National New Zealand Research Articles

An in-depth analysis of perinatal related mortality among women of South Asian ethnicity in Aotearoa New Zealand

BackgroundInternational and national New Zealand (NZ) research has identified women of South Asian ethnicity at increased risk of perinatal mortality, in particular stillbirth, with calls for increased perinatal research among this ethnic group. We aimed to analyse differences in pregnancy outcomes and associated risk factors between South Asian, Māori, Pacific and NZ European women in Aotearoa NZ, with a focus on women of South Asian ethnicity, to ultimately understand the distinctive pathways leading to adverse events.MethodsClinical data from perinatal deaths between 2008 and 2017 were provided by the NZ Perinatal and Maternal Mortality Review Committee, while national maternity and neonatal data, and singleton birth records from the same decade, were linked using the Statistics NZ Integrated Data Infrastructure for all births. Pregnancy outcomes and risk factors for stillbirth and neonatal death were compared between ethnicities with adjustment for pre-specified risk factors.ResultsWomen of South Asian ethnicity were at increased risk of stillbirth (aOR 1.51, 95%CI 1.29–1.77), and neonatal death (aOR 1.51, 95%CI 1.17–1.92), compared with NZ European. The highest perinatal related mortality rates among South Asian women were between 20–23 weeks gestation (between 0.8 and 1.3/1,000 ongoing pregnancies; p < 0.01 compared with NZ European) and at term, although differences by ethnicity at term were not apparent until ≥ 41 weeks (p < 0.01). No major differences in commonly described risk factors for stillbirth and neonatal death were observed between ethnicities. Among perinatal deaths, South Asian women were overrepresented in a range of metabolic-related disorders, such as gestational diabetes, pre-existing thyroid disease, or maternal red blood cell disorders (all p < 0.05 compared with NZ European).ConclusionsConsistent with previous reports, women of South Asian ethnicity in Aotearoa NZ were at increased risk of stillbirth and neonatal death compared with NZ European women, although only at extremely preterm (< 24 weeks) and post-term (≥ 41 weeks) gestations. While there were no major differences in established risk factors for stillbirth and neonatal death by ethnicity, metabolic-related factors were more common among South Asian women, which may contribute to adverse pregnancy outcomes in this ethnic group.

Examining adverse fetal/neonatal outcomes associated with severe maternal morbidity.

While there is a global focus on severe maternal morbidity (SMM), less is known about the impact of SMM on fetal and neonatal outcomes. To examine fetal/neonatal outcomes associated with SMM. A national New Zealand (NZ) retrospective cohort study describing fetal/neonatal outcomes of all women with SMM admitted to a NZ Intensive Care Unit (ICU) or High Dependency Unit (HDU) in 2014. Adverse fetal/neonatal outcomes were defined as one or more of the following: fetal or early neonatal death, hypoxic ischaemic encephalopathy, Apgar score less than seven at fiveminutes, admission to Neonatal Intensive Care Unit or Special Care Baby Unit. There were 400 women with SMM admitted to NZ ICU/HDU units in 2014, and 395 (98.8%) had complete birth/pregnancy outcome information. Of these, 49.4% (195/395) were associated with an adverse fetal/neonatal outcome. Indigenous Māori women had a 30% higher rate of adverse fetal/neonatal outcome compared to NZ European women (63.7% and 48.9% respectively; relative risk=1.30, 95% CI 1.04-1.64). Pre-eclampsia was associated with an adverse fetal/neonatal outcome in 67% (81/120). Perinatal-related mortality rate was 53.1 per 1000 total births compared to NZ perinatal mortality of 11.2 per 1000 total births for 2014. SMM events are associated with high rates of adverse fetal/neonatal outcomes with a higher burden of adverse events for Māori. Further research is needed to explore opportunities in maternal and neonatal care pathways to improve fetal/neonatal outcomes and address inequities.

Preventive Pharmacotherapy for Cardiovascular Disease: A Modelling Study Considering Health Gain, Costs, and Cost-Effectiveness when Stratifying by Absolute Risk

Cardiovascular disease (CVD) is the leading cause of death internationally. We aimed to model the impact of CVD preventive double therapy (a statin and anti-hypertensive) by clinician-assessed absolute risk level. An established and validated multi-state life-table model for the national New Zealand (NZ) population was adapted. The new version of the model specifically considered the 60–64-year-old male population which was stratified by risk using a published NZ-specific CVD risk equation. The intervention period of treatment was for five years, but a lifetime horizon was used for measuring benefits and costs (a five-year horizon was also implemented). We found that for this group offering double therapy was highly cost-effective in all absolute risk categories (eg, NZ$1580 per QALY gained in the >20% in 5 years risk stratum; 95%UI: Dominant to NZ$3990). Even in the lowest risk stratum (≤5% risk in 5 years), the cost per QALY was only NZ$25,500 (NZ$28,200 and US$19,100 in 2018). At an individual level, the gain for those who responded to the screening offer and commenced preventive treatment ranged from 0.6 to 4.9 months of quality-adjusted life gained (or less than a month gain with a five-year horizon). Nevertheless, at the individual level, patient considerations are critical as some people may decide that this amount of average health gain does not justify taking daily medication.

Triangulation in action

This article presents a summary review of the design and results of an independently conducted evaluation of a national New Zealand (NZ) Ministry of Education funded contract for professional development of staff of students with special education needs in 49 schools. The evaluation was conducted as a mixed method design (Johnson &amp; Onwuegbuzie 2004) in the following three phases: a broad questionnaire issued to all participants associated with the development; eight focus groups with a sample of participants; and success case studies (Brinkerhoff, 2003) with four schools. The most significant overall finding was that regardless of the approach to development engaged in (either action research, AR, or action learning, AL), there was an outstanding recurring characteristic of staff and supporters wanting to see the students excel. Other key participant self-report impacts from the small-scale projects on adaptation of the curriculum fell under the headings of improved social interaction and academic achievement for students, changes in values and attitudes (for students and teachers), and changes in teaching practice. Participants referred to the importance of school context factors (inclusive planning, management support) and internal and external experts as enablers towards the effectiveness of development. Barriers to effectiveness were noted as associated with initial national contract administration, the number of development initiatives involved in and lack of alignment between these varied initiatives. Maintaining and sustaining the effective impact of projects was seen as dependent on: ongoing commitment and follow-through by school management, governors and program teachers; having ongoing funding and support (internal and external); and bringing other staff on board. The Phase Three success case evaluation revealed an important element that distinguished projects perceived to be highly successful by both the participants and Ministry of Education personnel. In this small proportion of projects the participant action researchers/learners utilised ‘informed’ decision-making. Although many participants in Phases One and Two justified their limited use of informed decision-making by noting that it was either too early to validate project outcome changes, or it was difficult to show causal effect (changes could be attributed to the development program), a hallmark of the four success cases was the use of strong data in the reconnaissance and evaluation phases of the AR and AL and improvement initiatives that were informed by both this data and relevant previous literature.