Establishing a confidential Maternal Death Enquiry: the Irish experience

1. Establishing a confidential Maternal Death Enquiry: the Irish experience 09/09/2013 Edel Manning

2. 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

3. Maternity Services • All 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’.

4. Irish Maternal Death Rate Source: Central Statistics Office Ireland • 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

5. 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

6. Reasons for joining the UK based Enquiry • MDE was initiated in England & Wales 1952 • Ireland became a participant in 2009 • Advantages in joining the MDE UK • Anonymity / confidentiality • Validated & respected methodology • Comparative analysis with a relatively similar health care system • Larger cohort: more meaningful analysis/ valid conclusions & recommendations

7. 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/ anonymisationof 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

8. 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

9. ‘Buy In’ : Creating Awareness of the MDE Time 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, conferences • On going collaboration with coroners

10. ‘’Buy in’’ : Health professionals • Sell 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).

11. Case ascertainment • Logistics: 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)

12. Case ascertainment • Quality 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

13. 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

14. Un-foreseen challenges • Change 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)

15. Thank you for your attention