Issue 111

SEASONS GREETINGS, TENA KOUTOU KATOA, KIA ORANA, TALOFA LAVA, MALO LELEI, FAKAALOFA ATU.

In the middle of the year the National Maternity Monitoring Group (NMMG) released its 5^th Annual Report for the 18 months from July 2016 to December 2017. This group has thoroughly and diligently investigated and reported on a large number of issues that impact quality and safety in the maternity service provided in AotearoaNZ as well in this edition we take an in depth look at a number of the areas of the maternity services investigated by the NMMG and add consumer feedback relating to these from the online national consumer survey that was co-sponsored by Women’s Health Action, Maternity Services Consumer Council, MAMA Maternity and La Leche League.

One of the Guidelines reviewed by the NMMG was the “Screening, Diagnosis and Management of Gestational Diabetes in New Zealand: A clinical practice guideline”. This guideline mentioned the lack of evidence to support the benefits of Antenatal Milk Expression at the time it was written. We checked to see if, 4 years later, the evidence has caught up with the practice.

We also include a tribute to Ignaz Semmelweis on the 200^th anniversary of the year of his birth. He has been called the “saviour of women” for his work to establish the cause of puerperal fever. He is one of our heroes because he was willing to question and change his own practice and that of his profession, when the evidence showed it was necessary. At this time of year many of us are preparing to celebrate with our families and then relax in the sun. MSCC would like to express gratitude, on behalf of the women and families of AotearoaNZ, to all the midwives and other maternity service providers who will continue to work, missing the family gatherings and summer holidays, in order to ensure that maternity care continues to be available 24/7 throughout the holiday season.

We also wish all our readers a peaceful and joyful festive season and thank you for your interest and support of the work of the Maternity Services Consumer Council.

National Maternity Monitoring Group Annual Report

In the middle of the year the National Maternity Monitoring Group (NMMG) released its 5^th Annual Report for the 18 months from July 2016 to December 2017. https://www.health.govt.nz/publication/national-maternity-monitoring-group-annual-report-2017

“The NMMG is responsible for overseeing the New Zealand maternity system and for providing strategic advice to the Ministry of Health (MoH) on priorities for improvement. Monitoring and the implementation of quality systems is important to ensure that the MQSP (Maternity Quality and Safety Programme) contributes to safer outcomes for mothers and babies.” (p15)

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

• 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 normal life stage.
• 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.” (pg8)

The NMMG states that its priorities include:-
“…to improve the quality, safety and experience of maternity care in New Zealand, improve health and equity for women and babies, and support best value for public health system resources.” (pg9)

For the 2017 Annual Report, the NMMG reviewed each DHB’s 2016 and 2017 Maternity Quality and Safety Reports. The NMMG also reviewed the reports of the external reviews that have been conducted on five DHBs (Counties Manukau; Mid Central; Whanganui; Waikato and South Canterbury) since 2012 and reported that these revealed common themes of:

• staffing shortages within the DHBs and a resulting lack of capacity for professional development;
• issues with leadership, accountability, clinical governance and interdisciplinary collaboration;
• a lack of communication with or a clear understanding of the role of Access Holding LMCs within the hospital setting; and
• unhelpful differences in data collection, management and reporting of maternity related statistics and outcomes.

In reporting and commenting on the NMMG report, MSCC has added consumer feedback from the online survey jointly conducted by Women’s Health Action, MSCC, MAMA Maternity & La Leche League in July 2018. Whilst we applaud the NMMG for their diligence in reviewing and reporting on Maternity Quality and Safety Programmes throughout NZ, we are disappointed that DHBs appear not to have instituted changes in the areas, that successive NMMG reports have indicated are necessary to achieve equitable access to safe, women-centred maternity care.

NMMG’s workstream for 2016 – 2017.

1. Workforce

“Staffing is an important issue that significantly impacts quality and safety for midwifery and medical workforces, ensuring that a safe and high quality service is supported. The workplace culture must enable staff to work collaboratively, feel safe and supported, and maternity services must be women-centred.” (pg12)

The ”Dear David” campaign (see our May newsletter) showed that both employed and self -employed midwives are continuing to leave the service, exacerbating staffing shortages which in turn result in unsafe working environments and conditions, that compromise the quality of care able to be provided. Our September newsletter showed that midwifery shortages are negatively impacting the care and outcomes for women, especially postnatally. Women’s responses to the consumer survey show that there are hardly any parts of the country where women are unaffected by understaffing in our maternity workforce.

“My midwife had taken on too many women due in December 2017 as her partner midwife was overseas. I birthed on the same day as one of her other ladies so my midwife had been at the hospital for around 30 hours between us both. This issue of taking on too many ladies also affected our postnatal care very significantly. I ended up in hospital for 3 weeks over the first 5 weeks of my babies life due to mastitis which eventuated into breast abscesses. I had informed my midwife of suspected recurring mastitis during week three on the Friday. By Tuesday my midwife still had not managed to see me so I suggested that I could meet her on her clinic day that day to pick up a script for antibiotics. (I had asked her if I should see a GP on the previous Saturday as I knew she was just flat out busy but she said no she would get around to me.) By Friday of the following week (3 days after starting a course of antibiotics), I was very ill and was hospitalised with abscesses from mastitis that had not been treated quick enough. My midwife was quite unaware of abscesses and had put my situation down to having blocked ducts that led to mastitis and she tried to get me to pump but at that point it was too late and pumping was only making things worse. She spoke to a LC who then told us that she suspected it had turned into abscesses. So sorry for the massive novel but we had a horrendous time postnatally which still to this day makes me incredibly sad. My baby is almost 7 months (first child!) and I feel like I pretty much missed out on her whole newborn stage because I was gravely ill. I feel that with better care, it could definitely have been prevented. It just showed me the stress and strain LMC’s are under.”

