- Email: [email protected]
Contraception post severe maternal morbidity: a retrospective audit
Contraception xx (2015) xxx – xxx
Original research article
Contraception post severe maternal morbidity: a retrospective audit E. Jane MacDonald a,⁎, Beverley Lawton a , Stacie E. Geller b a
Women's Health Research Centre, Department of Primary Care, University of Otago, PO Box 7343, Wellington 6021, New Zealand b Department of Obstetrics and Gynecology, University of Illinois, Chicago, IL 60612, USA Received 2 December 2014; revised 27 April 2015; accepted 31 May 2015
Abstract Introduction: Rapid repeat pregnancy is associated with maternal and neonatal morbidity. Effective postpartum contraception should be offered to all women, including those who experience severe acute maternal morbidity (SAMM), but little is known about contraceptive initiation in this group. Severe preexisting comorbidities with high pregnancy-related mortality risks are an important subset. This study examines contraceptive advice and prescription for SAMM cases with or without severe preexisting comorbidity. Materials and method: A retrospective audit of 98 SAMM cases was conducted to identify contraceptive advice and prescription preconception (for women with severe preexisting comorbidities), antenatally and/or postnatally. This is a secondary analysis of SAMM cases audited for preventability of SAMM in four District Health Board areas (covering a third of annual births in New Zealand) during a 17-month period. Case notes and preventability audit were manually searched. Results: Of 98 SAMM cases reviewed, 84 (85.7%) left hospital without a contraception prescription. Of 14 with contraception documented on discharge from hospital, 4 (4.1%) had peripartum hysterectomy, 3 (3.1%) had tubal ligation at cesarean section, 1 partner had a vasectomy booked, 1 (1%) had a Jadelle© contraceptive implant inserted and 5 (5.1%) had condom prescriptions. Of 7 women with severe preexisting comorbidity, 4 had preconception advice against conceiving. All 7 left hospital postpartum without contraceptive prescription. Discussion: These results indicate substandard contraceptive care for women experiencing SAMM. All those with severe preexisting comorbidities left hospital postpartum without receiving contraception. Improvement in immediate postpartum contraceptive care for these women is advocated to avoid future morbidity and mortality. © 2015 Elsevier Inc. All rights reserved. Keywords: Postpartum contraception; Severe maternal morbidity; Maternal comorbidity; Long acting reversible contraception
1. Introduction Postpartum contraceptive advice is an accepted standard component of postpartum care [1]. Rapid repeat pregnancy is associated with maternal and neonatal morbidity; therefore, improved access to effective postpartum contraception makes economic sense as well as conferring individual and public health benefits [2,3]. However, little is known about contraceptive advice given to women recovering from severe acute maternal morbidity (SAMM). SAMM is defined as “a very ill pregnant or recently delivered woman who would have died had it not been luck or good care was on her side”
⁎ Corresponding author. Tel.: + 64-21-845-381, + 64-49-186-438 (office). E-mail addresses: [email protected] (E.J. MacDonald), [email protected] (B. Lawton), [email protected] (S.E. Geller). http://dx.doi.org/10.1016/j.contraception.2015.05.012 0010-7824/© 2015 Elsevier Inc. All rights reserved.
[4]. SAMM affects more than 1% of pregnant or recently delivered women [5]. Women who have a SAMM event are generally hospitalized for longer periods than normal deliveries and may suffer lasting morbidity and increased perinatal mortality [5]. This group may have a greater need for immediate effective contraception as they recover from severe pregnancy-related morbidity than the general healthy postpartum population [6,7]. Avoidance of rapid repeat pregnancy is especially relevant for these women [7] as short interpregnancy intervals are known to be associated with increased rates of fetal abnormalities, preterm delivery and low birth weight [8] and poorer outcomes for mothers [9], particularly for women having had cesarean section and those with preexisting complex comorbidities. As part of an audit assessing potential preventability of SAMM [10], one of the recurring themes of substandard care identified by the multidisciplinary expert panels was lack of contraceptive advice (antenatal or postnatal) or prescription by the time a
2
E.J. MacDonald et al. / Contraception xx (2015) xxx–xxx
woman who had suffered a SAMM event was discharged from hospital. In New Zealand, maternity care is government funded and the majority of care is undertaken by Lead Maternity Carers (LMCs) who can be midwives, general practitioners (GPs) or specialist obstetricians, although the majority of care providers (80%) are self-employed midwives. The remaining women who are not registered with an LMC are cared for by public hospital midwives and obstetricians. However, women suffering a SAMM event are invariably transferred to obstetric team care in a hospital setting. This study examines the contraceptive advice and prescription for SAMM cases with or without severe preexisting comorbidity.
