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Comment on the NZ 5 th Annual Perinatal & Maternal Mortality Report 2009 Emphasis – international perspectives and

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  1. Comment on the NZ 5th Annual Perinatal & Maternal Mortality Report 2009Emphasis – international perspectives and teenage mums Sue Kildea Professor of Midwifery Director, Midwifery Research Unit Mater Medical Research Institute & Australian Catholic University

  2. Focus on the mothers International Trans Tasman New Zealand Teenage mums Overview

  3. 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?

  4. Child deaths when a parent dies, per 1,000 Why focus on the mothers?

  5. Every woman and baby counts… International Context

  6. 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 Every year

  7. 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

  8. UN Millenium Development Goals 2000-2015 Target 5: To reduce the maternal mortality ratio by ¾, between 1990 and 2015

  9. 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 Target 5 - Progress

  10. Competencies Coverage Access How many midwives are ‘we’ training? Are ‘we’ poaching? Triple gap

  11. Why women die…

  12. What can we learn from the UK?

  13. MMR by age, UK, 2006-08

  14. MMR - Partners occupational group (UK)

  15. Service provision 1. Pre-pregnancy counselling 2. Professional interpretation services 3. Communications and referrals 4. Women with potentially serious medical conditions require immediate & appropriate multidisciplinary specialist care Quality of care 5. Clinical skills and training (Back to Basics!) 6. Specialist clinical care: identifying and managing very sick women (early obstetric warning score) 7. Systolic hypertension requires treatment 8. Genital tract infection/sepsis Clinical governance 9. Serious Incident Reporting and Maternal Deaths 10. Pathology: improve standard of maternal autopsy 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 Top 10 Recommendations

  16. Trans Tasman

  17. 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…… NZ - MM review … a potted history Haslam A., Maternal mortality in New Zealand Vol 11 No 1 Autumn 2009 23

  18. Estimates of number of maternal deaths, lifetime risk, MMR, and range of uncertainty (2005) WHO, 2007, Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank

  19. One of the “safest countries in the world in which to give birth or be born” Australia Improving maternity services in Australia: A discussion paper from the Australian Government. Commonwealth of Australia 2008. p.3.

  20. Mothers dying in childbirth per 100,000 • Australian Kildea, S., et al., ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health 10 (online), 2010. 1383.

  21. Mothers dying in childbirth per 100,000 • Australian • Malaysia Kildea, S., et al., ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health 10 (online), 2010. 1383.

  22. Mothers dying in childbirth per 100,000 • Australian • Malaysia • Sri Lanka & NZ - 2006-09 Kildea, S., et al., ‘Closing the Gap’: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health 10 (online), 2010. 1383.

  23. Could it be true? Safer Birthing?

  24. Mothers dying in childbirth per 100,000 No national target for MMR • Australian • Malaysia • Sri Lanka & NZ - 2006-09 • Aboriginal and Torres Strait Islander 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.

  25. Media release ‘considerable drop in deaths’ 65 deaths (03-05) vs 84 (20-02) Validation & ascertainment - not the same Australian report 03-05 ?? MMR 11.1 MMR 2006-08 NZ: 18.3 2009: 22.0 -H1N1 deaths: 15.7 UK 11.4 MMR 8.4 MMR ??? MMR 8.8

  26. 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) Maternal Mortality in NZ & Australia

  27. Surveillance Cycle The Maternal Mortality or Morbidity Surveillance Cycle 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203; p.23

  28. Contributory factors – 36% 3 deaths potentially avoidable A/H1N1 influenza - 4 deaths AFE (induction) - 4 deaths Suicide - 3 deaths NZ – specific factors to note PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2009. p. 68

  29. Contributing factors Organisation / management • Poor arrangements /access to seniors • Inadequate education /training • Lack of policies, protocols guidelines • Delays / Inadequate systems /sharing information Personnel • Failure of communication • Didn’t ask for help / recognise severity/ competence Environment • Distance accessing tertiary care Barriers to accessing or engaging with care • Substance use / Maternal mental illness PMMRC. 2011. Fifth Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2009. p. 77

  30. 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

  31. Co-morbidities common Problems Slow diagnosis, false –ve swabs, no management plan, communication, anti vaccination

  32. Teenage Pregnancy

  33. Maternal Anaemia, antepartum haemorrhage, gestational hypertension, pre-eclampsia Neonatal Small for gestational age (SGA), preterm birth, intrauterine growth restriction (IUGR), admission neonatal intensive care unit (NICU), stillbirth, neonatal death Teenage pregnancy = poorer outcomes

  34. Stress Domestic violence Poor nutrition Unstable housing Lack of social support Drug use Smoking Depression and/or anxiety Associated with…

  35. http://www.myd.govt.nz/policy-and-research/teenage-pregnancy.htmlhttp://www.myd.govt.nz/policy-and-research/teenage-pregnancy.html Teenage births 1965 – 2008 in NZ

  36. 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 Distribution of perinatal deaths by maternal age 2007-09

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

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

  39. 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” Maternity Care in NZ

  40. Lower antenatal visit attendance Higher number of unscheduled reviews Lower ‘compliance’ with health advice Standard Care • May not be culturally safe, accessible or appropriate • Later gestation at booking

  41. 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.

  42. 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

  43. A Known midwife • No comparative studies of caseload midwifery for teenagers • Paucity of research on young women’s experiences of having a known midwife • Audit of 375 teenage women in UK: • 5% preterm birth • 8% low birth weight • 84% spontaneous birth Pilot RCT

  44. Group antenatal care Peer support Enhanced payment to providers who provide ‘enhanced’ care Ability to reduce caseload Home visiting Schools More research is needed Interventions that may help:

  45. 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 References

  46. Every mother counts ANDevery baby counts!Thank you !!