Confidential Enquiries into Maternal and Child Health Learning from maternal death reviews Saving...

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


• Short history

• How Confidential Enquires into Maternal Deaths have helped in the past

• Why we continue

• Recent findings and recommendations


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


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


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


When local audit/CEMDs were introduced

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1

2

3

4

5

6

7

8

1840 1860 1880 1900 1920 1940 1960 1980 2000


Mat

erna

l dea

ths

/ 1,0

00 b

irths

Local CEMDs


When the national CEMD was introduced

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1

2

3

4

5

6

7

8

1840 1860 1880 1900 1920 1940 1960 1980 2000


Mat

erna

l dea

ths

/ 1,0

00 b

irths

National CEMD


When local audit/CEMDs were introduced

0

1

2

3

4

5

6

7

8

1840 1860 1880 1900 1920 1940 1960 1980 2000


Mat

erna

l dea

ths

/ 1,0

00 b

irths

Local CEMDs

National CEMD


“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


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


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 Health100 pages

Clinical factors

Confidential Enquiries into Maternal and Child Health360 pages

Social factors


• 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


Global recognition


Identify cases

Collect information

Analyse the resultsRecommendations

for action

ImplementEvaluate and refine

The maternal mortality surveillance cycle


Types of Maternal Death

• Direct

• Indirect

• Co-incidental (fortuitous)

• Late (between 42 -365 days after delivery)


• Direct

• Indirect

= UK Maternal Mortality Rate per 100,000 maternities


Co-incidental deaths count too……..


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…..


Mental health guidelines


Not just professionals either…….


Jessica's Trust


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


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


National guidelines

2001-20041995


2003-05


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


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


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


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


Leading causes of Direct deaths: UK rates per million maternities

2003-05

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5

10

15

20

25


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


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


Cardiac causes (per million maternities) maternal mortality

1952-2005

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10

20

30

40

50

60

Acquired

Congenital


Leading causes and rates per million maternities 2000-05

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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


Why do mothers really die?


Percentage of deaths due to substandard care; UK 1985 - 2005

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10

20

30

40

50

60

70

80

85-87

88-90

91-93

94-96

97-99

2000-

02

2003-

2005


Maternal mortality by maternal age per million maternities 1985-2005

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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+


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.


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


Maternal mortality rates by major ethnic group; England only 2003-05

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20

30

40

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60

70

80

Pakist

ani

Whi

te

Asian

Indi

an

Bangl

ades

hOth

er

Mid

dle E

ast

Black

Carib

bean

Black

Africa

n


Direct and Indirect rates; UK and effect of migration 1985-2005

0

2

4

6

8

10

12

14

16


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


Maternal mortality and deprivation

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5

10

15

20

25

30

35

Least deprived 2 3 4 Most deprived

Quintile of the Index of Multiple Deprivation 2004


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


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%


Top ten recommendations


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.


Commoner conditions

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


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.


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


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.


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.


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


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.


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.


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.


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.


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.


10 National guidelines

The management of

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


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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Confidential Enquiries into Maternal and Child Health Learning from maternal death reviews Saving...

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