MATERNITY CARE IN COUNTIES MANUKAU FAILS MOTHERS & BABIES
The report of the review of maternity care in the Counties Manukau DHB area was released on 15 November 2012. Commissioned by the Counties Manukau DHB, the Maternity Care Review Panel was chaired by Professor Ron Paterson and panel members included Anne Candy, Siniua Lilo, Professor Lesley McCowan, Dr Ray Naden and Maggie O’Brien.
In the Chairman’s Foreword, Ron Paterson stated that many women with high needs do not have access to an adequate standard of maternity care, and that decisive action is needed to address the underlying population health factors that contribute to Counties Manukau’s high rates of perinatal mortality.
The contributing factors to the rate of perinatal mortality and morbidity in Counties Manukau identified in the report are not new to many of the health professionals and consumer groups who have been involved in maternity care in the Auckland region over the past decade. Attempts have been made over the years to draw attention to the concerns of women about the state of maternity care in South Auckland and to get the DHB or the Ministry of Health to act. The general public knew almost nothing about the problems because, unlike other DHBs, the vast majority of items about maternity services in the Counties Manukau DHB meeting agenda papers took place behind closed doors.
What finally led to the commissioning of this review was the 5th Annual Report of the National Perinatal and Maternal Mortality Review Committee (PMMRC) which identified that Counties Manukau had a significantly higher perinatal mortality rate than the rest of New Zealand, particularly among Maori and Pacific women.
Access to LMC midwives and continuity of care
One of the issues identified by the review was that pregnant women in Counties Manukau do not have the same level of access to self-employed midwives that women in other DHBs do.
Only 51% of pregnant women in Counties Manukau have their primary maternity care provided by an LMC midwife. There are a number of reasons behind the low numbers of LMC midwives providing care in South Auckland. Many women in this area are living in poverty, have few resources and when they are pregnant they present with complex health, financial and social needs. Because the Section 88 funding mechanism is a one-size-fits-all payment system which has no financial incentives to provide the extra care that these women need, self-employed midwives are understandably reluctant to take on these women and provide LMC care.
The other models of care available in South Auckland are what are referred to as case-loading DHB midwives, and shared care in which maternity care is shared between a GP and the Counties Manukau DHB midwifery team. Neither of these two models of care provides the same level of continuity of care that LMC midwifery care does, and there have been complaints about the shared care arrangement for many years. There are concerns about the knowledge, expertise and skills of the GPs providing shared maternity care in South Auckland, some of whom are not appropriately qualified to provide maternity care. It is doubtful as to whether they engaged in continuing medical education activities that focus on providing primary maternity care, and whether they are vocationally registered.
The maternity care provided by this shared care model is substandard and the maternity groups have been aware for some years that pregnant women were not being advised of their options by the shared care GPs. Women have rung complaining about the care they received, their lack of choices, being seen by different doctors and midwives during their antenatal visits, and the unacceptably few postnatal visits.
The inadequate level of maternity care being provided in South Auckland has been allowed to continue for a number of years and this has undoubtedly contributed to self-employed midwives not wanting to work there. It should not have taken a PMMRC report to finally galvanise Counties Manukau DHB into action, if indeed they have been galvanized into action.
The Ministry of Health must also share some of the responsibility for the current situation. The Ministry has permitted the Counties Manukau DHB to continue flouting the maternity service requirements that other DHBs were required to meet. Concerns about the situation in Counties Manukau have been expressed at both national and regional meetings during the past decade. When exceptions to maternity service requirements are permitted it is of course the mothers and babies who suffer the consequences.
Increase in Section 88 funding
The increase in Section 88 funding that midwives obtained this year was insufficient and will do nothing to improve the LMC midwifery shortage in South Auckland. The NZ College of Midwives made extensive submiss-ions to the Ministry about the need to increase the Section 88 fees as there had been no fee increase since 2007. The result was a small increase in fees for first trimester care and for postnatal care. It is woefully inadequate and does little to cover the increased workload midwives have to take on. It also will not cover the extra maternity care and support needed by mothers in South Auckland who have complex health and social needs.
