Saving Mothers' Lives

296 Pages·2008·1.61 MB·English

by  Matt Cox

Confidential Enquiry into Maternal and Child Health
Saving Mothers’ Lives:
Reviewing maternal deaths to make motherhood safer - 2003-2005
December 2007
The Seventh Report of the Confi dential Enquiries
into Maternal Deaths in the United Kingdom
CEMACH Mission statement
Our aim is to improve the health of mothers, babies and children by
carrying out confi dential enquiries on a nationwide basis and by widely
disseminating our fi ndings and recommendations.
Please cite this work as: Lewis, G (ed) 2007. The Confi dential Enquiry into Maternal and Child
Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer
- 2003-2005. The Seventh Report on Confi dential Enquiries into Maternal Deaths in the United
Kingdom. London: CEMACH.
This work was undertaken by CEMACH. The work was funded by the National Patient Safety
Agency Centre, the Scottish Programme for Clinical Effectiveness in Reproductive Heath and by the
Department of Health, Social Services and Public Safety of Northern Ireland. The views expressed
in this publication are those of the Enquiry and not necessarily those of its funding bodies.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in
any form or by any means, without the prior written permission of CEMACH, or in the case of
reprographic reproduction, in accordance with the terms of licences issued by the Copyright
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stated here should be sent to CEMACH at the address printed on this page.
Making duplicate copies of this Report for legitimate clinical or other non-commercial purposes
within the UK National Health Service is permitted provided that CEMACH is identifi ed as the
originator of the information. Making alterations to any of the information contained within, or
using the information in any other work or publication without prior permission, will be a direct
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The use of registered names, trademarks etc. in this publication does not imply, even in the
absence of a specifi c statement, that such names are exempt from the relevant laws and
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Published December 2007
CEMACH, Chiltern Court, 188 Baker Street, London, NW1 5SD
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Saving Mothers’ Lives: Reviewing maternal deaths to make
motherhood safer – 2003-2005
The Seventh Report of the Confi dential Enquiries into Maternal Deaths in the United Kingdom
Director and Editor Judy Shakespeare
MRCP FRCGP
Gwyneth Lewis
MSc MRCGP FFPH FRCOG Michael de Swiet
MD FRCP FRCOG
Central Assessors and Authors Harry Millward-Sadler
FRCPath MHSH
Thomas Clutton-Brock
MRCP FRCA
Robin Vlies
FRCSEd FRCOG
Griselda Cooper
OBE FRCA FRCOG
Other authors and contributors
James Drife
Naufi l Alam
MD FRCOG FRCPEd FRCSEd FCOG(SA)
BSc (Hons) MSc
Grace Edwards
Valerie Beale
RN RM ADM Cert Ed Med PhD
RN RM Dip Man MSc
Ann Harper
David Bogod
OBE MD FRCPI FRCOG
FRCA LLM
Diana Hulbert
Victoria Brace
FRCS FFAEM
MRCOG
William Liston
Nirupa Dattani
FRCOG
BSc MPhil
Alison Macfarlane
Dawn Kernaghan
BA Dip Stat C Stat FFPH
MRCOG
James Neilson Alison Miller
MD FRCOG RN RM RDM
Catherine Nelson-Piercy Jo Modder
FRCP FRCOG MRCOG
John McClure Judy Myles
BAO FRCPsych
FRCA
Jane Rogers
Margaret Oates
BA PhD DPSM SRN RM
DPM FRCPsych
Gillian Penney Kate Sallah
MD FRCOG MFFP MBE RN RM ADM MPH
iii
Contents
Acknowledgements ................................................................................................................................... vi
Foreword ................................................................................................................................................... vii
Top ten recommendations ...................................................................................................................... viii
Introduction ............................................................................................................................................ xviii
Background ......................................................................................................................................... xviii
Aims and objectives of the Enquiry .......................................................................................................xxi
Defi nitions and methods for calculating maternal mortality rates ........................................................ xxiv
Key fi ndings for 2003-05
1. Summary and overall fi ndings Gwyneth Lewis ................................................................................... 1
Key fi ndings for 2003-05 ......................................................................................................................... 3
The clinical reasons why mothers died ................................................................................................... 7
Leading causes of maternal deaths: 2003-05 ......................................................................................... 9
The care the mothers received ................................................................................................................ 9
Underlying health status ........................................................................................................................ 22
Vulnerability ........................................................................................................................................... 29
Discussion and conclusions .................................................................................................................. 43
Acknowledgements ............................................................................................................................... 45
