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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