Wednesday, 3 July 2013

Severe Maternal Morbidity Audit report - Points to consider before we start Congratulating ourselves.

This week, an audit report of severe morbidity in the Irish maternity system, carried out by the National Perinatal Epidemiology Centre in Cork in 2011, was published. This report was eagerly anticipated by AIMS Ireland and we have been quoting the need for such an audit for some time.

The reasons for a need to audit morbidity in maternity care are outlined in the AIMSI 42 weeks campaign aricle,  "Healthy Births for Healthy Mothers and Babies"

For a long time, the quality of maternity care has been measured by the rate of deaths to mothers and babies. But, many now argue that this is not a true reflection of care as technology, nutrition, disease control, and hygiene have reduced the rate of deaths drastically. Instead, a way of measuring care is to look at the rates of complications that arise in pregnancy, and during labour, birth, and the postpartum period. These complications are called morbidity and can affect the health of mothers and babies ranging from moderate to severe harm. Some procedures and care increase the chances of these complications and, as a result, morbidity is on the rise in Ireland.
“Results have shown that maternal morbidities in Ireland are common and changing. Analysis of national trends in maternal morbidities from 2005-08 show a statistically significant increase in rates of postpartum haemorrhage (PPH), pelvic and perineal trauma, and gestational diabetes.Over an 11 year period (1999-2009), the overall PPH rate increased from 1.5% to 4.1%, with a significant increase in the rate of blood transfusion co-diagnosed with atonic PPH.....Further increasing rates of Caesarean section have led to an increase in the incidence of peripartum hysterectomy for morbidly adherent placenta. Such findings stress the need for continued surveillance of maternal morbidities to guide clinical practice, focusing on aetiological factors, preventative measures and quality of care.” Measuring maternal morbidity, Edel Manning
AIMS Ireland are concerned about rising intervention rates, which can vary greatly between hospitals and even between individual health care providers. Interventions are known to increase the chances of harm to the physical and psychological health of mothers and babies. We all want mothers and babies to come through birth feeling healthy and emotionally complete.

Severe Maternal Morbidity Report

For the purpose of this report, only severe maternal morbidities were collected. To you and me that means the NEAR MISSES.

The 20 maternity units in Ireland (19 public units and 1 private) were asked to provide data on instances of severe maternal morbidity.

What is 'severe morbidity'?

According to the report from UCC its:

" 15 categories of maternal morbidity including: major obstetric haemorrhage (MOH), eclampsia, renal/liverdysfunction, cardiac arrest, pulmonary oedema, acute respiratory dysfunction, coma, cerebrovascular accident, status epilepticus, septicaemic shock, anaesthetic complications, pulmonary embolism, peripartum hysterectomy, admission to intensive care and interventional radiology. Major obstetric haemorrhage was defined as an estimated blood loss of ≥ 2,500ml, and or a transfusion of ≥ 5 units of blood and or documented treatment for coagulopathy."

Key Findings of Severe Maternal Morbidity Report

"Overall, 260 women were reported as experiencing at least one severe maternal morbidity, which translated as a national morbidity rate of 3.8 cases per 1,000 maternities or 1 in 263 maternities."
 "The majority of women (57.7%) were diagnosed with one severe morbidity and one third (32.3%) were diagnosed with two severe morbidities. A small proportion was diagnosed with three or four morbidities."

"The perinatal mortality rate among women experiencing severe maternal morbidity was 32.6 deaths per 1,000 births. This was substantially higher than the national rate, which was estimated recently at 6.6 per 1,000 births." "Key findings and rates of women experiencing MOH mirrored findings from successive SCASSM reports. These include: Uterine atony was the most frequently reported cause of MOH, followed by: other specific causes; retained placenta; and placenta praevia. The majority of cases of MOH occurred in the postpartum period, with Caesarean section the most common associated mode of birth. MOH was also the most common morbidity associated with ICU admission."

With Ireland's rising Caesaeran Section rates, the rates of severe maternal morbidity look set to rise also.

And finally:

 "The incidence of severe maternal morbidity was disproportionately higher among ethnic minorities."