(Auckland 2017)

“Midwife was so overworked and stretched thin. Very stressful having appointments changed, her only just turn up in time for my baby to be born and I even went 11 days without seeing her for home visits in those first few weeks cause of her busy caseload.”

“When our middle child was born with anomalies, no support was offered and it took the hospital 6 months to get a pediatrician on the case to “oversee” the many specialists we see on yearly basis as a result.”

(2016)

“I feel like my postnatal experience could have been extremely different had the postnatalward and Birthcare been staffed adequately. I nearly died after being discharged because I was not properly cared for or assessed prior to being sent home. I don’t think that would have happened if the midwife assigned to me had a more reasonable workload.”

“Hospital midwives/registered nurses were overstretched and gave conflicting advice and directions. My son was iugr and I was given no instructions on how often or how much to feed him. Only told days later by a paediatric doctor what the expectations were (lectured and informed I should’ve been topping him up 18ml of EBM per feed) and threatened with having my son taken to nicu. I had not been involved or consulted in any earlier discussion between midwives and nicu doctors about where my son should be.”

“There is not enough support for exhausted and learning mothers. Postnatal staff are short staffed and short tempered. Running on a skeleton crew of trained professionals is not ok and mums and babies are suffering because of it.”

“After I gave birth the care I received in the (Wellington) hospital was terrible and I had a ‘straightforward’ birth. (I) was sent away from hospital within two hours to (Kenepuru) birthing centre to recover (where I) was left alone most of the time with no care or guidance to really speak of. Was a lonely terrifying time for me and I believe my experience contributed to the anxiety attacks I had afterward… part of the reason I have delayed planning for another baby. Completing this questionnaire has made me realise I never got closure on this experience.”

“My midwife was great but the staff shortage at the hospital meant I had to wait in hospital for days partially induced. Don’t start to induce woman in hospital without the staffing or rooms available to continue the process.”

(ACH)

“Christchurch hospital was terrible. My boy was in NICU didn’t see him for 14 hours after c section due to nurses being to busy to take me to see him.”

(2018)

““I felt like the hospital midwives cared but there was too much for them to do so I barely saw anyone throughout my time in hospital … I was pretty much left alone unless I called for the on call midwives. It is very isolating and lonely the first couple of nights as there were limited midwives on call and partners aren’t allowed to stay. My baby had a lot of liquid that she was bringing up so sounded like she was coughing/drowning all through the night so I had no sleep one night and being alone with my first baby was quite overwhelming.”

(Dunedin)

“My labour (c section) in the hospital was a great experience, however after care was not. Ihad a shared room with 4 other women. Over night there was only 1 midwife and a student on duty. Pain meds werent given on time as staff were rushed. When calling for assistance it would take 30mins for anyone to arrive…”

(Dunedin 2018)

“Midwives at Gisborne Hospital were great but clearly understaffed … Definitely need more staff. C-sections are hard enough as it is, let alone with barely any help from staff..”

(2018)

“The Hutt Hospital was DREADFUL and made me not want to ever have more children…

not enough staff to go around and we were neglected… there was NO breastfeeding support what-so-ever from the Hutt Hospital from day 1…”

(2016)

“After birth – proper breastfeeding support. This wasn’t anyone’s fault except that the nurses were so busy that not one could spend a length of time with me to get it right as a first time mother.”

(Invercargill 2016)

“After my homebirth I had to go to Middlemore Hospital for surgical repair of a 4th degreetear. I arrived around 1.30pm, and wasn’t stitched up until 11.30pm. By that time my baby had gone almost 6 hours without breastmilk as I had been wheeled down to the pre-theatre area but kept there for ages as they kept pushing my surgery out. Not very friendly staff and absolutely appalled that I had to wait 10 hours while I was bleeding and swollen, and also that they kept my baby from me for that long.”

(2018)

“I felt that although there seemed to be too few midwives on at any one time at the hospital I gave birth in, they were all very attentive and helpful. It (maternity) seems like it’s an underfunded area of NZ’s public health system”

(2017)

“Staffing at Palmerston North hospital was problematic. I had an emergency c section and it was torture listening to my baby cry and not being able to get to him. Had to wait for a nurse to help but they took time to get there as they were so busy.”

(2016)

“I felt as though postnatal care in the hospital could be greatly improved by having more staff.”

( Rotorua 2017)

““Lack of resources and staff. I was left four days waiting for an emergency induction. I kept getting bumped. All of my LMC midwife support was fantastic. Also the midwives in the hospital were great during my stays and the birth itself.”

(Waikato 2018)

“The care at Waikato Hospital could of been better they needed more staff, I waited over 6 hours for a epidural…”

(2016)

“Had to wait too long for an epidural which resulted in my needing a General Anaesthetic.”

