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Preference: Administration and Health Services

2

A population-based analysis of incentive payments to primary care physicians for the care of patients with complex disease [Research]

Background:

In 2007, the province of British Columbia implemented incentive payments to primary care physicians for the provision of comprehensive, continuous, guideline-informed care for patients with 2 or more chronic conditions. We examined the impact of this program on primary care access and continuity, rates of hospital admission and costs.

Methods:

We analyzed all BC patients who qualified for the incentive based on their diagnostic profile. We tracked primary care contacts and continuity, hospital admissions (total, via the emergency department and for targeted conditions), and cost of physician services, hospital care and pharmaceuticals, for 24 months before and 24 months after the intervention.

Results:

Of 155 754 eligible patients, 63.7% had at least 1 incentive payment billed. Incentive payments had no impact on primary care contacts (change in contacts per patient per month: 0.016, 95% confidence interval [CI] –0.047 to 0.078) or continuity of care (mean monthly change: 0.012, 95% CI –0.001 to 0.024) and were associated with increased total rates of hospital admission (change in hospital admissions per 1000 patients per month: 1.46, 95% CI 0.04 to 2.89), relative to preintervention trends. Annual costs per patient did not decline (mean change: $455.81, 95% CI –$2.44 to $914.08).

Interpretation:

British Columbia’s $240-million investment in this program improved compensation for physicians doing the important work of caring for complex patients, but did not appear to improve primary care access or continuity, or constrain resource use elsewhere in the health care system. Policymakers should consider other strategies to improve care for this patient population.

Health costs rise as rebate freeze bites

Patients face higher out-of-pocket costs as the medical profession struggles under pressure from the Federal Government’s Medicare rebate freeze.

As a result of the Government’s freeze, the gap between the Medicare rebate and the fee the AMA recommends GPs charge for a standard consultation will increase to $40.95 from 1 November, up from $38.95, continuing the steady devaluation of Medicare’s contribution to the cost of care.

The increase comes on top of the effects of the Medicare rebate freeze, which is forcing an increasing number of medical practices to abandon or reduce bulk billing and begin charging patients in order to remain financially viable.

Adding to the financial squeeze, the Government is considering changes that would cut the rents practices receive for co-located pathology collection centres that the AMA estimates would rip up to $150 million from general practice every year.

Under the changes recommended by the AMA, the fee for a standard Level B GP consultation will increase by $2 to $78, while the Medicare rebate remains fixed at just $37.05.

AMA Vice President Dr Tony Bartone said doctors had kept medical fee increases to a minimum, but Medicare indexation lagged well behind the cost of providing medical care.

“The MBS simply has not kept pace with the complexity or cost of providing high quality medical services,” Dr Bartone said.

The rise is roughly in line with Reserve Bank of Australia forecasts for underlying inflation, currently at 1.5 per cent, to rise anywhere up to 2.5 per cent by the middle of next year, and reflects steady increases in medical practice costs.

Staff wages, rent and utility charges have all increased, as have professional indemnity insurance premiums, continuing professional education costs and accreditation fees.

While practice running costs are rising, the Government’s contribution to the cost of care through Medicare has been frozen for more than two years, and in many cases far longer.

The Medicare rebate for GP services has not been indexed since mid-2014, while the last rebate increase for most other services was in November 2012. In the case of pathology and diagnostic imaging the rebate freeze is even longer, going back more than 15 years.

Dr Bartone said the rebate freeze was pushing up patient out-of-pocket costs.

“Many patients will pay more to see their doctor because of the Medicare freeze,” he said. “The freeze is an enormous burden on hardworking GPs. Practices cannot continue absorbing the increasing costs of providing quality care year after year. It is inevitable that many GPs will need to review their decision to bulk bill some of their patients.”

The AMA is pressing the Government to reverse the rebate freeze, and AMA President Dr Michael Gannon has declared he would be “gobsmacked” if it was still in place by the time of the next Federal election, due in 2019.

But Health Minister Sussan Ley has played down hopes that indexation will soon be reinstated, warning that there will not be a change of policy “any earlier than our financial circumstances permit”.

