Report: Comparative Study of Maternity Systems

Report: Comparative study of maternity systems Report prepared for the Ministry of Health November 2012 www.malatest-intl.com [email protected] Phone: 04 889 0083 Mail: PO Box 5584 Wellington, 6145 What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others. - Pericles Malatest International – Comparative study of maternity systems – November 2012 1 Authors This report was compiled by Malatest International Consulting and Advisory Services (Malatest International). Malatest International provides high quality research, programme evaluation and skilled advisory services to public, private, academic and non-profit sectors. The authors of this report are Tim Rowland (BSc), Dr Deborah McLeod (BSc (Hons), PhD, DipPH) and Natalie Froese-Burns (BA (Hons), M.Econ). Though we have completed a range of projects in the health sector, we have no conflicts of interest in producing this report. HTTP://www.Malatest-Intl.com Malatest International – Comparative study of maternity systems – November 2012 2 Summary Purpose This report provides an overview of maternity systems and maternity outcomes for mothers and babies in New Zealand and across six comparator countries (Australia, Canada, Ireland, the Netherlands, the United Kingdom and the United States), in the context of population demographics and risk factors. The purpose of this study is to provide a resource to help inform future development of policy and maternity services delivery in New Zealand. Maternity systems All the countries included in this study, except the Netherlands, have seen shifts in the roles and responsibilities of the different healthcare professionals in their maternity care systems. Many saw responsibility move from midwives to doctors over the 20th century and in latter years calls for more natural childbirth and more community based maternity services have contributed to a trend towards reintroducing or strengthening the roles of midwives. Workforce challenges have accompanied the often swift transitions in roles and responsibilities. Many countries have experienced shortages in their maternity workforces as in their general medical workforces. Some challenges are shared across the comparator countries, for example communication between health professionals, referrals and knowledge transfers. The literature shows that regardless of the roles different health professionals play in delivering maternity care, good communication and clear referral guidelines between health care providers underpin effective maternity care. Across all countries, adverse outcomes have been linked to communication challenges between health professionals and to different opinions about when referral from primary to secondary care is indicated. Communication at three key points in maternity care (entry to maternity care, acute referral and exit from maternity care) plays an important role in ensuring that women do not fall through the gaps. Key elements of best practice that apply to all countries include: • Access to good quality care and culturally appropriate care; • Screening processes in place identify risk factors and for women who have risk factors clear referral guidelines guide the transfer from primary to secondary care; • Communication and knowledge transfer between disciplines is effective; and • Monitoring adverse events and having continuous improvement processes in place enabling systems to develop. New Zealand established three standards for maternity care in 2011 consistent with these elements of best practice (MOH 2011): • Maternity services provide safe, high-quality services that are nationally consistent and achieve optimal health outcomes for mothers and babies; • Maternity services ensure a woman-centred approach that acknowledges pregnancy and childbirth as a normal life stage; and • 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. Malatest International – Comparative study of maternity systems – November 2012 3 Changes to funding arrangements can influence the way maternity services are delivered. Different funding packages can impact the roles of different health professional disciplines and influence the way they provide care, for example the rate of interventions. Maternity outcomes There are significant differences in maternity systems and models of care across the comparator countries selected for this study. There are also other differences. For example, in the Netherlands the homebirth rate is far higher than in the other comparator countries while the caesarean rate is far lower. Despite these differences, comparator countries share a number of similarities in the outcomes they achieve. Like other developed nations, they have all seen dramatic improvements in maternal and perinatal mortality over the last century. Advances in technology, general healthcare and evolutions in maternity system design have reduced the incidence of maternal and child deaths to a small fraction of those seen in the early 1900s. Approaches to making further progress in reducing mortality rates include the systematic investigation of all perinatal and maternal deaths and use of this information as part of a continuous improvement process. In the countries studied, perinatal and maternal mortality monitoring systems operate to varying extents. The investigation process in the United Kingdom is regarded as the ‘gold standard’. Similarly to the United Kingdom, New Zealand has in place the Perinatal and Maternal Mortality Review Committee which has carried out this function since 2006. In New Zealand the system reviews each death. Caution in comparing mortality rates should be exercised as not all countries have the similar national audit ability and high case ascertainment rates. Policy makers in the countries studied are moving towards closer examination of morbidity as an indicator for the quality of care. Morbidity indicators become more important as mortality indicators become more variable as a result of small numbers. Analysis of the causes of severe morbidity provides an opportunity to continue to develop understanding of treatment and prevention to further improve outcomes. There are varying degrees of morbidity many of which are related to interventions during childbirth. New Zealand reports a range of morbidity statistics in the New Zealand Maternity Clinical Indicators report. The leading cause of neonatal mortality and morbidity in developed countries is premature birth, with 60 to 80% of deaths without congenital anomalies related to premature birth. Measuring satisfaction with care is another way of assessing the maternity care process, describing the consumer’s view point and evaluating overall care. All comparator countries measured maternal satisfaction, usually through surveys. New Zealand results demonstrate that most new mothers are satisfied with the maternity care they have received. The outcomes achieved for the vulnerable populations in a country are a measure of the quality of that country’s health care. While many overall outcome indicators are similar, disparities remain between the outcomes achieved for women in vulnerable populations and others. Across comparator countries, poorer women, Indigenous peoples and immigrant populations have on average poorer maternity outcomes than their counterparts. While disparities are less marked in New Zealand than in some other countries, there remains room for improvement. Risk factors A large number of factors affect the level of risk pregnant women can face. Some are characteristics of the mother, for example older mothers and teenaged mothers. Other maternal factors in pregnancy can also lead to a higher risk of complications, for example smoking, use of alcohol or other substances. While the incidence of some risk factors, such as smoking in pregnancy, is falling Malatest International – Comparative study of maternity systems – November 2012 4 across comparator countries, others are increasing. More women are obese when they become pregnant, are giving birth at older ages and are giving birth to multiple children. It is important to note that there are associations between risk factors; mothers with low incomes are more likely to be younger, to have other risk factors (for example substance abuse or smoking) and to face barriers to accessing services. Many risk factors are over-represented in vulnerable populations, underpinning the poorer outcomes for these groups, at least to some extent. New Zealand has high rates of a number of these risk factors, for example high rates of teenage pregnancy and obesity. Improving maternity outcomes In all comparator countries, further significant improvements in outcomes will require interventions to reduce the risk factors associated with adverse maternity outcomes. The profiles of women served by the maternity systems in the comparator countries are changing in terms of both demographics and risk factors. Changes in the incidence of factors such as older and younger motherhood, obesity, smoking and substance abuse pose different challenges for maternity systems. Initiatives that reduce the prevalence of risk factors can reduce neonatal and perinatal mortality. Public health initiatives targeting women before they become pregnant have more of a role to play in reducing the incidence of many of these risks than maternity systems. Although the ability of maternity

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