2. Materials and method This is a retrospective audit of SAMM cases notes to identify contraceptive advice preconception (for women with severe preexisting comorbidities), antenatally or postnatally, and, if prescribed, the type used. This is a secondary analysis of SAMM cases that were part of an audit assessing preventability of SAMM in four New Zealand hospitals over a 17-month period [10]. These four District Health Boards are responsible for 21,000 deliveries per annum — approximately one third of all annual deliveries in New Zealand. Women were included in the analysis if they were pregnant or within 42 days of delivery and were admitted to an intensive care unit or high dependency unit. The method of case identification and process for review by multidisciplinary panels has been previously described [10]. In brief, deidentified cases were assessed for preventability using a validated international model [11–13]. Sociodemographic and clinical characteristics were collected on each woman and clinical data collection included antenatal care history, gestation at admission, previous pregnancies and outcomes, known pregnancy-related illness, preexisting medical conditions, and complications and outcome of delivery. Ethnicity and socioeconomic deprivation index were collected for each case from the Ministry of Health Information Services using the National Health Index number — a unique identifier that links to centrally held ethnicity and deprivation index information (NZDep index) [14]. The NZDep index is based on New Zealand census data of population and dwellings and gives a range of socioeconomic status ranging from decile 1 (least deprived) to decile 10 (most deprived). The index is constructed from variables reflecting types of possible deprivation such as income, owned home, employment, qualifications, access to car and living space [15]. National ethical approval was obtained from the Multiregional Ethics Committee (MEC/11/EXP/ 035) and local ethical approval was obtained from each District Health Board. For this present study, SAMM clinical case notes were searched by the study team for documentation of contracep-
tive advice and prescription. Additionally, the preventability review results were assessed for comment on contraception. The contraceptive outcome for all cases was identified and, to examine contraceptive advice given, cases were further categorized into two groups — group 1: women who had preexisting severe comorbidities and group 2: previously well women who developed pregnancy-related morbidity.
3. Results Ninety-eight SAMM cases were reviewed (Table 1). Sixty-seven percent of women were between the ages of 20 and 34 years. Approximately one third of the sample was of NZ Maori ethnicity (32.7%, 32/98) and one fifth, Pacific Island ethnicity (21.4%, 21/98). Over half the cases (55.1%, 54/98) were from the most socioeconomically deprived groups. Nulliparous women accounted for 36.7% (36/98) of the sample. Of those with recorded body mass index (BMI), 36% (26/72) of women had a BMI greater than 30. Flowchart 1 shows the contraceptive outcome at discharge from hospital for the total of 98 cases. Four women had a peripartum hysterectomy related to their severe morbidity. Of the remaining 94 women, 3 women (3.2%) had tubal ligation at cesarean section, 5 were given a prescription for condoms, 1 woman had a Jadelle© contraceptive implant inserted before discharge from Table 1 Demographic characteristics Characteristic Age band 14–19 20–24 25–29 30–34 35–39 40–44 Ethnicity of mother NZ European NZ Maori Pacific people Asian Other Parity Nulliparous Multiparous BMI b 30 30–34 35–39 N 39 Not recorded Deprivation Index (1–10) Quintiles 1 (1–2) 2 (3–4) 3 (5–6) 4 (7–8) 5 (9–10) (most deprived) Not recorded
n
%
11 20 27 19 13 8
11.1 20.2 27.3 19.2 13.1 8.1
28 32 21 14 3
28.6 32.7 21.4 14.2 3.1
36 62
36.7 63.3
46 13 7 6 26
46.9 13.3 7.1 6.1 26.5
9 10 10 15 53 1
9.3 10.3 10.3 15.5 54.1
E.J. MacDonald et al. / Contraception xx (2015) xxx–xxx
3
Total SAMM cases n=98
n=4 Peri-partum hysterectomy
n=1 Vasectomy booked for husband
n=3 Tubal ligation at caesarean section
n=1 Implant insertion
n=5 Condom prescription
n=84
No contraception prescribed
Flowchart 1. Contraceptive outcome at time of discharge from hospital.