The Government is trying to curb the Budget deficit and rein in ballooning debt.

As part of its strategy, it is increasingly pushing the cost of health care directly onto patients.

Australian Institute of Health and Welfare figures show the Commonwealth’s share of the nation’s health bill slipped down to 41 per cent in 2014-15, while patients’ share has increased to almost 18 per cent, and Australians now pay some of the highest out-of-pocket costs for health care among Organisation for Economic Co-operation and Development countries.

The cost of health

How AMA recommended fees compare with the frozen Medicare rebates

Medical Service

AMA Fee

(2015)

AMA Fee

(2016)

MBS Schedule Fee

(2016)

Level B GP consult

(MBS item 23)

$76.00

$78.00

$37.05

Level B OMP consult

(MBS item 53)

$76.00

$78.00

$21.00

Blood test for diabetes

(MBS item 66542)

$48.00

$49.00

$18.95

CT scan of the spine

(MBS item 56219)

$990.00

$1,055.00

$326.20

Specialist – initial attendance

(MBS item 104)

$166.00

$170.00

$85.55

Consultant Physician – initial attendance

(MBS item 110)

$315.00

$325.00

$150.90

Psychiatrist attendance

(MBS item 306)

$350.00

$355.00

$183.65

 Adrian Rollins

 

‘Obsolete’ Medicare system to be replaced

The Federal Government has commenced work on replacing the ageing Medicare, health and aged care payments system in a move welcomed by the AMA.

Health Minister Sussan Ley and Human Services Minister Alan Tudge have announced that the process of identifying a new system to supplant the current 30-year-old structure has commenced.

“Australia’s existing health and aged care payments system is 30 years old and is now obsolete,” the Ministers said. “A process has commenced to identify solutions for this new payments system, which will be based on existing commercial technology.”

But, seeking to prevent a repeat of Labor’s damaging election campaign claim that such a move amounted to the privatisation of Medicare, the Ministers insisted the Government would retain ownership and control.

“The new system will support the Australian Government continuing to own, operate and deliver Medicare, PBS, aged care and related veterans’ payments into the future,” they said.

AMA President Dr Michael Gannon said the Government’s move amounted to a modernisation rather than privatisation.

“The AMA made it very clear during the election campaign that replacing the backroom payment system for Medicare does not equate to the privatisation of Medicare,” Dr Gannon said. “The current payment system is 30 years old. It is clunky and inefficient. Its many faults create inefficiency and inconvenience for doctors and patients.”

The AMA President said medical practices had taken on much of the work of processing Medicare payments on behalf of the Government, costing them considerable time and effort.

The Government has promised to consult “extensively” with health providers and stakeholders in determining the final design of the new system.

Dr Gannon said such consultation was vital.

“It is critical the AMA is closely involved in the design of the new system to ensure it meets the needs of doctors and patients,” he said, adding that medical practices must be properly supported to incorporate and implement the new system for the benefit of patients.

Consultations on the new system are due to be finalised in January 2017.

Adrian Rollins

[Comment] Pursuing excellence in graduate medical education in China

Unquestionably, one of China’s primary challenges in health-care reform is improving the quality of clinical services.1 Patients who seek quality of care bypass poorly staffed primary care facilities for long waits in congested hospitals. Unsatisfactory quality of care is a major source of conflict between patients and doctors. Health inequity in China is due less to a shortage of health-care workers and more to abundant yet poorly educated service providers, especially in rural areas. That is why seven Chinese Government ministries in 2013 jointly launched the Standardized Residency Training (SRT) programme, which consists of 3 years of residency training after 5 years of medical school.

Bonds loosened on rural doctors

The Federal Government has relaxed the rules surrounding return of service obligations on doctors working in bonded placements, in a decision hailed by AMA President Dr Michael Gannon as a victory for common sense.

Health Minister Sussan Ley has responded to representations from the AMA by directing the Health Department to take a more flexible approach when applying return of service obligations on medical graduates enrolled in the Bonded Medical Places (BMP) program and the Medical Rural Bonded Scholarship Scheme (MRBS).

The move means that BMP and MRBS doctors will no longer be prevented from travelling to metropolitan areas for extra training or instruction.

