midwifery Safe Staffing Standards to DHB Ch 'ef<Executives (copied to 22/02/18 Secretariat Complete. the Midwifery Strategic Advisory Group, M ERAS, NZCOM, and Andrew Simpson and

Bronwen Pelvin, M inistry of Health).

11 Draft a response to Lyn Sadler relating to ~ry regarding the decision by the 22/02/18 Secretariat Draft with Frank for

Maternity Indicators Group to use I nt~ -21st centiles (for review by Frank review. Bloomfield).

12 Write to the Chairperson of the Inquiry into Mental Health and Addiction 22/02/18 Secretariat Complete. emphasising the importance of the inclusion of maternal mental hea lth in the

Page 19 of 25

13

14

15

16

17

inquiry and welcoming the opportunity for representatives of the NMMG to meet

with him to discuss.

Undertake a rapid literacy research scan on the subject of influences on womens' 22/02/18 preferences regarding planned place of birth.

Write to the Medical Council of New Zealand, Midwifery Council of New Zealand 22/02/18 and DHB Chief Executives seeking clarification on processes in place that ensured

registered practitioners were competent in cultural responsiveness.

~

Request DHBs t o provide evidence of their efforts to engage wit~l\.~sure equity of access t o services for all consumers (part icularly Maori, Pa 'fi~Asian, Middle

Eastern, Lat in American and African women, women wit~~sa ~11ti es and young women) in t heir next MQSP reports. V

22/02/18

Draft a letter to DHB MQSP Coordinators on how they intend to implement the 22/02/18 recommendations contained within the 12th Ptt.MRC Annual Report.

Draft letters to Hutt Valley and We~ Coast DHBs regarding maternity clinical 22/02/18 indicators data. V

Secretariat

Secretariat

Ministry

Secretariat

Secretariat

Complete. Provided

with meeting papers for information.

Complete.

Complete.

Complete.

Page 20 of 25

18

19

20

Undertake further analysis to high light any substantial increase or decrease in 22/02/18 maternity clinical indicators data over t he period 2009-2016 for further

examination.

Liaise with Simon Ross, Ministry of Hea lth to request an analysis on how many DH Bs 22/02} 1&;. have reported efforts to move elective caesarean sections to 39 weeks rather than V 38 weeks.

Conduct a brief content search of MQSP reports on how many DHBs have 1epop~d 22/02/18

efforts to move elective caesarean sections to 39 weeks rather than 38 weet<;s'i°nd

report to the Chair.

Actions relating to the Annual Report

21 Fina lise, print and distribut e t he NMMG's Annual Re~ e.:9JIY 2018.

00' ~

Actions to prepare for upcoming NMMG,.meetings

22 Invite the Director-General of Health to attend the NMMG's May meeting.

22/11/17

22/11/ 17

Secretariat

Secretariat

Secretariat

28/02/2018 Secretariat

Secretariat

Complete.

Complete. Information provided

on agenda.

Complete.

Report distribut ed early March.

Note: Errors found in report. Report t o be

reprinted and ci rculated.

Invited. No response

received.

Page 21of 25

23 Invite t he Chief Medical Officer to the NMMG's May meeting to discuss the 22/11/ 17 Maternal Child and Youth Healt h Leadership Group.

Long-term work programme actions

24 Write to DH B's six-months after the hypertension and pre-eclampsia guideline ha' lfl~/1.7 been released to ask for a report on how they are progressing with implemer(ng ... ,

the guideline. • ~

Secretariat

End of 2018 Secretariat

Complete. Andrew

Simpson attending May meeting.

Page 22 of 25

R>rv Q) CORRESPONDENCE SUMMARY - RECEIVED FROM 23 NOVEMBER 2017 - 22 FEBRUARY 2018 ~"'

G

1.

2.

3 .

Karen Gilliland, Chief Executive, NZ 24/11/2017 College of Midwives

Lyn Stark, MQSP Coordinator, 15/01/2018

Counties Manukau Health

Dr Sue Belgrave, Chair, PMMRC 19/01/2018

4 . Dr Audrey Long, Chair, Maternal 30/01/2018

Fetal Medicine Governance Board

5 . Lyn Stark, MQSP Coordinator, Counties Manukau Health

NNMG cc'd into letter from NZCOM to Cha i\(~~~ZCOG re concerns regarding the GAP NZ education P.aGl<a,gJ'! required to enable the use of GROW charts. r ~

Response to NMMG request for a dif ta1led progress report on

how Counties Manukau It a th are tracking towards

Requesting NMMG feed ~k on the PMMRC recommendation to develop a nationa·t~~isciplinary clinica l practice guideline on

the indications atici' t 'ming for induction of labour. Feedback due

27 Apri l. ~

~sponse to NMMG letter to MQSP Coordinators re progressing recommendations in PMMRC Annual Report relating to MAT

dataset.

Page 23 of 25

CORRESPONDENCE SUMMARY- SENT FROM 23 NOVEMBER 2017 - 22 FEBRUARY 2018

1.

2.

3.

4.

5.

6.

7.

... MQSP Coordinat ors at Counties 10/ 12/2017 Manukau DHB, M id-Central DHB, Whanganui DHB, South Canterbury

DHB & Waikat o DHB

MQSP Coordinators at all other 10/12/2017

DHBs.

Chai Chuah, Director-General 18/01/2018

Sue Belgrave, Chair PMMRC 19/01/2018

Bronwen Pelvin, Minist ry of Health

DHB MQSP Coordinators

Andrew Simpson, Chief Medical

Officer, Ministry of Health/~a_J,,

Maternal Child and Yout~"""aTth Leadership Group g

Requesting a detailed progress report on how ( c DHB is tracking towards implementation of t he ~q.mmendations made in that DH B's external review. ~

Shared diagram of findings from the f~~ll:£x'ternal reviews.

Update about NMMG Annual Repor ;tn~ng.

Sharing diagram of findings f o~a 5 DH B's external reviews.

Update about NMMG An~~eport t iming.

Summary report fX_~e him of the key point s discussed at the

maternity s ~toGeting .

Ackno~mg PMMRC letter of 2 October 2017 re progressing MAT r~mendations in PMMRCAnnual Report.

None.

None.

None.

None.

on MAT recommendations in None.

Requesting DHBs assist progressing MAT recommendations in None.

PMMRC Annual Report by collecting data.