hospital and 1 couple had a vasectomy booked for the husband 1 week after the woman was discharged from hospital. Of the total 98 cases, 84 women (85.7%) had no documented prescription of contraception at discharge from hospital. Flowchart 2 shows the documentation of contraceptive advice for groups 1 and 2. Of those group 1 women (n= 7) with preexisting severe morbidity (diabetes with multiple complications, severe pulmonary arterial hypertension, chronic renal failure), 4 women had seen nonobstetric specialists in the weeks or months prior to conception where they were counseled to avoid pregnancy as the pregnancy-related mortality risk was very high (up to 50%). In these
cases, no direct contraceptive advice was documented or referral made to ensure that the women received contraceptive advice or prescription. The panel review audit process identified three additional cases of women with severe preexisting morbidity where the probability of pregnancyrelated mortality was high but it was not documented whether contraceptive need preconception had been recognized. Of those 7 women in group 1, postnatal contraception discussion was not documented for 3 women and referral for contraceptive advice was made to the GP or LMC for the other 4 women. None were prescribed contraception. For those women in group 2, previously well women (n= 91), 3 women (3.3%) had documented evidence of
Total SAMM cases n=98
Group 1 n=7 Severe preexisting morbidity
n=4 Preconception contraceptive need recognised and documented
Group 2 n=91
n=3 Preconception contraceptive need not documented preconception
n=3* Antenatal contraceptive advice documented
n=10 Postpartum contraceptive advice documented
n=31 Postpartum referred to GP or LMC for contraception in discharge letter
n=49 Postpartum no contraceptive advice documented
* 2 women had both antenatal and postnatal advice documented n=4 Postpartum referred to GP or LMC for contraception in discharge letter
n=3 Postpartum no contraceptive advice documented
Flowchart 2. Contraceptive advice documented.
4
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discussion about contraception in the antenatal period and 10 (11%) had postnatal discussion about specific contraceptive options documented. Two women had contraception discussion documented both antenatally and postnatally. Thirty-one (34%) had “contraception — will see GP or LMC” in the discharge letter and 49 cases (53.8%) had no documentation of contraceptive advice, counseling, prescription or referral either in the notes or in the discharge letter.
4. Discussion This retrospective audit of contraceptive advice and prescription for women with severe maternal morbidity found that (excluding those who had a peripartum hysterectomy) just 10.6% received contraceptive prescription with only one woman receiving a long-acting contraceptive progesterone implant before discharge from hospital. Over 50% of women had no discussion about contraception documented. Seven women of the total 98 women had such severe preexisting comorbidities that it could be argued that preconception advice and prescription should have been prioritized to avoid the risk of an unplanned pregnancy. None of these 7 women left hospital postpartum with contraceptive prescription. Postpartum contraceptive advice is an accepted standard component of postpartum care [1] and the risks and benefits of different contraception types for postpartum women are well documented [16] but women often do not have access to their contraceptive preference [3]. The Faculty of Reproductive and Sexual Healthcare (Royal College of Obstetricians and Gynecologists, UK) recommends that all health professionals should find opportunities during both antenatal and postnatal periods to discuss all methods of contraception and that the benefits of long-acting reversible contraception (LARC) methods in terms of efficacy should be highlighted to all postpartum women. Prompt provision of postpartum contraception is needed to reduce rapid unplanned pregnancy because of its association with increased adverse outcomes [17]. There is little in the literature about postpartum contraceptive advice or prescription for those women who suffer severe morbidity or have preexisting comorbidity but women who have suffered a SAMM event may have great need for effective contraception [6,7,18]. They embark on a physical and emotional recovery from a severe pregnancy-related morbid event that may have resulted in a stillbirth [19] or a premature or sick baby in the neonatal unit. Immediate, effective contraception will give time to recover and adjust to these traumatic events. Preexisting severe comorbidities such as cardiac disease, pulmonary hypertension, chronic renal failure or diabetic complications put women at high risk of worsening morbidity or mortality with a repeat pregnancy, and therefore, these women should have their contraceptive needs prioritized. Rapid repeat pregnancy for women who