Does this send a red alert? It should.

AIMS Ireland has been highlighting concerns regarding care received by ethic minorities for some time. Clare Daly has put in numerous Parliamentary Questions from AIMS Ireland on the disproportionate instances of maternal mortality and morbidity among women of ethic minority backgrounds.

According to UK and Irish data, maternal deaths, while a rarity, nonetheless  statistically affect non-national emigrant women almost twice as frequently as women born in either the UK or Ireland (CMACE, 2011; MDE, 2012).  

Maternal Death Enquiry Ireland (2012) Confidential Maternal Death Enquiry in Ireland, Report for Triennium 2009-2011, Cork: MDE.

This report adds to concerns that ethnic minority women are not receiving appropriate, safe maternity care.

Limitations of the Audit

Unfortunately, there are limitations to this audit which result in unknown and misleading results.

1) Only 19 of 20 maternity units participated in the audit, the unit which did not participate has not been named. Transparency and availability of information have been issues raised by AIMSI to the Minister for Health (twice), and HIQA. This is a 'National Audit' - every unit must participate and those who do not, should be named so that women know that their maternity unit has (i) not been included in the findings (ii) has chosen not to participate  (As an aside, AIMSI have been campaigning for the full disclosure of annual audit reports of birth statistics per unit available to the public online in order to aide informed choice. Information such as episiotomy, caesarean section rate, assisted delivery, induction rates, pph, etc should be available per unit and per individual health care professional so that women can decide which units and professionals they choose to attend for their care.)

2) AIMSI have been informed that only 6 (yes 6) of Ireland's maternity units has an electronic record system, such as the MIS system. Relying on handwritten records increases the risk of unreliability and quality of the data available to audit.

3) Some of the records from units within the audit were only partial. When looking at the audit report, we see in the 'maternal characteristics' that 2 cases did not provide maternal age and 54 cases did not provide data on ethnicity. 71 cases were missing data on smoking habits and 93 cases had no background data on alcohol habits. BMI data was missing for 1/4 of women's cases. When reports from units are based on partial recording, it is difficult to (i) have a clear understanding of the true extent of instances (ii) some of the missing data would be important to draw conclusions to risk factors contributing to rising rates of severe morbidity (iii) the integrity of the information is put into question - if data is missing or only partially recorded, can we trust the data provided is accurate?

4) Most women with severe maternal morbidity had Caesarean sections. However the report says that 1/5 of women with severe maternal morbidity had spontaneous vaginal deliveries (SVD). However, in this report, SVD is defined in terms of mode of delivery, not mode of management in labour. This is incredibly significant. It means that all vaginal births are being classified in the same way, regardless to how the labour has been managed. Evidence has shown us that some interventions used to manage labour significantly increase the risk of maternal morbidity, such as PPH. To categorize all vaginal births together, regardless of intervention, is misleading.

5) This audit, while welcomed, only measures severe maternal morbidity; the near misses, within the definitions of the classifications. A woman with a PPH of 1500ml, which is still a significant bleed, has not been included in this report. Also, everyday maternal physical and psychological instances of maternal morbidity have not been measured. AIMS Ireland has seen an increase in these types of morbidity and they have a huge impact on the physical and emotional short and long-term health of mothers and babies.

Maternal morbidity is an important aspect in measuring the quality of care within our maternity services and the care we provide to women and babies. In many instances, less severe classifications of maternal morbidity are not considered as significant as a medical means of measuring the safety of maternity care, yet, the impact on women can be lifechanging. Injury from episiotomy, for example, can lead to chronic pain, urinary and fecal incontinence, and can greatly impact on women's self esteem, ability to be active/sport, and maintain a healthy sex life. Women can also suffer from psychological morbidity - depression, PTSD, anxiety - following such interventions.

Before we start congratulating ourselves on our low rates of maternal mortality and severe maternal morbidity in Ireland, we must look at the whole picture. Recording deaths and near misses is not enough - the health of mothers and babies, in the short and long-term must be protected.

Read More:

Just one-in-263 pregnancies has severe difficulties

Full Report:

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