Requesting the Maternal Child and Youth Health Leadership None.

Group to consider convening two national meet ings with represent at ives across the sector to discuss the support of

maternal ment al health and place of birth.

Page 24 of 25

... No. To Date Summary Action Required

8.

9.

Andrew Simpson, Chief Medical 30/01/2018 Officer, Ministry of Health

Hon Dr David Clark, M inister of 02/02/2018

Hea lth

10. St ephen McKernan, Acting Director- 02/02/2018

Genera l, Ministry of Health

*Copies of these letters are included in the Drop box.

I Invit ation to attend 22 February 2018 NMMG meeting. ~ None.

Extending an invit at ion t o meet with NMMG.~ None.

meet wit h Chair/Vice Char on another occa1i0n.

None

Page 25 of 25

20 April 2018 John Tait Chair National Maternity Monitoring Group Wellington By email: [email protected] Dear John Re: Recommendations from the Perinatal and Maternal Mortality Review Committee (PMMRC) 12th Annual Report The Perinatal and Maternal Mortality Review Committee (PMMRC) is in the process of completing its 12th Annual Report in which the focus of the special topic is neonatal mortality following on from the recommendation in the 11th PMMRC report:

The PMMRC investigate why there has been no reduction in neonatal mortality in New Zealand.

We would like to give you the opportunity to review these and greatly appreciate if you could provide feedback on these by the 1st May 2018. Recommendation The PMMRC recommends the Ministry of Health establish a multidisciplinary working group to review current evidence for universal or targeted screening for prevention of preterm birth in New Zealand, and consider how this might be implemented, taking care to:

• Identify and adequately resource evidence-based solutions

• Ensure equitable access to screening and/or treatment for priority populations

• Ensure that priority populations have a voice in the development of health policy, process and practice in order to achieve equitable health outcomes.

Justification The PMMRC have identified inequities in health care throughout their analyses that specifically impact Māor , Pacific and Indian ethnicities, young mothers under 20 years and those living in areas of high deprivation. This has been highlighted 24 times in the PMMRC 12th report. If inequity is to be addressed it would be sensible to focus on these mothers, family, whanau and their circumstance as a priority. Currently New Zealand has no national program for screening for risk of preterm labour or for preventive treatment. In 2016 26 percent of neonatal deaths were due to spontaneous preterm labour (PSANZ-PDC 9).

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Evidence The Cochrane systematic review on cultural competence education for health professionals showed some support for cultural competence education for health professionals, however recommended that future research on cultural competence education for health professionals seek greater consensus on the core components of cultural competence education, how participants are described and the outcomes assessed (Horvat et al. 2014). A systematic review of interventions to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, Canada and the USA reported improvements in health professionals’ confidence, and patients’ satisfaction with and access to health care. (Clifford et al. 2001) The Cochrane systematic review (Sandall et al. 2016) on Midwife-led continuity models of care compared with standard models of care for women during pregnancy, birth and early parenting, showed that women randomised to continuity of midwifery care models experienced less fetal loss less than 24 weeks and neonatal death. The groups of women who are more likely to experience preterm birth and neonatal death are least likely to register with LMC midwives providing continuity of midwifery care. (Ministry of Health 2017b) Recommendation Women with a previous preterm birth at less than 34 weeks are at increased risk of neonatal death. The PMMRC recommends that strategies to reduce preterm birth are targeted at this high risk group including:

• Counselling at the time of a preterm birth to outline the options ikely to be recommended for their next pregnancy.

• Ensuring that antenatal care is available to allow women to register as early as possible

• Ensuring referral for specialist consultation in the first trimester to facilitate discussion of treatment options, which might include cervical cerclage or vaginal progesterone treatment, and monitoring of cervical length using trans-vaginal ultrasound

• Counselling around signs and symptoms of preterm birth and how to respond to these to optimise outcome.

Justification Of the 729 babies who died after birth at 20 to 24 weeks, 305 were to multiparous mothers of singletons, and 119 (39%) of these had a history of previous preterm birth, including 64 (21%) who had a history of previous preterm birth between 20 and 28 weeks gestation. Evidence The use of vaginal progesterone and cervical cerclage, even in high risk women, remain controversial, but these treatment options should at least be presented equitably to all women for whom preterm birth is a risk. Meanwhile strategies to optimise outcome for babies who are born preterm should be available to all families/whanau. Recommendation Birth in a tertiary centre is associated with improved outcomes for preterm babies at the lower limits of viability (prior to 25 weeks gestation). The PMMRC supports the development of a national pathway for care of women in preterm labour or requiring delivery prior to 25 weeks gestation. The PMMRC recommends this pathway includes:

• Strategies to enable timely transfer from primary and secondary units to tertiary units of women in threatened or early preterm labour, or who require delivery, prior to 25 weeks gestation

• Secondary units establishing strategies for how to manage babies inadvertently born at their units at the lower limits of viability

• Ensuring that all groups of women (irrespective of ethnicity, age, socioeconomic status or place of residence) are offered and provided the same level of care

• Ensuring that priority populations have a voice in the development of health policy, process and practice in order to achieve equitable health outcomes.

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• Guidance on monitoring that care provision is equitable by ethnicity, age, socioeconomic status and place of residence.

Justification The relative risk of survival from 23 to 26 weeks was statistically significantly higher for babies born in a tertiary compared to a secondary hospital with a relative risk of 1.27 (95%CI 1.13-1.42) (p<0.0001). Ethnic and age inequities were found in neonatal care, including access to neonatal care for extremely preterm births. For babies born alive at 23 to 26 weeks gestation:

• Māori, Pacific, and Indian babies were less likely to receive an attempt at resuscitation and less likely to survive to 28 days of age.

• Māori mothers were more likely to birth at a secondary unit than a tertiary unit compared to mothers of all other ethnicities.

• Mothers under 20 years of age were more likely to birth in a secondary unit compared to mothers who were 20 years and older.

• Babies were more likely to receive an attempt at resuscitation if they were born at a tertiary unit than if they were born at a secondary unit.

