annual report 2016

National Maternity Monitoring Group

Cover Photo courtesy of Whakawhetū.

Thank you also to the many families who generously provided photos for this publication.

Abbreviations used in this report

DHB District Health Board

LMC Lead Maternity Carer

MQSP Maternity Quality and Safety Programme

MQI Maternity Quality Initiative

NMMG National Maternity Monitoring Group

PHO Primary Health Organisation

PMMRC Perinatal and Maternal Mortality Review Committee

Disclaimer

This publication informs discussion and assists New Zealand’s maternity policy development. The opinions expressed in the publication do not necessarily reflect the views of the Ministry of Health. All care has been taken in the production of this publication. Data was accurate at the time of release, but may be subject to change over time as more information is received. It is advisable to check the current status of figures with the National MaternityMonitoring Group before quoting or using them in further analysis. The National Maternity Monitoring Group makes no warranty, expressed or implied, nor assumes any legal liability or responsibility for the accuracy, correctness, completeness or use of the information or data in this publication. Further, the National Maternity Monitoring Group shall not be liable for any loss or damage arising directly or indirectly from the information or data presented in this publication. The National Maternity Monitoring Group welcomes comments and suggestions about this publication.

Contents

Chair’s message

About the National Maternity Monitoring Group

NMMG members

An overview of the NMMG’s recommendations for 2016

The Fourth Annual Report of the NMMG

People powered

Connect with and support the involvement of consumers in DHBs’ Maternity Quality and Safety Programmes

Closer to home

Investigate access to, and provision and use of rural and primary maternity facilities for women.

Investigate access to Anti-D following a sensitising event

Investigate increases in perineal trauma

Value and high performance

Monitor implementation of DHB MQSPs

Review key sector publications including the Report on Maternity

Support the ratification of national maternity clinical guidelines

Monitor the outcomes of the work undertaken by the Maternity Ultrasound Advisory Group

Smart system

Review the New Zealand Maternity Clinical Indicators data and monitor DHB responses to variations

The NMMG going for wards

Acknowledgements

Appendix 1:

Terms of Reference for the National Maternity Monitoring Group

Chair’s message

It has been an honour to serve as the first National Maternity Monitoring Group (NMMG) Chair. During this time, we have seen the implementation of the Maternity Quality Initiative and, through this, a wide range of national and local maternity- focused quality improvement initiatives have been implemented. It is encouraging to see the effort with which maternity sector stakeholders have approached maternity quality improvements since 2013.

As in previous years, in 2015/16 the maternity sector has completed a wide range of evidence-informed and data-driven improvements to investigate causes of poorer maternity outcomes and to implement systems, processes and programmes to improve on these outcomes and support world class services that are high performing, valued and smart. Together, these initiatives and the frameworks that support them are making a substantial contribution to improvements in women’s experience of pregnancy, birth and motherhood.

The refreshed New Zealand Health Strategy places a strong quality lens on the maternity sector. The NMMG’s multidisciplinary approach is well-suited to supporting cross- sector and integrated quality initiatives particularly under the Closer to Home, Value and High Performance and Smart Systems themes. Our working style also strongly supports the One Team theme as we continue to collaborate closely with other sector advisors in maternity care, including the Perinatal and Maternal Mortality Review Committee and the Maternity Ultrasound Advisory Group.

30 June 2016 marks the end of the first term of the NMMG. It is also the term-end for four sitting members of the NMMG: Bev Lawton, Elaine Langton, Margret Norris and myself. On behalf of the NMMG, I would like to thank outgoing members for their commitment to improving maternity in New Zealand and the valuable contributions they have each made during their time on the NMMG. I would also like to thank the remaining sitting members of the NMMG: it is not possible to developan effective, quality-focused group withoutstrong support from all members.

I wish the new NMMG all the best for the nextthree years.

Norma Campbell

About the National Maternity Monitoring Group

The NMMG was established in 2012 by the Ministry of Health as part of the Maternity Quality Initiative (MQI).This year (2015/16) is our fourth full year ofoperation.

The New Zealand Maternity Standards (2011)[1] consist of three high-level strategic statements to guide the planning, funding, provision and monitoring of maternity services in New Zealand:

  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, and
  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.

These high-level statements are accompanied by specific audit criteria and measurementsof these criteria. One of the criteria is thata national monitoring group be established to oversee the maternity system andthe implementation of the New Zealand Maternity Standards. Ultimately, the NMMG acts as a strategic advisor to the Ministryof Health on areas for improvement in the maternity sector, provides advice to district health boards (DHBs) on priorities forlocal improvement and provides a nationaloverview of the quality and safety ofNew Zealand’s maternity services.

During 2015/16, the NMMG’s work was also guided by the development of the refreshed New Zealand Health Strategy. The New Zealand Health Strategy outlines a high-level direction for New Zealand’shealth system to 2026. It is accompanied by a Roadmap of Actions[2], many of which have a focus on our maternity system, our pregnant women and our babies.

