‘Milestone’ audit of obstetric services

When news of the tragic death of Savita Halappanavar broke on November 13th, 2012, the glare of the world's media spotlight suddenly turned to the State's maternity services and questions were raised about the standard of care being provided to pregnant women in Ireland.

The HSE clinical review published earlier this month and the coroner's inquest in April were both severely critical of the level of care and management of Ms Halappanavar at Galway University Hospital's maternity department.

The first national audit on severe maternal complications in pregnancy published yesterday highlights the high quality of maternity care in Ireland when compared internationally and its low rates of septic shock.

The audit carried out by the National Perinatal Epidemiology Centre (NPEC) at University College Cork over 2011 involved 19 of the State's 20 maternity hospitals (18 public and one private). One hospital chose not to provide data for the first audit, but it is expected that this information will be provided by all 20 hospitals for future audits on an annual basis.

Historically, maternal mortality has been used as a measure of care in maternity services. However, maternity mortality is now, fortunately, too rare an event in developed countries to be used alone as a quality indicator and the evaluation of severe maternal morbidity is acknowledged as a useful complementary measure.

Range of conditions
The term morbidity encompasses the range of chronic and acute conditions that may result in the onset of complications during labour, delivery and the peripartum (occurring during the last month of pregnancy or the first few months after delivery) period.

In Ireland, increased incidence rates for selected maternal morbidities are a cause for concern. For instance, between 1999 and 2009, postpartum haemorrhage rates have more than doubled. Increasing Caesarean section rates have resulted in an increase in peripartum hysterectomy for morbidly adherent placenta (a rare complication of pregnancy). However, to date there has been no national data available on the incidence of severe maternal morbidity in Ireland.

In this context, the NPEC established a Maternal Morbidity Advisory Group which carried out an audit modelled on the Scottish Confidential Audit of Severe Maternal Morbidity (SCASMM) – the findings compared favourably to the Scottish findings which are the only such detailed findings available.

The audit shows that one in 263 pregnant women experienced a severe maternal morbidity (complication) during labour, delivery and the period following childbirth, in line with international figures.

Major obstetric haemorrhage was the most frequent cause of severe maternal complications identified in 2011 with a reported rate of 2.3 per 1,000 maternities, followed by intensive care unit admission, renal/liver dysfunction and peripartum hysterectomy.

There were four cases of septic shock – the cause of Ms Halappanavar's death – reported, a rate of about 0.06 per 1,000 which is similar to international rates. There were no deaths from this complication.

Reassuring low rates
In light of the Our Lady of Lourdes inquiry into the high rate of Caesarean hysterectomies carried out by Dr Michael Neary in Drogheda, the findings of low rates of peripartum hysterectomy are also reassuring.

Dr Philip Crowley, national director of quality and patient safety at the HSE, said the report represented a "milestone" in obstetric care in Ireland.

“With the leadership of the NPEC, our obstetric services have fully engaged in a constructive examination of the quality of care they provide.

“This honest examination of the complications of pregnancy will inform how we guide and support our obstetric services to continually improve the quality of care that they provide to women. While the results suggest our services provide care that compares well with other jurisdictions, they also provide guidance for how we must continually improve that care.”

Prof Richard Greene, director of the NPEC, stressed the willingness of maternity department staff all around the State, both at midwifery and consultant level, to take part in this audit to find out how their services were doing in comparison with other countries and other hospitals and to look at how they could improve these services.

The audit provides important baseline information for healthcare professionals invested in improving maternity care in Ireland.

Continuing national surveillance of severe maternal morbidity is a critical step in improving obstetric outcomes, according to the authors of the report.

Recommendations
The advisory group makes a number of recommendations based on the findings of the first national audit. They recommend that all maternity units should collect and submit complete data in severe maternal morbidity to the NPEC national audit and that obstetricians at consultant level and senior midwives should be involved in the audit process.

Frequent multidisciplinary training in skills and drills, including maternal collapse and major obstetric haemorrhage, should be prioritised in all maternal units for all staff at all levels from consultant to porter.