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Professor Julie Quinlivan University of Notre Dame Australia

Beyond the numbers: Understanding potentially avoidable deaths and the evidence based approaches to prevention. Professor Julie Quinlivan University of Notre Dame Australia University of Adelaide Women’s and Children’s Research Institute Ramsay HealthCare, Joondalup Health Campus.

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Professor Julie Quinlivan University of Notre Dame Australia

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  1. Beyond the numbers: Understanding potentially avoidable deaths and the evidence based approaches to prevention Professor Julie Quinlivan University of Notre Dame Australia University of Adelaide Women’s and Children’s Research Institute Ramsay HealthCare, Joondalup Health Campus

  2. Acknowledgements • Members of the Perinatal and Maternal Mortality Review Committee • Chair, Professor Cynthia Farquhar • Health Quality and Safety Commission New Zealand.

  3. Perinatal mortality • Key associations • Potentially avoidable factors • Evidence that may guide a response

  4. Associations with Ethnicity • Maori and Pacific women • Still birth • Preterm birth • Antepartum haemorrhage • Sudden Unexpected Deaths in Infancy • NZ European and non-Indian Asian women • Neonatal deaths • Hypertension and diabetes

  5. Associations with Socioeconomic Deprivation Increased stillbirth Increased neonatal death

  6. Associations with Age * Teenage mothers • Stillbirth • NND • Preterm birth * Older mothers (>40 years) • Maternal medical conditions • Congenital abnormalities

  7. Associations with Drug and Alcohol Use • Smoking • Data still incompletely reported (50%) • 35-29% deaths compared to background rate of 14% • Alcohol and marijuana • Preterm birth • Sudden unexpected deaths in infancy

  8. Associations with Overweight and Obesity

  9. Associations with Twins and multiple pregnancy

  10. Associations with Family violence, Preterm birth and Small for Gestational age

  11. Potentially avoidable deaths

  12. Perinatal related deaths (N=704)

  13. Contributory factor present (N=192)

  14. Avoidable contributory factors • Organizational • Personnel • Technology • Environmental • Barrier to care

  15. Organizational factors (N=39)

  16. Personnel factors (N=60)

  17. Technology factors (N=5)

  18. Environmental factors (N=19)

  19. Barriers to Care factors (N=149)

  20. Barriers to Care - Other (N=84/124) • No antenatal care • Late booking with antenatal care • Non-attendance with antenatal visits • Not following advice or treatment

  21. Staff education & behaviour

  22. Staffing education/behaviour (N=69/124) • Lack of recognition of complexity or seriousness of condition (N=23) • Failure to follow recommended best practice (N=21) • Knowledge and skills of staff were lacking (N=12) • Failure to seek help/supervision (N=5) • Inadequate training/education (N=5) • Lack of policies/protocols/guidelines (N=3)

  23. Discussion points • Evidence based management of teenage and older mothers • Evidence base behind staff training and behaviour in obstetrics • Evidence base behind non engagement with care (talk 2)

  24. The younger mother • Stillbirth • Preterm birth • Neonatal death

  25. What is the evidence base to improve outcomes for teenage mothers?

  26. The Quinlivan Triad of Care 1. Teenage antenatal clinics 2. Home visitation services 3. Postnatal re-engagement in education or workforce and parenting support • Quinlivan JA. Community Paediatric Review 2008; 16: 5-6.

  27. Triad 1: Teenage antenatal clinic “Teenage-specific antenatal clinics that have comprehensive screening policies for infection and psychosocial pathology are associated with lower rates of preterm birth.” • Quinlivan JA, Evans SF. BJOG 2004:111; 751-578.

  28. Teenage antenatal clinic care Care is provided by a multi-disciplinary team. CPG includes: • Screening for genital tract infection, anaemia and other infections (dental, urine) • Social work appraisals (housing, violence, income) • Management plan for illegal drug use, smoking and alcohol • An open hospital admission policy • Direct linkage to Centrelink. • Quinlivan JA, Evans SF. BJOG 2004:111; 751-578.

  29. Teenage ANC and Preterm birth Teenage antenatal clinics are associated with reductions in: • TPL • PPPROM • preterm birth • Quinlivan JA, Evans SF. BJOG 2004:111; 751-578.

  30. Cost of a teenage clinic Quinlivan JA.Teenage parents – improving their outcomes using evidence based medicine. Working towards closing the gap on Aboriginal and Torres Strait Islander Children and Young People’s Health and Well Being Queensland Government, Queensland Health. Brisbane May 2010.

