Learning from maternal death reviews

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• Learning from maternal death reviews
• Saving Mothers Lives

Royal College of Obstetricians and Gynaecologists
April 30th
Dr Gwyneth Lewis National Director of maternal
health CEMACH Clinical Director Maternal Death
Enquiry
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• Short history
• How Confidential Enquires into Maternal Deaths
  have helped in the past
• Why we continue
• Recent findings and recommendations

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Maternal deaths by major cause
England and Wales, 1935-78
350
300
Abortion and miscarriage
250
Toxaemia
200
Haemorrhage
Deaths per 100,000 total births
Puerperal sepsis
150
Puerperal phlebitis,
100
thrombosis and embolism
50
0
1935
1940
1945
1950
1955
1960
1965
1970
1975
Source General Register Office and OPCS,
Reproduced in
Birth counts
, Table A10.1.3
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Maternal deaths by major cause
England and Wales, 1935-78
350
CEMD
300
Abortion and miscarriage
250
Toxaemia
200
Haemorrhage
Deaths per 100,000 total births
Puerperal sepsis
150
Puerperal phlebitis,
100
thrombosis and embolism
50
0
1935
1940
1945
1950
1955
1960
1965
1970
1975
Source General Register Office and OPCS,
Reproduced in
Birth counts
, Table A10.1.3
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When local audit/CEMDs were introduced
Local CEMDs
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When the national CEMD was introduced
National CEMD
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When local audit/CEMDs were introduced
Local CEMDs
National CEMD
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• So far, all this procedure had been intended
  to do was to secure improvements by the local
  review of cases, but it was soon apparent that
  avoidable factors were too often present in
  antenatal and intranatal care for the opportunity
  for central remediable action to be ignored. This
  led to the decision to undertake a national
  confidential enquiry.
• Sir George Godber ex CMO England

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Maternal mortality rates UK 1952-2005
per 100,000 maternities
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Maternal mortality rates UK 1952-2005
per 100,000 maternities
CEMACH
ONS
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Clinical factors
100 pages
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Social factors
360 pages
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A new title a renewed purpose

• New title
• Top 10 recommendations and auditable standards
• Near misses UKOSS
• GP and EMD chapters
• Better statistical rigour
• Separate reports for GPs, ED, Path, Psych and
  Midwives

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Global recognition
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The maternal mortality surveillance cycle
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The maternal mortality surveillance cycle
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Types of Maternal Death

• Direct
• Indirect
• Co-incidental (fortuitous)
• Late (between 42 -365 days after delivery)

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• Direct
• Indirect
• UK Maternal Mortality Rate per 100,000
  maternities

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Co-incidental deaths count too..
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At 18 weeks the baby started kicking. At 22
weeks so did the father

• 30 of new cases start in pregnancy
• 40-60 of women already living with violence
  are also abused in pregnancy
• Coincidental deaths are important too..

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Mental health guidelines
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Not just professionals either.
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Jessica's Trust
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The first fifty years
1952-54 2000-02
(E.W.) (U.K.)

• Hypertensive disease 246 18
• Haemorrhage 188 14
• Abortion 153 2
• Thromboembolism 138 41
• Anaesthesia 49 6
• Sepsis 42 18

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Deaths from pulmonary embolism following
Caesarean section UK 1985-99, rate per million
maternities
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National guidelines
1995

• 2001-2004

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2003-05
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Death certificate data alone for international
comparison
Years No. Rate Maternities
1994-96 1997-99 2000-02 2003-05 158 128 136 149 7.2 6.0 6.8 7.0 2,197,640 2,123,614 1,997,472 2,114,004
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Maternal Deaths Numbers and rates per 100,000
maternities by type UK 1985-2005
Caused Direct Caused Direct Caused Direct Aggravated Indirect Aggravated Indirect Total
94-96 97-99 00-02 03-05 134 106 106 132 134 106 106 132 6.1 5.0 5.3 6.2 134 116 155 163 6.1 6.4 7.8 7.7 268 12.2 242 11.4 261 13.1 295 14.0
6.1 6.4 7.8 7.7

Suicide Some Cancers Sub arachnoids Aneurysms
UK Indirect
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Direct and Indirect rates UK 1985-2005
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Direct deaths rates per million maternities
UK1985-05
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Leading causes of Direct deaths UK rates per
million maternities 2003-05
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Leading causes of Indirect deaths rates per
million maternities 2003-05
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Overall rates per million maternities UK 2003-05
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Cardiac causes (per million maternities) maternal
mortality 1952-2005
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Leading causes and rates per million maternities
2000-05
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• Why do mothers really die?