have suffered a SAMM event should be avoided as these women will often be recovering from emergency cesarean section, postpartum hemorrhage, anemia or severe concurrent infection. It is assumed that most postpartum contraceptive advice and prescription will occur either in the 6 weeks postpartum by midwives or later by GPs. However, this has not been well studied. A small qualitative New Zealand study looking at the contraceptive advice given to 22 young women presenting for termination of pregnancy within 6 months of having a baby concluded that opportunities to provide contraceptive advice during and just after the previous pregnancy had been missed by clinicians providing pregnancy and postpartum care. Only 25% of the women had any contraceptive prescription by 6 weeks postpartum [20]. A publically funded program in USA showed that only 41% of women had a contraceptive claim within the first 90 days after birth [21]. In New Zealand, all women are allocated a midwife for funded postpartum checks at home, which should include contraception advice and/or prescription [22]. LARC may be especially relevant for women who have experienced a SAMM event and wish to avoid a repeat rapid pregnancy. The safety and benefits of LARC has been well established and LARC can be used for women with severe comorbidities [23]. LARC has also been shown to decrease rapid repeat pregnancy both in adolescents and in women after termination of pregnancy [24,25] and would therefore seem an appropriate contraception choice for women who have experienced a SAMM event. A limitation of this study is that contraceptive advice was assessed from hospital and antenatal notes until the time of discharge. Informal discussions about contraception may not have been documented. Strengths of the study include that these SAMM cases were reviewed by external multidisciplinary panels of clinicians who identified lack of contraception as an issue of substandard care and that the 98 SAMM cases were identified from a large birth cohort covering 21,000 deliveries per annum in New Zealand. Suggestions for improving contraceptive advice and prescription include detailed contraceptive advice during antenatal and postnatal care with clear documentation included in the maternity clinical care pathway in New Zealand, a dedicated contraceptive nurse/midwife practitioner position within maternity hospitals with the ability to attend antenatal clinics and postnatal ward rounds, more detailed clinical training for midwives on contraceptive advice and provision and clinical updates on postpartum contraception for midwives and GPs. A dedicated contraceptive nurse could give accurate information, offer immediate postpartum implant or prescription for other forms of contraception, teach junior medical staff and be readily available to give contraceptive advice or access for women of reproductive age with severe comorbidities seeing nonobstetric specialists. In summary, these results indicate substandard contraceptive care for women experiencing SAMM with only
E.J. MacDonald et al. / Contraception xx (2015) xxx–xxx
10.6% of women getting contraceptive prescription before discharge from hospital and only one woman having a LARC implant inserted before discharge from hospital. Of concern, those women suffering a SAMM event with severe preexisting comorbidities left hospital postpartum with little or no contraceptive advice. In New Zealand, a comparatively high-income country, it would appear that the maternity system, similar to low-income countries, is not attending to the immediate contraceptive needs of women who have experienced a SAMM event. These findings may therefore indicate that this is a larger global issue to be addressed by both high-income and low-income countries [6,7]. Future research should include follow-up of women who have experienced a SAMM event to analyze contraceptive advice and use in the later postpartum period after discharge from hospital. Trialing the option of LARC prescription immediately postpartum and the challenges of implementing this should be examined, looking at clinician training and attitudes and cost and comparing outcomes with other types of contraception prescription in the New Zealand maternity care setting.
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
Acknowledgements
[15]
The authors acknowledge the Health Research Council of New Zealand and the New Zealand Ministry of Health for the funding of this study. We would like to thank all the clinicians involved in the panel process for the audit of severe maternal morbidity.
[16]
References
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[1] Faculty of Sexual and Reproductive Healthcare. Postnatal Sexual and Reproductive Health. England Royal College of Obstetricians & Gynaecologists; 2009. [2] Rodriguez MI, Evans M, Espey E. Advocating for immediate postpartum LARC: increasing access, improving outcomes, and decreasing cost. Contraception 2014;90:468–71. [3] Potter JE, Hopkins K, Aiken ARA, Huberta C, Stevenson AJ, White K, et al. Unmet demand for highly effective postpartum contraception in Texas. Contraception 2014;90:488–95. [4] Mantel DG, Buchmann E, Rees H, Pattinson CR. Severe acute maternal morbidity: a pilot study of a definition for a near-miss. Br J Obstet Gynaecol 1998;105:985–90. [5] Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case–control study. BMJ 2001;322:1089–93. [6] Tuncalp O, Adu-Bonsaffoh K, Adanu RM, Hindin MJ. Family planning needs of women experiencing severe maternal morbidity in
