09/09/2013 Edel Manning

Republic of Ireland: 2011 Mothers & Babies Average maternal age = 31.7 years 99.3 % of mothers booked for antenatal care Timing of 1 st antenatal visit to health professional: 66% before 12 weeks, 27% between weeks Perinatal Mortality Rate (PMR) = 6.1 per 1,000 births, (corrected PMR = 4.1) Mode of delivery 27.3% = LSCS Population = 4.6 million Maternities = 73,008 (= rate of 16.2 per 1,000 population) Births 74,500 (≥ 500g) Nationality of mothers – 76.1% Irish, other EU nationalities = 11.6%; Asia = 4%; Africa = 2.6% Abortion is illegal (exception: imminent ‘real’ threat to maternal life) Sources: ESRI and the National Perinatal Epidemiology Centre

Maternity Services All mothers are entitled to free ‘public’ maternity services – State funded (HSE) Models of care : Combined (GP; Obstetrician & Midwife) / Obstetric lead antenatal care + midwifery care in labour/ Planned home births with self employed community midwives = 0.2% 19 public funded maternity units (tertiary referral = 8) + 1 private maternity unit (1.8% of all births ) 2 alongside midwifery units facilitating care for ‘low risk ‘ pregnancies’.

Irish Maternal Death Rate CountryMaternal Mortality Rate / Ratio Ireland: CSO per 100,000 Live and Stillbirths Ireland: MDE Ireland (95% CI: 4.1 – 12.5) per 100,000 maternities MDE UK per 100,000 maternities MDE Ireland: Results triennium  Classification of maternal deaths: 24% Direct, 52% Indirect and 24% coincidental  40 % of mothers were not born in Ireland Source: Central Statistics Office Ireland

Establishing commitment and support for the MDE at governance level Establishment of a multidisciplinary Maternal Mortality working group with the stated objective of linking Ireland with the UK based Confidential Enquiry (2007) Members included relevant stake holders necessary to support and drive implementation of a MDE in Ireland:  Health service providers / Institute of Obstetrics and Gynaecology/ Midwifery regulatory board/Anaesthetic Faculty /State’s Claims Agency  Expert advise: Data Protection Commissioner/Coroner’s Society

Reasons for joining the UK based Enquiry Anonymity / confidentiality Validated & respected methodology Comparative analysis with a relatively similar health care system Larger cohort: more meaningful analysis/ valid conclusions & recommendations  MDE was initiated in England & Wales 1952  Ireland became a participant in 2009  Advantages in joining the MDE UK

Identifying and addressing the relevant challenges Lobbying for funding : stand alone office and co- ordinator to coordinate the CEMD process Data protection in Irish context: legal opinion/ anonymisation of data Litigation- independent of clinical incident reporting/ confidentiality Collaboration with the UK Maternal Death Enquiry Format of death certificates/ civil registration system identifying maternal deaths

Implementing the Maternal Death Enquiry (MDE) 2009: Challenges Creating Awareness and ‘buy in’ for the MDE process amongst relevant Health Professionals Maternal death case ascertainment Quality and standardisation of maternal death case assessment

‘Buy In’ : Creating Awareness of the MDE Time consuming and labour intensive: Individual hospital visits / multidisciplinary presentations/ public health nurses Information leaflets/ web site. Dissemination through multidisciplinary journals (obstetric, psychiatry, anaesthetics and midwifery) /links to relevant web sites Workshops, conferences On going collaboration with coroners

‘’Buy in’’ : Health professionals Sell the ‘concept’. Highlighting the success of historic UK ‘Confidential Maternal Death Enquiry’ reports: informing clinical practice; identifying modifiable risk factors; recommendations used to create change/ improve maternity services Alleviate concerns re litigation (20% of medical claims against the state are obstetric)/ confidentiality/non- punitive Importance of powerful persuasion : support letters from relevant authorities (cooperation with the MDE is now policy, but not statutory, for all public funded services).

Case ascertainment Logistics: Co-ordinator with dedicated time to coordinate the project (cost and time implications) Establishing a wide, structured, reporting network to the MDE: hospitals/community/coroners. ‘’The wider the net the greater the catch’’ Clearly identifying a reporting coordinator in maternity units (‘buy in’ from management) Collaboration/ verification with civil registration system (via the central statistics office)

Case ascertainment Quality of Death Notification Forms:  Specific question on pregnancy status at time of female death: medical vs coroner’s death certification Timeliness of coronal reporting (can be up to 18 months in the case of an inquest) – impact on the MDE process

Quality and standardisation of data and case assessment Aligned to the UK standardised process (previously CMACE, going forward MBRRACE in the NPEU Oxford) Data requested: clinical notes, post mortem report, internal hospital review if available. Specific standardised reporting forms for health professionals involved in the care (identify Lessons Learnt) Transparent recruitment of Irish multidisciplinary assessors; training of assessors; panel meetings to discuss cases; use of standardised assessment forms

Un-foreseen challenges Change in governance of the UK based Maternal Death Enquiry (from CMACE to MBBRACE) Impact on the MDE in Ireland:  Maintaining commitment and interest at governance and clinical level (during interim period)  Collaboration with MBRRACE, however will maintain current title of MDE Ireland  1 st Irish triennial report (limitations of report)

Thank you for your attention