(Waitakere 2018)

“Hospital midwives were run off their feet and would often forget to bring pain meds etc requiring multiple requests. Not enough beds on the ward. I had to stay in the delivery suite after the birth, meaning we were pretty much forgotten about as the hospital midwives were required for actual deliveries.”

(Wellington Women’s 2017)

“I had one hospital stay for a suspected blood clot. However I felt the hospital was understaffed and my stay was longer than necessary because they didn’t have time to get me in for scans and then check them. It was very stressful as I suffer from white coat syndrome.”

(Wellington Women’s)

“Probably would have been better if I’d been able to find a midwife but that was really hard so ended up with the community team which always felt stretched and busy.”

(Wellington)

“I would improve the hospital experience, more nurses/midwives to improve the quality of care for mothers and baby’s. After my emergency cesarean I wasn’t even taken to see my son in the NICU for 4 hours after he was born partly due to nurses being short staffed. Overworked midwives and nurses giving conflicting breastfeeding advice and often taking a long time to respond to calls.”

(Wellington Women’s)

2. Maternity Quality and Safety Programme (MQSP) Annual Reports

“DHBs MQSP Annual Reports need to… be user-friendly/consumer focused: be publicly available; and ensure that the loops are closed between identifying an issue, responding to it and the reviewing and discussing the outcomes….” (pg12) For this 2017 Annual Report, the NMMG reviewed each DHB’s 2016 and 2017 Maternity Quality and Safety Reports. MSCC was unable to find many of these reports published online for public access, however we are pleased to read that all DHBs are now producing these reports. We would like to see a standard format for tables in these reports to facilitate comparison of outcomes between the different DHBs. What the reports we did find show is that most DHBs are slowly implementing projects and processes to improve outcomes. Some DHBs have managed to stem the upward trend in Induction of Labour rates, none have managed to prevent a continuing rise in c-section rates, (even for low risk, first time mothers) and few have been able to increase the numbers of women birthing in primary birthing units or at home.

3. Monitor the outcomes of work by the Maternity Ultrasound Advisory Group

The Maternity Ultrasound Advisory Group (MUAG) was set up to advise the MoH on issues related to supply, use and quality of publicly-funded primary maternity ultrasound services. Their report was submitted to the MoH in 2017. The National Screening Unit is apparently using this report to inform the development of national standards for ultrasound in pregnancy.

MUAG and NMMG report that, “Best practice antenatal care for a woman who has no complications during pregnancy, is low – risk, engages with health services in the first trimester of pregnancy and carries her baby to term involves referral for two screening-based ultrasounds:

1. A first trimester ultrasound optimally performed at around 12 weeks for dating, identification of twin pregnancy early anatomy assessment and screening from chromosomal anomaly (if consented by the woman): and
2. An anatomy ultrasound optimally performed at 19+ weeks for detailed assessment of fetal anatomy.” (p19)

MSCC would like to see the language relating to all best practice guidelines acknowledge the right of women to make informed choices about their care so that a statement like “…involves referral for two screening -based ultrasounds:” would change to “…involves the offer of referral for two screening-based ultrasounds:”

In addition, MSCC is aware that the majority of pregnant women, (especially those living in urban environments), even those who are low-risk, currently receive more than these two ultrasound scans during pregnancy. It is MSCC’s experience that an extra early pregnancy scan for confirmation of pregnancy and dating is fairly routinely offered (and expected) when a woman consults a GP following a positive pregnancy test. The NMMG identifies another reason for additional scans as being, “the allocation of appointment times that are too short to achieve the expected output. For example, a 30-minute appointment is considered too short for an anatomy ultrasound (19+weeks):” (p19)

The NMMG recognizes, “that there are inconsistencies in the way that women access primary maternity ultrasounds. We support the development and implementation of national quality standards for primary maternity ultrasounds (including standards relating to referral pathways and quality processes). We also support work to reduce barriers to access for all women…” (p19) MSCC wonders how much consumer input there was into the MUAG recommendations. While women are generally very happy to have the opportunity “to see” their babies at any stage of the pregnancy, our joint consumer survey revealed that women are also concerned about equitable access and quality of service reporting processes.

(i) Respondents commented on the ultrasound co-payment which they felt was unfair and inequitable.

“$50 isn’t much to some people but to others it’s literally taking food out of mouths”

(Chch 2017)

“Costs of scans were rather expensive, I am lucky we could afford them. Many people cannot and do not show up for the scans.”

(Dunedin 2018)

“Paying a lot of money for scans. Seems different regions charges vary wildly.”

“The cost of scans was a bit pricey too, specially because I had to take some extra scans because of the gestational diabetes I experienced in this recent pregnancy.”

(Auckland 2018)

“The costs of scans are way too expensive – many places charge at least $40 and some charge $ 60. I reckon they should decrease the costs of these – especially for first time mothers and those who are unemployed, beneficiaries or maybe even students with no suitable income?”

(Auckland 2018)

“I have twins. It seemed really unfair that we had to pay double for scans because there are two babies, especially because twin mums are expected to have way more scans than women with one baby.”

(ii) Women expressed concerns about having no real control over the number of scans that they are referred for, resulting in significant expense and often increased anxiety.

“I think that the costs of scans should be reduced. I needed many growths scans that were $50 each.”