References ............................................................................................................................................ 46
Annex 1:1. The changing face of motherhood in the UK;
trends in reproductive epidemiology Alison Macfarlane ....................................................................... 48
Maternal deaths Directly related to pregnancy
2. Thrombosis and thromboembolism James Drife .............................................................................. 55
Annex 2:1. Summary of the RCOG guidelines for thromboprophylaxis
during pregnancy, labour and after vaginal delivery and caesarean section. .................................... 67
3. Pre-eclampsia and eclampsia James Neilson ................................................................................... 72
4. Haemorrhage William Liston ................................................................................................................ 78
5. Amniotic fl uid embolism Robin Vlies ................................................................................................. 86
6. Early pregnancy deaths James Neilson ............................................................................................. 92
7. Genital tract sepsis Ann Harper .......................................................................................................... 97
8. Anaesthesia Griselda Cooper and John McClure.............................................................................. 107
iv
Contents
Maternal deaths Indirectly related to pregnancy
9. Cardiac disease Catherine Nelson-Piercy .........................................................................................117
10. Other Indirect deaths Michael de Swiet ........................................................................................... 131
11. Deaths from malignancy Gwyneth Lewis ........................................................................................ 145
12. Deaths from psychiatric causes Margaret Oates ........................................................................... 152
Suicide Margaret Oates ...................................................................................................................... 154
Substance misuse Judy Myles ........................................................................................................... 165
13. Domestic abuse Gwyneth Lewis ...................................................................................................... 173
Annex 13:1. National guidelines for England for the identifi cation
and management of domestic abuse in pregnancy ............................................................................ 179
Deaths unrelated to pregnancy
14. Coincidental and Late deaths Gwyneth Lewis ................................................................................ 180
Key issues and lessons for specifi c health services and/or health professionals
15. Pathology Harry Millward-Sadler ..................................................................................................... 184
16. Midwifery Grace Edwards ................................................................................................................. 199
17. General Practice Judy Shakespeare ................................................................................................ 213
18. Emergency medicine Diana Hulbert ................................................................................................ 230
19. Critical Care Tom Clutton-Brock ........................................................................................................ 238
Annex 19:1. The Modifi ed Early Obstetric Warning Score (MEOWS) chart ...................................... 247
20. Severe Maternal Morbidity - the Scottish experience 2003 to 2005 Gillian Penney et al ............. 248
Appendices
Appendix 1: The method of Enquiry ..................................................................................................... 254
Appendix 2: The Enquiry assessors..................................................................................................... 260
v
Acknowledgements
Thanks are due to all the health care professionals and staff who assisted with the individual cases and
who have contributed their time and expertise and without whom this Report would not have been possible.
With their help this Enquiry remains an outstanding example of professional self-audit, and will continue to
improve the care provided to pregnant and recently delivered women and their families.
In particular, thanks are due to:
• All Central Authors and Assessors, and other authors and contributors
• All Regional Assessors
• The Offi ce of National Statistics
• All CEMACH Regional Managers and Assistants for liaising with local clinicians and managing the
data collection process (listed in Appendix 2)
• The National Perinatal Epidemiology Unit (NPEU) for providing external review to this Report, and in
particular, Jenny Kurinczuk
• Rosie Houston, Projects Manager, for managing the publication of this Report
• Shona Golightly, Director of Research and Development; Richard Congdon, CEMACH Chief
Executive; Dharmishta Parmar, Data Manager and all other staff at CEMACH Central Offi ce for their
support and advice during the development of this Report.
vi
Foreword
Having a baby is a joyous and fulfi lling experience and, nowadays, a safe one for the great majority of women
in the United Kingdom. This safety has been hard won. It is the result of many years of painstaking work to
identify and reduce risks, and to defi ne the best treatment when complications do occur. Nevertheless some
mothers still die, and these deaths are all the more shocking because they are now so uncommon.