Mothers in Counties Manukau
The report notes that 14% of all births in New Zealand are to women residing in Counties Manukau. Approximately 8,500 babies are born each year to women living in the CMDHB area, of whom more than 50% are born to Maori or Pacific mothers, and to mothers who predominantly live in areas of high socioeconomic deprivation. Maori and Pacific mothers are more likely to have a stillborn baby or to lose a baby in the neonatal period compared to European mothers.
The report notes that Counties Manukau has more women with high health needs during pregnancy than any other part of the country. These include obese women, smokers, teenage mothers and older mothers who have had several pregnancies. However, in one of two reports produced for the CMDHB, researcher Dr Catherine Jackson, commented that “ethnicity was not an independent risk factor for perinatal death, ie it is not being Maori or Pacific that places you at higher risk. It is the increased odds of exposure to risk factors such as smoking, obesity, premature birth, etc.”
While the review was commissioned by the CMDHB and the report was focused on the issues and the needs of the women in South Auckland, there were many factors described in the report that also apply to women in West Auckland.
All women are vulnerable
The Panel interviewed staff and self-employed LMC midwives and asked about services provided to vulnerable women. They were repeatedly told that “all women are vulnerable.” The report notes that Dr Jackson concluded that 81% of women who delivered at CMDHB facilities during 2007-2009 would be classified as high risk based on the PMMRC criteria, but cautioned that this serves to highlight “the limitations of a high-risk approach in a population that is predominantly high risk.”
It is essential that all CMDHB women are provided with high quality maternity care, not just those singled out as being “vulnerable.” Improving services to all women avoids stigmatising or marginalising particular groups of women who are assessed, labelled and subsequently assigned to receive special services. All women are entitled to a high standard of maternity care, including continuity of care, not just those identified as “most vulnerable.”
The report contains a raft of recommendations for improving both maternity care and reproductive health services in Counties Manukau. Many of the recommendations have the word “urgent” attached to them.
The Panel makes a strong statement at the beginning of the report about “the critical importance of providing care in a culturally appropriate manner.” One of the recommendat-ions refers to the need to ensure “that educational material and information is provided in a variety of languages, that the maternity workforce better reflects the wider community, and that maternity care is provided in a manner that more appropriately meets the needs and requirements of different cultural groups.”
Other recommendations include:
– encourage women who are healthy and have a normal pregnancy to opt for midwifery care and to birth at a primary birthing unit
– seek an urgent review by the Ministry of Health of the section 88 funding mechanism for LMCs nationally, in order to create incentives to provide care for women who have clinical or social risk factors
– encourage midwives to work as self-employed practitioners in the CMDHB region and increase the number of LMCs available
– review, as a matter of urgency, the current delivery and funding of family
– planning services in the CMDHB area, with a view to increasing access to these services, particularly for young and “at-risk” women
– consider the establishment of a local non-surgical termination of pregnancy service at Counties Manukau
improve access to pregnancy-related ultrasound scanning
implement an integrated maternity information system
The prioritisation of the vulnerable
There are four recommendations concerning vulnerable women:
– establish a set of criteria to define and identify the most socially and medically vulnerable pregnant women
– establish a vulnerable women’s multi-disciplinary group to refer vulnerable women to
– consider ways in which those identified as most vulnerable can be provided with continuity of care
– urgently consider the development of comprehensive social worker and/or community health worker support services, to assist pregnant women to address the social factors that impact on their health status.
The report also stresses the importance of getting women to attend “a full pregnancy assessment appointment” with a midwife or GP in the first 10 weeks of pregnancy. About 25% of pregnant women in Counties Manukau do not have any antenatal care and this group has the highest perinatal mortality rate.
However, until a system of high quality, culturally appropriate maternity care is established in Counties Manukau pregnant women will remain isolated from the services they need. Defining them as one of those in the “most socially and medically vulnerable” group is also unlikely to win them over.
A copy of the External Review of Maternity Care in the Counties Manukau District is available at:
NZ’s maternity hospitals – how are they doing at keeping birth normal?
