Establishing a confidential Maternal Death Enquiry: the Irish experience

09/09/2013 Edel Manning

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 weeks

Perinatal Mortality Rate (PMR) = 6.1 per 1,000 births, (corrected PMR = 4.1)

Mode of delivery 27.3% = LSCS

Population = 4.6 million

Maternities = 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

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’.

Irish Maternal Death RateCountry Maternal

Mortality Rate / Ratio

Ireland: CSO 2009

4 per 100,000 Live and Stillbirths

Ireland: MDE Ireland 2009-2011

8.4 (95% CI: 4.1 – 12.5) per 100,000 maternities

MDE UK 2006-2008

11.39 per 100,000 maternities

Maternal deaths per 100,000 live births

0100200300400500600

1922 1932 1942 1952 1962 1972 1982 1992 2002

Year

Rate per 100,000 live

births

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 Statistics Office Ireland

Establishing commitment and support for the MDE at governance level

Establishment 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 Agency

Expert advise: Data Protection Commissioner/Coroner’s Society

Reasons for joining the UK based Enquiry

•Anonymity / confidentiality

•Validated & respected methodology

•Comparative analysis with a relatively similar health care system

•Larger cohort: more meaningful analysis/ valid conclusions & recommendations

MDE was initiated in England & Wales 1952 Ireland became a participant in 2009

Advantages in joining the MDE UK

Identifying and addressing the relevant challenges

• Lobbying for funding : stand alone office and co-ordinator to coordinate the CEMD process

• Data protection in Irish context: legal opinion/ anonymisation of data

• Litigation- independent of clinical incident reporting/ confidentiality

• Collaboration with the UK Maternal Death Enquiry

• Format of death certificates/ civil registration system identifying maternal deaths

Implementing the Maternal Death Enquiry (MDE) 2009: Challenges

Creating Awareness and ‘buy in’ for the MDE process amongst relevant Health Professionals

Maternal death case ascertainment

Quality and standardisation of maternal death case assessment

‘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

‘’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 services

Alleviate concerns re litigation (20% of medical claims against the state are obstetric)/ confidentiality/non-punitive

Importance of powerful persuasion : support letters from relevant authorities (cooperation with the MDE is now policy, but not statutory, for all public funded services).

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)

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 process

Quality and standardisation of data and case assessment

Aligned 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 forms

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 Ireland

1st Irish triennial report (limitations of report)

Thank you for your attention