(2018)

“Yes we have all this great technology now, and can monitor and catch things early, but making a woman have multiple scans can cause more anxiety than intended…”

“…it gets quite expensive, especially when you have to have extra scans and then follow-up scans because bub wasn’t showing them what they needed to see… I had to have extra scans to see if the placenta had grown away from my cervix and a couple of scans to check bub’s growth. We spent well over $1,000 on scans.”

(Waikato 2018)

(iii) Women expressed concerns about the impact that ultrasound assessments can have on their care and the outcomes of their pregnancy and birthing experience. Many women felt obliged or pressured to agree to interventions on the basis of ultrasound assessments that subsequently proved to be inaccurate.

“My initial scan gave my son an EDD 4 Aug. The dating scan gave him an EDD 13 Aug. He was born 28 Aug… It’s a long time! 15 days later… (Caregivers need to have ) More faith in parents who know when they conceived. Perhaps if I had been listened to and induced earlier … he would not have spent as many days in the NICU with breathing difficulties, on high flow oxygen and the whole situation would have been better for both of us.”

“I didn’t like how inaccurate my growth scans turned out to be as I was induced based on an anticipated large baby who came out completely average.”

(Waikato 2017)

“Baby was “big” on scans and expected to be 11 pounds so I was told induction was bestway to go – against my preferences. But I went along and 4 days later baby finally came out weighing 8 pounds 11 and ended up in NICU from the traumatic birth …”

(Auckland 2018)

(iv) Some parents were upset or angry about the attitude of, or comments made by, sonographers. Consumer feedback suggests that some sonographers do not understand the concept of informed choice or that their role is to provide information and recommendations to the referring LMC, not directly to the pregnant woman/whanau at the time of the scan, unless expressly requested.

“I would improve the treatment I got at ultrasound appointments – I was told during a scan that I would need a caesarean. I did not need one but even if I had that was not appropriate and caused me undue distress.”

“I had a terrible time, at several extra scans that I had to have, due to the poor attitude of several sonographers.”

“…an anatomy scan was our first and only scan… (The sonographer) proceeded to try to do the screening assessments anyway and guilt me into going for another scan 2 weeks later. I said “No, I’m not interested, please just do what’s on the referral form.” She ignored me and said she HAD to do it because her bosses required it. It’s like informed consent doesn’t exist and it doesn’t matter that it was my body, she HAD TO DO IT”

(Auckland 2018)

“I had to have a few growth scans to check that my baby was growing. Turns out she was fine but the scanning person recommended that I come back at around 39 weeks to check that baby was still OK and to see what my cervix was doing. Should these people even be offering women extra scans? Is it their job to cause worry by suggesting that something could be/go wrong with my baby/pregnancy – or is it an income-generating scheme?! More scans = more income”

(2018)

“I feel that all the measurements should be kept off the reports that the woman receives at the time and instead should go straight to the LMC to discuss with the woman…”

“The scan techs on two occasions needed some training on respectful practice. We asked not to know weight estimate but we were rudely told anyway. We had a postdates scan and the scan tech told us we should be induced. They should keep personal opinions to themselves and respect our choices without question.”

(Auckland 2018)

“When I went for my anatomy scan, I already felt really unwell if I lay on back for long. I didn’t want or need a full anatomy scan but the technician seemed more interested in her agenda than mine. Once the initial look was done and there were no apparent concerns, I was ready to stop but the technician would not let me get up, saying, “just a bit longer…just a little bit more,,,” for over 20 minutes. She wasn’t interested in me telling her I wasn’t comfortable on my back and needed a break until I threatened to vomit on her shoes (which was not an idle threat by then!). Even then she convinced me to lie back down for another 10 minutes to “finish”. Being my first baby, I wasn’t sure of how long an anatomy scan would take or if I needed to stay for the thing – I too nice and polite.”

“I was told during a scan that I would need a caesarean. I did not need one but even if I had that was not appropriate and caused me undue distress.”

(Auckland 2015)

“I experienced appalling communication skills from a sonographer who scanned me for my first miscarriage.”

(Dunedin)

MSCC recommends that a pathway for feedback to sonographers becomes routine. We believe that it is essential that ultrasound providers receive feedback from both women and their LMCs when, their assessments have proven to be incorrect.

4. Support ratification of national maternity clinical guidelines and monitor implementation of existing guidelines

The NMMG appraised a number of national guidelines including:
(i) Screening, Diagnosis and Management of Gestational Diabetes in New Zealand: A clinical practice guideline (2014)

The NMMG asked the DHBs to report on their implementation of the recommendations in this guideline. In yet another distressing example of the fact that there seems to be no way of ensuring that Best Practice Guidelines are nationally implemented, the NMMG report told us that only “Five DHBs noted changes to the care they are providing to women with gestational diabetes” since the relase of this Guideline.(pg 20)

Women who responded to our consumer survey also reported differing experiences with the services and recommendations(or dictates) they received subsequent to a diagnosis of GDM.

“I had GDM and reported to “diabetes midwives” throughout pregnancy. I had one normal midwife and a diabetes midwife, made it a bit weird. I also saw 2 different obstetricians and they both gave different recommendations. One of them was very textbook and I feel didn’t take me into account just looked at procedure, the other was great.”

(2018)

“Because of baby having low blood sugar levels they were giving top ups of formula. I wasn’t given much information about this and why it had to happen and it happened very quickly. One minute she was passing the sugar level test in my room the next minute she fails a test and is being rushed into special care with a tube being put in her nose and a drip in her arm. After being up all night in labour they didn’t take me aside and tell me what needed to happen they just did it. It was quite upsetting.”

