National Maternity Monitoring Group

2016-17Work Programme

Background

The National Maternity Monitoring Group (the NMMG) provides strategic advice to the Ministry of Health on priorities for improvement to the maternity system and the implementation of the New Zealand Maternity Standards. This document outlines the NMMG’s work programme for 2016/17. To deliver this work programme, we expect to meet quarterly (August, October, February and May).

Strategic context

The NMMG’s work is guided by the priorities set out in the refreshed New Zealand Health Strategy[1], the New Zealand Maternity Standards and the Maternity Quality Initiative.

In April 2016, the Minister of Health released the refreshed New Zealand Health Strategy. The Strategy outlines a high-level direction for New Zealand’s health system to 2026. It is accompanied by a Roadmap of Actions[2], many of which have a focus on our maternity system, pregnant women and babies. Together, the Strategy and the Roadmap provide guidance on how we can all work together to ensure that all New Zealanders live, stay and get well. It provides critical guidance on the work of the NMMG and has informed the preparation of our 2016/17 work programme.

The New Zealand Maternity Standards[3] consist of three high-level strategic statements to guide the planning, funding, provision and monitoring of maternity services:

  1. Standard 1: Maternity services provide safe, high-quality services that are nationally consistent and achieve optimal health outcomes for mothers and babies
  2. Standard 2: Maternity services ensure a woman-centred approach that acknowledges pregnancy and childbirth as a normal life stage
  3. Standard 3: All women have access to a nationally consistent, comprehensive range of maternity services that are funded and provided appropriately to ensure there are no financial barriers to access for eligible women.

The Maternity Quality Initiative (MQI), refocused in 2015, contains four key priorities:

  1. Strengthening maternity services including more timely access and more equitable access to community-based primary maternity care and services
  2. Better support for women and families that need it most, including better health and social support for young mothers and for maternal mental health and support for improving health literacy among vulnerable populations
  3. Embedding maternity quality and safety including further support for local clinical leadership and review, and meeting the Ministry’s obligations under the New Zealand Maternity Standards, and
  4. Improving integration of maternity and child health services including improving transitions between health services through improved communication, coordination and use of information technology.

Summary

Our work programme for 2016/17 aligns to the priorities set out in the refreshed New Zealand Health Strategy and Roadmap of Actionsas well as continuing previous workstreams where further work to investigate or monitor is required. A summary of our work programme is provided below.

In recognition of the range of health sector stakeholders working in maternity care, the NMMG expects to continue to work closely with other key groups working in maternity, including the PMMRC, the Maternity Ultrasound Group and the Midwifery Strategic Advisory Group. We also expect to consider how other stakeholders are addressing the following NZ Health Strategy priorities before incorporating related activities into future work programmes: Maternity Information System development, prevention of fetal alcohol spectrum disorders and the review funding, contracting and accountability arrangements for primary maternity services.

Closer to home priorities

a)Investigate access to, provision and use of primary maternity facilities for women

The number of babies born in primary maternity facilities has been slowly declining (i.e., from 11 percent in 2009 to nine percent of total births in 2014). Almost all births at primary maternity units are spontaneous vaginal births. Access to and use of primary maternity facilities remains an important issue for the NMMG, particularly in light of the NZ Health Strategy’s theme, Closer to home, and Action 6 in particular (ensure the right services are delivered at the right location). Specific issues that need to be considered include:

  • Influencers on women’s preferences regarding place of birth
  • Location of primary birthing facilities, staffing levels, and use/occupancy rates
  • Access to primary maternity facilities in rural and remote areas
  • Integration of primary birthing facilities into DHB management and quality frameworks
  • Closing data gaps (for example, in-labour and post-natal transfer rates between type of facility, number of LMCs working in remote and rural primary birthing facilities, etc.), and
  • Guidance DHBs require to maintain and manage primary birthing units within the MQSP framework.

In 2016/17, we expect to better understand data on the number of women who plan to birth at a primary facility compared to where they actually birth (including changes to bookings during the antenatal period and transfer during labour). We will also explore New Zealand data on baby outcomes by type of facility and the demographics of health practitioners by facilities.

b)Continue to investigate consistency in the quality of first trimester antenatal care

Approximately 60 percent of women who give birth see a non-LMC Section 88 claimant in their first trimester of pregnancy before registering with an LMC. Specifications for first trimester care are well-described in the Section 88 Primary Maternity Notice. Ensuring that health practitioners provide a high quality of maternity care is important as a wide range of health practitioners may be involved in early pregnancy care. The importance of general practice in maternity care is reflected in the appointment of a practising GP to our group for 2016-19. Continued investigation of this workstream supports the NZ Health Strategy theme, Closer to homeand Action 7 in particular (people working in the health system fully use their skills and training).