These inequities have a disproportionate effect on Māori, Pacific, and Indian mothers as they are more likely to birth at 23-26 weeks gestation than mothers of other ethnicities. Evidence Boland et al (2015) found improved survival for babies inborn at tertiary neonatal units between 22 and 27 weeks gestation compared to babies outborn in Victoria, Australia. Recommendation The PMMRC recommends appropriate information, including appropriate counselling, is made available for parents and whānau about birth outcomes prior to 25 weeks gestation to enable shared decision making and planning of active care or palliative care options Justification Resuscitation was attempted at 23 weeks gestation for 153 of 258 (59%) live births, and for 391 of 406 (96%) at 24 weeks in 2007-2016 (Error! Reference source not found.). Attempted resuscitation varied by place of birth, ie more often at tertiary than secondary hospitals, and more often at some tertiary units than others; and by ethnicity and ma ernal age. From 2007-2016, at 23+0 to 23+6 weeks gestation, half of non-anomalous live born babies survived to 28 days when an attempt was made at resuscitation (76 survivors) and almost three quarters (73%) at 24 weeks (284 survivors). At 23 weeks gestation 29.5% of ALL non-anomalous live born babies survived to 28 days, and at 24 weeks gestation 70% survived to 28 days. These outcomes include ALL non-anomalous infants born in New Zealand at any unit or at home.

Evidence These national outcomes compare to 46% survival of live born babies (inborn and outborn) at 23 weeks gestation and 77% survival at 24 weeks reported in Western Australia 2004-2010, where rates of provision of resuscitation are high (Sharp et al. 2018).

In a recent report from Wellington of births 2003 to 2012, survival rates at two years of inborn live born babies where resuscitation was attempted were 22/38 (58%) at 23 weeks and 36/60 (60%) at 24 weeks gestation (Berry et al. 2017). Recommendation The PMMRC recommends that DHBs audit the rates of antenatal corticosteroid administration to mothers of all neonates live born before 32 weeks gestation; including whether administration is equitable by ethnicity, age, socioeconomic status, and place of residence, and whether repeat doses were given when indicated.

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Justification Of babies who died in the first 28 days after live birth, 11% at 23 weeks, 33-34% at 24 to 26 weeks, and 43% at 27 to 31 weeks gestation at birth, had a complete course of antenatal corticosteroids. These data would suggest that many babies at 23 weeks, and some at 24-26 weeks, were not optimally prepared for preterm birth. Evidence Planning for location of birth and preparation with administration of steroids should be considered at a gestation of 23+0 weeks gestation. Both overseas and in New Zealand, a 65% rate of completing a course of antenatal corticosteroids in babies who were live born, resuscitated and transferred to the NICU has been reported, although 80 percent might be an appropriate and achievable goal (Kyser et al 2012; Berry et al. 2017; Travers et al. 2018). This would enable best outcomes for the baby if resuscitation is considered appropriate at the time of birth. (See Error! Reference source not found ; See Antenatal Corticosteroid Clinical Practice Guidelines). Recommendation The PMMRC recommends that tertiary neonatal units investigate and address the difference between units in survival rates amongst infants born at 23-26 weeks gestation as part of their benchmarking, quality and safety initiatives. Justification There were statistically significant differences in survival rate by tertiary unit at gestations of 23-25 weeks (p<0.001; p<0.001; p=0.047 respectively) but not at 26 weeks (p=0.058). The units with the highest survival rates at 23-25 weeks gestation are Dunedin and Wellington, both of which are units known to have an active approach to resuscitation at 23 weeks (93% and 94% compared to 35% to 68% in the remaining units; p<0.001). There was a significant difference in the proportions of babies where resuscitation was attempted from 23-26 weeks gestation at tertiary units with rates ranging from 87% (232/266) at Middlemore Hospital, 93% (137/148) at Christchurch, 94% (349/370) at Auckland, 97% (209/215) at Waikato, to 98% (311/316) and 99% (93/94) at Wellington and Dunedin Hospitals (p<0.001). Evidence The finding that birth in the units with an active approach to resuscitation at 23 weeks gestation was associated with better survival out to 25 weeks is consistent with findings in previous reports (Smith et al. 2012; Rysavy et al. 2015). However the role of other factors cannot be excluded. New Zealand neonatal intensive care units have been aware that there are different approaches to resuscitation practice by un t and are working within the New Zealand Neonatal Network (www.starship.org.nz/for-health-professionals/new-zealand-child-and-youth-clinical-networks/newborn-clinical-network/) to develop a consensus to align practice across the country. Recommendation The PMMRC recommends that regulatory bodies require cultural competency training for all individuals working across all areas of the maternity and neonatal workforce. Training should address awareness, and strategies to reduce and minimise the impact, of implicit bias and racism. Justification Māori, Pacific and Indian live born babies were statistically significantly less likely to have an attempt at resuscitation than babies of other ethnicity (Error! Reference source not found.); and Māori and Pacific babies were significantly less likely to survive compared to babies of “Other” ethnicity among all non-anomalous live born babies at 23-26 weeks gestation. Māori, Pacific and Indian mothers were less likely to have registered, or been able to register, with an LMC in the first trimester of pregnancy.

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While the reasons for these differences by ethnicity have not been elucidated in the analyses in this report, previous analysis on inequities by ethnicity in New Zealand suggest that institutional bias or implicit biases are likely to play at least some part. Evidence There is a large body of work in NZ (including this report) describing the inequities in access to care, quality of care, and health outcomes experienced by Māori and Pacific peoples. There is also a significant body of literature that clearly documents the association between exposure to racism/ethnic discrimination and adverse health outcomes internationally and in NZ (Harris et al. 2006; Harris et al. 2012a; Crengle et al. 2012). Furthermore, in NZ, exposure to ethnic discrimination has been associated with lower levels of cervical (Adjusted Odds Ratio AOR 0.51; 95%CI 0.30, 0.87) and mammography screening (AOR = 0.37; 95% CI = 0.14, 0.996) among eligible Maori women (Harris et al. 2012b). In NZ people who report experiencing ethnic discrimination by health professionals are significantly more likely (both separately and for all experiences together) to report they were not always listened to carefully, their care was not always discussed as much as they wanted, and that they were not always treated with respect and dignity (combined AOR 1.57; 95% CI 1.15 - 2.14). There is also evidence that exposure to discrimination is associated with adverse maternal and infant health outcomes (Thayer and Kuzawa 2015; Becares and Atatoa-Carr 2016; Hobbs, Morton et al. 2017). The influence of clinicians’ implicit racial/ethnic biases and explicit racial/ethnic stereotypes on their behaviours, cognition and decision making plays and how the contribution of these to producing and maintaining ethnic inequities in health has been discussed for some time (see for example van Ryn and Fu 2003; van Ryn et al. 2011) and more recently has received greater attention. In New Zealand ethnic bias has been observed amongst medical students (Harris et al. 2018). The contribution that clinicians’ biases per se make to ethnic health inequities is more difficult to quantify as there are many factors that are involved in the development and maintenance of these inequities. Never the less there is some evidence that these biases can impact on patient experience and clinical outcomes (Hall, Chapman et al. 2015; Ben et al. 2017; Dehon et al. 2017; Maina et al. 2018). Cultural competence is one strategy used to improve health outcomes and eliminate ethnicity-related health inequities and in NZ the Medical Colleges, the Medical Council of NZ and Midwifery Council all require ongoing evidence of cultural competence training/activities. The assessment of cultural competence training and other interventions to address clinician bias is also complex. However there is some evidence of effectiveness for cultural competence training (Horvat et al. 2014; Truong et al. 2014; Clifford et al. 2015).