(2018)

“Currently (receiving) combined care of midwife, and obstetrician (multiple) and diabetes team at the hospital. This time, not seeing a consistent obstetrician, and having different opinions and information from each is very dissatisfying. Appointments are made week after week with no need, no new information so having to get a lot of time off work. Being questioned on why I cancelled the third set of clinic appointments in a row at only 27 weeks pregnant.. Also the insistence on the “medical” model despite having no comorbidities (other than gestational diabetes with sugars controlled on insulin) (now at 30/31 weeks) and differing opinions on due dates and therefore when induction “should” take place.”

( Dunedin 2018)

“Very satisfied with my midwife, she fought for me so I could have the birth I wanted and also helped when I had trouble with my gestational diabetes nurse, who tried to scare me into making choices I knew where wrong for me. Obstetrician was good and listened to what myself and my midwife had to say. Gestational diabetes nurse- awful – she told me my baby would die if I didn’t go on insulin, I was only 0.1 over the blood sugar level that classed me as gestational diabetes so I felt that insulin would do more harm, I managed with diet and oral meds and delivered a healthy baby with no blood sugar issues. If I had of gone on insulin she would of had to go into the NICU and I would of been induced.“

(Wellington 2017)

MSCC is unsurprised to learn that the recommendations of this 2014 Guideline have not been nationally implemented. We are aware that, even within the same DHB, women receive different advice and treatment depending on the individual practitioners they see. (To assist women and their LMCs to make informed choices about their care we will publish a more in depth summary of this guideline on our website @ https://maternity.org.nz/hot-topics.html) Women and their primary care providers may be interested in a couple of evidence-based recommendations in this report:

Confirmed Diabetes in Pregnancy
Glucose targets are: a fasting level of ≤5.0 mmol/L; ≤ 7.4 mmol/L at one hour after meals; and < 6.7 mmol/L two hours after meals for more than 90% of readings during a week.
If glucose levels are higher than these for more than 10% of readings, metformin and/or insulin may be required. “Metformin appears to be as effective as insulin in treating women with gestational diabetes for maternal and infant outcomes.”(pg28)

Ultrasound Scans
The report notes that, fetal growth assessment by serial ultrasound scanning of women with GDM has not been shown to either be reliable in terms of accuracy, or to improve outcomes for mothers or babies.

Birth
If an ultrasound scan at 36 to 37 weeks reports normal fetal growth (< 90th percentile – presumably with reference to the personalised growth chart – ed) and there are no other maternal or fetal risk factors, labour and birth at 40+ weeks is indicated. “Vaginal birth is the preferred mode of birth. Elective delivery prior to 40 weeks’ gestational age is not recommended in women who have no obstetric complications (including hypertension, pre-eclampsia, large for gestational age infant ≥ 90th centile, maternal age > 40 years) and who have had good glucose control (> 90% of glucose readings within glucose treatment targets) throughout their pregnancy.” (pg xiv)
If fetal growth is > 90th percentile or if there are maternal and/or fetal risk factors in addition to GDM, the recommendation is for individual obstetric assessment with a view to delaying induction of labour till 38 -39 weeks gestation. (Only “Two DHBs noted an observed change in the timing of induction, from the 38^th to the 39^th week of gestation.” (pg 20)
Note: Women should be advised to stop taking any diabetes medication during labour.

Neonatal Blood Glucose Monioring
It is recommended that babies’ plasma glucose levels are measured at 2, 4, 8 & 12 hours of age, or until there have been three consecutive readings of >2.6mmol/L.
Note: “An appropriately sensitive method, such as the glucose oxidase method, should be used to test for neonatal hypoglycaemia. Accucheck is not sensitive enough and should not be used to measure neonatal blood glucose.” (pg.38) For neonatal hypoglycaemia, a small supplemental feed, preferably of breast milk is recommended. “Encourage women who are unable to breastfeed, or do not wish to breastfeed, to use donor breast milk* before formula milk.”(Pg xxiv)

Results
Babies with recurrent blood sugar levels of < 2.3 mmol/L should be referred to a paediatrician before intravenous dextrose is offered.

*Donor Breastmilk
MSCC supports the use of donor breastmilk and is interested to see this recommendation implemented. So far no DHB, (except Canterbury), has supported this recommendation by setting up breastmilk banks. Neither has the MoH helped ensure the safety and ready availability of donor milk by ensuring that women willing to donate their breastmilk have free access to blood testing for cytomegalovirus. Women also report a lack of support from DHB staff when they have organised through friends, families or voluntary breastmilk sharing organisations to feed their babies donor breast milk.