Dr Gannon said the policy shift addressed a damaging and unintended consequence of the obligation rules.

“The Department was previously bound by rigid guidelines to applying these return of service obligations, often leading to outcomes that made little sense,” the AMA President said. “Doctors who clearly were committed to their rural patients and more than meeting their obligations found that they were being essentially blocked from undertaking extra training or keeping up their clinical skills, simply because they would have to go to a city for a brief period to do so.”

Under the original terms of the BMP program, doctors were required to complete a period of eligible service in a rural area or district of workforce shortage equivalent to the length of their medical degree. MRBS graduates were required to complete at least six years eligible service in a rural area.

Related: National rural generalist program key to retention

Former AMA President, Professor Brian Owler, wrote to the Government last year highlighting that the rigid application of return of service obligations was having an unfair effect on participants who were trying to meet these obligations, particularly when they needed to undertake up-skilling and further training in a metropolitan area.

The AMA Council of Rural Doctors has previously identified the importance of rural doctors being able to access opportunities to up-skill in metropolitan centres from time to time.

The Council said such opportunities were vital to support sustainable, high quality, medical care and enable practitioners to share skills and knowledge with their rural colleagues, including doctors in training.

Dr Gannon said return of service arrangements were never intended to be an impediment to this, and the new, more flexible approach taken to their application was an important piece in the puzzle for supporting high quality rural health services.

Under the new policy approach, Health Department officials will have greater scope to approve requests by participants to undertake work in a broader range of areas, provided they are otherwise meeting their return of service obligations.

Dr Gannon urged a sensible approach to the more flexible arrangement.

“It is important that the Department of Health takes a practical approach when it applies the new policy so that it supports doctors who are committed to working in areas of workforce shortage,” he said.

“By taking steps that support a good working experience, this will encourage them to commit to long term practice in these areas – for the benefit of local communities.”

Latest news

Hospitals could pay for mistakes

Public hospitals would be charged for mistakes that seriously harm or kill patients and penalised for avoidable readmissions under reforms being developed at the behest of Health Minister Sussan Ley.

Ms Ley has directed the Independent Hospital Pricing Authority (IHPA) to model how funding and pricing could be used to cut the cost to the Commonwealth of so-called sentinel events such as operating on the wrong body part, incompatible blood transfusions, deadly medication errors, sending a baby home with the wrong parents or patient suicide.

The Authority has also been asked to look at ways to penalise hospitals that exceed a predetermined rate for avoidable readmissions.

The move coincides with the release of draft Productivity Commission proposals to publicise treatment outcomes for individual hospitals and doctors as part of measures to boost competition and contestability in the provision of health care.

In a consultation paper released on 30 September, IHPA said that incorporating safety and quality measures into pricing and funding models signalled the value Government attached to high quality care.

“Financial incentives can encourage a strengthened focus on identifying and reviewing ways in which the safety and quality of public hospital care can be improved. This can ensure that pricing and funding approaches are aligned with other strategies to improve safety and quality,” the Authority said.

It said activity-based funding was often criticised for emphasising the volume of services rather than their quality or appropriateness, and increasing attention on sentinel events and avoidable readmissions could counter this.

Ms Ley has asked IHPA to present its options to the COAG Health Council by 30 November.

This would mean they could be incorporated into a new funding model for sentinel events and preventable hospital-acquired conditions that has been foreshadowed to come into effect from 1 July next year.

But hospital funding remains a huge political football between the Federal and State levels of government.

Although a pledge by Prime Minister Malcolm Turnbull of an additional $2.9 billion in Commonwealth funding to 2020 helped mute public hospital services as an issue during the Federal election, long-term funding arrangements remain unresolved and are a point of tension between the two levels of government.

It makes a challenging setting for preliminary Productivity Commission (PC) proposals to increase information disclosure by hospitals and doctors and greater contestability between human services, including public hospitals.

While Australian public hospitals performed well by international standards, “there is scope to improve”, the PC said, including by matching domestic best practice and publicly disclosing more information.

