First national audit on maternal complications

24 Jun 2013

The first Irish national audit into severe maternal medical complications occurring during pregnancy, delivery and the post-natal period (known as maternal morbidity) has been published.

The report shows that 1 in 263 pregnant women experienced a severe maternal morbidity.  The audit found that the perinatal mortality rate among the cohort of women with severe maternal morbidity was 32.6 per 1,000 births and that the incidence of these complications was higher among ethnic minorities.

The national audit was carried out by the National Perinatal Epidemiology Centre (NPEC) based in the Departmet of Obstretics and Gynaecology at  Univeristy College Cork for the calendar year 2011 in collaboration with the medical and midwifery staff from the individual maternity units around the country. The audit collected anonymised data on severe maternal illness during pregnancy from 19 of the 20 maternity units in Ireland between 1^st January 2011 and 31^st December 2011. In total, 67,806 maternities (number of births, live and stillbirths) were reported from the participating maternity units, representing 93% of pregnancies in Ireland in 2011.

The methodology used in the study was based on a similar audit in Scotland, the Scottish Confidential Audit of Severe Maternal Morbidity (SCASMM).

“This report highlights the high quality of maternity care in Ireland, when benchmarked internationally. The audit report is the result of the hard work and commitment of the staff in all maternity units; not only to providing a high level of care, but also to participating in the review of the care they provide. Maternity services in Ireland are showing leadership in the assessment of the care provided through these national audits. Patients should be reassured by the findings and especially by the commitment of the service to reviewing outcomes with a view to enhancing the quality of care and patient safety” Professor Richard Greene, Director, NPEC.

The key findings

• 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. This compares favourably with the most recent audit in Scotland. (The SCASMM[1]).
• Of the women experiencing a severe maternal morbidity 57.7% were diagnosed with one severe complication and 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 morbidities was 32.6 deaths per 1,000 births. This was substantially higher than the national rate, which was recently estimated at 6.6 per 1,000 births[2].
• The incidence of severe maternal morbidities was disproportionately higher among ethnic minorities.
• Major obstetric haemorrhage was the most frequent cause of severe maternal complications identified in 2011 with a reported rate of 2.3 per 1,000 maternities, followed by Intensive Care Unit (ICU) admission, renal/liver dysfunction and peripartum hysterectomy.

A specific detailed audit was carried out on all women experiencing a major obstetric haemorrhage. A major obstetric haemorrhage was defined in this audit 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 and rates of women experiencing major obstetric haemorrhage mirrored findings from successive Scottish Confidential Audits in Severe Maternal Morbidity reports.

• In this audit, uterine atony (loss of tone in the uterine muscles) was the most frequently reported cause of major obstetric haemorrhage, followed by retained placenta; and placenta praevia (Placenta praevia occurs when a baby's placenta partially or totally covers the mother's cervix. Placenta praevia can cause severe bleeding before or during delivery)
• The majority of cases of major obstetric haemorrhage occurred in the postpartum period (after birth) with Caesarean section the most common mode of delivery. Major obstetric haemorrhage was also the most common morbidity associated with ICU admission.

Peripartum hysterectomy is a procedure performed most often as an emergency to save the life of a woman with persistent bleeding, or as a planned procedure to treat cancer associated with a pregnancy. The rate of peripartum hysterectomy was 0.3 per 1,000 maternities which is similar to findings in previous international studies^[3],[4] . The majority of women who required a peripartum hysterectomy were reported as experiencing a major obstetric haemorrhage as defined in this audit.

• Women experiencing a major obstetric haemorrhage who were delivered by Caesarean section prior to labour and ultimately required a peripartum hysterectomy were more likely to have a history of a previous Caesarean section and/or the presence of placenta praevia or a morbidly adherent placenta. A morbidly adherent placenta is defined as the abnormal adherence either in whole or in part of the placenta to the underlying uterine wall.

The identified rate of Eclampsia (seizures associated with pregnancy-associated high blood pressure) was 0.2 per 1,000 maternities and the rate of septic shock was 0.06 per 1,000 maternities. These findings are similar to those detailed in the SCASMM report[5] and the published literature. These figures are a marker of quality of care in obstetrics.

“This report represents a milestone in obstetric care in Ireland. With the leadership of the NPEC our obstetric services have fully engaged in a constructive examination of the quality of care they provide. This honest examination of the complications of pregnancy will inform how we guide and support our obstetric services to continually improve the quality of care that they provide to Women. While the results suggest our services provide care that compares well with other jurisdictions they also provide guidance for how we must continually improve that care.” Dr Philip Crowley, National Director of Quality and Patient Safety, Health Services Executive.

