NATIONAL MATERNITY MONITORING GROUP
2016-17 WORK PROGRAMME
BACKGROUND
The National Maternity Monitoring Group (the NMMG) provides strategic advice to the Ministry of
Health on priorities for improvement to the maternity system and the implementation of the New
Zealand Maternity Standards. This document outlines the NMMG’s work programme for 2016/17. To
deliver this work programme, we expect to meet quarterly (August, October, February and May).
STRATEGIC CONTEXT
The NMMG’s work is guided by the priorities set out in the refreshed New Zealand Health Strategy1,
the New Zealand Maternity Standards and the Maternity Quality Initiative.
In April 2016, the Minister of Health released the refreshed New Zealand Health Strategy. The Strategy
outlines a high-level direction for New Zealand’s health system to 2026. It is accompanied by a
Roadmap of Actions2, many of which have a focus on our maternity system, pregnant women and
babies. Together, the Strategy and the Roadmap provide guidance on how we can all work together to
ensure that all New Zealanders live, stay and get well. It provides critical guidance on the work of the
NMMG and has informed the preparation of our 2016/17 work programme.
The New Zealand Maternity Standards3 consist of three high-level strategic statements to guide the
planning, funding, provision and monitoring of maternity services:
1.
2.
3.
Standard 1: Maternity services provide safe, high-quality services that are nationally
consistent and achieve optimal health outcomes for mothers and babies
Standard 2: Maternity services ensure a woman-centred approach that acknowledges
pregnancy and childbirth as a normal life stage
Standard 3: 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.
The Maternity Quality Initiative (MQI), refocused in 2015, contains four key priorities:
1.
2.
3.
4.
Strengthening maternity services including more timely access and more equitable access
to community-based primary maternity care and services
Better support for women and families that need it most, including better health and social
support for young mothers and for maternal mental health and support for improving
health literacy among vulnerable populations
Embedding maternity quality and safety including further support for local clinical
leadership and review, and meeting the Ministry’s obligations under the New Zealand
Maternity Standards, and
Improving integration of maternity and child health services including improving
transitions between health services through improved communication, coordination and
use of information technology.
1
Minister of Health. 2016. New Zealand Health Strategy. Wellington: Ministry of Health.
Minister of Health. 2016. New Zealand Health Strategy: Roadmap of actions 2016. Wellington: Ministry of Health.
3 Ministry of Health. 2011. New Zealand Maternity Standards. Wellington: Ministry of Health.
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SUMMARY
Our work programme for 2016/17 aligns to the priorities set out in the refreshed New Zealand Health
Strategy and Roadmap of Actions as well as continuing previous workstreams where further work to
investigate or monitor is required. A summary of our work programme is provided below.
In recognition of the range of health sector stakeholders working in maternity care, the NMMG expects
to continue to work closely with other key groups working in maternity, including the PMMRC, the
Maternity Ultrasound Group and the Midwifery Strategic Advisory Group. We also expect to consider
how other stakeholders are addressing the following NZ Health Strategy priorities before
incorporating related activities into future work programmes: Maternity Information System
development, prevention of fetal alcohol spectrum disorders and the review funding, contracting and
accountability arrangements for primary maternity services.
CLOSER TO HOME PRIORITIES
a) Investigate access to, provision and use of primary maternity facilities for women
The number of babies born in primary maternity facilities has been slowly declining (i.e., from 11
percent in 2009 to nine percent of total births in 2014). Almost all births at primary maternity units
are spontaneous vaginal births. Access to and use of primary maternity facilities remains an important
issue for the NMMG, particularly in light of the NZ Health Strategy’s theme, Closer to home, and Action
6 in particular (ensure the right services are delivered at the right location). Specific issues that need
to be considered include:
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Influencers on women’s preferences regarding place of birth
Location of primary birthing facilities, staffing levels, and use/occupancy rates
Access to primary maternity facilities in rural and remote areas
Integration of primary birthing facilities into DHB management and quality frameworks
Closing data gaps (for example, in-labour and post-natal transfer rates between type of facility,
number of LMCs working in remote and rural primary birthing facilities, etc.), and
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Guidance DHBs require to maintain and manage primary birthing units within the MQSP
framework.
