Maternal Morbidity and Mortality - study group statement

Recommendations fall into three categories:

1. Recommendations for clinical practice (principally aimed at Fellows and Members of the Royal College of Obstetricians and Gynaecologists) based upon research evidence (where available) and the consensus view of the Group. The clinical practice recommendations have been graded from 'A' to 'C' according to the strength of evidence on which each is based (Table 36.1). The scheme for the grading of recommendations is based on the system adopted by both the NHS Executive and the Scottish Intercollegiate Guidelines Network.
2. Recommendations for future research in those clinical areas where the Group identified a need for further evidence on which to base practice.
3. Recommendations relating to health education and health policy.

Table 36.1. Grading of recommendations

Grade
Recommendation

A
Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.

B
Requires availability of well-conducted clinical studies but no randomised clinical trials on the topic of recommendation.

C
Requires evidence from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates absence of directly applicable studies of good quality.

Recommendations for clinical practice

1. Active management of the third stage of labour reduces blood loss. (Grade A)
2. The uterotonic for active management involves trade-offs between oxytocin and Syntometrine (Alliance Pharmaceuticals). (Grade A)
3. Routine episiotomy should be abandoned. (Grade A)
4. Saline plus oxytocin infusion into the cord vessels reduces the need for manual removal of placenta. (Grade A)
5. Patients with cardiac disease must be assessed at primary and secondary levels. Those with high risk (any of the risk factors of the Toronto study (Chapter 22⁴⁰) plus disease-specific risks must be managed in a tertiary centre. (Grade B)
6. Women who have had cancer treated recently may wish to become pregnant. Discussion between oncologist and obstetrician is better before conception. In some cancers, such as breast and melanoma, pregnancy should be deferred for two to three years after treatment. (Grade B)
7. Good-quality information about the health of mother and fetus should be provided using multiple media, accessible to all users of a service, at all stages of pregnancy. (Grade C)
8. All women should be offered screening for anaemia on at least one occasion during pregnancy. (Grade C)
9. Repeat screening for anaemia early in the third trimester is recommended to assess the effect of supplementation and/or treatment of underlying disease. (Grade C)
10. Iron supplements (together with folic acid) should be offered to all pregnant women with anaemia. In areas with high prevalence of malaria, prophylaxis or presumptive treatment for malaria should be provided in addition to these supplements. (Grade C)
11. All women should be screened for hypertension and proteinuria at each antenatal clinic visit - those at highest risk require more frequent screening (especially between 24--32 weeks). (Grade C)
12. Tertiary centres managing pregnant cardiac patients should have a multidisciplinary team that includes at least a specialist obstetrician, a cardiac physician with knowledge of obstetrics, an anaesthetist, a haematologist and a high-risk midwife. (Grade C)
13. Patients with epilepsy should be offered timely and appropriate counselling concerning teratogenic risks of anti-epilepsy drugs, strategies to minimise risk, importance of antenatal care and contraception issues. (Grade C)
14. General practitioners, neurologists, general physicians, obstetricians and midwives should be encouraged to volunteer such advice at any appropriate opportunity to any women with epilepsy within or approaching childbearing years. (Grade C)
15. Women with major convulsive seizures should deliver in hospital. (Grade C)
16. It is unnecessary to screen all pregnant patients for thrombophilias but patients with a significant personal or family history should be assessed. (Grade C)
17. If low molecular weight heparin is to be given to women with thrombophilia or those with a history of idiopathic venous thromboembolism, it should be started early in pregnancy. (Grade C)
18. Clinical consultation with the obstetric anaesthetist during antenatal assessment of patients with co-existing medical conditions can anticipate problems and reduce morbidity. (Grade C)
19. Management protocols for women with a past history of serious mental illness should be in place, including identification of local psychiatrist/team with special interest. (Grade C)
20. If patients are seen during pregnancy with unusual or common but persistent symptoms, the possibility of cancer must be considered and appropriate examination, imaging and biopsy should be performed. (Grade C)
21. Clinicians and medical students must be made more aware of atypical clinical presentations of ectopic pregnancy and the option of beta human chorionic gonadotrophin testing in women with unexplained abdominal pain of recent onset. (Grade C)
22. Laparoscopic surgery for ectopic pregnancies should only be undertaken by appropriately trained surgeons; laparoscopic surgery may be inappropriate in haemodynamically unstable women. (Grade C)
23. Septic miscarriage should be recognised as a potentially serious complication requiring experienced obstetric input; surgical evacuation of the uterus may be best performed around one hour after intravenous antibiotic treatment. (Grade C)

