Health Quality & Safety Commission | Report finds suicide remains leading cause of maternal death
The annual report of the Perinatal and Maternal Mortality Review Committee (PMMRC) shows suicide continues to be the leading cause of maternal deaths. There were 13 maternal deaths from suicide during 2006 to 2010, almost a quarter of the total recorded. Three maternal suicides were reported in 2010 and three in 2009.
The PMMRC is responsible for reviewing maternal deaths and all deaths of babies from 20 weeks gestation up to 28 days after birth, or weighing at least 400g if gestation is unknown. It advises the Health Quality & Safety Commission on how to reduce these deaths.
PMMRC Chair Professor Cynthia Farquhar says the report has a number of recommendations aimed at reducing maternal suicides.
“These include the setting up of a mother and baby unit in the North Island in addition to the unit based in Christchurch. Another recommendation is the referral of pregnant women and new mothers with a history of mental illness for psychiatric assessment and management even if they are currently well.
“There also needs to be better coordination between existing services in the primary and specialist sectors and processes for sharing information between providers.
“It is encouraging to this Committee that the Ministry of Health’s report Healthy Beginnings, released earlier this year, supports the establishment of new specialist inpatient facilities for mothers and babies.”
The most frequent causes of maternal death in New Zealand in the years 2006 to 2010 were suicide (13 cases), maternal pre-existing medical conditions (11 cases) and amniotic fluid embolism (9 cases).
New Zealand’s maternal mortality rate – the death of a mother while pregnant or up to six weeks after birth – is significantly higher than that in the United Kingdom. Our perinatal mortality rate – the death of a baby from 20 weeks gestation up to 28 days after birth – is comparable with that in the United Kingdom.
There were 704 perinatal-related deaths in 2010, including 211 due to a congenital abnormality, 111 due to pre-term birth, and 78 due to haemorrhage during pregnancy.
Professor Farquhar says the report found that 124 (one in five) perinatal deaths and 18 (one in three) maternal deaths were potentially avoidable.
“Every one of these deaths is a tragedy. While some were not preventable, we can learn from others to help reduce deaths in the future. The report aims to identify where maternity and neonatal services should focus to make the greatest difference.
“New Zealand has very good maternity services, but there is always scope to learn and improve.”
She says the most common factors contributing to the potentially avoidable deaths of babies and mothers are not being able to access the necessary health services – such as not booking for pregnancy care, issues with the skills of health care professionals, and organisational factors such as a lack of protocols or delays in procedures.
“Maternity providers need to consider the recommendations from this report and seek to implement them.”
This year’s report contains new information on babies diagnosed with neonatal encephalopathy, where a term baby is born in poor condition requiring resuscitation and ongoing care. In 2010, there were 82 babies diagnosed with neonatal encephalopathy, of whom 59 survived. This is the initial analysis of data and more comprehensive analysis of two years of data will be reported in 2013.
- A maternal death is the death of a woman while pregnant or within 42 days of the end of pregnancy, from any cause related to or aggravated by the pregnancy or its management. It does not include accidental or incidental causes of death of a pregnant woman.
- Perinatal mortality is fetal and early neonatal deaths from 20 weeks gestation until less than seven days of age or weighing at least 400g if gestation was unknown.
- Perinatal related mortality is fetal deaths and early and late neonatal deaths from 20 weeks gestation up to 28 days after birth or weighing at least 400g if gestation is unknown.
KEY POINTS FROM THE REPORT
Perinatal related mortality
- In 2010, the perinatal mortality rate was 10.1/1000 births, and the perinatal related mortality rate was 10.8/1000 births, which represents a small non-significant decrease compared to the previous year. This rate is higher than the rate in Australia in 2009 and similar to the United Kingdom in 2009.
- Māori and Pacific mothers are more likely to have stillbirths and neonatal deaths compared to New Zealand European and non-Indian Asian mothers.
- There is a significantly increased rate of stillbirth and neonatal death among mothers who live in the most deprived areas.
- Teenage mothers are at higher risk of perinatal related mortality, specifically stillbirth and neonatal death, compared to mothers aged 20–39 years. Mothers of 40 years and older are also at increased risk of perinatal related mortality
- Nine percent of mothers reported using alcohol, and 3.4 percent reported using marijuana in pregnancy. Alcohol and marijuana use were associated with perinatal death due to spontaneous preterm birth and deaths due to sudden unexpected deaths in infancy (SUDI). These findings may be confounded by smoking, deprivation and young age.
- Eighteen percent of all perinatal related deaths were thought to be potentially avoidable deaths – 2 percent of late terminations, 15 percent of stillbirths and 19 percent of neonatal deaths.
- Contributory factors were identified in 27.3 percent of all perinatal related deaths – 2.6 percent of late terminations, 20.5 percent of stillbirths and 23.8 percent of neonatal deaths. The most common contributory factors were barriers to accessing or engaging with maternity and health services (19%), personnel (7%) and organisational and management factors (4%).
- The maternal mortality ratio for the five-year interval 2006–2010 was 17.8/100,000 maternities.
- The New Zealand maternal mortality ratio is significantly higher than the ratio reported by the United Kingdom for 2006 to 2008.
- There were eight maternal deaths in 2010.
- The most frequent causes of maternal death in New Zealand in the years 2006 to 2010 were suicide (13 cases), maternal pre-existing medical conditions (11 cases) and amniotic fluid embolism (9 cases).
- Thirty-six percent of maternal deaths in New Zealand from 2006–2010 were considered to be potentially avoidable.
- Māori and Pacific mothers are more likely than New Zealand European mothers to die during pregnancy or in the six weeks postpartum.
Recommendations perinatal-related illness and death
- If a baby is small for gestational age, and this is confirmed by ultrasound at term, timely delivery is recommended.
- Maternal gestational weight gain: Pregnant women should be given an indication of ideal weight gain in pregnancy according to their body mass index.
- Smoking cessation: All health professionals who provide care to pregnant women should offer smoking cessation advice.
- Neonatal encephalopathy: Cord gases should be performed on all babies born with an Apgar <7 at one minute. If neonatal encephalopathy is clinically suspected in the immediate hours after birth, early consultation with a neonatal paediatrician is recommended in order to avoid a delay in commencing cooling. All babies with moderate or severe neonatal encephalopathy should undergo a formal neurological examination and have the findings clearly documented prior to discharge.
Recommendations maternal illness and death
- Pregnant women who are identified with pre-existing medical disease during pregnancy should be referred appropriately.
- The committee notes the publication of the Ministry of Health’s Healthy Beginnings report in January 2012 and supports the recommendations with particular regard to the establishment of mother and baby units in the North Island and the importance of screening mothers for a history of mental health disorders.
- A comprehensive perinatal and infant mental health service includes screening and assessment, timely intervention, access to respite care and specialist inpatient care for mothers and babies, consultation and liaison services.
- Termination of pregnancy services should undertake holistic screening for maternal mental health and family violence and provide appropriate support and referral.