In 2016/17, we expect to investigate care provided in non-LMC first trimester contacts/consultations by:

  • examining the first contact a woman has with a GP and the timing of LMC registration by DHB to identify if there are particular regions where there are trends ofwomen registering late
  • investigatingearly pregnancy and prenatal care initiatives to assess whether social investment in the start of life is having a positive impact on vulnerable children
  • asking DHBs about timing of first contact and whether they are aware of any identified timeliness of registration issues and confirm with them about GP knowledge of how to facilitate access to LMCs, and
  • discussing withthe Colleges (including the Royal College of General Practitioners) the need for referral letters to maternity care around what tests and investigations have been done, so as to support better information sharing.

c)Monitor access to anti-D

One of the NMMG’s previous investigative workstreamsfocuses on providing a great start for children (Action 9 in the NZ Health Strategy Roadmap): investigation into access to anti-D prophylaxis following a sensitising event in pregnancy. In 2015, the Ministry of Health requested that the NMMG investigate whether Anti-D should be made available to all Rh negative women antenatally. Our initial investigation raised a number of queries about consistent access to anti-D across New Zealand. In 2016/17, we will monitor the use of the Anti-D in DHBs and we expect to receive an update on the National Women’s Health audit of all intrauterine transfusions for fetal anaemia.

d)Monitor timely access to community-level non-acute mental health services

Accessing community level maternity mental health services in a timely way supports the NZ Health Strategy theme, Closer to home. Women need access to appropriate primary maternal mental health services during pregnancy and post-partum and for some women, access to and provision of primary mental health services during and after pregnancy is essential to their safety and that of their babies. Women with existing mental health issues are at risk of escalation during the pregnancy and postnatal period. This is particularly true for women with a history of bipolar disorder, psychosis or postnatal depression/severe depression.

Suicide remains a leading cause of perinatal death: maternal suicide is seven times more common in New Zealand than in the UK. The tenth annual Perinatal and Maternal Mortality Review Committee (PMMRC) report includes a review of maternal suicides from 2006 to 2013 which found that risk factors for major depression were not always identified, and that there is a need for improved communication between services. This analysis has also led to the PMMRC planning to do further analysis of death from suicide in 2015–2016.

In 2016/2017, we will continue to support better knowledge in the maternity sector of available mental health services, timeliness of access to mental health services for women, and better integration between maternity and mental health services through the provision of transparent pathways of access in DHBs. We will do this by:

  • exploring examples of good practice in this area
  • monitoringDHBs to determine whether there is unmet need/capacityof primary and secondary care in relation to maternal mental health pathways and service accessibility including theprimary maternal health pathway at a community level (as well as acute mental health)
  • reviewingPMMRC’s report (when it is released) to determine what maternal mental health recommendations should be taken forward as a priority, and
  • monitoringthe development of the maternal morbidity working group and its findings.

Smart system priorities

e)Review the New Zealand Maternity Clinical Indicators and monitor DHBs’ responses to variations

The New Zealand Maternity Clinical Indicators are a key part of the MQI. The Indicators are nationally standardised benchmarked maternity data which provides information about the quality of and national consistency within New Zealand’s maternity services. Maternity sector stakeholders rely on this data to determine whether the New Zealand Maternity Standards are being met. The NMMG uses this data to identify national and local priorities for action. Action 25 of the Health Strategy’s Roadmap of Actions, involves increasing analytical capability and the quality of national data to improve the design and delivery of services and increase transparency.

In 2016/17, we expect to:

  • review available Indicator data (with emphasis on indicators relating to:
  • timeliness of women registering with an LMC within the first 12 weeks of pregnancy
  • the impact of healthcare provider-determined time of deliveryon gestation at birth
  • perineal trauma, and
  • the impact that DHB MQSPs have had on maternity outcomes for mothers and babies)
  • share our findings with and seek advice from each DHB regarding any identified significant and consistent variations from the national average and the DHBs’ responses to these (including where DHBs are performing well)
  • provide advice to the Ministry of Health on possible improvements or amendments to the current Indicator set (as required)
  • determine instances where DHBs have identified clinical coding as a possible explanation for data variances and providing advice to the Ministry and DHBs on the implications of this
  • develop consensus regarding which population growth charts should be used in New Zealand for both pre-term and term, and
  • meet with Expert Advisory Group annually to discuss the picture provided by the Indicators.