Recommendation Sudden Unexpected Early Neonatal Death (SUEND): the Ministry of Health and DHBs have a responsibility to ensure that midwifery staffing ratios and staffing acuity tools:

• Enable active observation of mothers and babies who are undertaking skin to skin in the post-natal inpatient period

• Allow for the identification of, and additional needs of, mothers who have increased risk factors for SUEND.

Justification There were four deaths in hospital attributable to SUEND among the SUDI deaths to 28 days of life reviewed for this report from 2007 to 2016. Evidence The Ministry of Health 2012 consensus statement Observation of the mother and baby in the immediate postnatal period: consensus statements guiding practice notes that Sudden Unexpected Early Neonatal Deaths (SUEND) is an increasingly recognised problem. Risk factors include unsupervised skin-to-skin contact, inexperienced mothers and mothers being left unsupervised in the immediate postnatal period.

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It also notes that mothers are less able to ensure a safe environment for breastfeeding or sleeping when they have experienced a long or complicated labour and birth, are under the influence of medications, or have some medical conditions. Babies are more at risk of respiratory difficulties from a compromised airway where their mother or family/whānau have been or are exposed to medications, drugs, alcohol and/or smoking. Skin to skin contact has been demonstrated to support increased breastfeeding, however if risk factors for SUEND are present (such as; smoke exposed pregnancy, if the mother is tired, under the influence of medications) it is important to ensure that women are actively observed by someone who is capable of carrying out this responsibility confidently, and have immediate access to additional support when required.

Recommendation LMCs and DHBs ensure that every baby will have access to a safe sleep on discharge from the hospital or birthing unit, or at home, that is their own place of sleep, on their back and with no pillow. If hey do not have access to a safe sleep place then a wahakura or Pepi-Pod® must be made available by the DHB for the baby’s use prior to discharge from hospital.

Justification The review of SUDI deaths to 28 days from 2007 to 2016 found that at least 22 of the 68 babies reviewed (32%) who died did not have a usual safe place of their own to sleep. Usual place of sleep was not stated for a further 10 (15%) of babies. Evidence To keep babies safe while sleeping, all babies need to be in their own place of sleep (bassinet, cot, Pepi-Pod® or wahakura, free from adults of children who might accidentally suffocate them). https://www.health.govt.nz/your-health/pregnancy-and-kids/first-year/first-6-weeks/keeping-baby-safe-bed-first-6-weeks A randomised controlled trial with the wahakura found that they were at least as safe as bassinets, and in addition encouraged breastfeeding (Baddock et al. 2017).

Recommendation Maternity and primary care providers need to be aware of the increasing risk of perinatal mortality for mothers aged under 20 years in New Zealand. Inequity in perinatal mortality for babies born to mothers aged under 20 years needs to be actively addressed. The Ministry of Health and DHBs need to:

• Develop, in consultation with young mothers, acceptable and safe methods for their peers to access and engage wi h care in order to achieve equitable health outcomes

• Identify and adequately resource evidence-based solutions to address risks for mothers aged under 20 years paying attention to smoking cessation, screening and treatment for infections, screening for fetal growth restriction, and providing adequate information about the causes and symptoms of preterm labour

• Cons der how they can support LMCs caring for aged under 20 years. Justif cation The PMMRC have identified inequities in health care throughout their analyses that specifically impact Māori, Pacific and Indian ethnicities, young mothers under 20 years and those living in areas of high deprivation. This has been highlighted 24 times in the PMMRC 12th report. If inequity is to be addressed it would be sensible to focus on these mothers, family, whanau and their circumstance as a priority. The number of mothers aged under 20 has halved from 2007 to 2016, and in this time there has been a significant increase in perinatal related mortality in this group (p=0.0045). Mothers aged under 20 years are at higher risk of perinatal related death (excluding termination) from spontaneous preterm birth,

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antepartum haemorrhage, and perinatal infection than any other age group (Error! Reference source not found.). When women who gave birth under 20 years old in 2015 and 2016 are compared to women who gave birth under 20 in 2008 and 2009, women who gave birth under 20 in 2015-2016 were more often 19 than less than 19 than in the earlier period (44.2% cf 38.9%), more often in deprivation quintile 5 (51.4% cf 46%), more often Māori (61.3% cf 56.6%) Pacific (13.7% cf 12.9%), MELAA (0.9% cf 0.6%) and less often European (22.8% cf 28.4%) or Other Asian (0.9% cf 1.1%) ethnicity, more often had a BMI of 30 or higher (19.3% cf 14.5%) but less often smokers (34.6% cf 36.8%) and more likely to have registered with an LMC in the first trimester (47.6% cf 35.4%) (Error! Reference source not found.). Inequities were also found in access to antenatal and neonatal care for extremely preterm births. For babies born alive at 23 to 26 weeks gestation: mothers under 20 years of age were less likely to birth in a tertiary unit compared to mothers who were 20 years and older. This applies to Māori and “other” (predominantly European and Other Asian) ethnicity mothers but has a greater impact on Māori because they are more likely to be mothers at under 20 years of age. Evidence Teenage pregnancy has continued to decline in New Zealand however teenage mothers in 2016 were at higher risk of perinatal and neonatal death than they were in 2007. Support services do exist in New Zealand for teenage mothers however these have not impacted on perinatal death for these mothers. Nationally, women under 20 years of age are less likely to register for LMC care in the first trimester than women from any other age group (Ministry of Health 2017b) Recommendation Maternal and Infant Mental Health Network The 10th PMMRC report recommended that a Maternal and Infant Mental Health Network be established to provide an interdisciplinary and national forum to discuss perinatal mental health issues (PMMRC 2016). This work has progressed to development of service specifications for a Network. We strongly reiterate the previous recommendation That a Maternal and Infant Mental Health Network is funded by the Ministry of Health and that the network then determines an achievable work stream by the end of 2018 detailing work to be completed by the end of 2020, and to include as potential areas of priority:

• A stocktake of current mental health services available across New Zealand for pregnant and recently pregnant women to identify both the strengths of services and gaps or inequity in current services and skills in the workforce

• A national pathway for accessing maternal mental health services; including o appropriate screening o cultural appropriateness to ensure equity of service access and provision o care for women with a history of mental illness o communication and coordination

Justification This recommendation highlights and supports a Healthy Beginnings 2012 recommendation (Ministry of Health 2012b). When women have maternal mental health concerns there may be multiple services involved – primary care, maternity, general mental health, perinatal mental health, alcohol and other drugs, social services, and termination of pregnancy services. Communication, support and sharing information to ensure a consistent approach to care is important. Maternal mental health services need to be equitable, available and accessible across the country with consistent pathways for engagement. Evidence As a number of different agencies are involved in the provision of mental health care during the perinatal period there is a need for a strategic approach to the planning of services, including the

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development of integrated care pathways within a stepped-care framework. This is in keeping with recommendations within the UK, including the National Institute for Health and Care Excellence (NICE) guidelines on antenatal and postnatal mental health (NICE 2014), which recommend the establishment of perinatal mental health clinical networks of perinatal clinicians and resources and other stakeholders including service users, and the Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the management of perinatal mood disorders (SIGN 2012). The 2008 Ministry of Health guideline about management of depression in primary care describes the evidence around screening for depression (NZGG 2008). Information on the establishment of a perinatal mental health network in the UK is described in a summary entitled Joining Up Care in Maternal Mental Health: Setting Up a Perinatal Mental Health Network (RCOG 2016). The cost to the public sector of perinatal mental health problems is 5 times the cost of improving services, seventy-two percent of these costs relate to the care of the child. Even a relatively modest improvement in outcomes as a result of better services would be sufficient to justify the additional spending to establish a Maternal Perinatal and Infant Mental Health Network (http://eprints.lse.ac.uk/59885/). Please don’t hesitate to contact me if you wish to discuss this recommendation, or have any questions;

. Thank you for your help. Yours sincerely

Dr Sue Belgrave

Chair

Perinatal and Maternal Mortality Review Committee

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16 April 2018 Mr John Tait Chair, National Maternal Monitoring Group By email: [email protected] Dear John, Recommendations from the Maternal Morbidity Working Group Annual Report The Maternal Morbidity Working Group (MMWG) is in the process of completing its second annual report, and has developed recommendations based on their findings. We would greatly appreciate your feedback on these, particularly on recommendation 1, which applies to the National Maternity Monitoring Group and the Ministry of Health.

Recommendation 1:

The MMWG recommends that the Ministry of Health develop a national guideline for the management of sepsis in pregnancy, within the next three years. These guidelines should include information for women about being unwell during pregnancy, after the birth, or after miscarriage or termination.

Rationale:

In the 32 cases of sepsis that the MMWG reviewed, the following factors were identified as contributing to the severity of sepsis:

- failure to follow recommended best practice (59%) - lack of policies, protocols or guidelines (56%) - lack of recognition of severity (53%) delay in treatment (47%) - inadequate communication (47% - lack of knowledge and skills of health care providers (47%).

One of the key themes that emerged in the panel reviews of cases of sepsis was the theme of poor knowledge regarding early identification of infection and sepsis in pregnant or recently pregnant women. For example, no DHB was able to provide a maternity-specific sepsis guideline when asked, and for those that provided a general guideline on sepsis, the guidelines were not always followed.

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The development of a nationally consistent, evidence-based guideline for the recognition and treatment of sepsis in pregnancy would support clinical judgement, expertise and knowledge. This would enable the rapid identification and treatment of sepsis. “Identifying priorities for national clinical guidelines” is a function of the National Maternity Monitoring Group (NMMG), as set by their Terms of Reference. The MMWG recommends that the NMMG prioritise guidelines for sepsis in pregnancy, as it a cause of significant maternal morbidity.

Recommendation 2: The MMWG recommends that district health boards a) Establish clinical pathways across primary and secondary/tertiary care to enable

earlier recognition and treatment, within the next 18 months b) Establish septic bundle kits to address human factor components, such as stress in

high acuity settings, within the next six months. The kits should include all the requirements of the septic six.

Rationale: Care bundles and clinical pathways are pre-established processes that reduce the need for individual decision making and clinical judgement in complex environments. They help to reduce the risk of human error and provide an avenue for expedited care and treatment in time-critical situations e.g. the diagnosis of sepsis in p egnancy.

We appreciate that this is short notice, but we would appreciate your feedback by Monday 23 April. Please don’t hesitate to contact Leona Dann, Maternity Specialist at the Health Quality & Safety Commission if you wish to discuss of have any questions ([email protected],

). Thank you for your ongoing help and support in this important work; together we can improve outcomes for pregnant women, their babies and whānau. Nāku noa

Mr John Tait and Ms Arawhetu Gray Co-Chairs MMWG

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7 November 2017 Mr John Tait Chair National Maternity Monitoring Group (NMMG) Allen & Clarke Via email: Dear John Maternal Morbidity Working Group update I would like to update the National Maternity Monitoring Group on two key projects that the Maternal Morbidity Working Group (MMWG) are progressing:

1. A national programme on the recognition and response to the deteriorating maternity inpatient will commence in late 2017. This will include developing a nationally-consistent tool for early recognition of deterioration, and advice about developing localised escalation, governance, measurement and education processes. The programme will link with the deteriorating adult patient work already underway in DHBs led by the Commission.

A multi-discipline workshop to begin the development of a standardised track and trigger tool will be held in Wellington on 12 December 2017.

2. Seven DHBs have volunteered to test the Maternity Services toolkit for maternal

morbidity review. This toolkit was developed in response to an MMWG survey of the sector in late 2016 that demonstrated the need for a nationally consistent process. The toolkit will be released on the Health Quality & Safety Commission website in May 2018 for all maternity services to access.