The Ministry of Health has just released a report with statistical information that enables the general public and mothers and their families in particular to see how their local secondary or tertiary maternity hospital is performing when it comes to keeping birth normal.
The report covers births in 2009 and is a first in that it is focused on maternity clinical indicators for women aged between 20 and 34 who are expecting their first baby and who have had a normal pregnancy uncomplicated by any health problems in either the baby or the mother. These women should therefore expect to have a normal birth with few if any medical interventions. As the report puts it, using this standard definition “allows the separate assessment of a group of women for whom interventions and outcomes should be similar.” (1)
The clinical indicators are based on Australasian clinical indicators, are evidence-based and cover a range of procedures and outcomes for mothers and their babies. They include spontaneous vaginal birth, instrumental vaginal birth, caesarean section, induction of labour, intact lower genital tract, episiotomy and no tear, third or fourth degree tear and no episiotomy, episiotomy and third or fourth degree tear, use of general anaesthetic for caesarean section, blood transfusion, premature birth.
However, what the statistics reveal is that the rate of interventions between various DHBs and between individual secondary and tertiary hospitals varies enormously, and such significant variation “among a group of women who would be expected to have similar outcomes needs to be investigated.” Women’s health groups around the country now need to put pressure on their local hospital to do something about the high intervention rates occurring in some hospitals.
Spontaneous vaginal birth
This indicator measures the proportion of first-time mothers having a spontaneous vaginal birth. “It is expected to encourage maternity service providers to review, evaluate and make necessary changes to clinical practice aimed at supporting women to achieve an unassisted birth.” (2)
For Auckland the rates of spontaneous vaginal births were 56.1% at North Shore Hospital, 61.3% at Auckland City Hospital, 69.5% at Waitakere Hospital and 70.2% at Middlemore Hospital.
Christchurch had the lowest rate at 50.7%, Southland had 57.6%, Wairarapa Hospital had 58.1% and Waikato had 58.5%.
Instrumental vaginal birth
This indicator is to assist service providers evaluate the use of ventouse and forceps in their hospitals, and if their rates are significantly higher than their peer group at a national level, they will need to examine the rate of maternal and perinatal morbidity.
For Auckland the rates of first-time mothers undergoing an instrumental vaginal birth were 18.8% at Auckland City Hospital, 17% at North Shore Hospital, 15.4% at Middlemore Hospital and 10.2% at Waitakere Hospital.
Christchurch had the highest rate at 26.4%, Waikato had 24.2%, Southland had 19.4%, and Dunedin Hospital had 18.3%.
The purpose of this indicator is to encourage maternity service providers to evaluate whether caesarean sections were performed on the right women at the right place and at the right time. “The longer-term aim is to reduce the risks associated with an unnecessary caesarean section, reduce the number of women at risk of a subsequent caesarean section and reduce the number of women who experience difficulties with their second and subsequent births as a consequence of a primary caesarean section.”
For Auckland the rates of first-time mothers undergoing a caesarean section were 23.2% at North Shore Hospital, 19.8% at Auckland City Hospital, 13.9% at Waitakere Hospital and 13.4% at Middlemore Hospital.
Wairarapa Hospital had the highest rate at 27.9%, Wairau had 25.7%, Grey Base Hospital had 24%, Southland had 23% and Christchurch had 22.4%.
Induction of labour
This indicator will assist maternity service providers to evaluate the effects of inducing labour in low-risk women, effects which include caesarean section, postpartum haemorrhage and episiotomy.
For Auckland the rates of first-time mothers undergoing an induction of labour were 9.1% at Auckland City Hospital, 5.6% at North Shore Hospital, 2.4% at Middlemore Hospital and 1.9% at Waitakere Hospital.
Southland had the highest rate of inductions at 13.1%, Grey Base Hospital had 10%, Wellington had 8.1% and Waikato had 6.1%.
This indicator aims to encourage further investigation to ensure that risks to the mother as well as the infant are assessed before undertaking an episiotomy, risks that include bleeding, infection and maternal morbidity.