One teampriorities

f)Monitor maternity workforce recruitment and retention through the work of the Midwifery Strategic Advisory Group

Workforce development initiatives are crucial for supporting a sustainable and adaptive maternity workforce. These are reinforced by action 24 of the Health Strategy Roadmap of Actions under the goal of One Team, which involves establishing workforce development initiatives to enhance capacity, capability, diversity, succession planning, and workforce flexibility. Health Workforce New Zealand has established a Midwifery Strategic Advisory Groupto ensure that New Zealand has a sustainable and supported midwifery workforce.

In 2016/17 we will monitor workforce recruitment and retention through consideration of the Midwifery Strategic Advisory Group’s work. We expect to:

  • support the Midwifery Strategic Advisory Group in its work relating to maternity workforce recruitment and retention
  • review findings and advice provided by the Midwifery Strategic Advisory Group, and
  • provide advice to the Ministry of Health on possible improvements or amendments to current recruitment and retention strategy and practices (as required).

Value and high performance priorities

g)Monitor the outcomes of work by the Maternity Ultrasound Advisory Group

The New Zealand Health Strategy’s goal to improve performance and outcomes, involves smarter and more transparent use of data. In 2014/15, the NMMG highlighted the rising primary maternity ultrasound rates in New Zealand and variability in access and quality. In 2016/17 we intend to continue monitoring the outcomes of the Maternity Ultrasound Advisory Group’s work. We expect to:

  • support the Maternity Ultrasound Advisory Group in its work to develop standards for this area and monitoring responsibilities by participating as a Group member and by receiving and commenting on reports from the Group as the NMMG, and
  • review findings and advice provided by the Maternity Ultrasound Advisory Group.

h)Support ratification of national maternity clinical guidelines and monitor implementation of existing guidelines

Action 14 of the Roadmap, which relates to the goal to improve performance and outcomes, calls for the development and implementation of a monitoring framework focused on health outcomes. National maternity clinical guidelines are a key component of the maternity sector. They set standards based on the latest clinical evidence or best practice and enable consistency in clinical maternity practice nationally.

In 2016/17, our aim is to ensure that national evidence-informed clinical guidance is appraised and ratified using the AGREE II Instrument and algorithm. We expect to:

  • consider draft material for ratification as national guidelines (as required)
  • support the Ministry’s efforts to develop guidance on pregnancy and hypertension/pre-eclampsia, and
  • monitor the developmentof at least one new guideline per annum.

i)Review key sector reports

Reviewing key maternity sector publications is one of the NMMG’s responsibilities. It includes reviewing publications like the Ministry of Health’s Report on Maternity, an annual statistical report on pregnancy and childbirth in New Zealand. This further supports the Health Strategy goal to improve performance and outcomes, by utilising data. In 2016/17, we expect to:

  • review the Report on Maternity and the accompanying data tables as these are produced and provide advice to the Ministry about our findings and possible priorities for action (including considering the relationship between early planned birth, maternal age and ethnicity)
  • determine instances where DHBs have identified clinical coding as a possible explanation for data variances and providing advice to the Ministry and DHBs on the implications of this, and
  • review the PMMRC annual report, provide advice to the Ministry about any notable findings or recommendations, and work closely with the PMMRC to ensure that information requests to DHBs are coordinated.

We also expect that DHBs are reviewing the same key sector reports and considering how the recommendations apply to services provided in their areas. We expect DHBs to be reporting on these.

j)Monitor the implementation DHBs’ MQSPs

In 2016/17, we aim to support the Ministry of Health in its overview of each DHB by:

  • concentrating our monitoring efforts on DHBs recently transitioned to the “establishing”tier to support advancement to more connected and integrated local MQSPs (West Coast and Southern DHBs)
  • encouraging“establishing” and “excelling” DHBs to further embed existing programmes into long-term, organisation-wide quality frameworks while retaining strong clinical leadership and management support
  • reviewingeach DHB’s MQSP Annual Report to determine each DHB’s priorities for maternity services, to determine the level of progress made by each DHB against its priorities, determine the extent to which DHBs have taken on board and implemented any recommendations/feedback provided by the NMMG (including liaising with DHBs about the development of formal integrated pathways for maternal mental health) and ensure that each report is published online, and
  • providing advice to the Ministry about DHB achievement and placement within the contract tiers.

1

[1]Minister of Health. 2016. New Zealand Health Strategy. Wellington: Ministry of Health.

[2] Minister of Health. 2016. New Zealand Health Strategy: Roadmap of actions 2016. Wellington: Ministry of Health.

[3]Ministry of Health. 2011. New Zealand Maternity Standards. Wellington: Ministry of Health.