Sue Kildea Professor of Midwifery Director, Midwifery Research Unit

Comment on the NZ 5Comment on the NZ 5thth Annual Annual Perinatal & Maternal Mortality Perinatal & Maternal Mortality

Report 2009Report 2009

Emphasis – international Emphasis – international perspectives and teenage perspectives and teenage

mumsmumsSue Kildea

Professor of MidwiferyDirector, Midwifery Research Unit

Mater Medical Research Institute &Australian Catholic University

OverviewOverview

• Focus on the mothers

• International

• Trans Tasman

• New Zealand

• Teenage mums

Why focus on the mothers?

• What had we lost?• Harry and Emily had lost their mother at

the tender ages of three and six days old, I had lost my best friend. My confidante. My rock. My wife. My lover. My raison d’eˆtre. My world.’ – Ben Palmer, 2008

• Palmer B. Friday’s Child: The Heartbreaking Story of a Mother’s Love and a Family’s Loss. London: Virgin Books, 2008. 90 pp.

• If this Report helps to avert this tragedy for women and families in the future, it will have achieved its aim.

• 2011 Centre for Maternal and Child Enquiries, BJOG 118 (Suppl. 1), e1–e11

Why focus on the mothers?

Child deaths when a parent dies, per 1,000

International ContextInternational Context

• Every woman and baby counts…

Every year Every year • 350,000 women die

– pregnancy related condition

• 1 every 90 seconds

• 2 million newborns die in first 24 hrs of life

• 2.6 million stillbirths

• No universal access – Education– Skilled providers

– Nairobi Kenya– All women deserve

access to a skilled attendant

– Midwifery skills - the single most effective way to reduce maternal death

Safe motherhood initiative 1987

UN Millenium Development UN Millenium Development Goals 2000-2015 Goals 2000-2015

Target 5: To reduce the maternal mortality ratio by ¾, between 1990 and 2015

Target 5 - ProgressTarget 5 - Progress• This goal will not be reached

• Worldwide drop by 1/3• 546,000 (1990) to 358,000 (2008) pa.• <1/2 of what is needed

• Countries MMR>100 • On track 10/87• Some - no progress

• Progress uneven • Across and within countries

• ‘Global Call to Action’ 2010

Triple gapTriple gap

• CompetenciesCompetencies

• Coverage Coverage

• AccessAccess

• How many midwives are

‘we’ training?

• Are ‘we’ poaching?

Why women die…Why women die…

What can What can we learn we learn from the from the

UK?UK?

MMR by age, UK, 2006-08MMR by age, UK, 2006-08

MMR - Partners MMR - Partners occupational group (UK)occupational group (UK)

Top 10 RecommendationsTop 10 RecommendationsService provision•1. Pre-pregnancy counselling•2. Professional interpretation services•3. Communications and referrals•4. Women with potentially serious medical conditions require immediate & appropriate multidisciplinary specialist care

Quality of care•5. Clinical skills and training (Back to Basics!)•6. Specialist clinical care: identifying and managing very sick women (early obstetric warning score)•7. Systolic hypertension requires treatment•8. Genital tract infection/sepsis

Clinical governance•9. Serious Incident Reporting and Maternal Deaths•10. Pathology: improve standard of maternal autopsy

• 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203

Trans TasmanTrans Tasman

NZ - MM review NZ - MM review … a potted history … a potted history

• 1950s - specific conditions (eclampsia, haem)• 1959 - a maternal death review Prof L. Wright• Next 10 yrs - more structure

• Maternal Mortality Research Act 1968; committee; secretariat; assessors; requirements; payment; protection

• 1990 - Maternal Deaths Assessment Committee• 1993 - Different definitions to Aust & UK.• 2000 - Public Health and Disability Act • 2005 - Perinatal & MM Review Committee• 2006 - Most perinatal deaths collated• 2006 - MM Review Working Group

• national coordinator; network; systematic review; changing professional attitude

• 2011…… Haslam A., Maternal mortality in New Zealand Vol 11 No 1 Autumn 2009 23

Estimates of number of maternal Estimates of number of maternal deaths, lifetime risk, MMR, and deaths, lifetime risk, MMR, and range of uncertainty (2005)range of uncertainty (2005)

Country

Number of maternal deaths**

Lifetime risk of maternal

death**: 1 in:

MMR** (maternal deaths per 100 000

live births)

Range of uncertainty

lower

Range of uncertainty

upper

Australia 11 13 300 4 4 9Fiji 41 160 210 55 720New Zealand 5 5 900 9 9 18Papua New Guinea 820 55 470 130 1 300 Solomon Islands 34 100 220 65 580United Kingdom 51 8 200 8 8 15

WHO, 2007, Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank

AustraliaAustralia

• One of the “safest countries in the world in which to give birth or be born”

Improving maternity services in Australia: A discussion paper

from the Australian Government.

Commonwealth of Australia

2008. p.3.

Mothers dying in childbirth per Mothers dying in childbirth per 100,000100,000• Australian

Kildea, S., et al., ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health 10 (online), 2010. 1383.


• Malaysia



• Malaysia

• Sri Lanka & NZ - 2006-09


Could it be true?Could it be true?

Safer Birthing?


• Malaysia

• Sri Lanka & NZ - 2006-09

• Aboriginal and Torres Strait Islander Australian

No national target for MMRKildea, S., et al., ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health 10 (online), 2010. 1383.

