A Multidisciplinary Approach to Maternal and Perinatal Quality of Care
Like clockwork, five times a year, Dr. Michael Helewa would meet with colleagues to discuss maternal and perinatal mortality and morbidity cases in the province. They would micro-analyze each case to determine the preventable factors for those deaths and morbidities and share that knowledge to alert physicians and healthcare workers in maternity and neonatal care.
That group was known as the Maternal and Perinatal Health Standards Committee (MPHSC), a committee at the College of Physicians and Surgeons of Manitoba (CPSM), supported by funding from Manitoba Health. This committee had been monitoring and improving the quality of maternal and perinatal care in Manitoba for 47 years. The committee reviewed hundreds of cases yearly until 2022, when the province informed CPSM that funding for this committee and its sister committee, the Child Health Standards Committee, would not be renewed.
“This committee was a jewel,” said Dr. Helewa, medical consultant for the MPHSC committee. Having served many years on the committee, his commitment to improving obstetrical and neonatal care is unquestionable. He first joined the committee when he was Head of Obstetrics at St. Boniface Hospital and served first as a member, then as a chair for over ten years before taking a hiatus to serve as president at The Society of Obstetricians and Gynaecologists of Canada. He did not stay away from MPHSC for too long; when he was asked to return to the committee by Dr. Pope and Dr. Babick as the medical consultant in 2008, he happily accepted and occupied the role until recently.
MPHSC reviewed maternity audit case reports from hospital standards committees and rural standards committees. As the medical consultant, Dr. Helewa reviewed about 500 cases annually. In any cases where preventability or resultant corrective actions were deemed suspect or unsatisfactory by the local audit committees, he would advance to the MPHSC committee for further discussion.
MPHSC was highly regarded across the disciplines involved in maternity care because of its comprehensive reviews and province-wide approach to maternal and neonatal health.
When Dr. Helewa joined the committee, he saw the importance of a multidisciplinary approach. He secured representation from rural and urban settings and representation from generalists, specialists and subspecialists, including obstetricians, neonatologists, midwives, family physicians, perinatologists, anesthesiologists, and obstetrical nurses, and a representative from the regional health authority. When needed, opinions were further sought from radiologists, infectious diseases specialists, and psychiatrists. For decades, this approach to maternal health provided immense value to the health care workers and the public.
Many recommendations the committee made have turned into improvements to the system through education and action. These were disseminated to healthcare workers through confidential, personalized letters, the CPSM newsletter, and the Annual MPHSC reports made available on the CPSM website and raised to the regional health authorities and Shared Health. These annual reports were of great educational value to those in training and practice.
MPHSC’s work went beyond audits. One example is the Manitoba Prenatal Record, which was recently updated by a working group of committee members and outside specialists and led by Dr. Helewa. The Prenatal Record currently being used was developed in 1998 and is outdated and out of synchrony with improvements in obstetrical care and requirements for documentation. The new form was designed with diversity and equity in mind, with space to document psychosocial issues, vaccinations, perinatal workup, organized lab results, patient teaching items for each trimester, and validated questionnaires to assess for depression and substance use. The new form took over three years to develop and has been approved for use by CPSM’s Central Standards Committee, the Registrar, and by Shared Health. It remains with Shared Health for distribution.
Another example is lobbying for Brandon, where 24-hour in-house obstetrical coverage was unavailable. With over 2500 deliveries per year and with some cases of adverse outcomes being identified because of a deficiency in continuous in-house coverage, the committee made serious lobbying efforts and offered suggestions to the health region for the provision of such coverage.
MPHSC’s work did not stop at provincial boundaries or the medical profession. Because MPHSC and CPSM can only act on cases involving CPSM registrants, cases with complications managed outside Manitoba referred to the province or cases involving other disciplines in maternity care would still be reviewed at MPHSC, but these cases were forwarded further to their appropriate jurisdictions to undertake their review and action. Dr. Helewa recalls a case from Northwestern Ontario that resulted in preventable death during transport; MHPSC sent a report to the medical regulatory college in Ontario. Cases from Nunavut that were managed in Manitoba were also reviewed by MPHSC.