For Auckland the rates of first-time mothers undergoing an episiotomy without mention of a third or fourth degree tear were 28.7% at Auckland City Hospital, 23.9% at North Shore Hospital, 19.4% at Middlemore Hospital and 13.6% at Waitakere Hospital.
Christchurch had the highest rate of episiotomies at 32.9%, Wairarapa Hospital had 29%, Wellington had 28.9%, and Palmerston North had 25.1%.
Keeping birth normal
The statistical information contained in this 71-page report reveals that there is a significantly high rate of variation in the intervention rates for low-risk mothers giving birth to their first baby after an uncomplicated pregnancy. Far too many secondary and tertiary maternity hospitals are doing far too little to stem the growing tide of interventions in the normal birth process, interventions that result in significant risks to the future health and well-being of both mother and baby.
In Auckland, North Shore Hospital has continued to countenance unnecessarily high rates of intervention in the birth process for decades, higher even in some cases than those at National Women’s at Auckland City Hospital. There have been concerns for over two decades about the maternity services provided at North Shore Hospital, and over the past five years Waitemata DHB has attempted to hide North Shore Hospital’s poor performance by producing annual maternity reports that combine the rates of intervention for both Waitakere and North Shore hospitals.
Nationally, women in Southland, Christchurch and the Waikato may also want to question their local maternity hospitals about their high intervention rates and firmly request to be a part of initiatives that seek to identify and implement improvements to the maternity services provided in their local hospitals.
1. Ministry of Health. “NZ Maternity Clinical Indicators 2009.” March 2012.
2. MOH. “NZ Maternity Clinical Indicators 2009.” March 2012. Page 7.
3. MOH. “NZ Maternity Clinical Indicators 2009.” March 2012. Pages 7-8.
COUNTING THE COST OF STILLBIRTHS
On the 14th April 2011 The Lancet published a series of ground-breaking online articles on an issue that is not only invisible in the majority of societies around the world but is ignored on international policy, programme and investment agendas. The issue is stillbirth, a devastating event for millions of women and their families every year, and one that the series of articles in The Lancet identified as one of the most shamefully neglected areas of public health.
Stillbirth is not counted in the Millennium Development Goals; it is not counted by the United Nations (UN); nor is it counted in the Global Burden of Disease figures. This despite the fact that in 2008 there were an estimated 2.65 million stillbirths with over a million of them occurring intrapartum – during labour and birth. The international definition of stillbirth is the death of a baby after 28 weeks gestation.
Most intrapartum stillbirths are associated with obstetric emergencies, whereas deaths during the third trimester of pregnancy are associated with maternal infections and foetal growth restriction.
In the first of six papers about stillbirth entitled “Stillbirths: why they matter,” Dr J Frederik Froen and his colleagues report:
“To be registered, counted and recognised also has profound humane implications. Although stillbirth can be as devastating as a child’s death, often the baby is known and mourned solely by the parents. Even in high-resource settings in which psychological support might be available, one in five mothers has appreciable long-term depression, anxiety, or post-traumatic stress disorder after a stillbirth. Fathers are also affected by negative psycho-social consequences. When compared with the leading global causes of death in all age categories, all-cause stillbirths would rank fifth among the global health burdens – before diarrhoea, HIV/AIDS, tuberculosis, traffic accidents, and any form of cancer.” (1)
The focus on maternal health
Over the past few decades there has been an increasing focus on maternal and child health which has seen a number of significant initiatives and interventions. Despite this, stillbirths have been ignored and the loss of these babies remains largely invisible.
For example, in September 2010, the UN summarised the commitments to improve maternal and child health by seven UN agencies, 36 countries, and more than 75 non-governmental organisations (NGOs) and professional organisations: stillbirth is not mentioned in any of them.
Stillbirths linked to deprivation
98% of stillbirths occur in countries of low and middle incomes, and within high-income countries disadvantaged populations have a much greater risk of stillbirth than affluent populations. The five major causes of stillbirths in low and middle income countries are childbirth complications, maternal infections during pregnancy (syphilis), maternal disorders (especially hypertension), maternal under-nutrition and foetal growth restriction, and congenital abnormalities.