“Public patients are often given little or no choice over who treats them or where. Overseas experience indicates that, when hospital patients are able to plan services in advance and access useful information to compare providers (doctors and hospitals), user choice can lead to improved service quality and efficiency,” the PC said.

It said that any reforms to boost user choice would have to be supported by “user-oriented information”, and suggested the English model in which increased choice is offered at the point where GPs refer patients to a specialist.

The Commission said experience in England had shown that patients given a choice of hospital and consultant-led team sought out better performing providers, and hospitals in locations where competition was most intense recorded the biggest improvements in service quality.

In order to exercise their choice, patients had access to web-based information enabling them to compare providers according to waiting times and mortality rates, and could use an online booking service.

“Greater competition, contestability and informed user choice could improve outcomes in many human services,” the PC said. “Well-designed reform, underpinned by strong government stewardship, could improve the quality of services, increase access…and help people have a greater say over the services they use and who provides them.”

Treasurer Scott Morrison said he had ordered the review to improve the efficiency and cost effectiveness of human services.

But Opposition leader Bill Shorten, reprising Labor’s scare campaign during the Federal election on the privatisation of Medicare, said he feared it would be used to justify the wholesale handover of human services to the private sector.

“We’ve all seen this move before,” Mr Shorten said. “When Malcolm Turnbull and the Liberal Party start talking about changing human services it means that poor people get it in the neck.”

The Commission said that not all human services were amenable to increased competition, contestability and choice, but identified public hospitals and palliative care services among six priority areas targeted for reform.

The enormous variety of Australia’s public hospitals, including big differences in the populations they serve, workforce arrangements and characteristics and the complexity of their links to the rest of the health system, militate against like-for-like competition – something the Commission admitted.

If such issues or political considerations made fostering direct competition unfeasible, the Commission instead suggested exerting pressure for improved performance by making the position of senior hospital managers more precarious.

“There have been difficulties in the past commissioning non-government providers, and lessons from these attempts should not be forgotten,” it said. “As a result, it may be more feasible to implement contestability as a more transparent mechanism to replace an underperforming public hospital’s management team (or board of the local health network) rather than switch to a non-government provider.”

The PC’s preliminary report is open for submissions until 27 October, and the Commission is due to deliver its final report by October 2017.

 Adrian Rollins

Women’s health: local and global matters of great significance

A life cycle approach is important, as is acknowledging the importance of socio-cultural and lifestyle factors

Women’s health, in its broadest sense, encompasses all aspects of their health and wellbeing. From this perspective, this issue of the MJA includes a wide selection of articles covering key issues in women’s health, both locally and globally. The topics covered are diverse, and include pregnancy and reproductive health, as well as health and wellbeing at various stages of a woman’s life cycle. Taking a life course perspective of women’s health clarifies links between their socio-cultural background, reproductive health, lifestyle, and chronic disease risk.1 Significant events across the lifespan, including birthweight and age of menarche, have been identified as likely markers of cardiovascular disease risk,2 pre-menopausal breast cancer risk,3 and diabetes4 in women.

Most women in high and middle income countries will come into contact with health systems and health professionals while they are pregnant, but in Australia there is a confusing plethora of models of care. In some models the care is fragmented, as women move between primary and secondary care, private and public services, and medical and midwifery providers. Outcomes of pregnancy are important indicators of health for women and their families, so it is essential that women have access to a model of care that provides them with the best possible outcomes in every respect.

The narrative review by Homer5 examines the evidence in favour of continuity of care models in which a midwife is the primary maternity caregiver. The evidence, much of which is from Australia, is very clearly in favour of such models. Women report high levels of satisfaction with the midwife’s holistic approach to care during pregnancy and the postnatal period; the maternal and perinatal outcomes are the same as for other medical models, and are achieved with less intervention and at lower cost. The considerable high level evidence from randomised clinical trials now forms the basis of guidelines that advocate this approach for low or normal risk women. Why is it then so difficult for many women to choose this evidence-based model of midwifery care during pregnancy? Only a minority of women can access this form of care, and maternity hospitals appear reluctant to recognise the evidence. Inter-professional rivalries, lack of collaborative leadership models, and inaccurate citing of evidence all block further development, and the translation of the available evidence into practice is held up. As Homer remarks, it really needs to be asked whether it is ethical to deny women access to a model of care that is so strongly supported by the evidence.

