The Herald has used the Official Information Act to obtain details of serious adverse events related to maternity services. Photo / 123rf
The Herald has used the Official Information Act to obtain details of serious adverse events related to maternity services. Photo / 123rf
The deaths of two women during pregnancy or soon after birth are among recent serious maternity incidents, information obtained by the Herald reveals.
Other events include a delay for an emergency C-section, and a swab left inside a woman after birth. After an unexpected stillbirth, investigators recommended increasingthe number of midwives in an unnamed maternity unit.
“Serious adverse events” are generally defined as an event that is unintended or unexpected and results in serious harm or death.
The Herald has used the Official Information Act to obtain details of serious adverse events related to maternity services.
A brief summary of each of the 73 events in 2023 was provided. Health NZ-Te Whatu Ora said more information couldn’t be released, including what city or hospital an incident occurred in, to protect patient privacy.
The incidents, which did not necessarily involve any shortfalls in care, must be seen in the context of the 56,955 live births in the 2023 calendar year, Health NZ said.
“These events represent around 0.1% of the total number. Health NZ engaged directly with individuals’ concerns and addressed those with them directly.”
A maternal death is defined as when a woman dies during or soon after pregnancy. In New Zealand, such deaths are rare and lead to in-depth investigations.
The information release reveals there were two maternal deaths in 2023, both in the Northern region, encompassing Northland and greater Auckland.
One maternal death was still under review when the information was released, and the other resulted in a “review of the optimal emergency call process” in the unnamed birthing and assessment unit.
Also in the Northern region, local guidelines for hypertension and pre-eclampsia management were updated in line with more recent national guidelines, after a woman had an eclamptic seizure after giving birth.
The Health Quality and Safety Commission, which monitors serious adverse events, says open and proactive reporting of them is important. Photo / 123rf
Clinicians were reminded of the need for clear communication between teams and “to consider the whole clinical picture and that situations can change rapidly and may require a new plan”, after a placental abruption, when the placenta separates from the uterine wall before birth.
There was also a case of congenital (mother-to-baby) syphilis, which is preventable and risks stillbirth and perinatal death, and has been on the rise in New Zealand.
There were 20 serious adverse events recorded in the Te Manawa Taki (Midland) region, which covers Waikato, Bay of Plenty, Taranaki, Lakes District and Tairāwhiti/Gisborne.
Several involved neonatal encephalopathy, a syndrome that involves disturbed neurological function, often because of a lack of oxygen to the baby during birth.
Numerous changes were made at an unnamed hospital after a delay in proceeding to theatre for an emergency C-section.
Other problems included two cases of delayed recognition of fetal distress, a delay in transfer, and a delay in realising a woman’s condition had deteriorated. Ongoing reviews concerned the unexpected death of a baby during birth and a stillbirth.
The central region, including greater Wellington, Whanganui and Hawke’s Bay, recorded 20 adverse events relating to maternity in 2023.
There were six unexpected intrauterine fetal deaths, when a fetus dies in the womb after 20 weeks of pregnancy. Investigations mostly found no problems with the healthcare provided, but a recommendation after one of the deaths was to, “increase the number of midwives working in the maternity unit”.
After a newborn baby suffered hypoxic-ischaemic encephalopathy – a brain injury caused by lack of oxygen or blood flow – a review recommended continued education for staff, and “consideration given to the installation of a camera system or the implementation of iPads” in the special care baby unit and neonatal intensive care unit, “so that parents can see their baby when separated”.
Across the South Island, there were 15 events recorded, including a “critical event that was a near miss for a death outcome” during a birth. That led to reviews of alert systems and the orientation pack for locums, and more training on communication.
An oxygen cylinder was found to be empty after a birth, and several ongoing reviews were ordered after babies were born in poor condition.
The Herald has requested information on serious adverse events last year. The response from Health NZ on 2023 events took more than six months, well beyond the 20 working days government agencies are generally expected to respond within.
The Health Quality and Safety Commission, which monitors serious adverse events, says open and proactive reporting of them is important so organisations can learn what, if anything, went wrong and make changes to prevent others.
Like other areas of the health system, maternity and birthing services have been under pressure, including because of workforce shortages.
