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Improved system for reviewing deaths of newborn babies and mothers

13 March 2009


Chair of the Perinatal and Maternal Mortality Review Committee, Professor Cynthia Farquhar, said the report released today presents the most accurate data available on the number of deaths of mothers and babies. It’s been a collaborative effort, with information gathered from Lead Maternity Carers, local coordinators and clinicians from the District Health Boards.

“While every death represents a huge loss for the families concerned, I hope those affected can take heart that the circumstances surrounding each case have been very carefully reviewed to see whether there is anything we can do differently in the future to improve outcomes. As a result, we have identified areas in maternity and newborn care where improvements can be made.

“The committee has made a number of recommendations to the Minister of Health, for DHBs and the Ministry of Health to implement.

“We now have a national database of perinatal deaths held by the Mortality Review Data Group of the University of Otago. This report is based on perinatal mortality data from the second six months of 2006 and a full year’s data on maternal mortality (Jan 2006 -December 2006). We can now produce a report on an annual basis going forward.”

“Our rates of perinatal mortality (deaths of babies) are similar to those of the United Kingdom and the Australian states of Victoria and Western Australia.

Professor Farquhar said communication was the key to ensuring co-operation and collaboration in reporting perinatal mortality. “Training workshops were held in 2006, 2007 and 2008 with local co-ordinators based in District Health Boards (DHBs). I’m pleased to report that all DHBs are now holding regular local mortality review meetings, which has only happened since the establishment of the PMMRC.

During the period covered by this report, which for perinatal deaths covers the period 1 July 2006 - 31 December 2006, there were a total of 365 deaths of babies aged from *20 weeks gestation to 28 days old. Almost a third of these deaths (120) were associated with fetal abnormalities, and the next most common reason for the baby’s death was pre-term birth. *A pregnancy is usually 40 weeks gestation.

There were fourteen maternal deaths reported in the 12 months from 1 January 2006 - 31 December 2006. Eight of these deaths were the result of previously existing diseases or conditions that developed during pregnancy, but were not due to obstetric causes. Six maternal deaths were the result of obstetric complications of pregnancy, birth and the six week period immediately after birth.

“I would like to publicly thank all those who have supported the work of the committee. There are a number of recommendations made in this report which we believe will contribute towards better outcomes for mothers and babies,” Professor Farquhar said.

The report is available on the Perinatal and Maternal Mortality Review Committee (PMMRC) website http://www.pmmrc.health.govt.nz/

The Perinatal and Maternal Mortality Review committee was established in 2005 to provide advice to the Minister of Health on the best way to reduce the numbers of preventable perinatal and maternal deaths, says committee Chair, Professor Cynthia Farquhar.

ENDS

For further information or to arrange an interview with Prof. Farquhar please phone:
Karalyn van Deursen
Ph 04 496 2115 or 021 832 459


Frequently asked questions


What is a maternal death?


Death of a woman while pregnant or within 42 days of termination of pregnancy [ie, end of pregnancy due to birth of baby, stillbirth, miscarriage or abortion], irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

In this definition of maternal deaths the Maternal Working Group includes the following in its scope:

Direct maternal deaths
Those resulting from conditions or complications or their management that are unique to pregnancy, occurring during the antenatal, intrapartum or postpartum period.

Indirect maternal deaths
Those resulting from previously existing disease or disease that develops during pregnancy and is aggravated by physiologic effects of pregnancy. e.g. epilepsy, diabetes, cardiac disease, deaths from suicide.

What is a perinatal death?


Perinatal or infant deaths are babies born after 20 weeks gestation up to and including 28 days of life or weighing at least 400 grams if gestation is unknown.

What is a fetal death?


Fetal death is the death of a baby born at 20 weeks or beyond or weighing at least 400grams if gestation is unknown. Fetal death includes stillbirth and termination of pregnancy.

What is an early neonatal death?


This is the death of a baby that occurs within the first seven days of life (including deaths on the seventh day)

What is a late neonatal death?


This is the death of a baby that occurs between the 8th day of life and the 28th day, including deaths on the 28th day.

Why does the rate of maternal deaths seem to be higher than in previous years?


New Zealand’s rate of maternal deaths appears to be higher than in previous years. The difference can be explained by increased ‘real time’ reporting via local coordinators, based in DHBs. Figures for previous years (1993 – 2006) are likely to be an underestimate as no maternal mortality committee existed.