Further assessment of how effectively these models work for women with higher risks during pregnancy is required, and one of the greatest challenges is ensuring that all health professionals involved in maternity care work collaboratively to achieve the best outcomes. It makes sense that women at higher psycho-social risk would benefit from greater continuity. Whether or not such models lead to better medium and long term psychological and emotional outcomes for all women needs to be determined, but there is potential for significant benefits for the entire family if the model enhances their wellbeing in the postnatal period and beyond. The likelihood that this outcome of pregnancy will impact on women later in life should be obvious to all.

In their later years, non-communicable diseases (NCDs) pose one of the greatest threats to women’s health globally. NCDs such as cardiovascular disease, cancer, diabetes, and chronic respiratory diseases currently account for around 18 million deaths in women annually, and it is estimated that this will rise by 17% over the next decade.6 The perspective article on global women’s health by Davidson and colleagues7 identifies that much of the increased risk has been attributed to socio-cultural factors, although lifestyle factors, such as unhealthy diet, alcohol consumption and smoking, physical inactivity, and obesity, also play pivotal roles.6 Davidson and colleagues argue that the ramifications of the burden of NCDs for women, their families and the global community is significant, and will lead to escalating health care costs, lost productivity, and adverse social and economic outcomes for families.7

Importantly, the perspective article by Teede and colleagues8 explains how biological differences, gender roles, and social marginalisation affect women, and mean that their risk behaviours are not the same as those of men, with consequences for the success of health-related interventions. From this perspective, more targeted health programs for women and health models of care are likely to better promote the wellbeing of women generally, as well as during pregnancy. This approach should help reduce the impact of modifiable risk factors and the burden of chronic disease, and enhance the development of comprehensive evidence-based policy and practice that improve women’s health.

There is increasing evidence that women’s health needs, both locally and globally, are best served by interventions tailored to their specific needs, acknowledging the links between socio-cultural background, reproductive health, lifestyle and chronic disease risk. Improving health outcomes for women, during pregnancy and at other stages of their life cycle, requires health service providers to recognise this, and to use the evidence to inform their provision of care that is both effective and acceptable to women.

NHMRC funding of mental health research

A case for better alignment of research funding with burden of disease

Mental health research has long been the poor cousin in medical research, despite mental illness being both an independent and comorbid risk factor for every major medical disease, and a significant contributor to morbidity and mortality. Of the five major non-communicable disease areas, mental illness has the largest impact on the world economy by reducing gross domestic product.1 Yet, 11 times more money is donated from the private and corporate sectors to cancer research than to mental health research. In addition, cancer research receives twice the funding from governments.2

This pattern is reflected in the funding distribution from the National Health and Medical Research Council (NHMRC) in Australia, where mental health research has received a lower proportion of NHMRC health funding compared with other National Health Priority Areas such as cancer, diabetes and cardiovascular disease. Between 2001 and 2010, for example, mental health received about 9.5% of NHMRC funding.3 NHMRC funding for suicide research was lower than funding for falls, skin cancer and motor vehicle accidents, despite the fact that suicide is responsible for more deaths.4 In 2015, when NHMRC announced the membership of its strategic committees, there were no members with mental health expertise, in contrast to previous years.

We tested whether the proportional NHMRC funding to mental health has changed since our 2010 analysis, by estimating the number and dollar value of NHMRC funding schemes awarded to mental health-related topics during 2015. We also compared burden of disease estimates with NHMRC funding for mental health to determine whether the proportion of funding allocated to mental health-related research is in line with its effect on the population.

Using data from the October–November 2015 announcement of NHMRC results, we conducted a search of the following fields: grant title, field of research, all keywords and research summary. Our search used the following text strings: mental health, mental illness, depressi*, anxi*, psychosis, schizophrenia, substance use, alcohol use, smoking, adhd, stimulants, cocaine, heroin, amphetamine, sleep, obsessive, autism, panic, ptsd, suicid* and bipolar. The search conservatively counted psychosocial research with any mental health component as 100% “mental health”.