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Accra, Ghana: another missed opportunity? Afr J Reprod Health 2014;18:15–21. Ganaba RMT, Sombie I, Baggaley RF, Ouedraogo TW, Filippi V. Women's sexual health and contraceptive needs after a severe obstetric complication (“near-miss”): a cohort study in Burkina Faso. Reprod Health 2010;7, http://dx.doi.org/10.1186/1742-4755-7-22. Wendt A, Gibbs CM, Peters S, Hogue CJ. Impact of increasing interpregnancy interval on maternal and infant health. Paediatr Perinat Epidemiol 2012;26:239–58. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Effects of birth spacing on maternal health: a systematic review. Am J Obstet Gynecol 2007;196:297–308. Lawton B, MacDonald EJ, Brown SA, Wilson L, Stanley J, Tait JD, et al. Preventability of severe acute maternal morbidity. Am J Obstet Gynecol 2014;210:557.e1–6. Geller SE, Cox SM, Kilpatrick SJ. A descriptive model of preventability in maternal morbidity and mortality. J Perinatol 2006;26:79–84. Geller SE, Adams MG, Kominiarek MA, Hibbard JU, Endres LK, Cox M, et al. Reliability of a preventability model in maternal death and morbidity. Am J Obstet Gynecol 2007;196:57.e1–6. Lawton BA, Wilson LF, Dinsdale RA, Rose SB, Brown SA, Tait J, et al. Audit of severe acute maternal morbidity describing reasons for transfer and potential preventability of admissions to ICU. ANZJOG 2010;50:346–51. New Zealand Health Information Service. National Health Index. Wellington: Ministry of Health; accessed 2013. Salmond C, Crampton P, Atkinson J. NZDep2006 Index of Deprivation. Wellington: Ministry of Health; 2007. Evans A. Postpartum contraception. Women's Health Med 2005;2:23–6. Kaunitz A. Postpartum and postabortion, contraception. www. uptodate.com2014. Storeng KT, Drabo S, Ganaba R, Sundby J, Calvert C, Filippi V. Mortality after near-miss obstetric complications in Burkina Faso: medical, social and health-care factors. Bull World Health Organ 2012;90:418–25B. Healthcare Improvement Scotland. Scottish Confidential Audit of Severe Maternal Morbidity: reducing avoidable harm. National Health Service for Scotland; 2013. Joseph K, Whitehead A. Unintended pregnancy and therapeutic abortion in the postpartum period. Is an opportunity to intervene being missed? N Z Med J 2012;125:30–40. Thiel de Bocanegra H, Chang R, Menz M, Howell M, Darney P. Postpartum contraception in publicly-funded programs and interpregnancy intervals. Obstet Gynecol 2013;122:296–303. New Zealand Ministry of Health. Section 88 Primary Maternity Services. Wellington: MOH; 2007. World Health Organization. Medical eligibility criteria for contraceptive use4th ed. ; 2010. Rose SB, Lawton BA. Impact of long-acting reversible contraception on return for repeat abortion. Am J Obstet Gynecol 2012;206:37.e1–6. Tocce KM, Sheeder JL, Teal SB. Rapid repeat pregnancy in adolescents: do immediate postpartum contraceptive implants make a difference? Am J Obstet Gynecol 2012;206:481.e1–7.
Original research article
Contraception post severe maternal morbidity: a retrospective audit E. Jane MacDonald a,⁎, Beverley Lawton a , Stacie E. Geller b a
Women's Health Research Centre, Department of Primary Care, University of Otago, PO Box 7343, Wellington 6021, New Zealand b Department of Obstetrics and Gynecology, University of Illinois, Chicago, IL 60612, USA Received 2 December 2014; revised 27 April 2015; accepted 31 May 2015
Abstract Introduction: Rapid repeat pregnancy is associated with maternal and neonatal morbidity. Effective postpartum contraception should be offered to all women, including those who experience severe acute maternal morbidity (SAMM), but little is known about contraceptive initiation in this group. Severe preexisting comorbidities with high pregnancy-related mortality risks are an important subset. This study examines contraceptive advice and prescription for SAMM cases with or without severe preexisting comorbidity. Materials and method: A retrospective audit of 98 SAMM cases was conducted to identify contraceptive advice and prescription preconception (for women with severe preexisting comorbidities), antenatally and/or postnatally. This is a secondary analysis of SAMM cases audited for preventability of SAMM in four District Health Board areas (covering a third of annual births in New Zealand) during a 17-month period. Case notes and preventability audit were manually searched. Results: Of 98 SAMM cases reviewed, 84 (85.7%) left hospital without a contraception prescription. Of 14 with contraception documented on discharge from hospital, 4 (4.1%) had peripartum hysterectomy, 3 (3.1%) had tubal ligation at cesarean section, 1 partner had a vasectomy booked, 1 (1%) had a Jadelle© contraceptive implant inserted and 5 (5.1%) had condom prescriptions. Of 7 women with severe preexisting comorbidity, 4 had preconception advice against conceiving. All 7 left hospital postpartum without contraceptive prescription. Discussion: These results indicate substandard contraceptive care for women experiencing SAMM. All those with severe preexisting comorbidities left hospital postpartum without receiving contraception. Improvement in immediate postpartum contraceptive care for these women is advocated to avoid future morbidity and mortality. © 2015 Elsevier Inc. All rights reserved. Keywords: Postpartum contraception; Severe maternal morbidity; Maternal comorbidity; Long acting reversible contraception
1. Introduction Postpartum contraceptive advice is an accepted standard component of postpartum care [1]. Rapid repeat pregnancy is associated with maternal and neonatal morbidity; therefore, improved access to effective postpartum contraception makes economic sense as well as conferring individual and public health benefits [2,3]. However, little is known about contraceptive advice given to women recovering from severe acute maternal morbidity (SAMM). SAMM is defined as “a very ill pregnant or recently delivered woman who would have died had it not been luck or good care was on her side”
⁎ Corresponding author. Tel.: + 64-21-845-381, + 64-49-186-438 (office). E-mail addresses: [email protected] (E.J. MacDonald), [email protected] (B. Lawton), [email protected] (S.E. Geller). http://dx.doi.org/10.1016/j.contraception.2015.05.012 0010-7824/© 2015 Elsevier Inc. All rights reserved.