It is our duty to learn all we can from such tragedies. Confi dential enquiries into maternal deaths began in
England and Wales more than fi fty years ago and have covered the United Kingdom since 1985. The triennial
reports have become essential reading for health professionals, and a model for similar enquiries in many other
countries. The Enquiry, however, is continually evolving and the present report has a new title, Saving Mothers’
Lives. The previous name, Why Mothers Die, failed to emphasise that these reports not only describe the
reasons for maternal mortality but also make important recommendations to reduce the risk of death in the future.
We are concerned that the UK maternal mortality rate has not fallen in recent years. This is partly due
to the changing nature of our mothers’ overall health. In general, the women who died appeared to be in
poorer general health and smoked more, and over half were overweight or obese. Many also had chaotic
lifestyles and found it hard to engage with maternity services. The rate is almost certainly infl uenced by the
increasing number of deaths amongst migrant women, whose numbers have also risen.
For this triennium the Report not only identifi es areas of substandard care but also, even though the overall
percentage of such cases has not increased, includes for the fi rst time a list of ten overall recommendations
highlighting the key issues to be addressed as a matter of priority by commissioners, providers and
policymakers. We expect these, and the other recommendations in the Report, to lead to action.
O ther innovations include contributions from a general practitioner and a consultant in emergency
medicine. These new chapters emphasise the need for wider awareness of risk factors and early signs
and symptoms of problems which may be crucial in pregnancy. The broad range of specialties represented
in the writing panel refl ects the teamwork required in modern maternity care. The team also includes the
woman herself. Women who are socially excluded, such as asylum seekers or homeless people, have a
disturbingly high risk of death.
P ublication of this report has been achieved on schedule despite pressures from health service
reorganisation. This is due to the hard work and enthusiasm of many people but we are particularly grateful
to Dr Gwyneth Lewis, the National Clinical Lead for Maternal Health and Maternity Services in England. As
well as directing the UK Enquiry and making insightful innovations she has personally collated the data and
prepared the report. We thank her for her continuing commitment and dedication.
Saving Mothers’ Lives has important messages for everyone involved in maternity care. It is essential that
we do not become complacent. Although some maternal deaths are unavoidable, other women are still
dying needlessly in the UK. This can be prevented in future only if lessons are learned and acted upon,
and the process begins here.
Sir Liam Donaldson Dr Tony Jewell
Chief Medical Offi cer – England Chief Medical Offi cer – Wales
Dr Michael McBride Harry Burns
Chief Medical Offi cer – Northern Ireland Chief Medical Offi cer – Scotland
vii
Top ten recommendations
The overwhelming strength of successive Enquiry Reports has been the impact their fi ndings have had on
maternal and newborn health in the United Kingdom and further afi eld. Over the years there have been
many impressive examples of how the implementation of their recommendations and guidelines have
improved policies, procedures and practice and saved more mothers’ and babies’ lives.
The ‘top ten’
Over time, as new specialties have come on board and with the expansion of the Enquiry into the wider
social and public health determinants of maternal health, the number of recommendations has inevitably
grown. Whilst this is as it should be, the increasing numbers make it diffi cult for commissioners and
service providers to identify those that require action as a top priority. Therefore, in order to ensure
the key overarching or most crucial issues are not lost, this Report contains a list of the new ‘top ten’
recommendations which every commissioner, provider, policy maker and other stakeholder involved in
providing maternity services should plan to introduce, and audit, as soon as possible.
This new list adds to, but does not replace, recommendations made in earlier Reports.