This is the first report of maternal deaths in NZ since the establishment of the Perinatal and Maternal Mortality Review Committee (PMMRC) It would be premature to draw conclusions from one year of data. The number of deaths overall is too low to support statistical comparisons with other countries.

How does NZs perinatal mortality rate compare with that of overseas countries?


Perinatal mortality rates in New Zealand are comparable with the rates reported in Australia and the UK. New Zealand's rate is 11.6 per 1000 births for 2006. Comparable Australian State rates were 12.7 per 1000 births in Victoria, and 10.1 per 1000 births for Western Australia. Both areas use the same definitions as the NZ PMMRC.

How many babies died because of fetal abnormalities?


One third of perinatal deaths (120) were associated with fetal abnormalities. The next most common cause of perinatal death was preterm birth. It should be noted that for one in five stillbirths no cause is found.

Does ethnicity or age have any bearing on perinatal mortality rates?


Pacific and Maori women and women under the age of 20 years were found to have higher rates of perinatal mortality.

What has the committee recommended to address this disparity?


Detailed analysis of stillbirths among Pacific women and neonatal deaths among Maori infants will be a focus of the PMMRC’s next report, particularly focusing on the cause of death.

What was the maternal mortality rate for the period of the review?


The total maternal mortality ratio (i.e. including both direct and indirect maternal deaths) was 23.5 per 100,000 maternities*.
The direct ratio of maternal deaths was 10.1 per 100,000 maternities.
The indirect ratio (which includes one unclassifiable death) of maternal deaths was 13.4 per 100,000 maternities.

Note: Maternities are live births of any gestation, and stillbirths.

What were the actual numbers of maternal deaths?


There were a total of fourteen maternal deaths, eight were due to previously existing disease but not due to obstetric causes. Six were due to obstetric complications of pregnancy, birth and the six weeks following birth.

The six attributed to obstetric complications included three instances of amniotic fluid embolism, one due to postpartum haemorrhage and two resulted from maternal infection.

The eight maternal deaths not due to obstetric causes included four suicides, one intracranial haemorrhage, two from pre-existing medical conditions and one unclassified, as there was no investigation into the cause of death.

Why has it taken so long for the report to be released?


Each death is investigated and reviewed, and this takes time. The late reporting of one death caused an unexpected delay, and the change of government also has meant that we needed to wait for the new Minister to be briefed and to respond.

Why are there differences in the numbers of deaths in this report and those previously reported by the Ministry of Health?


There are differences in the way the two publications are compiled. The Ministry's Fetal and Infant Deaths publication is the formal record of official health statistics on all fetal and infant deaths registered in a calendar year, i.e. up to one year of age. The last report covered the years 2003-2004. The PMMRC's Perinatal Mortality in New Zealand 2006 publication presents perinatal deaths that actually occurred within a given period. The Ministry of Health publishes fetal and infant death data based on year of death registration, while the PMMRC publishes data based on year of death. Registration of death may take some time, so the Ministry's data will lag behind the PMMRC's data.

The Perinatal and Maternal Mortality in New Zealand 2006 publication produced by the PMMRC uses data collected by their newly-established data collection system. This system uses a Rapid Reporting Form for all perinatal deaths. This form is completed by the clinical staff involved (usually the woman's LMC). The local PMMRC co-ordinator provides additional information and completes the classification of the death. This form ensures timely and accurate notification to the national mortality database enabling all the data

The Ministry of Health has published Fetal and Infant Death series since 1972. This series uses data contained in the National Mortality Collection, which starts as information provided by the Births, Death and Marriages (BDM) Registry and is augmented with information from other sources. The Ministry of Health Mortality team assigns the underlying cause of death, using post-mortem reports, corresponding medical certificates and coronial findings, in accordance with the World Health Organisation (WHO) definitions and International Classification of Diseases codes.

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.
  1. 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.
  2. 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.
  3. The Minister of Health notes complete case ascertainment is essential to ensure maternal mortality statistics are accurate.
  4. All maternal deaths should be referred to a coroner (a legal requirement that has been in place since 1 July 2007)
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. The Minister of Health recommends that all staff involved in the care of pregnant women should undertake regular training in management of obstetric emergencies.
  10. 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.

Is there anything in the statistics that suggests one type of Lead Maternity Carer is safer than another?


No, there is nothing in the statistics that suggests any differences in outcomes between GP, midwifery-led or obstetrician care.



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