[4]. SAMM affects more than 1% of pregnant or recently delivered women [5]. Women who have a SAMM event are generally hospitalized for longer periods than normal deliveries and may suffer lasting morbidity and increased perinatal mortality [5]. This group may have a greater need for immediate effective contraception as they recover from severe pregnancy-related morbidity than the general healthy postpartum population [6,7]. Avoidance of rapid repeat pregnancy is especially relevant for these women [7] as short interpregnancy intervals are known to be associated with increased rates of fetal abnormalities, preterm delivery and low birth weight [8] and poorer outcomes for mothers [9], particularly for women having had cesarean section and those with preexisting complex comorbidities. As part of an audit assessing potential preventability of SAMM [10], one of the recurring themes of substandard care identified by the multidisciplinary expert panels was lack of contraceptive advice (antenatal or postnatal) or prescription by the time a
2
E.J. MacDonald et al. / Contraception xx (2015) xxx–xxx
woman who had suffered a SAMM event was discharged from hospital. In New Zealand, maternity care is government funded and the majority of care is undertaken by Lead Maternity Carers (LMCs) who can be midwives, general practitioners (GPs) or specialist obstetricians, although the majority of care providers (80%) are self-employed midwives. The remaining women who are not registered with an LMC are cared for by public hospital midwives and obstetricians. However, women suffering a SAMM event are invariably transferred to obstetric team care in a hospital setting. This study examines the contraceptive advice and prescription for SAMM cases with or without severe preexisting comorbidity.
2. Materials and method This is a retrospective audit of SAMM cases notes to identify contraceptive advice preconception (for women with severe preexisting comorbidities), antenatally or postnatally, and, if prescribed, the type used. This is a secondary analysis of SAMM cases that were part of an audit assessing preventability of SAMM in four New Zealand hospitals over a 17-month period [10]. These four District Health Boards are responsible for 21,000 deliveries per annum — approximately one third of all annual deliveries in New Zealand. Women were included in the analysis if they were pregnant or within 42 days of delivery and were admitted to an intensive care unit or high dependency unit. The method of case identification and process for review by multidisciplinary panels has been previously described [10]. In brief, deidentified cases were assessed for preventability using a validated international model [11–13]. Sociodemographic and clinical characteristics were collected on each woman and clinical data collection included antenatal care history, gestation at admission, previous pregnancies and outcomes, known pregnancy-related illness, preexisting medical conditions, and complications and outcome of delivery. Ethnicity and socioeconomic deprivation index were collected for each case from the Ministry of Health Information Services using the National Health Index number — a unique identifier that links to centrally held ethnicity and deprivation index information (NZDep index) [14]. The NZDep index is based on New Zealand census data of population and dwellings and gives a range of socioeconomic status ranging from decile 1 (least deprived) to decile 10 (most deprived). The index is constructed from variables reflecting types of possible deprivation such as income, owned home, employment, qualifications, access to car and living space [15]. National ethical approval was obtained from the Multiregional Ethics Committee (MEC/11/EXP/ 035) and local ethical approval was obtained from each District Health Board. For this present study, SAMM clinical case notes were searched by the study team for documentation of contracep-
tive advice and prescription. Additionally, the preventability review results were assessed for comment on contraception. The contraceptive outcome for all cases was identified and, to examine contraceptive advice given, cases were further categorized into two groups — group 1: women who had preexisting severe comorbidities and group 2: previously well women who developed pregnancy-related morbidity.