Research

1. Concerted efforts are needed to improve routine data sources and enquiry methods on a global scale for determining inequalities and inequities in maternal health.
2. The global persistence of significant levels of substandard care as avoidable factors in maternal mortality requires fresh perspectives.
3. Greater attention should be paid to the indirect causes of maternal mortality, which may reflect different socio-economic inequalities from those linked with direct causes.
4. The use of haemoglobin as a 'marker of morbidity' should be evaluated.
5. There is a need for improved knowledge of factors contributing to anaemia in different regions of the world. This knowledge should form the basis for regional guidelines for the prevention and treatment of anaemia.
6. Trials are needed to evaluate whether iron should be given in combination with other micronutrients, for example as a multivitamin preparation.
7. There is a need to examine more carefully the interaction between micronutrient deficiency and infection in pregnancy.
8. The estimated contribution of malaria to maternal morbidity in developing countries is considerable. These estimates should be studied in relation to malaria prevalence, which is available for many developing countries.
9. Evidence is required from intervention studies, using appropriate health packages, to determine their effectiveness in reducing malaria-related outcomes. This is especially relevant in high-risk groups such as adolescents.
10. Research is required to elucidate whether malaria contributes to the pathogenesis of pre-eclampsia.
11. In order to improve mortality ascertainment, improved monitoring and evaluation is required through sentinel sites. This is also necessary to determine the contribution of HIV infection and drug-resistant malaria to malaria-related mortality.
12. It is necessary to address and focus on those areas and interventions in which funding, time and human resources should be invested to ensure sustainable and long-term impact against HIV infection.
13. There is a significant link between maternal mortality and a history of psychiatric illness and domestic violence. Research is necessary on how to elicit the key elements of such history without compromising the relationship between patient and caregiver.
14. Future research should focus on whether 'aggressive' anti-hypertensive therapy reduces the risks of maternal mortality and serious morbidity.
15. A carefully designed randomised controlled trial (RCT) is necessary to determine the safety of allowing patients home after an admission with an antepartum haemorrhage and a diagnosis of placenta praevia.
16. For the treatment of postpartum haemorrhage, high-dose (800 - 1200 µg) misoprostol should be evaluated in appropriately designed RCTs.
17. There should be further funding to allow the development and implementation of a national maternity minimum data set.
18. Further pilot studies are needed to define useful and applicable definitions of maternal morbidity.
19. The RCOG should be working, in collaboration with the Royal College of Midwives, Obstetric Anaesthetists Association and possibly others, on a few representative performance measures that could be used nationally and reflect overall services and individual clinician performance.
20. Systems should be established for recording pregnancy-related morbidity requiring intensive/high-dependency care, to include monitoring of admission criteria, treatments and outcomes.
21. Further information is needed on how uncertainty about the wellbeing of the fetus, the pregnancy and the birth can most effectively be provided to all women to minimise anxiety and give reassurance, while facilitating informed choices.
22. If the term 'debriefing' is to be used in maternity services, a consensus needs to be reached on its definition.
23. Qualitative research is needed to explore frequency, timing, setting and content of debriefing and who is the appropriate person to conduct that session.
24. Postmortem studies should be undertaken to determine how frequently fetal material is found in the maternal lungs.
25. When cancer occurs during or soon after pregnancy, appropriate tissue samples should be banked to allow research and understanding in the future.

