Post on 11-Jan-2016
Confidential Enquiries into Maternal and Child Health
Learning from maternal death reviews
Saving Mothers’ Lives
Dr Gwyneth LewisNational Director of maternal health
CEMACH Clinical Director Maternal Death Enquiry
Royal College of Obstetricians and Gynaecologists April 30th
Confidential Enquiries into Maternal and Child Health
• Short history
• How Confidential Enquires into Maternal Deaths have helped in the past
• Why we continue
• Recent findings and recommendations
Confidential Enquiries into Maternal and Child Health
0
1
2
3
4
5
6
7
8
1840 1860 1880 1900 1920 1940 1960 1980 2000
Source: General Register Office, OPCS and ONS mortality statisticsBirth counts , Tables A10.1.1-A10.1.4
Mat
erna
l dea
ths
/ 1,0
00 b
irths
Confidential Enquiries into Maternal and Child Health
Maternal deaths by major cause England and Wales, 1935-78
0
50
100
150
200
250
300
350
1935 1940 1945 1950 1955 1960 1965 1970 1975
Source: General Register Office and OPCS, Reproduced in Birth counts, Table A10.1.3
Dea
ths
per
100,
000
tota
l bir
ths Abortion and miscarriage
Toxaemia
Haemorrhage
Puerperal sepsis
Puerperal phlebitis,thrombosis and embolism
Confidential Enquiries into Maternal and Child Health
Maternal deaths by major cause England and Wales, 1935-78
0
50
100
150
200
250
300
350
1935 1940 1945 1950 1955 1960 1965 1970 1975
Source: General Register Office and OPCS, Reproduced in Birth counts, Table A10.1.3
Dea
ths
per
100,
000
tota
l bir
ths Abortion and miscarriage
Toxaemia
Haemorrhage
Puerperal sepsis
Puerperal phlebitis,thrombosis and embolism
CEMD
Confidential Enquiries into Maternal and Child Health
When local audit/CEMDs were introduced
0
1
2
3
4
5
6
7
8
1840 1860 1880 1900 1920 1940 1960 1980 2000
Source: General Register Office, OPCS and ONS mortality statisticsBirth counts , Tables A10.1.1-A10.1.4
Mat
erna
l dea
ths
/ 1,0
00 b
irths
Local CEMDs
Confidential Enquiries into Maternal and Child Health
When the national CEMD was introduced
0
1
2
3
4
5
6
7
8
1840 1860 1880 1900 1920 1940 1960 1980 2000
Source: General Register Office, OPCS and ONS mortality statisticsBirth counts , Tables A10.1.1-A10.1.4
Mat
erna
l dea
ths
/ 1,0
00 b
irths
National CEMD
Confidential Enquiries into Maternal and Child Health
When local audit/CEMDs were introduced
0
1
2
3
4
5
6
7
8
1840 1860 1880 1900 1920 1940 1960 1980 2000
Source: General Register Office, OPCS and ONS mortality statisticsBirth counts , Tables A10.1.1-A10.1.4
Mat
erna
l dea
ths
/ 1,0
00 b
irths
Local CEMDs
National CEMD
Confidential Enquiries into Maternal and Child Health
“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
Confidential Enquiries into Maternal and Child Health
Maternal mortality rates UK 1952-2005 per 100,000 maternities
0
10
20
30
40
50
60
70
80
1954 58 64 70 76 82 88 94 2000
Triennia
Ra
te p
er
10
0,0
00
ma
tern
itie
s
Confidential Enquiries into Maternal and Child Health
0
10
20
30
40
50
60
70
80
1954 58 64 70 76 82 88 94 2000
Triennia
Ra
te p
er
10
0,0
00
ma
tern
itie
s
ONS CEMACH
Maternal mortality rates UK 1952-2005 per 100,000 maternities
Confidential Enquiries into Maternal and Child Health
Confidential Enquiries into Maternal and Child Health100 pages
Clinical factors
Confidential Enquiries into Maternal and Child Health360 pages
Social factors
Confidential Enquiries into Maternal and Child Health
• 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
A new title: a renewed purpose
Confidential Enquiries into Maternal and Child Health
Global recognition
Confidential Enquiries into Maternal and Child Health
Identify cases
Collect information
Analyse the resultsRecommendations
for action
ImplementEvaluate and refine
The maternal mortality surveillance cycle
Confidential Enquiries into Maternal and Child Health
Identify cases
Collect information
Analyse the resultsRecommendations
for action
ImplementEvaluate and refine
The maternal mortality surveillance cycle
Confidential Enquiries into Maternal and Child Health
Types of Maternal Death
• Direct
• Indirect
• Co-incidental (fortuitous)
• Late (between 42 -365 days after delivery)
Confidential Enquiries into Maternal and Child Health
• Direct
• Indirect
= UK Maternal Mortality Rate per 100,000 maternities
Confidential Enquiries into Maternal and Child Health
Co-incidental deaths count too……..
Confidential Enquiries into Maternal and Child Health
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…..
Confidential Enquiries into Maternal and Child Health
Confidential Enquiries into Maternal and Child Health
Mental health guidelines
Confidential Enquiries into Maternal and Child Health
Not just professionals either…….