3. Results Ninety-eight SAMM cases were reviewed (Table 1). Sixty-seven percent of women were between the ages of 20 and 34 years. Approximately one third of the sample was of NZ Maori ethnicity (32.7%, 32/98) and one fifth, Pacific Island ethnicity (21.4%, 21/98). Over half the cases (55.1%, 54/98) were from the most socioeconomically deprived groups. Nulliparous women accounted for 36.7% (36/98) of the sample. Of those with recorded body mass index (BMI), 36% (26/72) of women had a BMI greater than 30. Flowchart 1 shows the contraceptive outcome at discharge from hospital for the total of 98 cases. Four women had a peripartum hysterectomy related to their severe morbidity. Of the remaining 94 women, 3 women (3.2%) had tubal ligation at cesarean section, 5 were given a prescription for condoms, 1 woman had a Jadelle© contraceptive implant inserted before discharge from Table 1 Demographic characteristics Characteristic Age band 14–19 20–24 25–29 30–34 35–39 40–44 Ethnicity of mother NZ European NZ Maori Pacific people Asian Other Parity Nulliparous Multiparous BMI b 30 30–34 35–39 N 39 Not recorded Deprivation Index (1–10) Quintiles 1 (1–2) 2 (3–4) 3 (5–6) 4 (7–8) 5 (9–10) (most deprived) Not recorded
n
%
11 20 27 19 13 8
11.1 20.2 27.3 19.2 13.1 8.1
28 32 21 14 3
28.6 32.7 21.4 14.2 3.1
36 62
36.7 63.3
46 13 7 6 26
46.9 13.3 7.1 6.1 26.5
9 10 10 15 53 1
9.3 10.3 10.3 15.5 54.1
E.J. MacDonald et al. / Contraception xx (2015) xxx–xxx
3
Total SAMM cases n=98
n=4 Peri-partum hysterectomy
n=1 Vasectomy booked for husband
n=3 Tubal ligation at caesarean section
n=1 Implant insertion
n=5 Condom prescription
n=84
No contraception prescribed
Flowchart 1. Contraceptive outcome at time of discharge from hospital.
hospital and 1 couple had a vasectomy booked for the husband 1 week after the woman was discharged from hospital. Of the total 98 cases, 84 women (85.7%) had no documented prescription of contraception at discharge from hospital. Flowchart 2 shows the documentation of contraceptive advice for groups 1 and 2. Of those group 1 women (n= 7) with preexisting severe morbidity (diabetes with multiple complications, severe pulmonary arterial hypertension, chronic renal failure), 4 women had seen nonobstetric specialists in the weeks or months prior to conception where they were counseled to avoid pregnancy as the pregnancy-related mortality risk was very high (up to 50%). In these
cases, no direct contraceptive advice was documented or referral made to ensure that the women received contraceptive advice or prescription. The panel review audit process identified three additional cases of women with severe preexisting morbidity where the probability of pregnancyrelated mortality was high but it was not documented whether contraceptive need preconception had been recognized. Of those 7 women in group 1, postnatal contraception discussion was not documented for 3 women and referral for contraceptive advice was made to the GP or LMC for the other 4 women. None were prescribed contraception. For those women in group 2, previously well women (n= 91), 3 women (3.3%) had documented evidence of
Total SAMM cases n=98
Group 1 n=7 Severe preexisting morbidity
n=4 Preconception contraceptive need recognised and documented
Group 2 n=91
n=3 Preconception contraceptive need not documented preconception
n=3* Antenatal contraceptive advice documented
n=10 Postpartum contraceptive advice documented
n=31 Postpartum referred to GP or LMC for contraception in discharge letter
n=49 Postpartum no contraceptive advice documented
* 2 women had both antenatal and postnatal advice documented n=4 Postpartum referred to GP or LMC for contraception in discharge letter
n=3 Postpartum no contraceptive advice documented
Flowchart 2. Contraceptive advice documented.
4
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discussion about contraception in the antenatal period and 10 (11%) had postnatal discussion about specific contraceptive options documented. Two women had contraception discussion documented both antenatally and postnatally. Thirty-one (34%) had “contraception — will see GP or LMC” in the discharge letter and 49 cases (53.8%) had no documentation of contraceptive advice, counseling, prescription or referral either in the notes or in the discharge letter.