The MMWG would favour NMMG monitoring use of the toolkit for local maternal morbidity reviewing and the implementation of the national maternity early warning system in DHB annual reports. Together through these projects we hope to make a difference to the outcomes of mothers and babies in the future. If you require further information, please do not hesitate to contact me. Kind regards

Dr Leona Dann Maternity Specialist MMWG Secretariat Health Quality & Safety Commission

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WAIORA WAiKATd HOSPITAL CAMPUS .....

22 February 2018

Dr John Tait Chair National Maternity Monitoring Group PO Box 10730 WELLINGTON 6143

Dear John

Waikato D i ~ · ri c H eulth Boo1J

IRIECIE~VIED

2 6 FEB 2017

---------------

Re: External Review of Waikato DHB Maternity Services

Thank you for your letter to Ruth Galvin - Maternity Quality and Sa ~ rogramrne Coordinator at Waikato DHB, regarding an update of the external re6ie of Waikato DHB's Maternity and Women's Health services.

Attached please find a progress report on how our Women s ealth services are tracking in relation to the recommendations made in the review.

J am delighted to inform you that the work of th~ omen's Health Commissioner and the

transformation team has been completed, and t~ Service Leadership Group will now take responsibility for ensuring the transformaUori w ork' continues.

I am also delighted to announce th~ W~k to DHB is being reaccredited for registrar training subject to formal ratification by the Ward of RANZCOG in the near future. The Women's Health service was congratulate the committee in relation to the workplace culture which was now 'exemplary' with a..w m, welcoming and supportive environment.

I look forward to heari :piore of National Maternity Monitoring Group's work programme and the 2017 Annual F\_ep rt so that we can continue to ensure women and babies receive safe

and high quality ~a)ernity care.

Yours.sincerely,

Michelle Sutherland Director Women's and Children's Health Waikato District Health Board

www wu1kotodhb.hcc1hh.nz

WAIKATO DHB, WOMEN'S HEALTH - PROGRESS REPORT

FEBRUARY 2018

WORKFORCE AND RESOURCING

SUMMARY OF RECOMMENDATIONS PROGRESS & COMMENTS STATUS1

• Address immediate concerns regarding medical workforce resourcing issues.

. The most pressing workforce resourcing issue over the last 2 years has been establishing a full .,/ Com e · registrar workforce following the loss of trainee registrars in December 2015. It became apparent a Hal"IQ.<G\ack to

few months into the transformation w~rk that the service' recruitment process was slow and * Yeadership numerous applicants were lost before interviews were arranged and/or appointments were made. ~SStlP Nov 2017.

Due to the lack of progress with recruitment, a recruitment coordinator was appointed in October ,N 2016, reporting directly to the Commissioner for Women's Health. This p'osition has taken ~'' responsibility for the coordination of all steps of the recruitment process for midwives and mt,_c@i staff. ~

Thirteen registrars have been appointed over the last 2 years. Unfortunately five ha~~eft-tlie service Recruitment ongoing over this period, including two registrars who were lost to the service as they w~r ·~ cepted into the RANZCOG training programme. A further two registrars were accepted into th;.f'!'-arbing programme this year. The service has increased the number of registrars to cover the a&,t~0 15.0 and is currently at 13.0 FTE and will continue to recruit to the budget FTE.

Over the last 2 years, six SMOs have terminated their employment ~e DHB. These changes were an expected outcome of many of the changes made under the trpi;formation programme. A further two part time SMOs ceased employment with the service i1W~}but have been retained on a contract for service basis due to their high level laparoscoJ)i£.,~1? and their status as supervisors for fellows in advanced laparoscopy. This is a very positive Q\ltcome which allows the service to continue to provide an advanced laparoscopy service and a \:I~ ip position, whilst further developing the capability within the permanent SMO workforce. 0 Whilst the turnover noted above was not unexQted, it has resulted in considerable pressure to recruit to SMO positions and the use of loc. as been required whilst recruitment undertaken.

1 The service will have a fully appointe,SWor Medical Officer workforce by April 2018.

g ' "Complete" indkates that the wo•k of the Trnnsfo•maUon P•ogrn•v,f,fl'J' "ll.en achieved and ongoing monlto•lng and management wm be handed back to the sen lo• leadership group r> ~

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SUMMARY OF RECOMMENDATIONS

• In order to understand resourcing requirements undertake:

o Service sizing

o Senior Medical Officer job sizing.

• Address the high level of vacancies in the midwifery workforce

PROGRESS & COMMENTS

Service sizing was completed in June 2016. This provided an indication that the current senior medical workforce numbers are approximately correct for the volume of service delivery and teaching at the time. Service sizing will be reviewed in 2018 due to new models of care being undertaken e.g. Outpatient hysteroscopy clinics.

The individual job sizing will be completed once the team structure is fully implemented as SMO clinical schedules will change when the SMO and Registrar workforce are fully appointed at the end of April 2018.

i Following almost a decade of significant midwifery vacancies at Waikato Hospital, the service was4~ , fully appointed to all midwifery positions in June 2017. ~

' In December 2018 recruitment of an additional 14.64 midwives were approved for the deliv~ uite · and the Women's Assessment Unit. ,~

; A number of strategies were implemented to stop the attrition, attract mid~iv~ ,;;Jtservice and i encourage midwives to increase their FTE (the average FTE was 0.6 up ua 1HVI ii'o17). The actions ' included:

: o A change in rostering approach to ensure permanent midwives H ve 11eir roster preferences met

1 o The introduction of a 12 hour shift option (following feedba'0m a survey)

· o Proactive efforts to minimise any delays in the recruit~process.

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STATUS' 9::>rv ../ Complete I"~ Although ong~Gj-

•!• :;~tull ~Vorce

(lj. Complete

' Handed back to ' service leadership . group November

2017.

Ongoing recruitment to the additional approved FTE

(l).Cj 2

"Complete" indicates that the work of the Transformation Progra~~ been achieved and ongoing monitoring and management will be handed back to the senior leadership group r> ~

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TEAM STRUCTURE


• Establish a team-based structure as the base units for the delivery of clinical work, teaching and supervision of residents and students, and the focus for interdisciplinary referral of patients

• Develop relevant sub-speciality interests

• Develop a system for rostering junior and senior medical staff

PROGRESS & COMMENTS

A four team structure has been agreed.