Antenatal Milk Expression (AME)
The 2014 Guideline goes on to say that at the time of writing, Antenatal Milk Expression (AME) to both, help avoid the need for hypoglycaemic babies to be given infant milk formula and to assist the early establishment of lactation, was not able to be supported by any research. The most recent, good quality research MSCC was able to find, comes from an Australian RCT published in 2017.^[1] Women with pre-existing DM or GDM were randomized into study and control groups. Women in the study group were advised to express colostrum (2 x daily) antenatally from 36 weeks’ gestation whereas women in the control group did not express colostrum. The outcomes showed that there was no statistical difference in the incidence of neonatal hypoglycaemia, the requirement for intravenous dextrose or the numbers of babies admitted to the neonatal unit, between babies of mothers in the AME group and the control group. However, babies who had access to expressed colostrum were given less formula milk (45.5% vs 58.7%) and more women in the AME group exclusively breastfed their babies up to 3 months of age (60% vs 55%).
MSCC is disappointed that 4 years after the publication of this report there appears to have been almost no progress at either MoH or DHB level with setting up Breastmilk Banks or researching, encouraging and supporting AME as a way of increasing the numbers of newborn babies who are fed human milk.

STOP PRESS: Mothers Milk NZ, Charitable Trust is a mother-to mother online breastmilk sharing initiative set up to fill the need for donor human milk that has largely been ignored by our DHBs. Emma Ryburn-Phengsavath, from Mothers Milk, has passed on information about a compact and affordable human milk pasteurization system that could make small, local breastmilk banks (e.g. at PBUs) a reality.
Professor Anna Coutsoudis, academic and researcher in the Department of Paediatrics & Child Health, University of KwaZulu-Natal (UKZN) has co- developed this low-cost, effective, flash pasteurisation system for breastmilk. Up until now the prohibitive cost of commercial pasteurisers has made the establishment of human milk banks in small hospitals and community organizations almost impossible. Commercial pasteurisers use the Holder method of pasteurisation, which heats the milk to 62° C and holds this temperature for 30 minutes. Flash Pasteurisation is a high temperature short time (HTST) form of pasteurisation. The Piastra flash heating system uses flash heating to bring the donor milk up to 72° C for approximately 15 seconds. This rapid heating for a short time is less destructive of properties in breastmilk and so is considered to be superior to other forms of pasteurisation.
For further information about the Piastra System go to PiAstra.org

5. NMMG reviewed key sector reports including:

(i) Perinatal and Maternal Mortality Review Committee:11th Annual Report.

The NMMG “reviewed the Perinatal and Maternity Mortality Committee’s (PMMRC) report on cases of amniotic fluid embolism and investigated the level of emergency obstetric skills training in DHBs.”(pg22) They go on to say that, “…we are pleased to note that the development of appropriate skills in this area is a priority for DHBs. However, we would like to see more consistency between DHBs in the expected level of emergency obstetric training …” In-house multidisciplinary training in the management of obstetric emergencies occurs in sixteen DHBs. Attendance at these training sessions is not mandatory for all obstetric, midwifery (core and lead maternity carer) and anaesthetic staffin all of these DHBs. (Perinatal and Maternal Mortality Review Committee:11th Annual Report. Pg29)

Fortunately the incidence of amniotic fluid embolism (AFE) is very rare. A combined Australian & New Zealand study^[2] using 2010 – 2011 data, put the incidence at approximately 5.4 per 100,000 women giving birth with an estimated maternal mortality rate of 0.8 per 100,000 women. The PMMRC (2017) report reveals that 1 woman in NZ died from AFE in 2015 (1:59,808).

MSCC is pleased to see that most DHBs are providing training to ensure that maternity care providers are able to recognize the symptoms and respond promptly and appropriately to AFE. However, we would also encourage the DHBs to assist in reducing the risk of AFE by implementing policies and staff trainings, that will lower the rates of IOL and c-section, since these interventions have been shown to be risk factors for AFE. Although the numbers of cases in the, Amniotic fluid embolism: an Australian-New Zealand population-based study(2015) referred to above, are thankfullysmall, the increase in risk following either IOL or c- section is significant.^[3]

	Amniotic Fluid Embolism: Number(%)
Spontaneous Onset of Labour	9 (27%)
Induction of Labour	12 (36%)
Vaginal Birth	11 (33%)
Caesarean Section	22 (67%)

AME can occur up to 48 hours post birth. We have further concerns that staff shortages in the postnatal wards of most of NZ’s Maternity/Obstetric Units, and the resulting inability of staff to either regularly check on women or to respond in a timely manner to calls for assistance (as reported in our September 2018 newsletter), add to the risk of adverse outcomes for women who have an AFE.

(ii) 2015 Report on Maternity

NMMG also reviewed this report, we question the committee’s generous conclusion that this report provides “a wide range of useful clinical, statistical and demographic information.” (pg 22). Despite the fact that it is now the end of 2018, the 2015 report is the latest national Report on Maternity available; the latest national Maternity Consumer Survey available is for the 2014 year(!) and; the latest national New Zealand Maternity Clinical Indicators Report available is for the 2016 year. Given the current crisis in maternity – nationwide midwife shortages, overcrowded facilities and increases in intervention throughout women’s maternity care experience – MSCC would have expected the MoH would ensure that more recent data is available to inform strategies that could assist in reversing the growing crisis.

6. Investigate Access to and provision/use of primary maternity facilities

The NMMG reports that, “the proportion of babies born in primary maternity facilities has been trending downwards since 2007 (15.6% in 2007; 9.9% in 2015).” The NMMG notes that almost all births at primary maternity units are spontaneous vaginal births and that the numbers of transfers in labour from PBUs is low. MSCC continues to be frustrated by both the MoH’s and the DHBs lack of commitment primary birthing. There is no national strategy for promoting birth in a primary setting for low risk women; PBUs continue to be closed; the planning for and building of new publicly funded PBUs is so slow as to be practically non-existent; and a large number of existing PBUs are in urgent need of upgrading.