Confidential Enquiries into Maternal and Child Health
Jessica's Trust
Confidential Enquiries into Maternal and Child Health
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
Confidential Enquiries into Maternal and Child Health
Deaths from pulmonary embolism following Caesarean section UK 1985-99, rate per million maternities
0
1
2
3
4
5
6
7
8
85-87 88-90 91-93 94-96 97-77Triennium
Confidential Enquiries into Maternal and Child Health
National guidelines
2001-20041995
Confidential Enquiries into Maternal and Child Health
2003-05
Confidential Enquiries into Maternal and Child Health
Years No. Rate Maternities
1994-961997-992000-022003-05
158128136149
7.26.06.87.0
2,197,6402,123,6141,997,4722,114,004
Death certificate data alone for international comparison
Confidential Enquiries into Maternal and Child Health
Maternal Deaths: Numbers and rates per 100,000 maternities by type:
UK 1985-2005Caused
Direct
Aggravated Indirect
Total
94-96
97-99
00-02
03-05
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
UK Indirect SuicideSome CancersSub arachnoidsAneurysms
Confidential Enquiries into Maternal and Child Health
Direct and Indirect rates UK 1985-2005
0
2
4
6
8
10
12
14
16
85-89 88-90 91-93 94-96 97-99 00-02 2003-5
Direct
Indirect
Total
Confidential Enquiries into Maternal and Child Health
Direct deaths: rates per million maternities UK1985-05
0
5
10
15
20
25
1985
-87
1988
-90
1991
-93
1994
-96
1997
-99
2000
-02
2003
-05
Pregnancy induced hypertension Thromboembolism
Haemorrhage AFE
Sepsis
Confidential Enquiries into Maternal and Child Health
Leading causes of Direct deaths: UK rates per million maternities
2003-05
0
5
10
15
20
25
Confidential Enquiries into Maternal and Child Health
Leading causes of Indirect deaths: rates per million maternities 2003-
05
0
5
10
15
20
25
Cardi
ac
Suici
de
CNS Hae
morr
hage
Epile
psy GI
Respira
tory
Imm
ununity
Confidential Enquiries into Maternal and Child Health
Overall rates per million maternities
UK 2003-05
0
5
10
15
20
25
Cardia
cVTE
Suicid
e
CNS Hae
morr
hage
Sepsi
s
Preec
lam
psia
AFE
Haemorrh
age
Infe
ctio
ns
Confidential Enquiries into Maternal and Child Health
Cardiac causes (per million maternities) maternal mortality
1952-2005
0
10
20
30
40
50
60
Acquired
Congenital
Confidential Enquiries into Maternal and Child Health
Leading causes and rates per million maternities 2000-05
0
5
10
15
20
25
30
Cardia
cVTE
Suicide
CNS Hae
mor
rhag
e
Sepsis
Preec
lamps
iaAFE
Haem
orrh
age
Infe
ction
s
2003-05
2000-02
Confidential Enquiries into Maternal and Child Health
Why do mothers really die?
Confidential Enquiries into Maternal and Child Health
Percentage of deaths due to substandard care; UK 1985 - 2005
0
10
20
30
40
50
60
70
80
85-87
88-90
91-93
94-96
97-99
2000-
02
2003-
2005
Confidential Enquiries into Maternal and Child Health
Maternal mortality by maternal age per million maternities 1985-2005
0
10
20
30
40
50
60
70
85-8
7
88-9
0
91-9
3
94-9
6
97-9
9
2000
-02
2003
-05
<20 20-24 25-29 30-34 35-39 40+
Confidential Enquiries into Maternal and Child Health
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.
Confidential Enquiries into Maternal and Child Health
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
Confidential Enquiries into Maternal and Child Health
Maternal mortality rates by major ethnic group; England only 2003-05
0
10
20
30
40
50
60
70
80
Pakist
ani
Whi
te
Asian
Indi
an
Bangl
ades
hOth
er
Mid
dle E
ast
Black
Carib
bean
Black
Africa
n
Confidential Enquiries into Maternal and Child Health
Direct and Indirect rates; UK and effect of migration 1985-2005
0
2
4
6
8
10
12
14
16
Confidential Enquiries into Maternal and Child Health
Maternal death rates per 100,000 maternities by employment and
partnership status United Kingdom 2003-05
7.612
94
0
10
20
30
40
50
60
70
80
90
100
All employed Women with partners Unemployed/unclasifiable
Confidential Enquiries into Maternal and Child Health
Maternal mortality and deprivation
0
5
10
15
20
25
30
35
Least deprived 2 3 4 Most deprived
Quintile of the Index of Multiple Deprivation 2004
Confidential Enquiries into Maternal and Child Health
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
Confidential Enquiries into Maternal and Child Health
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%
Confidential Enquiries into Maternal and Child Health
Top ten recommendations
Confidential Enquiries into Maternal and Child Health
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.
Confidential Enquiries into Maternal and Child Health
Commoner conditions
• Epilepsy• Diabetes • Cardiac disease • Auto-immune disorders• BMI > 30• Current / past mental illness
Confidential Enquiries into Maternal and Child Health
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.
Confidential Enquiries into Maternal and Child Health
Women should also have had their full booking visit and hand held maternity record completed by 12 weeks of pregnancy.
Confidential Enquiries into Maternal and Child Health
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.
Confidential Enquiries into Maternal and Child Health
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.
Confidential Enquiries into Maternal and Child Health
Women from countries where genital mutilation is prevalent should be sensitively asked about this and management plans for delivery agreed during the antenatal period.
Confidential Enquiries into Maternal and Child Health
5 Systolic hypertension
All pregnant women with a systolic BP of =/> 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.
Confidential Enquiries into Maternal and Child Health
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.
Confidential Enquiries into Maternal and Child Health
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.
Confidential Enquiries into Maternal and Child Health
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.
Confidential Enquiries into Maternal and Child Health
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.
Confidential Enquiries into Maternal and Child Health
10 National guidelines
The management of
• The obese pregnant woman• Sepsis in pregnancy• Pain & bleeding in early pregnancy.
Confidential Enquiries into Maternal and Child Health
Port Talbot Birth Centre
Royal College ofObstetricians andGynaecologists
Setting standards to improve women’s health
Risk Management and Medico-Legal Issues In Women’s HealthJoint RCOG/ENTER Meeting
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