SMOs, registrars and SHOs have been assigned to each team. Each team has a special interest as follows:

o Team one - Urogynaecology

o Team two - Laparoscopy

o Team three - High risk obstetrics

STATUS R:>rv

~"Oj •!• Delays ~

experienc~

to medica.I~ -workfpr~

o Team four - Gynae oncology & Colposcopy.

All teams provide obstetrics and gynaecology care and cover a set day of the on-call roster.

vara~i~s, due \}'~pletion by

~ril2018

o'~ All senior medical staff clinical schedules were revised in June 2016 to enable team- 1:),fs~orking, continuity of clinics (and care), and regular on-call duties. However, this has not bj~le to be fully implemented due to SMOs covering registrar duties. • ~ V The registrar rosters have recently been reviewed and it has been deterni~'tP tt two additional registrars are required to ensure compliance with the MECA. Y' '

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~ Review complete

Implementation has been delayed due to vacancies (as above)

LEADERSHIP

SUMMARY Of RECOMMENDATIONS

• Re-establish the clinical Service Leadership Group to support more effective planning, and prioritisation.

• Review service leadership structure including the following:

o Redefine the unit manager position

o Redefine the Associate Director Midwifery position.

PROGRESS & COMMENTS

The Service Leadership Group (SLG) was re-established in February 2016, consisting of clinical and non-clinical members. The SLG leads and implements strategic direction and clear goals for the Women's Health Service.

A new leadership structure for Women's and Children's Health was determined in June 2017 and is now in place. The changes strengthen the clinical managerial partnerships and improve the operational management and service development functions of the Women's and Children's Health services. The establishment of a new Clinical Midwife Director position within the Women's Health service has afforded authority to midwifery leadership thereby strengthening the role (an Associa Director of Midwifery position has formerly sat outside of Women's Health and did not hav~ ,Q delegated authority within the service). The changes also provide much greater clarity ab~~ responsibil ities and accountabilities which had been sorely lacking in the Women's Hea-1\1;!~ ice. A newly created Associate Clinical Midwife Director supports the breadth of midwifer~aders ip in both the hospital and community. • ~

It is of note that, through performance management, the leadership restr~et~ some natural attrition the service now has new people in the following positions (sinci~cti 2016):

o Clinical Unit Leader o o Clinical Director, Obstetrics

~0 o Associate Clinical Midwife Director ~ o Service Manager, Women's and Children's He~"l} o Charge Midwife Manager Delivery Suite ~ U o Charge Midwife Manager E1 ~ ...

o Director, Women's and Children's Health

o Clinical Midwife Director

o Charge Midwife Manager Women'~sse ment Unit

o Charge Midwife Manager Outp~'l!)

STATUS

.tf' Complete (j

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.tf' Complete

These changes in leadership hav~;J significantly positive impact on the culture of the service.

~ -- -~~~·

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CULTURE AND OPERATIONS


Address issues of poor collegiality and low morale

• Roles, responsibilities and expectations of Service SMOs are revisited and agreed

• Develop a new Service Manual based on the Service vision, governance and systems for the delivery of service excellence

PROGRESS & COMMENTS

A climate survey was undertaken in August 2016 which indicated that the two areas of most concern for staff were communication and feeling valued.

Improvements in communication have been challenging to progress as sharing information is not part of the culture of the service. However a number of actions have taken hold such as a monthly service newsletter ('People at Heart') and regular meetings of the Director with medical and midwifery workforces. The Director meets with the registrar group on a monthly basis to listen to and respond to their concerns (or more often when required). Despite there still being some vacancies in both workforces, the overall 'mood' of the service has significantly improved. The Climate survey was undertaken again in September, and results reflected a significant change in the culture of the ser1l·ce

Changes of personnel in the medical and midwifery workforce and the appointment of the C i~ Unit leader and Director have assisted to build a positive and supportive culture and lea ni~ environment. There is a notable change in the collaborative efforts by the medical~non.-medical

workforce to continue to improve the service and to foster positive working rel \ tio 1 s that enable

a supportive training environment. • ~

Workshops will continue to be held which will focus on the organisation ~nd also allow for

team building. o

STATUS

A poster campaign with positive patient stories was implemente~d new posters will be displayed

on an annual basis. 'X'('\ __ __ ------ --..---------• The roles, responsibilities and expectations of SM Os ha'-" b~arified in the decision on team ./ Complete structure and organisation of the medical workforce · ;t;Jn,e 2016. This decision included very clear expectations for the SMO workforce, many of whie f:eAilso included in the Service Manual as described below.

The Service Manual is completed and ~ude :

o SMO Responsibilities, e U o Guidelines for effective tea~rJoning, and

o Service Operating Proced '~

Page 5 of 8


• Revise Model of Service Delivery to improve patient flow and quality of care

PROGRESS & COMMENTS

There have been numerous improvements to the model of care over the last 2 years including:

o Changes to the provision of elective caesareans

o The development of a HSCAN Rapid Access clinic for gynae-oncology

o Outpatient hysteroscopy clinics

o Re-establishment of in-house Urodynamics clinics

o The opening of a new Day Assessment Unit (DAU) - a midwife-led clinic which allows for a more coordinated service for women who require ongoing monitoring and care during the antenatal period.

The outstanding model of care change is the reconfiguration of the antenatal and gynaecology ward including improvements to the induction of labour process. ~~

0

STATUS R:Jrv ./ Complete "~

~ • o<:.'-~ r-econfiguration due for completion March 2018

TRAINING, EDUCATION AND RESEARCH


• Improve level of support of trainees by all consultants including handovers, post-acute rounds and oncall

• Establish routine time out for nonclinical activity to allow time for teaching and education activity

• Research opportunities need to be more actively encouraged; registrar research activities should be supported by the provision of paid protected time

PROGRESS & COMMENTS

During week days there are now two SMOS on-call rather than one; one is assigned to acute obstetrics and one to acute gynaecology. This allows a SMO to be available to directly supervise the junior registrars.

A greater presence by the SMOs for ward rounds and handovers, and changes in senior medical personnel, has assisted in providing a higher level of commitment to fully support the registrars. There is consistent feedback from registrars within the fortnightly registrar meetings that they have no concerns accessing support and supervision from SMOs. All SMOs support registrar teaching and hold the acute phones during teaching sessions.