Together, the Maternity Quality Initiative, the Maternity Standards and the New Zealand Health Strategy with the Roadmap provide guidance on how the NMMG and maternity stakeholders can work together in the future to ensure that women and babies live well, stay well and get well if they are sick.

NMMG members

Norma Campbell (Chair)

Norma is a Midwifery Advisor (Quality and Sector Liaison) for the New Zealand College ofMidwives and during the course of this year her role with the College has moved to part time as she has now taken on the 0.5 FTE role of Executive Director of the Midwifery and Maternity Providers Organisation (MMPO). She has been a member of the International Confederation of Midwives Council for the past nine years. Norma has been involved ina number of expert advisory groups and multidisciplinary work on clinical guidelines. Norma has been involved in developing and supporting the Maternity Quality Initiative nationally and supporting the MQSPs in DHBs since their inception.

John Tait (Vice-Chair)

John is a consultant obstetrician and gynaecologist, and New Zealand Vice Presidentof the Royal Australian and New Zealand College of Obstetricians and Gynaecologists(RANZCOG). He is the Chief Medical Officer at Capital and Coast DHB and continuesto practise in the public sector in gynaecology. John has been involved in a number of expert advisory groups including developing and supporting the MQSP.

Rose Swindells

Rose is a mother with a passion for community development. She is an Adult Literacytutor, antenatal education facilitator and involved with Playcentre. Rose served as a consumer member on the Capital and Coast DHB Maternity Quality panel before joining the NMMG and sees her work in this area as part of the wider system which aims for women to feel empowered, knowledgeable, calm and confident in their birth experience.

Elaine Langton

Elaine is a specialist anaesthetist and, until recently, was the Clinical Leader of ObstetricAnaesthesia at Capital and Coast DHB. She is a member of the New Zealand Society of Anaesthetists and a fellow of the Australian and New Zealand College of Anaesthetists. She has specialised in obstetric anaesthesia for more than 20 years and has represented obstetric anaesthesia on a number of maternity advisory groups. Elaine is also currently involved in the Severe Acute Maternal Morbidity research project, which is reviewing near-miss maternity events.

Frank Bloomfield

Frank is a neonatal paediatrician at National Women’s Health, Auckland City Hospital,Director of the Liggins Institute and Professor of Neonatology at the University of Auckland. He is currently the President of the Perinatal Society of Australia and New Zealand, a corresponding member of the New Zealand Paediatric and Child Health Division Committee of the Royal Australasian College of Physicians and Council member of the Perinatal Research Society (USA). Frank also is part of a large research group investigating perinatal care at the Liggins Institute, University of Auckland. He contributed to the Working Group on Maternity Standards.

Judith McAra-Couper

Judith is Chair of the Midwifery Council and the Head of Midwifery at AucklandUniversity of Technology. Judith is an Associate Professor and Director of the Centre for Midwifery and Women’s Health Research and is involved in a number of research projects including maternal mental health, sustainability of midwifery practice andplace of birth. Judith regularly works for the World Health Organisation in Bangladesh in midwifery education. She has worked in Counties Manukau Health for many years and continues to be involved in this community.

Margret Norris

Margret is the Midwifery Leader for Bay of Plenty DHB. She has had various rolesin the midwifery profession as an employed midwife working in the DHB and as a lead maternity carer (LMC) midwife working in the rural areas. To maintain her clinical competencies, she supports the maternity services, has a small caseload and also does weekend cover for local LMC Midwives. As part of her role, Margret is the Perinatal and Maternal Mortality Review Committee (PMMRC) coordinator for the Bay of Plenty DHB, and the Chair for the local MQSP Governance Group.

Rachael McEwing

Rachael works at Christchurch Women’s Hospital and in a private practice forChristchurch Radiology Group, almost exclusively in Obstetric and Gynaecology imaging. She is a Fellow of the Royal Australian and New Zealand College of Radiologists and an advisor to the National Screening Unit on first trimester screening. Rachael is a member of the Maternity Ultrasound Advisory Group and the New Zealand Fetal Maternal Medicine Governance Board.

Bev Lawton

Bev is the Director of the Women’s Health Research Centre and an Associate Professorat the University of Otago. She is Ngati Porou and a member of Te Ohu Rata O Aotearoa(Māori Medical Practitioners Association) and Te Akoranga a Maui (Māori faculty ofthe Royal New Zealand College of General Practitioners). Bev is currently involved in a number of projects looking at maternal and child outcomes.

Bronwen Pelvin (ex officio)

Bronwen is the Ministry of Health’s Principal Advisor on Maternity. A midwife withmore than 40 years of experience, Bronwen has worked as a domiciliary midwife, a community-based LMC, a core midwife and a maternity manager. She worked as the national Midwifery Advisor for the New Zealand College of Midwives and was also the Professional Midwifery Advisor for Nelson Marlborough DHB before moving into her current role in 2008. A major focus of her work in the Ministry of Health has been the development of the Maternity Quality Initiative and its implementation.