Baseline data and audit of progress
The data needed to audit these ‘top ten’ recommendations are not currently collected routinely in all units.
This Report proposes that baseline data in the form of numbers and percentages are collected continuously
from April 2008 onwards. These data can then form the baseline by which progress can be measured.
The more specifi c individual Chapter recommendations
Whilst these ‘top ten’ recommendations are of general importance, the individual Chapters in this Report
contain more targeted recommendations for the identifi cation and management of particular conditions
for specifi c services or professional groups. These are no less important and should be addressed by any
relevant national bodies as well as by local service commissioners, providers and individual health care staff.
The Confi dential Enquiry into Maternal and Child Health (CEMACH) will be working with key stakeholders,
including the Health Care Commission for England, to consider how the implementation and auditing of the
‘top ten’, as well as the more specifi c recommendations, might best be achieved.
viii
The ‘top ten’ key recommendations
Pre-conception care
1. 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 recommendation especially
applies to women prior to having assisted reproduction and other fertility treatments.
Rationale
This Report has identifi ed that many of the women who died from pre-existing diseases or conditions
which may seriously affect the outcome of their pregnancies, or which may require different management
or specialised services during pregnancy, did not receive any pre-pregnancy counselling. In particular,
this was the case for several women with major risk factors for maternal death who received treatment for
infertility. This Report has also demonstrated that obese pregnant women with a body mass index (BMI)
> 30 are far more likely to die. Where possible, obese women should be helped to lose weight prior to
conception or receiving any form of assisted reproductive technologies (ART).
The commoner conditions that should require pre-pregnancy counselling and advice include:
• Epilepsy
• Diabetes
• Congenital or known acquired cardiac disease
• Auto-immune disorders
• Obesity BMI of 30 or more
• Severe pre existing or past mental illness.
Baselines and auditable standards
• Maternity service commissioners, maternity trusts and any centre, NHS or private, which provides
maternity services and/or assisted reproduction:
– Number and percentage of pregnant women with pre-existing medical conditions for whom
specialist pre-conception counselling is offered at April 2008 and then by the end of 2009.
– Number and percentage of pregnant women at booking, or women attending for ART or
pre-pregnancy counselling, who have their Body Mass Index (BMI) calculated and noted.
Target 100% by April 2008.
ix
Top ten recommendations
Access to care
2. Maternity service providers should ensure that antenatal services are accessible and welcoming
so that all women, including those who currently fi nd it diffi cult to access maternity care, can
reach them easily and earlier in their pregnancy. Women should also have had their fi rst full
booking visit and hand held maternity record completed by 12 completed weeks of pregnancy.
3. Pregnant women who, on referral to maternity services, are already 12 or more weeks pregnant
should be seen within two weeks of the referral.
Rationale
Around 20% of the women who died from Direct or Indirect causes either fi rst booked for maternity care
after 20 weeks’ gestation, missed over four routine antenatal visits, did not seek care at all or actively
concealed their pregnancies. This contrasts starkly with the 98% of women overall who reported having
“booked” with NHS maternity services by 18 weeks of gestation in a recent study undertaken by the
1
National Perinatal Epidemiology Unit (NPEU) . Identifying and overcoming the barriers to care women
face in reaching and staying in touch with maternity services will help improve both the accessibility and
continuity of local care for all women and outcomes for maternal and newborn health.
Some of the women who died were let down because, although the GP referral was timely, they did not
receive a fi rst maternity service appointment until they were around twenty weeks gestation. This delay
denied them the opportunities that early maternity care provides for mother, baby and family.
Baseline and auditable standards
• Number and percentage of women who have had an antenatal care “booking visit” and hand held
maternity record completed by 12 completed weeks of gestation.
• Number and percentage of women referred who were sent a date for their fi rst booking appointment
by 12 weeks of their pregnancy, or within two weeks of referral for women with gestations greater
than 12 weeks.
Baseline measurement by April 2008, review December 2009, by when 80% coverage should be attained.
x