Additional support is now being provided to junior registrars through a new buddy/mentor sys~ All junior registrars are now assigned a SMO mentor, separate to their formal MCNZ supervig"o~o provides regular support to the registrar, both in terms of teaching and training and pasto~ e.

An advanced trainee has taken on a "Chief Resident" role and has made significart egress in developing the teaching programme including: • ~ o Establishment of protected weekly registrar teaching sessions (SMOvt~e pager)

0 Establishment of weekly CTG education meetings 0 o Journal Club every 4 to 6 weeks

o Re-establishment of Ultrasound training. (2,

The appointment of a SMO with a half time ap~ointmen~and University will assist. There are currently two SMOs with part-time academic roles and ere are several SMOs who are actively involved in research. ),,,._ <l} The unit has prioritised protected time for res:~~ the two advanced trainees, which is generating exciting research projects, with ~~~ainees having secured ethics approval for their research. V

STATUS

'1' Complete (j

Ongoing mon~ ahnd im~~ent, ~Y t ~~~19,e lea r~$ip group

(lj.

'1' Complete

Ongoing monitoring and development by service leadership group

'1' Complete

Ongoing monitoring and development by

I

service leadership group

'--~~~~~~~~~~~~~~--'~~~~~~~~~~~~~-=~-f~~~~~-~~~~~~~~~~~~~~~-'-~ ~~~

Page 7 of8

QUALITY AND PERFORMA.NCE IMPROVEMENT


• Review MQSP and other quality and safety work to ensure they provide a clear pathway for stakeholders to take ideas about potential areas of improvement and matters related to quality and safety.

• Develop systems for data and information collection and management with a view to better supporting service quality and performance improvement efforts

PROGRESS & COMMENTS

MQSP is an integral part of regular Senior Leadership Team meetings.

The development of a service quality dashboard is underway and due for completion in 201~ Q

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STATUS

,/' On track

National Maternity Monitoring Group

From: Sent: To: Cc: Subject: Attachments:

Dear John,

Amanda Rouse <[email protected]> Monday, 26 February 2018 2:43 PM National Maternity Monitoring Group Robyn Williamson Project Report MDHB - for Dr John Tait Maternity Service Review.docx; MSCGG TOR FINAL (7Jun17).pdf

Please see the attached project report from MidCentral DHB.

R:>rv "Q)

c} Nga mihi, Amanda

Amanda Rouse, RGN, RM,PgDlp Health Care

~ • o<:.'-~

&~ Maternity Quality Coordinator, Womens's Health Unit MCH Phone: 06 350 8973 Email: [email protected]

"If we wish consumers to engage with the full potential of their live~ Q d to consider whether the barriers we place in their way are to protect them or us" Embracing risk; e lbljnl choice UK

· ~ Attention: ~· ~ This e-mail message and any attachments contain informatio~ ! iS>confidential and may be subject to Legal and Medical privilege. If you are not the Intended recipient, you must not perusee s s'on or copy this message or any attachments. If you have received this e-mail in error, please notify us by return e-mail an eras a copies of this message including any attachments. Mid Central District Health Board does not accept any liability in respect of an · ~ - s which Is not detected. This e-mail message has been scanned and cleared by MallMarshal www.Irustwave.com

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MidCentral Maternity Service Review- Progress update regarding implementation of recommendations January 2018

I Achieved Not achieve/in progress

Work stream 1- Contextual Factors 1 RWHS to be reviewed and disestablished, with a less complex arrangement for

obstetric SMO cover at WDHB.

2

3

• Disestablished June 2016. Midwifery relationships are maintained between both DHBs through the Midwifery Advisor, Directory of Midwifery and Charge Midwife connections

MDHB and WDHB develop a memorandum of understanding (MOU) that clearly states for staff and the community the process to be undertaken In the event of suspension of services due to staff shortages

• A draft MOU is in the process of being approved. • Once approval by both Chief Executives has been clarified a

collaborative decision making process to ensure SMO cover at both sites will have to be developed

Accountability and responsibility for developing and maintaining relationships between clinicians within these maternity services needs to be clarlfled

• As above

4 MDHB needs to provide clear leadership and an expectation that the Clinical Leaders will work to support the New Zealand model of Maternity Care

s

• See below The role of LMCs w ithin the service need to be supported within a colleglal environment reflective of the philosophy underpinning the New Zealand Maternity Service model of care

• There has been considerable work in this space through t he wor programme in 2016/17

• Four communication workshops were held during the worf:; r:_ogh mme with all a varlet of staff attending, SMO's, senior midwJve , ~CM's,

In Progress

MOU approved by MDHB Board

Progressing /needs more

In ut

Requires approval from each DHBs Chief

Challenges

Chan~s to nior leaders.!:'4> posit ions

Not all staff who wished to attend the workshops could attend, either due to roster requirements or unable to obtain cover

This Is in progress.

As Above

core staff and LMCs as well as consumers attended these meetings

• These workshops socialised the referral guidelines, service specifications and worked through common issues

• The plan is to develop and implement referral pathways for

• Multiple pregnancies

• Women with BM1~35

• IUGR • Diabetes large for dates babies

• Hypertension in pregnancy ·

•

•

•

•

LMCs and consumers involved with Maternity projects and groups, e.g . Maternity Guidelines Group (3 LMCs with one representing NZCOM & consumer representation once the Consumer Liaison role filled)

The Birthing Suite morning handover had been changed to allow for more inclusion and partnership between medical/midwifery staff and core and LMCs. The service is working to implement the Tuia Framework (See Appendix 1) which aims to provide a culturally responsive and inclusive service. A project group has been formed which consists of representatives from the core staff, Maori core midwife, SMO, Pae Ora Maori Health Directorate, LMCs, Consumer Liaison and senior midwifery X. A RMO handbook has been written. Work to Improve the ov~ral U orientation process is in progress and to update RMO's on th z del of maternity care

In Progress PrQ&resslng /needs more

In ut The pathways require further input as well as dedicated resource to lead the project. Lack of funding is a huge issue

RMO orientation

Challenges

for case loads

Changes in senior leadership positions

Lack of project management once the work programme had been completed, therefore clinical st~ unable to comple 'e e pathways

~

The current RMO change over does not allow for an orientation period

Completed

Indicator 17: Preterm birth - Ministry of Health NZ · Indicator 17: Preterm birth Indicator 17...

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