In 2016/17, we expect to better understand data on the number of women who plan to birth at a
primary facility compared to where they actually birth (including changes to bookings during the
antenatal period and transfer during labour). We will also explore New Zealand data on baby
outcomes by type of facility and the demographics of health practitioners by facilities.
b) Continue to investigate consistency in the quality of first trimester antenatal care
Approximately 60 percent of women who give birth see a non-LMC Section 88 claimant in their first
trimester of pregnancy before registering with an LMC. Specifications for first trimester care are welldescribed in the Section 88 Primary Maternity Notice. Ensuring that health practitioners provide a
high quality of maternity care is important as a wide range of health practitioners may be involved in
early pregnancy care. The importance of general practice in maternity care is reflected in the
appointment of a practising GP to our group for 2016-19. Continued investigation of this workstream
supports the NZ Health Strategy theme, Closer to home and Action 7 in particular (people working in
the health system fully use their skills and training).
In 2016/17, we expect to investigate care provided in non-LMC first trimester contacts/consultations
by:
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examining the first contact a woman has with a GP and the timing of LMC registration by DHB
to identify if there are particular regions where there are trends of women registering late
investigating early pregnancy and prenatal care initiatives to assess whether social
investment in the start of life is having a positive impact on vulnerable children
asking DHBs about timing of first contact and whether they are aware of any identified
timeliness of registration issues and confirm with them about GP knowledge of how to facilitate
access to LMCs, and
discussing with the Colleges (including the Royal College of General Practitioners) the need
for referral letters to maternity care around what tests and investigations have been done, so
as to support better information sharing.
c) Monitor access to anti-D
One of the NMMG’s previous investigative workstreams focuses on providing a great start for children
(Action 9 in the NZ Health Strategy Roadmap): investigation into access to anti-D prophylaxis following
a sensitising event in pregnancy. In 2015, the Ministry of Health requested that the NMMG investigate
whether Anti-D should be made available to all Rh negative women antenatally. Our initial
investigation raised a number of queries about consistent access to anti-D across New Zealand. In
2016/17, we will monitor the use of the Anti-D in DHBs and we expect to receive an update on the
National Women’s Health audit of all intrauterine transfusions for fetal anaemia.
d) Monitor timely access to community-level non-acute mental health services
Accessing community level maternity mental health services in a timely way supports the NZ Health
Strategy theme, Closer to home. Women need access to appropriate primary maternal mental health
services during pregnancy and post-partum and for some women, access to and provision of primary
mental health services during and after pregnancy is essential to their safety and that of their babies.
Women with existing mental health issues are at risk of escalation during the pregnancy and postnatal
period. This is particularly true for women with a history of bipolar disorder, psychosis or postnatal
depression/severe depression.
Suicide remains a leading cause of perinatal death: maternal suicide is seven times more common in
New Zealand than in the UK. The tenth annual Perinatal and Maternal Mortality Review
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Committee (PMMRC) report includes a review of maternal suicides from 2006 to 2013 which found
that risk factors for major depression were not always identified, and that there is a need for improved
communication between services. This analysis has also led to the PMMRC planning to do further
analysis of death from suicide in 2015–2016.
In 2016/2017, we will continue to support better knowledge in the maternity sector of available
mental health services, timeliness of access to mental health services for women, and better
integration between maternity and mental health services through the provision of transparent
pathways of access in DHBs. We will do this by:
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exploring examples of good practice in this area
monitoring DHBs to determine whether there is unmet need/capacity of primary and
secondary care in relation to maternal mental health pathways and service accessibility
including the primary maternal health pathway at a community level (as well as acute mental
health)
reviewing PMMRC’s report (when it is released) to determine what maternal mental health
recommendations should be taken forward as a priority, and
monitoring the development of the maternal morbidity working group and its findings.
SMART SYSTEM PRIORITIES
e) Review the New Zealand Maternity Clinical Indicators and monitor DHBs’
responses to variations
The New Zealand Maternity Clinical Indicators are a key part of the MQI. The Indicators are nationally
standardised benchmarked maternity data which provides information about the quality of and
national consistency within New Zealand’s maternity services. Maternity sector stakeholders rely on
this data to determine whether the New Zealand Maternity Standards are being met. The NMMG uses
this data to identify national and local priorities for action. Action 25 of the Health Strategy’s Roadmap
of Actions, involves increasing analytical capability and the quality of national data to improve the
design and delivery of services and increase transparency.
In 2016/17, we expect to:
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review available Indicator data (with emphasis on indicators relating to:
o timeliness of women registering with an LMC within the first 12 weeks of pregnancy
o the impact of healthcare provider-determined time of delivery on gestation at birth
o perineal trauma, and
o the impact that DHB MQSPs have had on maternity outcomes for mothers and babies)
share our findings with and seek advice from each DHB regarding any identified significant
and consistent variations from the national average and the DHBs’ responses to these
(including where DHBs are performing well)
provide advice to the Ministry of Health on possible improvements or amendments to the
current Indicator set (as required)
determine instances where DHBs have identified clinical coding as a possible explanation for
data variances and providing advice to the Ministry and DHBs on the implications of this
develop consensus regarding which population growth charts should be used in New Zealand
for both pre-term and term, and
meet with Expert Advisory Group annually to discuss the picture provided by the Indicators.