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Percentage of deaths due to substandard care UK
1985 - 2005
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Maternal mortality by maternal age per million
maternities 1985-2005
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Key signs and symptoms of possible serious
illness in pregnant women or recently delivered
mothers

• A heart rate greater than 100bpm,
• A systolic blood pressure of 160 mm/Hg or above
  or lower than 90 mm/Hg, and /or a diastolic blood
  pressure of 90 mm/Hg, or more.
• A temperature greater than 38 degrees Centigrade
  and/or
• A respiratory rate more than 21 breaths per
  minute. The respiratory rate is often overlooked
  but rates over 30 per minute are indicative of a
  serious problem.

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Obesity

• 52 of mothers who had booked for antenatal
  care died were overweight or obese c/f estimates
  of 11-10 in the general population.
• 25 overweight
• 12 obese (BMI 30-34.9)
• 15 were morbidly obese (BMI greater than 35)
• 8 had BMI greater than 40

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Maternal mortality rates by major ethnic group
England only 2003-05
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Direct and Indirect rates UK and effect of
migration 1985-2005
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Maternal death rates per 100,000 maternities by
employment and partnership status United Kingdom
2003-05
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Maternal mortality and deprivation
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Attendance for antenatal care (ANC)
Total Late book poor ANC No ANC of all deaths
Direct 132 11 7 14
Indirect 163 24 8 20
Direct Indirect 295 35 15 17
Coincidental 55 5 4 16
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Percentage of women who were poor or
non-attenders for antenatal care

• Domestic abuse 81
• Known to CPS 81
• Substance misuse 78
• Black Caribbean 57
• Black African 57
• Single unemployed 56
• Both partners unemployed 47
• No English 35
• Recently arrived in UK 26
• At least one partner in employment 5

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• Top ten recommendations

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1 Pre-conception care

• Pre-conception counselling and support, both
  opportunistic and planned, should be provided for
  women of child-bearing age with pre-existing
  serious medical or mental health conditions which
  may be aggravated by pregnancy. This includes
  obesity. This applies especially to women prior
  to assisted conception and other infertility
  treatments.

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Commoner conditions

• Epilepsy
• Diabetes
• Cardiac disease
• Auto-immune disorders
• BMI gt 30
• Current / past mental illness

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2 Access

• Maternity service providers should ensure that
  antenatal services are accessible and welcoming
  so that all women, including those who currently
  find it difficult to access maternity care, can
  reach them easily and earlier in their pregnancy.

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• Women should also have had their full booking
  visit and hand held maternity record completed by
  12 weeks of pregnancy.

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3 Access at 12 weeks

• Pregnant women who, on referral to maternity
  services, are already 12 or more weeks pregnant
  should be seen within two weeks of the referral.

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4 Migrant women

• All pregnant mothers from countries where
  women may experience poorer overall general
  health, and who have not had a full medical
  examination in the UK, should have a medical
  history taken and clinical assessment made of
  their overall health, including a cardiovascular
  examination at booking. This could be the GP.

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• Women from countries where genital mutilation
  is prevalent should be sensitively asked about
  this and management plans for delivery agreed
  during the antenatal period.

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5 Systolic hypertension

• All pregnant women with a systolic BP of /gt
  160 require anti-hypertensive treatment.
  Consideration should also be given to initiating
  treatment at lower pressures if the overall
  clinical picture suggests rapid deterioration and
  / or where the development of severe hypertension
  can be anticipated.

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6 Caesarean section

• Mothers must be advised that CS is not a
  risk-free procedure and can cause problems in
  current and future pregnancies.
• Women with previous CS should have placental
  localisation to exclude praevia and, if present,
  further investigation to try to identify praevia
  accreta.

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7 Clinical skills

• Providers and CDs must ensure that all
  clinical staff learn from any critical events and
  serious untoward incidents occurring in their
  Trust or practice.

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8 Training

• All clinical staff must undertake regular,
  documented and audited training for
• Identification, initial management and referral
  for serious medical mental health conditions
• Early recognition and management of severely ill
  pregnant women
• Life support skills.

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9 Early warning scoring

• All trusts should adopt a modified early
  obstetric warning system to help timely
  identification of women who have, or who are
  developing, a critical illness. These charts
  should be used for pregnant women in eg
  gynaecology, emergency depts and critical care.

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10 National guidelines

• The management of
• The obese pregnant woman
• Sepsis in pregnancy
• Pain bleeding in early pregnancy.

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Port Talbot Birth Centre
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Royal College ofObstetricians andGynaecologists
Setting standards to improve womens health
Risk Management and Medico-Legal Issues In
Womens Health Joint RCOG/ENTER Meeting
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