  31. Triad 2: Home visitation Meta-analyses and surveys of over 3,000 studies show that nurse home visitation consistently provide the most positive outcomes for vulnerable mothers children both in the short term and sustained over time. • Karoly LA, Greenwood PW et al. Investing in our children.: RAND Corporation, Santa Monica, CA, 1998

  32. Triad 3: Postnatal parenting programs where childcare is provided. Findings of a systematic review, based upon 14 studies involving teenage mothers, found that parenting programs can be effective in improving a range of psychosocial and developmental outcomes for teenage mothers and their children. However, childcare is vital to program success. Coren E et al, J Adol 2003.

  33. The older mother • Congenital anomalies • Maternal chronic disease • LokeAY, Poon CF. J ClinNurs 2011; 20: 1141-50

  34. What is the evidence base to improve outcomes for older mothers?

  35. Older age and stillbirth • Systematic review of 31 retrospective cohort and 6 case control studies found that greater maternal age was associated with increased risk of still birth. • Relative risks vary from 1.20 to 4.53. • Huang L et al. CMAJ 2008; 178: 165-172.

  36. Older age a risk for many adverse outcomes. • Retrospective study of45,033 women • Significant linear association documented between advanced maternal age and: • IUGR, LBW, malformations, perinatal mortality. • Most of the risk driven by • chronic disease driven preterm birth and IUGR, and • fetal malformations. • Salem YS et al. Arch GynecolObstet 2011; 282: 755-9

  37. Intrapartum anoxia a risk • Retrospective cohort study of 1,043,002 women with singleton term cephalic infants. • Compared with women aged 25-34 years, women >35 years had an increased risk of delivery related perinatal death at term • OR 2.20 95%CI 1.42-3.40 • Excess risk explained by intrapartum anoxia • Primip OR 5.34 95%CI 2.34-12.20 • Multip 2.14 95%CI 0.99-4.60 • Pasupathy D et al J Epid Com Med 2011; 65: 241-5.

  38. Managing Risk • Excess fetal anomalies needs early advice of options and screening • Excess medical problems needs early optimisation of conditions • Excess anoxia in labourneeds appropriate birth plans

  39. To address the evidence, nulliparous women over 35 years of age and parous women over 40 years of age should have a first trimester visit dedicated to discussing: • Screening for prenatal anomalies • Screening for chronic disease • A realistic birth plan is discussed.

  40. Staff training and clinical guidelines

  41. Clinical practice guidelines improve patient care outcomes in obstetrics. Santo S, Ayres-de-Campos O. Crr Opinion ObstetGynecol 2012; 24(2): 84-8 Berglund A, Leferre-Cholay H, Bacci A et al. ActaObstetGynecol 2010; 89: 230-237 Strasser DC, Falconer JA, Stevens AB et al. Arch Phys Dis Rehab 2008; 89(1): 10-5

  42. Clinical Practice GuidelinesObstetric RCT • Study across three hospitals to review impact of clinical practice guidelines. • High compliance rate with guidelines • Improvements in all outcome measures for pregnancy including reduction in PMR. • Berglund A, Leferre-Cholay H, Bacci A et al. ActaObstetGynecol 2010; 89: 230-237

  43. Clinical Practice GuidelinesObstetric RCT • “Improvements in health outcomes does not require primarily expensive technology. Rather staff must be trained and motivated to adhere to evidence-based routines to prevent unnecessary complications and treat the unavoidable ones.” • Berglund A, Leferre-Cholay H, Bacci A et al. ActaObstetGynecol 2010; 89: 230-237

  44. What is the evidence base behind staff training and persuading staff to follow clinical guidelines?

  45. RCT trials data…. • Interactive computer based training is better than lecture based training • Rosen J, Mulsant BH, Kollar M et al. J Am Med DirAssoc 2002; 3(5): 291-6 • Multidisciplinary team based training with problem solving and individual performance feedback is better than education based training • Strasser DC, Falconer JA, Stevens AB et al. Arch Phys Med Rehab 2008; 89(1): 10-5. • Setting examination benchmarks improves performance in training • Santo S, Ayres-de-Campos O. Curr Opinion ObstetGynecol 2012; 24(2): 84-8

  46. In most areas of medicine education and training change clinician practice and improve patients outcomes.Does this hold true for obstetrics?

  47. Obstetrics appears to be different.

  48. Systematic review of RCT The systematic review of 33 studies concluded: In obstetrics,educational strategies with medical providers are generally ineffective;… audit and feedback with personal reminders, local leadership, and multifaceted strategies are generally effective • Chaillet N, Dube E, Dugas M et al. ObstetGynecol 2006; 108: 1234-45

  49. Interestingly Most healthcare providers in obstetrics require more than just education and training They require * Audit * Personal Feedback * Local leadership.

  50. Audit with personalized feedback Individual *Can benchmark performance Hospital/Healthcare authority *Allows outliers to be identified

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