1. Interventions to reduce maternal deaths in New Zealand Professor Julie Quinlivan University of Notre Dame Australia University of Adelaide Women’s and Children’s Research Institute Ramsay HealthCare, Joondalup Health Campus

2. Acknowledgements Perinatal and Maternal Mortality Review Committee Chair, Professor Cynthia Farquhar Health Quality and Safety Commission New Zealand.

3. Maternal deaths What are potentially avoidable factors ? What evidence is there to help?

4. C0incidential maternal deaths In the five years from 2006-2010 eight mothers died of coincidental causes. All deaths occurred in the community. Six due to MVA One due to cancer One due to an accident Four deaths found to be potentially avoidable due to not wearing a seat belt whilst a passenger in a motor vehicle.

5. Risk Associations Fourth or higher order birth Overweight or obese Smoking, drug and alcohol abuse Age over 40 years Maori or Pacific mothers Domestic violence and mental illness

6. Potentially avoidable deaths 32% of all maternal deaths were potentially avoidable deaths

7. Contributory factor present (N=57) Contributing factorN% Yes3053% No2543% Unknown24%

8. Maternal deaths (N=57) Potentially avoidableN% Yes1832% No3765% Missing data24%

9. Avoidable contributory factors Organizational Personnel Technology Environmental Barrier to care

10. Organizational factors (N=18) Lack of policies/protocols/guidelines14 Poor education and training6 Poor communication5 Failure or delay in emergency response4 Poor organization of staff4 Delay in procedure3 Poor access to senior staff2 Delayed access test result1

11. Personnel factors (N=17) Knowledge and skills of staff lacking8 Lack recognition of seriousness of situation 8 Failure to communicate between staff8 Delayed emergency response5 Failure to seek help/supervision3 Failure to follow best practice2 Other9

12. Technology factors (N=1) Lack of maintenance of equipment1

13. Environmental factors (N=3) Geography (long transfer)3

14. Barriers to Care factors (N=21) No or infrequent care or late booking11 Lack recognition of seriousness of condition 8 Mental illness5 Substance use4 Family violence3 Other7

15. Staffing education/behaviour Lack of policies/protocols/guidelines (N=14) Lack of recognition of complexity or seriousness of condition (N=8) Knowledge and skills of staff were lacking (N=8) Inadequate training/education (N=6) Delayed emergency response by staff (N=5) Failure to seek help/supervision (N=3) Failure to follow recommended best practice (N=2)

16. Barriers to Care – Patient No or infrequent antenatal care or late booking Family violence Mental illness

17. Discussion points Staff training in O&G (talk 1) Evidence base behind non engagement with care Domestic violence Mental illness

18. Why do patients not engage with care?

19. Patient engagement with care 1 Travel – longer travel time to the center associated with reduced number of referrals for eligible women, but once they attend, no difference in default rates Astell-Burt T, Flowerdew R, Boyle P, Dillon J. Soc Sci Med 2012; 75(1): 240-7

20. Patient engagement with care 2 Advice given – If patients are uncomfortable or do not understand the reasons behind advice given, they are more likely to default from care than attend and explain why they did not follow advice. Cartwright B, Holloway D, Grace J et al. Obstet Gynaecol 2012; 32(4): 357-61

21. Patient engagement with care 3 Ethnicity – There are genuine ethnic differences in attendance for care that cannot be explained by simple socioeconomic status, geography and severity of illness Bansal N, Bhopal RS, Steiner MF et al. Br J Cancer 2012; 106(8): 1361-6

22. Patient engagement with care 4 Care giver advice - Incentives to attend for care are greater levels of patient knowledge, a sense of duty and fear. The main disincentives to attend for care is the absence of a strong recommendation that care is beneficial by a healthcare provider. Cartwright B, Holloway D, Grace J et al. Obstet Gynaecol 2012; 32(4): 357-61

23. Patient engagement with care 5 Administrative factors – women defaulting from care stated that they were unaware of the appointment date and time, were confused about need to attend or forgot the appointment. Wilkinson J, Daly M. J Prim Health Care 2012; 4(1): 39-44

24. Patient engagement with care 6 Domestic violence and housing instability – In multivariate analysis following 500+ women across three years, the only independent variables associated with persistent default and eventual loss to follow up in O&G clinics were domestic violence and housing instability Quinlivan J et al.. J Low Gen Tract Dis 2012; doi; 10.1097/LGT.Ob013e3182480c2e Collier R, Petersen RW, Quinlivan J Arch Wom Ment Health 2012 (in press); Paper to be presented at ASPOG ASM Melb August 2012

25. You need to know your local factors for disengagement with care.

26. Domestic violence and mental illness

27. Domestic violence 1 Common in the reproductive years – NZ lifetime prevalence 33-39% – Severe 19-23% – Experienced annually 5% Women exposed to domestic violence present for care Women do not mind being screened in healthcare settings Fanslow J, Robinson E. NZ Med J 2004; 117: 1206 Violence Intervention program 2011 http//www.aut.ac.nz/_data/assets/pdf_file/0020/235640/ITRC-SUMMARY-FINAL-2011- WEB.pdf

28. Domestic violence 2 With the exception of psychopathic domestic violence, the precipitating event is frequently excessive use of alcohol and drugs. Need to screen to identify Need to refer for intervention once identified Quinlivan JA. Where should research now be focussed in domestic violence and alcohol. International Journal of Substance Use. Commentary 2001; 6: 248-50.

29. Family Violence and NZ Maternal Deaths Family violence data only available in 40% of cases, but where available, was involved in 24% of cases Six of these eight women died from suicide.

30. Family Violence and NZ Maternal Deaths All District Health Boards required to screen for domestic abuse However, only 82% of NZ Hospitals monitor partner abuse screening, Only 22% of these achieve screening rates >50%

32. Poor history taking There is poor history taking in relation to mental illness in obstetric histories. Often bipolar disorders and major psychotic disorders are mislabeled as ‘depression’ Anxiety disorders are also missed » Chessick CA, Dimidjian Arch Womens Ment Health 2010; 13: 233-248

33. Screening tools Improve rates of disease detection. Need to rescreen in each pregnancy as sufficient variation between pregnancies to justify this. EPDS only screens for depression » La Porte LM, Kim JJ, Adams M et al. Am J Obstet Gynecol 2012; 206(3): 261-4 » Leddy MA, Lawrence H, Schulkin J Obstet Gynecol Surv 2011; 66(5): 316-23

34. Must be an entire program Good history taking for mental illness and screening tools A network of providers to accommodate screen positive referrals 24/7 hotline appropriately staffed Midwifery and obstetrician education Centralized scoring and referral process Take care to ensure private providers implement policies Intensive therapy must be available for those identified as requiring this input » Gordon TE, Cardone IA, Kim JJ. Obstet Gynecol 2006; 107(2 Pt1): 342-7

35. The Suicide profile Based on a review of 46 published articles on obstetric suicide. Risk factors: – current or past history of psychiatric disorder, young (<20 years), unmarried, unemployed, unplanned pregnancy, illicit drug use, alcohol use in pregnancy, low supports, previous sexual or physical violence. » Gentile S, J Inj Violence Res 2011; 3(2): 90-7

36. You need to screen for domestic violence and mental illness and act on the findings