In 2015, the NHMRC funded 1037 projects or fellowships across all health categories, which were worth a total of $763 million. Of these, 85 were on the topic of mental health, constituting 8.6% of funding (Box). In 2009, the proportion of the total funding allocated to mental health was 9.5%. Recent data from the Australian Institute of Health and Welfare5 suggest that the burden of disease for mental disorders is 12.1%, or 14.6% if suicide and self-inflicted injuries are included, with mental and substance misuse disorders accounting for the largest burden in younger age groups. If funding was proportional to the burden of disease (disability adjusted life years), mental health research was short $26.6 million or 41% of the total funding. A comparison of cancer, cardiovascular and diabetes research using a similar search strategy found that 14.3%, 15.5% and 5.7% of funding went to these areas. Based on the burden of disease for these disease areas (18.5%, 14.6% and 2.3% respectively), these funding figures represent a smaller relative shortfall for cancer research ($32.1 million, 29%), a small gain for cardiovascular research ($7.1 million, 6%) and a large net gain for diabetes research ($17.6 million, 41% gain).

Our analysis indicates that, in the major NHMRC funding announcement for 2015, mental health research received significantly less funding than its disease burden (8.6% versus 12.1%), and less total funding than the average received in the previous decade (8.6% versus 9.5% for 2001–2010). This funding pattern is in contrast to the United Kingdom, where the research investment in mental health by the government has increased as a proportion of overall spend by 1.5% over the decade 2004–2014.2 The present analysis had limitations, such as not being able to deal with the problem of infrastructure and clinical environment in detail, compare in detail the nature of cardiovascular and cancer research, or reconfirm the high quality of Australian mental health research.3

There are many potential reasons as to why mental health research does not receive NHMRC funding proportional to disease burden. Given that the problem is not the quality of the research (mental health research outperforms other disciplines on the world stage),3 the working hypothesis remains that the primary causes are capacity (limited number of active mental health researchers) and the nature of mental health research (NHMRC category descriptors do not favour translational research — real-world trials are rarely flawless). Considering the capacity concern, it is disappointing that the number of opportunities provided to early- and mid-career fellowship applicants in mental health remains low.

The prevalence of depression and suicide rate has not changed in the past decade, while the costs of mental health to the community are increasing rapidly. Recent figures indicate that the government spent about $4.5 billion on mental health with about 21% of this spent on hospital funding; 21% on carer funding and 20% on the Medicare Benefits Schedule. These spends represented an increase of between 13% and 53% over the past 7 years.6 Critically, this investment has not increased access to evidence-based mental health care, which remains low at 11–20%.7 Yet, research funding has remained stagnant over the same period, with considerable decreases after adjusting for inflation. Mental health research has the potential to transform the lives of Australians and to save costs.

So what is to be done? First, impress upon the public, scientists, government and politicians the importance of research as the key solution to managing the escalating costs of mental health — estimated to be $4.5 billion, which represents an increase of up to 53% over the past 7 years.6 Second, recognise that research funding in Australia has to change, as in the UK, where the proportion of funding to mental health has increased by 1.5% from 2004–2014.2 Third, we need to determine the reasons for low yields from philanthropy and non-government support for mental health, and actively overcome barriers and capture funds.

We call on the Australian government to develop a clear, empirical basis for using health priorities to allocate funding from the emerging Medical Research Future Fund that accounts for indices such as burden of disease and building capacity in underfunded areas. The government approved the establishment of the Medical Research Future Fund in 2015 to drive innovation in medical research, with funding guidelines currently being developed. The resulting doubling of investment in medical research in Australia offers a unique opportunity to overcome the gap in the funding of mental health research identified here. The mental health community (consumers, researchers, clinicians and the wider community) look forward to continuing to contribute ideas to the Australian Medical Research Advisory Board regarding a more equitable distribution of research funding.

