Establishing a confidential Maternal Death Enquiry: - PowerPoint Presentation

Slide1

Establishing a confidential Maternal Death Enquiry: the Irish experience

09/09/2013

Edel

ManningSlide2

Republic of Ireland: 2011 Mothers & Babies Average maternal age = 31.7 years 99.3 % of mothers booked for antenatal care Timing of 1st antenatal visit to health professional: 66% before 12 weeks, 27% between 13-19 weeksPerinatal Mortality Rate (PMR) = 6.1 per 1,000 births, (corrected PMR = 4.1)Mode of delivery 27.3% = LSCSPopulation = 4.6 millionMaternities = 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 Slide3

Maternity ServicesAll 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’.Slide4

Irish Maternal Death RateCountryMaternal Mortality Rate / Ratio Ireland: CSO 20094 per 100,000 Live and StillbirthsIreland: MDE Ireland 2009-20118.4 (95% CI: 4.1 – 12.5) per 100,000 maternities

MDE UK 2006-2008

11.39 per 100,000 maternities

MDE Ireland: Results triennium

2009-20011

Classification of maternal deaths: 24% Direct, 52% Indirect and 24% coincidental

40 % of mothers were not born in Ireland

Source: Central

S

tatistics Office IrelandSlide5

Establishing commitment and support for the MDE at governance levelEstablishment 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 AgencyExpert advise: Data Protection Commissioner/Coroner’s SocietySlide6

Reasons for joining the UK based Enquiry Anonymity / confidentialityValidated & respected methodologyComparative analysis with a relatively similar health care systemLarger cohort: more meaningful analysis/ valid conclusions & recommendationsMDE was initiated in England & Wales 1952

Ireland

became a participant in

2009

Advantages in joining the MDE UK Slide7

Identifying and addressing the relevant challenges Lobbying for funding : stand alone office and co-ordinator to coordinate the CEMD processData protection in Irish context: legal opinion/ anonymisation of dataLitigation- independent of clinical incident reporting/ confidentialityCollaboration with the UK Maternal Death Enquiry Format of death certificates/ civil registration system identifying maternal deathsSlide8

Implementing the Maternal Death Enquiry (MDE) 2009: ChallengesCreating Awareness and ‘buy in’ for the MDE process amongst relevant Health ProfessionalsMaternal death case ascertainmentQuality and standardisation of maternal death case assessmentSlide9

‘Buy In’ : Creating Awareness of the MDETime 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, conferencesOn going collaboration with coroners Slide10

‘’Buy in’’ : Health professionalsSell 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 servicesAlleviate concerns re litigation (20% of medical claims against the state are obstetric)/ confidentiality/non-punitiveImportance of powerful persuasion : support letters from relevant authorities (cooperation with the MDE is now policy, but not statutory, for all public funded services). Slide11

Case ascertainmentLogistics: 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) Slide12

Case ascertainmentQuality 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 processSlide13

Quality and standardisation of data and case assessmentAligned 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 formsSlide14

Un-foreseen challengesChange 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 Ireland1st Irish triennial report (limitations of report)Slide15

Thank you for your attention