Ministry of Health endorses recommendations made in Perinatal and Maternal Mortality Review Committee

 Ministry of Health endorses recommendations made in Perinatal and Maternal Mortality Review Committee’s annual report

Dr Pat Tuohy, chief advisor on child and youth health for the Ministry of Health said the Ministry welcomed the 2007/08 report from the Perinatal and Maternal Mortality Review Committee

“While the findings show New Zealand’s perinatal mortality rate is comparable to rates reported in Australia and the UK, we can always do better,” Dr Tuohy said. “When a baby or mother dies, it’s devastating for everyone - families, friends and the health professionals involved. Since the inception of the PMMRC, there’s improved real-time reporting on the ground at DHBs. This gives us very reliable information and also ensures that every adverse event is thoroughly reviewed and recurring issues are picked up and acted on.

“The PMMRC reviewed the deaths of 365 babies aged between 20 weeks gestation to 28 days old – almost one third of those babies died due to fetal abnormalities, the next most common reason for the baby’s death was pre-term birth.

“The higher rates of perinatal mortality amongst Maori and Pacific women under the age of 20, is of concern. I am, however, heartened to see that the committee will be focusing on this disparity in its next report.

“Deaths of mothers during or shortly after birth are rare. There were 14 reported in the period covered by this report. Eight were the result of pre-existing conditions and not due to causes related to pregnancy or childbirth,” Pat Tuohy said.

“One of the recommendations for the Ministry of Health to implement is to promote the Ministry’s pregnancy guidelines to Lead Maternity Carers for diabetes screening, smoking cessation and family violence screening. This is already underway.

“The Ministry is also charged with reminding all LMCs of clinical guidelines relating to monitoring the growth of babies while in-utero; risk factors associated with bleeding during pregnancy; post mortem and pathology services as well as improved awareness of and access to maternal mental health services.

“Another recommendation seeks to improve the support and information available to families who are affected by the death of a baby. There are already good systems in place at many DHBs, however we will be encouraging all DHBs to ensure resources and support processes for bereaved families are in place and accessible.

Dr Tuohy said there was nothing in the data to suggest that the outcomes are related to the provider of the maternity care . “New Zealand women are well-served by the maternity care system we have but communication between providers needs to improve.

“Improved communication between providers is something we’re frequently advocating, particularly between primary and secondary services. To this end, there is work underway on measures such as woman-held maternity notes, health care and hospital notes that can be integrated and electronic transfer of information between care providers,” Pat Tuohy said.

View the report on the PMMRC website - http://www.pmmrc.health.govt.nz

ENDS

For further information please contact:
Karalyn van Deursen
Senior Advisor – Media Relations
Ministry of Health
Phone (04) 496 2115 or (021) 832 459

Frequently Asked Questions

What are the key recommendations from the report?

The maternal recommendations are:

The Maternal Mortality Review Working Group of the PMMRC recommends that the following actions be undertaken with a view to reducing maternal deaths.

The Minister of Health continues to support national reporting of maternal deaths. On an individual level, lessons can be learned from every maternal death. Each death has the potential to highlight where improvements in clinical care and social services are needed and where more resources are required. As a rare sentinel event, a maternal death can be an indication of the function and quality of the entire health and social welfare system.

The Minister of Health request each DHB carry out a review on all maternal deaths under the auspices of the regional perinatal and maternal mortality review groups.

The Minister of Health notes complete case ascertainment is essential to ensure maternal mortality statistics are accurate.

All maternal deaths should be referred to a coroner (a legal requirement that has been in place since 1 July 2007)
The New Zealand medical death certificate should be modified to include a tick box to indicate if a woman has been pregnant within one year of the death.

The Minister of Health requests the Ministry of Health to identify women at risk due to poor maternal mental health, and improved access to maternal mental health services is required across all DHBs. Women at risk must have a clear management plan and in particular a crisis management plan.

The Minister of Health encourages improved communication between primary and secondary services. A variety of means should be used such as woman-held maternity notes, integrated notes systems and electronic transfer of information.

The Minister of Health notes that the PMMRC has hosted a national conference on maternal mental health in 2008 to raise awareness of the risks of maternal mental health problems and determine methods to improve access to care.

The Minister of Health recommends that all staff involved in the care of pregnant women should undertake regular training in management of obstetric emergencies.

The Ministry of Health recommends that each acute obstetric unit develops a massive transfusion protocol* to respond to major obstetric haemorrhage. One possibility would be to develop this protocol as a national process to support local processes.

The perinatal recommendations are:

The Minister of Health notes that the PMMRC will undertake the following actions with a view to reducing perinatal deaths.

Undertake detailed analysis of stillbirths among Pacific women and of neonatal deaths among Maori infants in its next annual report.

Undertake detailed analysis of perinatal mortality among mothers under the age of 20 years in its next annual report.

The Minister of Health requests the Ministry of Health to undertake the following actions with a view to reducing perinatal deaths.

Promote the Ministry of Health’s pregnancy guidelines to Lead Maternity Carers for:

Diabetes screening
Smoking cessation
Family violence screening

Inform Lead Maternity Carers that bleeding during pregnancy, regardless of the apparent cause, is a possible risk factor for perinatal death. Therefore women with bleeding during pregnancy should be closely monitored for fetal growth restriction and preterm labour.

Request Lead Maternity Carers to measure height and weight at the first antenatal visit and to use a customised growth chart to record fundal height to improve the recognition of infants who are small for gestational age.

Request that all families who experience a fetal or neonatal death be offered a post mortem examination for their infant, especially if a clear cause of death has not been established. Ideally the post mortem examination should be provided by a perinatal pathologist.

Develop and improve the provision of perinatal pathology services with regards to accessibility, training and appropriateness and to ensure quality and equitable services are available across the country.
Assign all babies, regardless of whether stillborn or live-born, a National Health Index number at the time of birth.

Develop national guidelines for District Health Boards (DHBs) to provide better support to parents, families and whanau around a perinatal death. The Ministry of Health develops support and information resources for the community.

The Minister of Health requests the Information Directorate (formerly New Zealand Health Information Service) to undertake the following action with a view to reducing perinatal deaths.

Provide timely and robust denominator data on births in New Zealand.

*What is a massive transfusion protocol?

A "massive transfusion protocol" is a set of treatment guidelines to be followed in the event of a woman losing a large amount of blood before, during or after childbirth.