The MSCC has spent decades lobbying for the establishment of more PBUs and for MoH & DHB to publicly promote the benefits to mothers and babies of birthing in primary environment. We fully endorse NMMG’s statement of support for primary birthing. “…the NMMG supports strengthening primary maternity services including timely, equitable, access to community-based primary maternity care…We encourage the Ministry and DHBs to promote physiological birth and to better understand women’s preferences about place of birth.” (pg24)

Many women are prevented from birthing in a primary environment by booking criteria. Most have a list of conditions e.g. maternity history, maternal age and method of conception etc that automatically exclude women instead of facilitating women’s choice and trusting the clinical assessment of her LMC. e.g. MSCC was recently contacted by a woman who was prevented from birthing in her local PBU (that is alongside the Maternity Hospital and shares the same main entrance!) because she had had a previous c-section!

Feedback from the consumer survey indicated that restricted access to a PBU for both birthing and postnatal care is an issue throughout the country.

“Midwifery is vitally important, New Zealand women and their partners deserve choice when it comes to the type of care they receive. To me this means funded Birthing Centres in all major cities at a level that adequately caters for the population. I would hate to live in a city where my only real choice to birth is at a hospital – we are lucky in Hamilton.”

“I would have preferred to birth at a birthing centre that provided accomodation for my partner also and after care. Would have been more than happy to have paid for the luxury but no choices other than home or hospital were available in Lower Hutt at that time. The hospital was very full after the birth of our second child and I had a room that felt like a broom cupboard with no windows.”

(2016 – NB – Te Awakairangi PBU opened in this area in 2018)

“Lack of beds in the Paraparaumu birthing unit (there are only 2) meant that after one of my births I had to bundle up my 2 hour old baby and drive to Kenepuru Maternity Unit at 4am.”

“Wanted to give birth in birthing center but it was full so I had to stay in hospital.”

(Tauranga 2017)

“Tauranga should have more birthing units too as our only one limits who they let stay now.”

(2015)

For decades, DHBs have not prioritised the funding of PBUs, for either building or maintainance or even to keep existing PBUs open!

“Papakura maternity unit needs to be done up (the building). Not the staff, they were awesome. but its so old (and cold).”

“Our first child was born at Elizabeth R Maternity Unit which was such an awesome place it was like a home away from home and the care I received in there was beyond amazing I wish it was still open.”

“Definitely need a birth centre in Wellington and more evidence based practice performed in hospitals.”

(2018)

The NMMG attempted to review data on transfer rates between primary, secondary and tertiary maternity facilities. Unfortunately, “No data is collected on reasons for transfers, and the data that is available only shows place of birth not planned place of birth.”(pg23) This section concludes with NMMG stating, “We encourage the Ministry and DHBs to promote physiological birth and to better understand women’s preferences about place of birth.”(pg24) MSCC wholeheartedly supports this recommendation!

7. Investigate consistency in the quality of first trimester antenatal care.

NMMG reports that at least half of DHBs have launched initiatives to meet MoH’s target of having 90% of women register with an LMC in the first trimester by 2021. Whilst it is pleasing to see that the MoH and the DHBs are promoting this aim, the midwifery shortage (which has been largely unaddressed for over a decade) and under-payment of LMCs (which makes responding to multiple enquiries each day from women trying to find a midwife impossible for overworked LMCs) are making it more and more difficult for women in some areas to register with an LMC before the end of the first trimester.

NMMG noted that, “Approximately 60% of women …see a non- LMC practitioner in their first trimester…”(pg24) this is almost always an GP and has led the NMMG to appoint a “practising GP to the NMMG for 2016- 19.” While there are some women who will choose to consult with their family GP during early pregnancy, the majority of women who consult a GP before

finding an LMC do so because they do not have information about how maternity care is provided in NZ or how to access an LMC. MSCC is concerned that the LMC midwifery shortage will result in GPs providing 1^st trimester care by default. We urge the MoH to look at alternatives to facilitate access to midwifery care from the beginning of pregnancy. There must be a large number of midwives who are not able to provide full continuity of LMC care for age, family, health related etc reasons, who would be happy to provide 1^st trimester information and care to women till they can register with the LMC of their choice. A 7 to 9 minute consult with a GP is insufficient to provide women with information about their options for maternity or to support them to make informed choices about routine early pregnancy screening etc. In addition, very few GPs now have vocational training in obstetrics or any real knowledge about the availability, or even how to contact, LMCs in their area.

The MoH’s priorities for 1st trimester care are focused on “Core Health Outcomes” e.g. increasing the percentage of babies living in smoke-free households, improving maternity and child immunization rates, reducing the numbers of babies at risk of Fetal Alcohol Syndrome and other deficits relating to maternal addictions to drugs etc, early identification and treatment for women with DM or GDM etc. NMMG discovered that many DHBs produced resources and developed plans and processes to encourage 1^st trimester registration with an LMC especially targeting women from population groups who have been shown to be the least likely to do so.

However, the joint consumer survey revealed that women throughout the country are experiencing considerable trauma as a result of the lack of care and compassion available following miscarriage. In 2007 the single service payments for LMC attendance at a miscarriage and follow-up visits after miscarriage were dropped. Women’s experiences clearly indicate that there is a need to reinstate these service modules.