Cases involving midwives would be sent to the College of Midwives of Manitoba with MPHSC opinion; cases involving nursing care would go to the Chief Nursing Officers of those institutions, and those involving physicians in training would go to the respective program directors.
Dr. Helewa fears cases like these may not be identified and slip through the cracks during the disruption and beyond. This is particularly so when uncertainties dominate the transition process, and ongoing disruption to the database and multidisciplinary character and modus operandi of the MPHSC committee, developed and used successfully for years, does not continue to be used going forward.
“MPHSC was efficient. Issues were discovered, educational opportunities were identified, and feedback was provided to physicians, all in the name of improving patient care,” Dr. Helewa says.
He stresses that the committee was not just collecting and reviewing cases and data; they looked at underlining issues and the dynamics that resulted in the adverse outcomes identified. “Numbers are just numbers without the context MPHSC brought to the table. We did something about it,” he says, referring to the educational pieces the committee regularly disseminated to CPSM registrants, the system issues they identified, and the resources they provided.
Some of the topics the committee advised other physicians to be vigilant about in recent years included fetal surveillance and labour, vaccinations, monitoring for depression, interpersonal violence in the family, management of patients with high BMI or pregnancy with multiples, optimizing conditions for delivery of abnormal placentation, safe transport, communication and respectful, collegial behaviour between health care workers, documentation, etc.
Classifying cases of mortality and morbidity into preventable and non-preventable helped to formalize a process to identify areas of preventability and, when such preventability was physician related, to hold physicians accountable. In adverse outcome cases or near misses classified as preventable and involving a physician, they provided the physician with recommendations and educational resources for improvement. The work of MPHSC was educational and not punitive. In instances where standards violations were repetitive or extreme, MPHSC would refer the case for corrective action by escalating the case to Central Standards Committee or the CPSM Registrar. On the other hand, when potentially difficult cases were managed well by physicians, these physicians would receive letters of acknowledgment and recognition.
The multifaceted collaboration that transpired within the committee of experts was unique; Manitoba is one of a few provinces that monitored maternal and perinatal mortality and morbidity. Without MPHSC or with a similarly functioning committee at Shared Health in the future, the province may lose the hard-gained benefits of years passed and risks falling behind nationally in identification gaps in maternity care, one case at a time.
The MPHSC committee had to cease its operations in mid-2022. However, Dr. Helewa and CPSM lobbied with Shared Health on the importance and value of committee outputs. Once it was declared that Shared Health would take responsibility for this work in the future, he cooperated in an advisory capacity to help create the infrastructure for this work under Shared Health. This capacity building at Shared Health is ongoing.
Dr. Helewa fears this leaves a gap in the flow and momentum of the previously established provincial audit process for maternal and perinatal mortality and morbidity in Manitoba. “Such pause disrupts the network established, trust and guidance built between the hospital audit committees for maternity care including the office of the Chief Medical Examiner, and the MPSHC,” he stated. He quickly notes that the Evidence Act protects MPHSC audit work and calls for implementing educational corrective measures for physicians and healthcare workers, especially for preventable adverse outcomes.
Dr. Helewa may not have MPHSC meetings to attend anymore, but he plans to remain dedicated to obstetrics through his contributions to practice, teaching, and various ongoing research projects. CPSM thanks Dr. Helewa for his tremendous contributions and dedication to improving obstetrical and neonatal care in the province. “To express gratitude seems insufficient compared to the achievements he fulfilled during his many years on MPHSC,” said Dr. Anna Ziomek, CPSM Registrar.
MPHSC compiled their work into an annual report that includes a summary of cases and the actions taken by MPHSC and/or the local hospital standards committees. Reports from the committee can be found here.