Ends

See the full report

https://www.dropbox.com/s/bxpnz66b2vxq8rg/SMM%20REPORT%20for%20Web%20Richard%20Greene.pdf

About the National Perinatal Epidemiology Centre

The National Perinatal Epidemiology Centre (NPEC) is based in the UCC Department of Obstetrics and Gynaecology in Cork University Maternity Hospital and is under the directorship of Professor Richard A Greene.

Our Mission

To improve the health and wellbeing of Irish mothers and babies by translating epidemiological data and testing new treatments to enable well-informed discussion and decision making about reproduction and perinatal health.

The National Perinatal Epidemiology Centre (NPEC) was established in 2007 under a service-level agreement between the Health Service Executive (HSE) and University College Cork.  Its overall objective is to translate outcome data from Irish maternity hospitals and evidence-based best practice into improved clinical services for Irish patients. 

The core function of NPEC includes the collection, collation and analysis of outcome data from maternity hospitals in Ireland, the provision of a perinatal epidemiological monitoring service and the development of expert committees in maternal and perinatal morbidity, and perinatal mortality. The overall objective is to translate epidemiological data and evidence-based best practise into improved clinical services for women and babies in Ireland.  The centre is nationally-funded and offers a unique opportunity to maternity services to assess themselves on a national basis by audit and monitoring of practise.  This will hopefully lead to improved perinatal care and outcomes, as well as the strengthening of the trust between patient and caregiver.

Specifically, the roles of NPEC are:

• To collaborate with all Irish maternity units in order to collect outcome data from all births in Ireland.
  • To publish the analysis of perinatal data and outcomes, on an annual basis including:maternal and perinatal mortality and morbidity.
  • To collaborate with government agencies (including the ESRI) in order to assess outcome data.
  • To act as a resource for the Minister and the Department for Health and Children.
  • To disseminate scientific information related to maternal and infant health to various audiences, including researchers, clinicians, policymakers, the media and the general public.

In 2009, the NPEC established the NPEC National Advisory Group. This is an advisory group designed to support the Centre in the achievement of its mission and particularly to address issues relating to access by clinicians and researchers to NPEC data for research purposes.  Membership of the group represents a diverse range of key stakeholders from many maternity units and universities in the country.

Measurement of the outcome of care is central to the development of safe and high quality health care services. Through surveillance of maternal and neonatal outcomes, we, at the NPEC, endeavour to provide Irish maternity units with the facility to undertake in-depth reviews of their own service and care. In 2009 the Perinatal Mortality Group was established under the auspices of NPEC with aim of developing a nationwide surveillance programme on perinatal mortality in Ireland.  In collaboration with the Perinatal Mortality Group, the NPEC has developed a Perinatal Death Notification Form which provides a robust framework for audit of perinatal mortality

In 2010, the NPEC established a multidisciplinary specialist Severe Maternal Morbidity Group to address the investigation of severe maternal morbidity in Ireland. The Group aims are to carry out a confidential audit on all cases of severe maternal morbidity in Ireland and to perform a detailed assessment of major obstetric haemorrhage cases.

In addition to this surveillance work, the NPEC has conducted research using the Hospital In-Patient Enquiry (HIPE) data to derive nationally representative rates of maternal morbidity. The Centre continues to support confidential enquiries into maternal death, and also holds the license for access to the Vermont Oxford Network in Ireland, which is a collaboration of healthcare professionals dedicated to improving the medical care of very low weight neonates.

The NPEC continues to nationally monitor perinatal mortality and severe maternal morbidity from a clinical perspective. In 2011, a number of exciting new initiatives were instigated in the Centre, including collaboration with the Self-Employed Community Midwives, aiming to develop a perinatal surveillance system for home birth deliveries. In terms of research, the NPEC entered into the fields of qualitative research and health economics. A number of qualitative research studies are currently underway, focusing on parents’ experiences and perceptions of the Irish maternity service; and aspects of parental decision-making after experiencing an early pregnancy loss or perinatal death.  It is hoped that the knowledge gained from parents' personal accounts will help inform future clinical practice.  In addition, a project on the economics of maternity care has brought a whole new facet to our clinical research. Given the current economic climate and the on-going discourse regarding models of maternity care, this particular project has garnered extensive interest and support amongst maternity health care professionals throughout the country.

Whilst it is not a statutory requirement to report data to the NPEC, but in 2011, 19 maternity units voluntarily provided obstetric and neonatal data to the Centre, thereby demonstrating their commitments to improving the service and outcomes for their patients