The variation in stillbirth rates across and within high-income countries indicate that further reduction in stillbirth is possible in these countries as well. While stillbirth rates have declined dramatically from around 1940, over recent times the decline has slowed or even stalled. (2)
In most countries the causes of stillbirths are inseparable from those that result in the deaths of pregnant women and their newborn babies. The Millennium Development Goals estimate that there are 350,000 maternal deaths and 3.6 million neonatal deaths every year. In countries with high mortality rates, emergency obstetric care has the greatest effect on these deaths, as well as on stillbirths. (3)
In high-income countries the familiar link between low socioeconomic status and adverse outcomes are starkly evident with large increases in the risk of stillbirth in minority populations. Inuit-inhabited areas of Canada have almost three times the rate of stillbirths as compared to the rest of Canada. Indigenous Australia women have almost twice the risk of non-indigenous women, as do African-American women in the USA when compared with white women. Reports from the UK and New Zealand reveal a similar scenario. (2)
Other risk factors
Smoking is a major contributor to stillbirths in some disadvantaged populations. For example, among indigenous Australian and Canadian women smoking contributes to about 20% of stillbirths compared with 4-7% overall in high-income countries.
Obesity is another major and potentially modifiable risk factor for stillbirths.
Other risk factors include:
• A maternal age of more than 35 years
• Alcohol consumption during pregnancy
• A first pregnancy
• A previous caesarean birth
• A multiple pregnancy
• Use of reproductive technology
• Lack of antenatal care
Call to action
The sixth paper in the series calls for high-income countries to eliminate all preventable stillbirths and close equity gaps. By 2020 low income and middle income countries should aim to have reduced their current stillbirth rates by at least 50%.
However, first stillbirths need to be recognised by all countries and the UN as a major public health issue. Then each stillbirth must be counted.
1. J. Frederik Froen et al. “Stillbirths: why they matter.” www.thelancet.com 14 April 2011.
2. Vicki Flenady et al. “Stillbirths: the way forward in high-income countries.” www.thelancet.com 14 April 2011.
3. Robert Pattinson et al. “Stillbirths: how can health systems deliver for mothers & babies?” www.thelancet.com 14 April 2011.
Antenatal HIV Screening Without the Screening Programme
The June 2015 issue of “Screening Matters,” (1) the National Screening Unit’s newsletter, contains an article which euphemistically referred to “changes” to antenatal HIV screening.
The NSU is actually dismantling the screening programme, but antenatal HIV screening will continue as “an integral part of antenatal care.” This means there will be no more “comprehensive monitoring reports and district health boards (DHBs) will no longer receive funding for an HIV co-ordinator.”
As the AWHC pointed out in our May 2015 newsletter (see article below), the antenatal HIV screening programme was only detecting one HIV+ woman each year, and that these women were in high risk groups and should have been offered an HIV screening test as a standard part of their antenatal care.
It is seven years since antenatal HIV screening was rolled out DHB by DHB after a child became infected with HIV through perinatal transmission after the mother who came to New Zealand from a high risk country was not offered an HIV test. At the time a number of women’s groups felt that establishing a formal antenatal HIV screening programme was using a sledge hammer to kill an ant. We also had concerns around the need for women to make an informed decision to have an HIV test.
However, the solution to the problem is not to dismantle the screening programme, remove the monitoring and reporting processes, but continue routine antenatal HIV screening. This is unethical and totally unacceptable for a number of reasons.
Women are not always asked to give their consent to an HIV test which is usually included in the first blood test that is done following confirmation of pregnancy. Past monitoring of HIV screening revealed that around 87% of pregnant women are being tested for HIV, but it is not clear how many of these women are asked to consent to an HIV test or know they have been tested. GPs order the majority of these first blood tests, and some women subsequently learn from their LMC midwife that they have had an HIV test.
Then there is the harm caused when a woman gets a non-negative result and is asked to return to the laboratory and provide another blood sample for a second test. As reported in previous articles on this issue GPs are not always able to answer the woman’s questions about her test results and sometimes get defensive.