Box –
Counts and funding for major NHMRC grants and fellowship categories announced on 9 November 2015

Category

Number awarded

Number awarded related to mental health

Total funding across all domains ($)

Funding related to mental health ($)

Career development fellowship

55

5 (9.1%)

23 915 192

2 184 844 (9.1%)

Early career fellowship

124

13 (10.5%)

38 102 059

3 779 955 (9.9%)

Research fellowship

69

8 (11.6%)

51 239 170

6 070 820 (11.8%)

Development grant

24

0

14 142 312

0

Standard project grant

483

48 (9.9%)

404 722 995

48 622 759 (12.0%)

NHMRC–ARC dementia research development fellowship

76

6 (7.9%)

43 669 587

3 308 618 (7.6%)

Total (all schemes)

1037

85 (8.2%)

$763 481 138

$65 746 208 (8.6%)

ARC = Australian Research Council. NHMRC = National Health and Medical Research Council.

Maternal mortality trends in Australia

Maternal death is low and decreasing in Australia, but continuing surveillance is important

The death of a mother or a baby has significant short and long term impacts for the surviving family members and for the community and health workers who cared for them. The World Health Organization estimates that 303 000 women died in pregnancy and childbirth in 2015, with 99% of these deaths occurring in low income countries.1

In Australia, a series of reports regarding maternal deaths has been published over the past five decades; the first in the series covered the 1964–1966 triennium.2 These reports examine the deaths that occurred during pregnancy or within 42 days of the end of pregnancy. They are compilations of data sourced from multidisciplinary state maternal mortality review committees that undertake detailed reviews of each case.

The incidence of maternal death is expressed as a maternal mortality ratio (MMR). The MMR is the number of deaths due to complications of the pregnancy (direct deaths) or aggravation of existing disease processes by the pregnancy (indirect deaths) per 100 000 women giving birth. The calculation does not include deaths from unrelated causes that occur in pregnancy or the puerperium (incidental deaths) and deaths that occur more than 42 days after the end of a pregnancy.

The MMR in Australia is low; it has decreased from 41.2 in the 1964–1966 period to 7.1 in the years 2008–2012.3 The comparable figures are 14.7 for the period 2010–2012 in New Zealand4 and 9.0 for the period 2011–2013 in the United Kingdom.5

Until now, publications in the Maternal deaths in Australia series have been irregular. The Australian Institute of Health and Welfare (AIHW) established the National Maternity Data Development Project (NMDDP) in response to the recommendations in the 2008 Maternity Services Review from the Commonwealth and the subsequent 2010–2015 National Maternity Services Plan.6 A recent report regarding the progress of the NMDDP notes that sustainable data collection on national maternal mortality will be established to facilitate “consistent and regular national reporting” of maternal mortality in the future.6

The genesis of the almost sixfold reduction in maternal death rates in Australia is multifactorial, including the improved general health of the population and the availability of better health care options, such as the availability of antibiotics, blood transfusion, safer anaesthesia and effective diagnostic ultrasound. Advanced maternal age, maternal obesity and caesarean deliveries3,5 are all associated with an increase in the risk of maternal death, and any future growth in their incidence will threaten the efforts to further reduce the maternal mortality rate.

In the list of most common causes of death, infection, abortion and pre-eclampsia have been replaced by maternal cardiovascular disease and psychosocial health problems, while obstetric haemorrhage and thromboembolism remain prominent. The current method of classifying maternal deaths into direct, indirect and incidental deaths was first used in the report on the 1973–1975 triennium.7 Between that first 1973–1975 report and the most recent one for 2008–2012, 944 direct and indirect maternal deaths have been reported in Australia. Over that 48-year period, cardiovascular disease (MMR, 1.5), sepsis (MMR, 1.3) and obstetric haemorrhage (MMR, 1.1) have been the most prominent causes of death.

Aboriginal and Torres Strait Islander women are twice as likely to die in association with pregnancy and childbirth as other Australian women. In 2008–2012, the Aboriginal and Torres Strait Islander MMR was 13.8 compared with 6.6 for non-Indigenous Australian women who gave birth.3 The differential between the MMRs is decreasing and caution should be exercised in drawing conclusions due to the small numbers analysed. The leading causes of maternal deaths among Aboriginal and Torres Strait Islander women were cardiovascular conditions, sepsis and psychosocial conditions.