Health policy and education

1. This Study Group endorses the Recommendations contained within the latest Confidential Enquiry into Maternal Deaths.
2. The value of the Confidential Enquiry into Maternal Death cannot be underestimated or presumed. Adequate funding and professionally led expertise must be ensured to allow further investigation into the areas of highest mortality.
3. Estimating the maternal mortality ratio is an essential component of health care for women.
4. The avoidability of the majority of maternal deaths in all countries should be acknowledged as a human rights issue.
5. In judging the success of intervention strategies in reducing maternal mortality, it is crucial that not only clinical effectiveness and cost-effectiveness are considered, but also the implications for equity goals.
6. There is a need to increase political awareness, financial investment and commitment to maternal health and safe motherhood.
7. There should be promotion, dissemination and implementation of key interventions that are known to be evidence-based and cost-effective to reduce maternal and newborn morbidity and mortality.
8. There should be increased collaboration with the WHO Making Pregnancy Safe Initiative and other institutions to improve professionals' role in supporting maternal and newborn health programmes.
9. Where human or financial resources are limited, detailed analysis of maternal mortality should be focused on major remediable problems.
10. In countries with high HIV/AIDS rates, we must encourage availability of funding to test pregnant women for HIV, provide anti-retroviral drugs and offer hope to HIV-positive mothers.
11. Continuity of carer leads to better labour outcome and lower intervention rates. Therefore, there must be more investment in maternity services, especially in the recruitment, retention and continuing development of midwives.
12. The RCOG should address the exploitation of healthcare workers immigrating to the United Kingdom from developing countries and explore the role of developed countries in reversing this trend.
13. Reductions in maternal mortality in the UK can be achieved by improving access to care. This includes making services more acceptable, tailored to each woman, stressing the importance of early booking, providing suitable translation services, overcoming dismissive staff attitudes and engaging representatives of vulnerable groups in the planning of services.
14. If possible, partners, friends, family members and children should not be used to interpret for women unable to speak English. An interpreter should be provided.
15. Antenatal services should be flexible enough to meet the needs of all women, bearing in mind that the needs of those from the most disadvantaged, vulnerable and less articulate groups in society are of equal if not greater importance. Many women who died found it difficult to establish or maintain access with the services, and follow-up mechanisms for those who failed to attend were poor. Women who regularly fail to attend clinics should be actively followed up.
16. We must enhance the status of listening to all women and explore ways to provide all women with the opportunity to discuss their experience (e.g. link workers, appropriate interpreters, special needs practitioners).
17. There should be local training programmes for midwives and obstetricians in 'listening skills'.
18. Sufficient time must be costed for providing to patients the information generated as part of antenatal care.
19. There is evidence that, where women can choose, it is medically better to have children between the ages of 20--35 years. All healthcare professionals should give consistent medical advice that pregnancy is more adverse at the extremes of reproductive life.
20. It is recognised that unplanned pregnancy and the deferral of childbearing are culturally determined. Older childbearing may be related to financial security. The RCOG and Department of Health should advise government how social policy impacts negatively or positively on women's health and wellbeing.
21. Primary care nurse, midwifery or general practice preconceptional services should be developed, with secondary support from genetics, obstetrics, mental health and medical services.
22. Commissioners should ensure that all women have access to a local mental health team with a special interest in perinatal psychiatric disorders.
23. Women requiring psychiatric admission following delivery should be admitted to a specialist mother and baby unit.
24. An effective anti-hypertensive agent and magnesium sulphate should be available to all women when appropriate.
25. All regions should have guidelines for the management of women with pre-eclampsia and stipulate indications for referral to tertiary centres.
26. As women with epilepsy may sometimes be from socially deprived populations, every effort should be made to ensure that they receive and understand the need for regular multidisciplinary antenatal care.
27. Cases of amniotic fluid embolism (AFE) should be reported to a national register.
28. There are still uncertainties about the behaviour of cervical and breast cancer during pregnancy. Collection of data by establishing a register in the UK would appear desirable.
29. With regard to anaesthesia, the lessons of history should not be forgotten. These include the need to train anaesthetists in obstetric anaesthesia, adequate staffing and equipping of maternity units and early consultation of high-risk cases.
30. Obstetric anaesthetists should be involved in the policy making of individual maternity units.
31. Women having caesarean section require the same standard of postoperative care as those undergoing non-obstetric surgery.
32. Multidisciplinary agreement on clinical definitions of pregnancy-related conditions requiring intensive or high-dependency care is urgently required.
33. High-dependency units must be set up and maintained within maternity units, as called for by the Confidential Enquiry into Maternal Deaths, including the educational and financial support that such units require.
34. The contribution of the autopsy findings to understanding maternal death is dependent on the quality of the autopsy examination: this should be achieved by identifying small teams of pathologists for each region.
35. It is important that autopsy examinations in cases of maternal death are conducted in a time and a place such that the clinicians involved can attend.
36. The experience, past and present, of assessing maternal mortality in developed countries may be helpful to developing countries.
37. Recommendations for improvements in maternal health care may be based on observational studies and informed professional opinion, where RCT data are not available.
38. Maternal deaths have an over-representation of certain ethnic groups, women who did not speak English or who were illiterate.
39. Overall, 30% of women who died from direct or indirect causes were poor attenders. Late bookers tend to be poor subsequent attenders.
40. There is a need to agree on definitions of a direct and indirect malaria death in pregnancy.
41. Patients with cardiac disease and their general practitioners and obstetricians should be made aware of the risks of pregnancy.
42. Antepartum haemorrhage remains an important contributor to maternal mortality and morbidity.
43. Clinicians should be aware of the presentations of AFE and the importance of early multidisciplinary care.
44. Obstetricians and midwives need training in how to ask patients in a systematic fashion, at booking, about a history of psychiatric disorder.
45. Specific written and verbal advice should be offered to mothers with epilepsy concerning practical measures to minimise the risk of harm to the baby.
46. There is a need for evidence-based training in effective and sensitive communication of risk and other information during pregnancy.