The NSU’s Policy and Quality Standards for the Antenatal HIV Screening Programme were updated in June 2010 and stated in the monitoring & evaluation section that:
“Monitoring and evaluation of the Programme will follow the screening pathway and assess process (the organisational aspects of the Programme and policy implementation) and outcomes (health outcomes and process utility). The main aspects of monitoring and evaluation include:
• Screening uptake – by DHB, requester type, age, ethnic group & NZDep score.
• Information provision and informed consent
• Screening results in DHBs: (a) confirmed newly diagnosed HIV positive pregnant women; (b) pregnant women with non-negative results who were not infected.
• Referral management and follow up of women
• Interviews with clinicians and women who had: (a) positive results; (b) required to be retested but were not infected in order to mitigate any adverse effects resulting from the screening process. (1)
So all of the above will be abandoned and women will now be routinely screened without oversight of those doing the screening.
While the NSU claims that “if testing shows a reactive or positive result, the screening laboratory will provide practitioners with guidance on the next steps” this is obviously not always the case. This is very worrying as it is the retesting needed when the first HIV test returns a non-negative result that is causing the most harm.
Being tested without your knowledge or consent is far more common and may contravene the Code of Consumers’ Rights, but very few women choose to complain to the Health and Disability Commissioner. Once the monitoring ceases there will be no information collected on the amount of harm caused by antenatal HIV screening, nor on the numbers of women being screened, and whether there is any benefit to anyone at all.
HIV SCREENING DURING PREGNANCY
Each year the AWHC puts in an Official Information Act request to the National Health Board asking for the numbers and ethnicity of women identified as being HIV+ during pregnancy as a result of the antenatal HIV screening programme.
The resulting letter from this year’s request revealed that in 2014 one woman was found to be HIV+ as a result of antenatal screening.
In both 2013 and 2011 only one woman was identified as being HIV+ as part of antenatal screening. In 2012 two women were diagnosed as HIV+ during pregnancy.
Costs of the screening programme
This raises the issue of the cost of a screening programme that results in the identification of one or two women who may gain a benefit. To provide further context for this result, it has been estimated that an HIV+ woman has a 25% chance of passing the virus to her baby during pregnancy. So it is quite possible that none of the women identified as being HIV+ over the past 4 – 5 years would have given birth to a baby with HIV.
Aside from the millions being spent on the National Antenatal HIV Screening programme, there are also concerns around the adverse impact on some of the women being screened for HIV, as well as the lack of informed consent for an HIV test.
Lack of informed consent
Reports from childbirth educators in the Auckland region reveal that many pregnant women are unaware that they have been tested for HIV, something women’s health groups have been concerned about since the programme was first proposed.
Some women will be screened for HIV and receive what is referred to as a non-negative result. A non-negative result is one in which there was a low level of reactivity to the test, and a subsequent blood test will usually result in a negative HIV test.
The impact of being told that the test for HIV was not negative, and that another blood sample is needed is considerable. Women and their partners are likely to experience a range of extremely distressing emotions and don’t hear the reassuring information that the second test is highly likely to result in a clear result that shows she does not have HIV.
Several months ago a very distressed woman rang the AWHC as result of a non-negative result. She had no idea she had been tested for HIV, and she struggled to understand why the practice nurse would be phoning and telling her she needed to have another HIV test because the first one had produced a non-negative result. She described how she had then tried to get information from her GP who contacted her but was unable to answer any of her questions. He advised that he would ask another GP to ring her. She tried phoning the laboratory who said they could not give her any information. When the second GP phoned her he either would not or could not answer any of her questions and simply told her to go and have another HIV test.
When screening programmes are introduced the most important maxim is the requirement to first do no harm. Careful monitoring is therefore needed to make sure that the benefits of screening far outweigh any possible negative impacts.
Antenatal HIV screening is currently offering a potential benefit to just one woman. It is difficult to justify the resources being spent on it, especially when consent to being screened is not always obtained, only one family potentially benefits from the mother being identified as HIV+, and the screening test causes considerable harm to many other women and their partners.