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Maternal Mortality and Morbidity Ontario · mortality in Canada. This prompted the Society of...
Transcript of Maternal Mortality and Morbidity Ontario · mortality in Canada. This prompted the Society of...
Maternal
Mortality and Morbidity Ontario
An Ontario Pilot
Dr. Jon Barrett. BORN , Ottawa, Nov2017
Learning objectivesAfter this session, participants will be able to:
•To describe reporting systems for maternal mortality and available data;
•To report on the current SOGC initiative to re‐establish maternal mortality and morbidity as a priority.
•To provide opportunity for discussion to inform a model that may be applicable to Canada in the future.
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Disclosure
Received Financial Support from Ferring and Smith
and Nephew
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Maternal Mortality
The maternal mortality ratio (MMR) is one of the main indicators of a country’s health. This ratio is reported and compared globally, within and across sectors. MMR: Pregnancy-related deaths per 100,000 live births.
The recommended definition is based on work in other countries, such that data and trends can be compared and contrasted, with the goal of capturing all pregnancies. Maternal Death - The death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.
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What’s Happening in Canada?
In Canada, maternal mortality is an infrequent event with devastating consequences
for women, their families and care providers.
The Public Health Agency of Canada (PHAC) reported variation in pregnancy
related mortality between 5.1 and 11.9 per 100,000 deliveries (1999/2000 to
2014/2015).
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Maternal Mortality in Canada
Existing Canadian data sources have been shown to under-
ascertain and misclassify maternal deaths, leading to
underestimation of Canada’s MMR, and limited
understanding of the causes of maternal deaths.
Canada does not have a national enquiry process and has
not set targets for maternal mortality reduction.
Provinces and territories are critical leaders in the
measurement of maternal mortality in Canada and some
have existing processes in place to measure, report and to
provide recommendations, to varying degrees.
Despite this, there is little standardization across jurisdictions and no
accurate national picture.
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SOGC Updates (2010)
The World Health Organization’s 2010 report indicated a rise in maternal
mortality in Canada.
This prompted the Society of Obstetricians and Gynaecologists of Canada
(SOGC) to work with partners to review national maternal mortality
surveillance.
A Committee on Maternal Mortality and Severe Morbidity was formed in
August 2010 with the mandate to make recommendations for measurement.
The Committee found that national maternal health surveillance faces serious barriers
relating to data access, coverage, timeliness and completeness.
Since 2010, there have been significant shifts in the demographics of the
child-bearing population in Canada.
A new set of contributing causes of maternal mortality that the existing system was not
designed to measure, and was unequipped to analyze.
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SOGC Updates (2017)
In June 2017, the SOGC hosted a face-to-face meeting with key experts (PHAC, CPSS, BORN, UK and US experts) on “Measurement of Maternal Morbidity and Mortality”. Outcomes were:
Received an update on the UK and US surveillance systems.
Reviewed progress to date with partnerships.
Formed the Maternal Mortality Steering Committee.
Over the last year, the SOGC’s Maternal Mortality Steering Committee has met every 6-7 weeks to discuss updates, work plans and timelines on activities related to maternal mortality.
Committee includes individuals from the SOGC, CPSS, PHAC, and MOREob.
Planned a National Maternal Mortality Workshop (2018).
Met with the Chief Public Health Officer to receive support on maternal mortality activities.
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SOGC Updates (2018)
Outcomes of the National Maternal Mortality Workshop:
It was agreed upon that all provinces and territories should use the
same definitions related to maternal mortality
It was decided that a National Consortium on Maternal Mortality
should be created, as well as a National Confidential Enquiry
System on measuring and reporting on maternal mortality (to
support provinces and territories who want to report their own
data, but ultimately to produce a national report that is specific
for regional differences and challenges)
The ultimate goal is to eliminate all future preventable deaths
The use of the minimum dataset and associated reporting
templates (MMRIA and MMBRACE) are currently being reviewed
by four provincial perinatal programs
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What can we learn from others?