Sue Belgrave (ex officio)

Sue is the current Chair of the Perinatal and Maternal Mortality Review Committee(PMMRC). She is a consultant obstetrician and gynaecologist at North Shore and National Women’s Hospitals and Clinical Director of Obstetrics for Waitemata DHB. She is a local coordinator at Waitemata DHB for the PMMRC and is an advisor on ultrasound in Obstetrics and Gynaecology. Sue is also a RANZCOG training supervisor.

Allen + Clarke (Secretariat)

Allen + Clarke provides a wide range of secretariat and policy services required tosupport the effective administration and management of the NMMG. It also specialisesin delivering core policy services, programme development, implementation and review, evaluation and regulatory analysis. Its clients include a wide range of central and localgovernment agencies, professional bodies, and NGOs in New Zealand and abroad.

An overview ofthe NMMG’srecommendations for2016

A number of things need to happen to ensure the continued improvement of maternity services in New Zealand. Many of these items reflect and will support the achievement of specific actions within the New Zealand Health Strategy. Below, we outline thoseareas in which we expect to see action from key maternity stakeholders.

  • Connecting and supporting consumer members: all DHBs should support the effective engagement of at least two consumer members in their MQSP governance arrangements. DHBs should ensure that mechanisms to involve a range of consumer perspectives in the substantive design and monitoring of maternity services exist.
  • Other national groups and committees involved in maternity quality improvement: we expect all such groups to be working collaboratively and in a coordinated manner to ensure that identified recommendations are implemented.
  • New Zealand Maternity Clinical Indicator data: following six years of data with limited positive change in maternity outcomes, the Ministry, DHBs and professional colleges should consider barriers that may be adversely affecting improvements in maternity outcomes.
  • Primary maternity facilities: we expect the Ministry of Health to establish a group to investigate normal birth and to focus on understanding the factors influencing place of birth decisions made by women and their health care providers.
  • Consistency in the quality of first trimester care: DHBs must consider innovative service delivery that inspires women to engage with maternity services in a timely manner. We also recommend that that the Ministry of Health appoint a practising general practitioner to the NMMG. Health practitioners should still ensure that they are well-informed about what should be covered in an evidence-informed early pregnancy consultation.
  • Anti-D: DHBs should have comprehensive guidelines on the administration of Anti-D immunoglobulin, including processes to ensure that all Rh D negative women receive the appropriate dose when required (including prophylactically).
  • Perineal trauma: DHBs should continue to closely monitor and observe third and fourth-degree tearing with a focus on improving clinical practice.
  • The refreshed New Zealand Health Strategy: all DHBs should use the New ZealandHealth Strategy and Roadmap of Actions to guide investment in child and maternal health.

The Fourth AnnualReport of the NMMG

Over the following pages, we describeour work for 2015/16. We explain why we have chosen to focus on specifictopics, our findings and areas for further improvement. We also share examples of good practice and useful statistics.

In line with our brief to oversee theNew Zealand Maternity Standards, the NMMGmet four times in 2015/16. We discussed the implementation of our work programme and our priorities to improve the quality, safety and experience of maternity care in New Zealand, improve health and equity for women and babies, and support best valuefor public health system resources. Our work programme for 2015/16 is described below.

Following publication of the refreshed New Zealand Health Strategy, we considered our work programme andwere pleased to note considerable alignment between our work and the New Zealand Health Strategy’s priorities. As such, we have presented our 2015/16 report in the same themes as the refreshed Strategy.

The NMMG’s 2015/16 priorities for investigation

  1. Investigate consistency in the quality of first trimester antenatal care
  2. Investigate access to, provision and use of rural and primary maternity facilities for women
  3. Investigate access to Anti-D after a sensitising event for Rh negative women, and
  4. Investigate the increase in perineal trauma and variability within and between DHBs.

The NMMG’s 2015/16 priorities for monitoring

  1. Monitor the involvement of consumer members in DHBs’ MQSPs
  1. Review the outcomes of work undertaken by the Maternity Ultrasound Advisory Group
  2. Support the ratification of new national maternity clinical guidelines and monitor the implementation of existing guidelines
  3. Review the New Zealand Clinical Indicators data and monitor DHBs’ responses to variations
  4. Monitor DHBs’ implementation of their local MQSPs (including maintaining a focus on maternal mental health and variation in gestation at time of birth), and
  5. Review key maternity sector publications including the Ministry of Health’s Report on Maternity.

People powered

Connect with and support the involvement of consumers inDHBs’ Maternity Quality and Safety Programmes

Our focus for 2015/16 was to connect with and support the involvement of maternity consumer members in DHB MQSP governance arrangements particularly as MQSPs are further embedded into broader DHB quality frameworks.

Ensuring women’s experience is recognised and feeds into service design and delivery is critical to developing effective and responsive services that both inform and involve women

in their care. DHB MQSP consumer members need to be involved in discussions and decision- making at every level of the maternity sector, including actively contributing to MQSP direction setting, monitoring and reporting. To do this effectively, DHB MQSP consumer members must be able to gather information and support from their communities. Members need adequate guidance and support from the DHB to ensure that they can fulfil their role effectively.