Australian report 03-05Australian report 03-05• Media release ‘considerable drop in deaths’• 65 deaths (03-05) vs 84 (20-02)• Validation & ascertainment - not the same

Maternal Mortality in Maternal Mortality in NZ & AustraliaNZ & Australia

• Such a small number – does it matter?

• Maternal mortality is often used as a measure of a country’s overall health and development status.

• Aust – no robust system for monitoring and reporting

• A contributing factor ‘possibly present’ or ‘certainly present’– 48% Aust 2000-02; NZ 36% 2009)

Surveillance CycleSurveillance Cycle

The Maternal Mortality or Morbidity Surveillance Cycle2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203; p.23

NZ – specific factors to NZ – specific factors to notenote• Contributory factors – 36%

• 3 deaths potentially avoidable

• A/H1N1 influenza - 4 deaths

• AFE (induction) - 4 deaths

• Suicide - 3 deaths

PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2009. p. 68

Contributing factorsContributing factorsOrganisation / management

• Poor arrangements /access to seniors

• Inadequate education /training

• Lack of policies, protocols guidelines

• Delays / Inadequate systems /sharing information

Personnel

• Failure of communication

• Didn’t ask for help / recognise severity/ competence

Environment

• Distance accessing tertiary care

Barriers to accessing or engaging with care

• Substance use / Maternal mental illness


H1N1, UK, 1.4.09 – 13.1.10 H1N1, UK, 1.4.09 – 13.1.10 • Pregnant women

– 4 x hospital admission; 7 x risk of ICU admission

• 12 Maternal deaths– + 1 Ireland

• All pregnant women advised:– flu vaccine if not already received

A/H1N1/2009 (swine influenza) vaccine.– Antiviral medication as appropriate

Oseltamivir (Tamiflu) and zanamivir (Relenza)Modder,J., Review of Maternal Deaths in the United Kingdom related to A/H1N1 2009 Influenza, December 2010

Co-morbidities commonCo-morbidities common

ProblemsSlow diagnosis, false –ve swabs, no management plan, communication, anti vaccination

Teenage PregnancyTeenage Pregnancy

Teenage pregnancy = poorer outcomes

• MaternalAnaemia, antepartum haemorrhage, gestational hypertension, pre-eclampsia

• NeonatalSmall for gestational age (SGA), preterm birth, intrauterine growth restriction (IUGR), admission neonatal intensive care unit (NICU), stillbirth, neonatal death

Associated with…Associated with…

• Stress

• Domestic violence

• Poor nutrition

• Unstable housing

• Lack of social support

• Drug use

• Smoking

• Depression and/or anxiety

Teenage births 1965 – 2008 in NZ

http://www.myd.govt.nz/policy-and-research/teenage-pregnancy.html

Distribution of perinatal deaths by maternal age 2007-09

PMR 14.7 10.3 13.4

Per 1000

Adapted from: PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2009. p. 68

Young mums in NZYoung mums in NZ• 7.8% births & 10.6% perinatal deaths

• 50% of teenage mums who lost babies were Maori

• 45% highest deprivation quintile

• 50% were smokers

• Spontaneous pre-term birth, fetal growth restriction and perinatal infection more common causes in teenagers than 20-39 yrs.


Adapted from: PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2009. p. 67

Maternity Care in NZMaternity Care in NZ

• 75% of women now access a midwife as a lead maternity carer (LMC)

• ‘Teen Pregnancy’ services – Continuity antenatal and postnatal only– Peer support and education programs

• Few LMCs who specialise in caring for teenage pregnant women

• Problems with access to midwifery care– “Midwives turn away pregnant teens”

Standard CareStandard Care

• Lower antenatal visit attendance

• Higher number of unscheduled reviews

• Lower ‘compliance’ with health advice

• May not be culturally safe, accessible or appropriate

• Later gestation at booking

• Insufficient evidence of adequate quality to recommend routine implementation of any of the programs as a means of reducing infant mortality in disadvantaged/vulnerable women. Several interventions merit further more rigorous evaluation.

• Non-standard maternity care: – some benefit and no known detriment

• Strong evidence Group ANC: – increase ANC / BF & decrease preterm birth

• Young Women’s Clinic model may:– increase ANC & decrease preterm birth

• Dearth of evidence MGP

A Known midwifeA Known midwife

• No comparative studies of caseload midwifery for teenagers

• Paucity of research on young women’s experiences of having a known midwife

• Audit of 375 teenage women in UK:–5% preterm birth –8% low birth weight –84% spontaneous birth

Pilot RCT

Interventions that may Interventions that may help:help:• Group antenatal care

• Peer support

• Enhanced payment to providers who provide ‘enhanced’ care– Ability to reduce caseload

• Home visiting

• Schools

• More research

is needed

ReferencesReferences

• Family Care International Maternal Mortality Fact Sheet

• Safe Motherhood Resource Guide• Maternal Deaths in Australia 1997-99, 2000-

02, 2003-05• Why Mothers Die, UK, 2000-02• NZ Perinatal Mortality Reports• The State of the World‘s Midwifery Report

2011(sidebar photos and other facts)• Thanks to Jyai Allen who assisted with this

presentation

Every mother counts Every mother counts ANDAND

every baby counts!every baby counts!

Thank you !!Thank you !!

Sue Kildea Professor of Midwifery Director, Midwifery Research Unit

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