Under-reporting of maternal and perinatal adverse events in New Zealand

Abstract

Objectives: To determine the proportion of maternal and perinatal mortality and morbidity cases, identified by the Perinatal and Maternal Mortality Review Committee (PMMRC), that are also reported within the annual serious adverse events (SAEs) reports published by the Health Quality and Safety Commission (HQSC).

Setting: Nationally collated data from the PMMRC and HQSC, New Zealand.

Participants: Analysis of maternal and perinatal mortality and morbidity data 2009-2012.

Interventions: Every SAE report published by the HQSC from 2009 to 2012 was scrutinised for maternal and perinatal cases using the case history provided by district health boards (DHB). Further detail of each case was requested from each DHB to establish whether they had been identified as maternal or perinatal mortalities or morbidities by the PMMRC.

Primary outcome measure: The proportion of maternal and perinatal mortality and morbidity cases identified by HQSC SAE reports, compared with PMMRC reporting.

Results: 58 maternal and perinatal SAEs were identified from the SAE reports 2009-2012. Of these, 50 fit under the PMMRC reporting definitions, all of which were also reported by the PMMRC. In the same time frame, the PMMRC captured 536 potentially avoidable maternal and perinatal mortalities and morbidities that fitted the HQSC SAE definition. Fewer than 9% of maternal and perinatal SAEs are captured by the HQSC SAE reporting process.

Conclusions: The rate of maternal and perinatal adverse event reporting to the HQSC is low and not improving annually, compared with PMMRC reporting of eligible events. This is of concern as these events may not be adequately reviewed locally, and because the SAE report is considered a measure of quality by the DHBs and the HQSC. Currently, the reporting of SAEs to the HQSC cannot be considered a reliable way to monitor or improve the quality of maternity services provided in New Zealand.

Keywords: AUDIT; NEONATOLOGY; OBSTETRICS.

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Figures

Figure 1

Maternal and perinatal morbidities and mortalities recorded by the PMMRC and SAE per annum. *The PMMRC started data collection on NE and maternal morbidity in 2010 (NE, Neonatal encephalopathy; PMMRC, Perinatal and Maternal Mortality Review Committee; SAE, serious adverse event).