Women aged 35 years or over were more than twice as likely as their younger counterparts to die in association with pregnancy and childbirth, and those aged 40 years or more were over three times more likely to die in association with pregnancy and childbirth.3

Of the six most prominent causes of maternal death between 1973 and 2012, psychosocial death is the only group where the MMR is rising; the incidence of maternal death due to cardiovascular disease, obstetric haemorrhage, thromboembolism, hypertensive disorders and sepsis are all decreasing. Most of the deaths classified as psychosocial deaths are due to suicide, although some are related to fatal complications of substance misuse and homicide in domestic situations. While some of that apparent rise may be due to changes in the ascertainment of maternal deaths in general and to problems reporting both maternal suicide and deaths due to substance misuse in particular, it is clear that more needs to be done in this sphere. There is a growing belief that a significant portion of late maternal deaths are related to suicide; however, without a clear review of the cases by multidisciplinary committees, the relationship between pregnancy and suicide more than 42 days after the end of pregnancy remains speculative.

It is not clear whether the incidence of suicide in association with pregnancy is more or less common than in comparable non-pregnant women. This comparison is fraught, as the true denominator for pregnancy is not known due to lack of information regarding pregnancies lost as a result of miscarriage and termination. Given that caveat, the overall suicide rate in the 15- to 45-year-old Australian female population in 2006–2010 was 6.0 per 100 000 women,8 while the maternal mortality rate due to psychosocial issues in the same period was 0.9 per 100 000 women giving birth. A similar finding has recently been noted in the United States.9 Nevertheless, the apparently increasing incidence of psychosocial maternal death is a matter of concern, given that pregnant women are among the most medically supervised members of the population.

Screening during pregnancy for mental health, substance misuse and domestic violence problems is recommended,10 but it is not universally undertaken. All maternity care providers should commit to making these items a standard part of their care delivery. The follow-up of identified concerns by the relevant specialist services must be a priority and should continue for a significant period after the end of pregnancy. Similar screening attention is needed for women who had miscarriages and pregnancy terminations.

In many cases, an autopsy is necessary to understand the true cause of a maternal death. A number of causes of maternal death, such as amniotic fluid embolism and pulmonary thromboembolism, may be easily confused clinically. In the case of amniotic fluid embolism, for example, the diagnosis can only be confirmed by autopsy. The question of an autopsy should be pursued with the family by a senior clinician, and the presumption of a diagnosis that has been made in an intensive care unit or similar setting should not be an excuse to not request this critical form of investigation.

Maternal death is one of the few defined core sentinel events in health care; however, it is disturbing to find that a significant portion of these deaths have not been subjected to a root cause analysis or similar review. The application of a systematic review to identify gaps in hospital systems and health care processes, which are not immediately apparent and may have contributed to the occurrence of an event, should be applied to all maternal deaths, whether occurring in the public or private health systems.

The question of the presence or absence of contributory factors is now being actively pursued by some state and territory maternal mortality review committees, and similar questions are also being raised internationally. A consolidation of such information is yet to be published in an Australia-wide context. Experience with such review in New Zealand11 has shown that more than 50% of maternal deaths were associated with contributory factors, and 35% of the deaths were potentially avoidable.

The Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity model12 appears to be of value, and examines two questions:

  • Were suboptimal care factors identified?

  • What was the relevance of any suboptimal care factors identified?

Suboptimal care factors may be classified as factors related to the woman, her family and social situation, factors related to access to care and factors related to professional care. Moreover, these factors may be classified as identified but unlikely to have contributed to the outcome (insignificant), identified and might have contributed to the outcome (possible), or identified and likely to have contributed to the outcome (significant).

It is critical to maintain a continuing intensive surveillance of maternal death — with particular reference to recognised risk factors — and to examine the contributory factors. Health departments must require that all direct and indirect maternal deaths are subjected to a systematic review. At present, data on late maternal deaths — occurring more than 42 days after the end of pregnancy — are not collected in all states and territories and are not reported nationally. Reviews of late maternal deaths and of severe maternal morbidity are future necessities, but the resources and methodologies are not yet available at a national level.