The overall number of maternal deaths in the UK has fallen over the last three years despite a rise in the number of women dying from infection, says the Eighth Report of the Confidential Enquiries into Maternal Deaths, Saving Mothers’ Lives, published today as a supplement in BJOG: An International Journal of Obstetrics and Gynaecology.
The maternal mortality rate was 11.39 per 100,000 maternities compared to 13.95 per 100,000 maternities for the previous triennium, 2003-05. As this enquiry is far more inclusive than in other countries, for direct comparison with international figures, the UK maternal death rate was 6.7 per 100,000 live births.
In the triennium 2006-2008, 261 women in the UK died from conditions directly or indirectly related to pregnancy. 107 mothers died of conditions that could only have arisen if they had been pregnant (direct deaths), and 154 died of other underlying medical or psychiatric causes (indirect deaths).
The direct death rate decreased from 6.24 per 100,000 maternities in 2003-2005 to 4.67 per 100,000 maternities in 2006-2008. The leading cause was infection. Many of these deaths were from Group A Streptococcal disease caught in the community, mirroring a rise in the general population. The report calls for mothers and healthcare workers to be aware of the need for scrupulous hygiene especially after birth, and most importantly if new mothers are in contact with people with sore throats. It also calls for national guidelines to be drawn up for the identification and management of sepsis in pregnant and recently delivered women.
There has been a welcome, significant, decline in deaths from pulmonary embolism and to a lesser degree, haemorrhage, following the publication and implementation of guidelines that were recommended in previous reports. The number of deaths attributed to pulmonary embolism and thromboembolism were 18 between 2006-2008 compared to 41 in 2003-2005.
For the first time there has been a reduction in the inequalities gap, with a significant decrease in maternal mortality rates among those living in the most deprived areas and those in the lowest socio-economic group. Report authors suggest that this is in part to do with recommendations from previous CMACE reports being followed.
In addition report authors have also produced an aide-memoire for healthcare professionals. The new chapter ‘Back to basics’, provides a list for the identification and management of the most commonly occurring conditions in pregnancy.
Professor Gwyneth Lewis, Editor of the report said, “The reason why the maternal mortality rate in the UK is comparatively low is because we make every effort to understand and then act on the root causes of why some mothers die during and after pregnancy. Much hard work has been undertaken to produce these maternal enquiries. This eighth report has highlighted some of the successes over the last few years in preventing death but we must not become complacent. More needs to be done to ensure that maternal death is kept as low as possible.”
Dr Imogen Stephens, Clinical Director, CMACE said, “This report has highlighted several key areas for those working in maternity services to heed, in particular, the need for GPs and midwives to identify women requiring specialist care and the need for quick referrals. These recommendations provide us with a snapshot of maternity services and are meant to help healthcare professionals improve standards of care.”
Dr Tony Falconer, President of the Royal College of Obstetricians and Gynaecologists (RCOG) said, “Some of the areas which were identified in the previous report, such as the warning around the rise in maternal obesity have been acted upon. Consequently, the follow-up activity undertaken by CMACE, that is, the development of the clinical guidelines shows the true impact of these maternal enquiries. They provide us with good data and help us to monitor trends so that we can prevent maternal death.”
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The report provides 10 key recommendations for policy makers, service commissioners and providers and healthcare professionals. The main points include:
- Pre-pregnancy counselling – Women with pre-existing medical illness, including psychiatric conditions, whose conditions may require a change of medication should be informed of how this may relate to their pregnancy.
- Pre-existing medical conditions – Women whose pregnancies are likely to be complicated by potentially serious underlying medical or mental health conditions, and women who develop these problems should be immediately referred to appropriate specialist centres where care can be optimised. Referrals should be made a priority.
- Specialist clinical care – There remains an urgent need for the routine use of a national modified early obstetric warning score (MEOWS) chart in all pregnant or postpartum women who become unwell and require either obstetric or gynaecology services. This will help in the recognition, treatment and referral of women who have, or are developing, a critical illness during or after pregnancy.
- Genital tract infection/sepsis – All pregnant and recently delivered women need to be informed of the risks and signs and symptoms of genital tract infection and how to prevent its transmission and all health care professionals should be aware of the signs and symptoms of sepsis.
A maternal death is defined as ‘the death of a woman while pregnant or within 42 days of the end of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
The Eighth Report of the Confidential Enquiries into Maternal Deaths, Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008 was funded by the National Patient Safety Agency, the Scottish Programme for Clinical Effectiveness in Reproductive Health, the Department of Health, Social Services and Public Safety of Northern Ireland and the States of Jersey and Guernsey, and Isle of Man.
Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118 (Suppl. 1):1–203.