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ONE TEAM PRIORITIES
f) Monitor maternity workforce recruitment and retention through the work of the
Midwifery Strategic Advisory Group
Workforce development initiatives are crucial for supporting a sustainable and adaptive maternity
workforce. These are reinforced by action 24 of the Health Strategy Roadmap of Actions under the
goal of One Team, which involves establishing workforce development initiatives to enhance capacity,
capability, diversity, succession planning, and workforce flexibility. Health Workforce New Zealand
has established a Midwifery Strategic Advisory Group to ensure that New Zealand has a sustainable
and supported midwifery workforce.
In 2016/17 we will monitor workforce recruitment and retention through consideration of the
Midwifery Strategic Advisory Group’s work. We expect to:
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support the Midwifery Strategic Advisory Group in its work relating to maternity workforce
recruitment and retention
review findings and advice provided by the Midwifery Strategic Advisory Group, and
provide advice to the Ministry of Health on possible improvements or amendments to current
recruitment and retention strategy and practices (as required).
VALUE AND HIGH PERFORMANCE PRIORITIES
g) Monitor the outcomes of work by the Maternity Ultrasound Advisory Group
The New Zealand Health Strategy’s goal to improve performance and outcomes, involves smarter and
more transparent use of data. In 2014/15, the NMMG highlighted the rising primary maternity
ultrasound rates in New Zealand and variability in access and quality. In 2016/17 we intend to
continue monitoring the outcomes of the Maternity Ultrasound Advisory Group’s work. We expect
to:
 support the Maternity Ultrasound Advisory Group in its work to develop standards for this
area and monitoring responsibilities by participating as a Group member and by receiving and
commenting on reports from the Group as the NMMG, and
 review findings and advice provided by the Maternity Ultrasound Advisory Group.
h) Support ratification of national maternity clinical guidelines and monitor
implementation of existing guidelines
Action 14 of the Roadmap, which relates to the goal to improve performance and outcomes, calls for the
development and implementation of a monitoring framework focused on health outcomes. National
maternity clinical guidelines are a key component of the maternity sector. They set standards based
on the latest clinical evidence or best practice and enable consistency in clinical maternity practice
nationally.
In 2016/17, our aim is to ensure that national evidence-informed clinical guidance is appraised and
ratified using the AGREE II Instrument and algorithm. We expect to:
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consider draft material for ratification as national guidelines (as required)
support the Ministry’s efforts to develop guidance on pregnancy and hypertension/preeclampsia, and
monitor the development of at least one new guideline per annum.
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i) Review key sector reports
Reviewing key maternity sector publications is one of the NMMG’s responsibilities. It includes
reviewing publications like the Ministry of Health’s Report on Maternity, an annual statistical report on
pregnancy and childbirth in New Zealand. This further supports the Health Strategy goal to improve
performance and outcomes, by utilising data. In 2016/17, we expect to:
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review the Report on Maternity and the accompanying data tables as these are produced and
provide advice to the Ministry about our findings and possible priorities for action (including
considering the relationship between early planned birth, maternal age and ethnicity)
determine instances where DHBs have identified clinical coding as a possible explanation for
data variances and providing advice to the Ministry and DHBs on the implications of this, and
review the PMMRC annual report, provide advice to the Ministry about any notable findings or
recommendations, and work closely with the PMMRC to ensure that information requests to
DHBs are coordinated.
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We also expect that DHBs are reviewing the same key sector reports and considering how the
recommendations apply to services provided in their areas. We expect DHBs to be reporting on these.
j) Monitor the implementation DHBs’ MQSPs
In 2016/17, we aim to support the Ministry of Health in its overview of each DHB by:
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concentrating our monitoring efforts on DHBs recently transitioned to the “establishing” tier
to support advancement to more connected and integrated local MQSPs (West Coast and
Southern DHBs)
encouraging “establishing” and “excelling” DHBs to further embed existing programmes into
long-term, organisation-wide quality frameworks while retaining strong clinical leadership
and management support
reviewing each DHB’s MQSP Annual Report to determine each DHB’s priorities for maternity
services, to determine the level of progress made by each DHB against its priorities, determine
the extent to which DHBs have taken on board and implemented any
recommendations/feedback provided by the NMMG (including liaising with DHBs about the
development of formal integrated pathways for maternal mental health) and ensure that each
report is published online, and
providing advice to the Ministry about DHB achievement and placement within the contract
tiers.
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