4. Discussion This retrospective audit of contraceptive advice and prescription for women with severe maternal morbidity found that (excluding those who had a peripartum hysterectomy) just 10.6% received contraceptive prescription with only one woman receiving a long-acting contraceptive progesterone implant before discharge from hospital. Over 50% of women had no discussion about contraception documented. Seven women of the total 98 women had such severe preexisting comorbidities that it could be argued that preconception advice and prescription should have been prioritized to avoid the risk of an unplanned pregnancy. None of these 7 women left hospital postpartum with contraceptive prescription. Postpartum contraceptive advice is an accepted standard component of postpartum care [1] and the risks and benefits of different contraception types for postpartum women are well documented [16] but women often do not have access to their contraceptive preference [3]. The Faculty of Reproductive and Sexual Healthcare (Royal College of Obstetricians and Gynecologists, UK) recommends that all health professionals should find opportunities during both antenatal and postnatal periods to discuss all methods of contraception and that the benefits of long-acting reversible contraception (LARC) methods in terms of efficacy should be highlighted to all postpartum women. Prompt provision of postpartum contraception is needed to reduce rapid unplanned pregnancy because of its association with increased adverse outcomes [17]. There is little in the literature about postpartum contraceptive advice or prescription for those women who suffer severe morbidity or have preexisting comorbidity but women who have suffered a SAMM event may have great need for effective contraception [6,7,18]. They embark on a physical and emotional recovery from a severe pregnancy-related morbid event that may have resulted in a stillbirth [19] or a premature or sick baby in the neonatal unit. Immediate, effective contraception will give time to recover and adjust to these traumatic events. Preexisting severe comorbidities such as cardiac disease, pulmonary hypertension, chronic renal failure or diabetic complications put women at high risk of worsening morbidity or mortality with a repeat pregnancy, and therefore, these women should have their contraceptive needs prioritized. Rapid repeat pregnancy for women who
have suffered a SAMM event should be avoided as these women will often be recovering from emergency cesarean section, postpartum hemorrhage, anemia or severe concurrent infection. It is assumed that most postpartum contraceptive advice and prescription will occur either in the 6 weeks postpartum by midwives or later by GPs. However, this has not been well studied. A small qualitative New Zealand study looking at the contraceptive advice given to 22 young women presenting for termination of pregnancy within 6 months of having a baby concluded that opportunities to provide contraceptive advice during and just after the previous pregnancy had been missed by clinicians providing pregnancy and postpartum care. Only 25% of the women had any contraceptive prescription by 6 weeks postpartum [20]. A publically funded program in USA showed that only 41% of women had a contraceptive claim within the first 90 days after birth [21]. In New Zealand, all women are allocated a midwife for funded postpartum checks at home, which should include contraception advice and/or prescription [22]. LARC may be especially relevant for women who have experienced a SAMM event and wish to avoid a repeat rapid pregnancy. The safety and benefits of LARC has been well established and LARC can be used for women with severe comorbidities [23]. LARC has also been shown to decrease rapid repeat pregnancy both in adolescents and in women after termination of pregnancy [24,25] and would therefore seem an appropriate contraception choice for women who have experienced a SAMM event. A limitation of this study is that contraceptive advice was assessed from hospital and antenatal notes until the time of discharge. Informal discussions about contraception may not have been documented. Strengths of the study include that these SAMM cases were reviewed by external multidisciplinary panels of clinicians who identified lack of contraception as an issue of substandard care and that the 98 SAMM cases were identified from a large birth cohort covering 21,000 deliveries per annum in New Zealand. Suggestions for improving contraceptive advice and prescription include detailed contraceptive advice during antenatal and postnatal care with clear documentation included in the maternity clinical care pathway in New Zealand, a dedicated contraceptive nurse/midwife practitioner position within maternity hospitals with the ability to attend antenatal clinics and postnatal ward rounds, more detailed clinical training for midwives on contraceptive advice and provision and clinical updates on postpartum contraception for midwives and GPs. A dedicated contraceptive nurse could give accurate information, offer immediate postpartum implant or prescription for other forms of contraception, teach junior medical staff and be readily available to give contraceptive advice or access for women of reproductive age with severe comorbidities seeing nonobstetric specialists. In summary, these results indicate substandard contraceptive care for women experiencing SAMM with only
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10.6% of women getting contraceptive prescription before discharge from hospital and only one woman having a LARC implant inserted before discharge from hospital. Of concern, those women suffering a SAMM event with severe preexisting comorbidities left hospital postpartum with little or no contraceptive advice. In New Zealand, a comparatively high-income country, it would appear that the maternity system, similar to low-income countries, is not attending to the immediate contraceptive needs of women who have experienced a SAMM event. These findings may therefore indicate that this is a larger global issue to be addressed by both high-income and low-income countries [6,7]. Future research should include follow-up of women who have experienced a SAMM event to analyze contraceptive advice and use in the later postpartum period after discharge from hospital. Trialing the option of LARC prescription immediately postpartum and the challenges of implementing this should be examined, looking at clinician training and attitudes and cost and comparing outcomes with other types of contraception prescription in the New Zealand maternity care setting.
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Acknowledgements
[15]
The authors acknowledge the Health Research Council of New Zealand and the New Zealand Ministry of Health for the funding of this study. We would like to thank all the clinicians involved in the panel process for the audit of severe maternal morbidity.
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