MMRIA
A standardized data system available to support
essential review functions among 13 state
MBRRACE – Reducing Risk through Audit and
Confidential Enquiry
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Maternal
MortalityNational Vital Statistics System
Pregnancy Mortality Surveillance System
Maternal Mortality Review Committee
Death certificate data, Death certificate data Specific clinical
Coded with ICD‐10 from state divisions of information includingDiagnoses Vital Statistics identified medical records and
by pregnancy check box autopsy reportsand matching algorithm
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Pregnancy‐Related
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Maternal Mortality is Preventable
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MBRRACE Method
Information on most women who die is
reported directly to MBRRACE by staff in
the hospitals caring for them
More than two thirds of maternal deaths are reported
this way
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Confidential Enquiry
Assessors18 Obstetricians16 Anaesthetists3 Obstetric Physicians4 Cardiologists2 Neurologists16 Midwives6 GPs7 Intensive care consultants6 Pathologists6 Psychiatrists6 Infectious disease physicians2 Emergency medicine consultants
Over 600 people are involved at all stages of the process Only 4 are paid
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Vignette: sepsis
Two hours after delivery a woman became unwell on the postnatal ward feeling faint. Her oxygen saturation was low. She was reviewed by junior staff and found to be shocked, without evidence of major bleeding. Her temperature was never measured. A diagnosis of haemorrhage was made and she was treated with
fluids. She failed to improve and was taken to theatre where she had a cardiac arrest and could not be
revived. At autopsy she was noted to have a florid purpuric rash and found to have overwhelming infection
due to Group A Streptococcus.
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Maternal Morbidity Why study morbidity?
Severe illness (morbidity) is more common than maternal death and conclusions from studies may therefore be more robust
Study of severe illness may give more insight into risk factors and possible means of prevention, particularly in countries (UK, Canada) where deaths are rare and events associated with death may be atypical
Because the woman survives, studies may be seen as less threatening than investigations of women who die
The woman herself may be interviewed about her perspectives on the care she received
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UK Obstetric Surveillance
System (UKOSS)
Monthly prospective case collection from
obstetrician, midwife, obstetric anaesthetist
and risk midwife (individualised by hospital -
unpaid)
Cohort or case control studies conducted as
well as descriptive studies
Rolling programme of studies
Central anonymous data collection
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Summary
Maternal deaths can be identified through
routine data sources
– Not all will be identified without additional methods
Confidential Enquiry
– Adds the ‘why’ to the ‘what’
Surveillance and review of severe maternal
morbidities adds value
– Consider a topic-specific approach
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Maternal Morbidity - an
Ontario Solution
Develop a review process for provincial review of
severe morbidity and mortality cases
Develop a mechanism to share review findings
across provinces (roll up of provincial reports to
federal level)
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BORN Enquiry into Maternal Morbidity
Modify the EMBRACE (U.K.) process for review.
Each provincial process for review will likely be
different, but as long as we use the same forms and
can collect the same information, comparability, roll-
up and international comparisons will be possible.
In Ontario we have reviewed and tentatively
discussed a minimum data set needed for review.
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BORN Enquiry into Maternal
Morbidity
Currently, reviews of adverse events usually
happen in hospitals and maybe within regions (as
per provincial quality directives).
The coroner’s perinatal group also reviews (but
with a different mandate).
However, there isn’t a formal feedback loop for
either process and no one learns how to prevent the
same issues from re-occurring.
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SOON/BORN Enquiry into
Maternal Morbidity
If the review process was started in hospitals and
rolled up to a provincial review group, would it still
be protected under QCIPA,
YES!
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SOON/BORN Enquiry into Maternal
Morbidity
Who would form this committee?
The coroner group already has people, but it likely
needs augmentation and different questions need to be
answered.
PCMCH has a safety committee already – would that
be a potential mandate of that group?
BORN committee
University(s) QuIPS Cte
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BORN Enquiry into Maternal
Morbidity
Then, when the review committee comes together
they would access the forms and complete a
summary form with recommendations
Pilot Project in SOON/CNMRP
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An Ontario Solution – SOON PILOT
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Terms of Reference (October 2013)
The vision of the SOON is:
To become an international leader in research, best practice and advocacy in women’s and infants’ health by leveraging the collective power of a collaborative approach
The Southern Ontario Obstetrical Network’s goals are:
Improve quality and standards of care: Create and implement shared standards and guidelines to improve patient-centred quality of care and, ultimately, the longitudinal health of women and babies across the region with important world-wide implications;
Conduct collaborative, multi-site clinical research: Design and conduct novel randomized controlled studies as well as studies that will leverage existing databases such as BORN, ICES, CNN, and serve as a forum to discuss shared questions that the group wishes to research;
Promote knowledge sharing: we will foster professional and practice development among all members.
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Membership(as of Aug 2018)
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The Future – Nov 4 2019
The BORN SOON Confidential Enquiry into
Maternal Morbidity
Step 1 – Decide what to Capture
Step 2 Chief of Hospital Institute QCIPA
Fill in Data Form and narrative
Review and Lessons Learned!
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