“I had a miscarriage at 6 weeks in January 2017. I did not have a midwife at that point so was still under the care of my GP. This was my first ever pregnancy and when I went to see my GP for a suspected miscarriage, I was told “it’s normal” and “don’t worry, you will get pregnant again”. Not ideal!”

(Auckland)

“I had 3 miscarriages before my first baby, and another one between my first and second. I could have done with more support at those times. Just because it is common doesn’t mean it’s not intensely painful.”

“I had 3 miscarriages in between my son born in 2016 and my current pregnancy. I was never offered any support even after a D&C in hospital. I found this extremely hard to deal with.”

“I was not satisfied with some of the care/processes in place for my losses. The process for inducing a missed miscarriage and D&C was horrific. I was made to go to the birthing unit the first 2 times I needed treatment – it was beyond horrific to go where live babies are born to birth your dead baby … for the third time, my wonderful GP called the hospital and arrange for me to attend the day surgery unit instead, it was much less traumatic. Also having the staff describe your lost baby was “products of conception” is pretty awful to hear.”

(Rotorua)

“I also had a miscarriage a couple of months ago and the EPAU(Early Pregnancy Assessment Unit) couldn’t even see me for 5 days after I got my referral. It was my first miscarriage and honestly that kind of delay in support is unacceptable. It’s a traumatic time and again lack of staffing to cope with patients seemed to be the issue.”

(Auckland 2018)

“In December 2016 I experienced a pregnancy loss requiring a D&C and had a very upsetting experience being placed in recovery hear a new and crying baby post surgery. It was hugely traumatic and upsetting go for me to be made to listen to the crying of a new baby immediately after experiencing the finality of losing a much wanted baby. I was too upset at the time or afterwards to give any feedback so this is a good opportunity to have the chance to say that I felt that the emotional and psychological side of miscarriage and D&C experience was hugely lacking and that it might be something that can be considered. For other women in that situation to be spared exposure to the very thing they have just lost, at such a vulnerable time”

At 15 weeks I had bleeding and cramps, I went to ED on my midwife’s advice and they were very cold and told me it was a threatened miscarriage and sent me home without even checking my baby still had a heart beat or anything. Thankfully my midwife sent me for an urgent scan the next day and baby was okay. But some more compassion from the hospital doctor would’ve been nice, I know they’re extremely busy!

“We suffered two miscarriages and no support was given nor offered. I was told “it just happens”.”

“Better support (needed) for mothers after miscarriage – better recognition of the absolute heartbreak that exists for most women ‘even’ with 1st trimester losses. Miscarriage support to include consistent levels of support by midwives, more info readily available to women as soon as they learn/know they are miscarrying, better referral to support services/groups/counselors if needed. Different waiting area at Capital & Coast WAAS so when you are miscarrying you don’t have to sit next to women with beautiful big round bellies. More readily available testing of miscarriage/baby if desired, so peace of mind can be given to parents experiencing multiple miscarriages.”

Considering that approximately 1:4-5 pregnancies end in miscarriage, it is an appalling oversight that our maternity services provide no suitable support for mothers/couple/whanau during this experience. It is also a clear example of how our maternity services pay lip service to providing “women centered care” but in fact define priorities for services and funding without actually asking women what they need.

MSCC has consistently drawn attention to the fact, that more and more funding is spent on medical interventions in maternity care, but the services that women consistently identify as being needed, e.g. miscarriage support services, information about and easy access to LMC midwifery care, access to longer inpatient postnatal care, more assistance with establishing breastfeeding, access to tongue tie remediation and lactation consultant services, are overlooked and underfunded.

Ignaz Semmelweis (1 July 1818 – 13 August 1865)

Finally, before we enter a new year, MSCC would like to acknowledge the 200 year anniversary of the birth of Ignaz Semmelwies, the Hungarian surgeon obstetrican who discovered that handwashing saved mothers’ lives. While working in a Vienna, he observed that the incidence of puerperal fever, which killed hundreds of new mothers, was much higher in the clinic where women were attended by surgeons, compared with the clinic where women were attended by midwives.

He meticulously worked through all the differences in the two clinics, their staff and patients, till he realized that the women who were attended by doctors, who also performed autopsies, experienced a much higher incidence of puerperal fever and death.

In 1847 he concluded that the doctors carried “cadaverous particles” on their hands from the autopsy room to obstetrical clinic and instituted a policy of washing hands between autopsy work and the examination of labouring women. He recorded dramatic reductions in maternal mortality following his insistence on handwashing. In 1848 he instituted a policy of washing of all medical instruments and bed linen that were used during labour and noted a further reduction in the incidence of puerperal fever to almost zero. Semmelweis’ observations conflicted with established medical beliefs and practices of the time and his ideas were ridiculed and ignored – doctors would not accept that they were the cause of childbed fever. In 1865, nearly twenty years later, Louis Pasteur was able to articulate a theoretical explanation for Semmelweis’ observations — the germ theory of disease – leading to a more universal aceptance of need for handwashing and aspetic medical protocols.
Semmelwies was not only the “saviour of mothers”, he was also a father of modern medical science. He used observation, comparison and statistics to establish differences between 2 study groups, formed a hypothesis then tested it before instituting new practice protocols.

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