1. Confidential Enquiries into Maternal and Child Health Learning from maternal death reviews Saving Mothers’ Lives Dr Gwyneth Lewis National Director of maternal health CEMACH Clinical Director Maternal Death Enquiry Royal College of Obstetricians and Gynaecologists April 30 th

2. 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

3. Confidential Enquiries into Maternal and Child Health

4. Maternal deaths by major cause England and Wales, 1935-78 0 50 100 150 200 250 300 350 193519401945195019551960196519701975 Source: General Register Office and OPCS, Reproduced inBirth counts, Table A10.1.3 Deaths per 100,000 total births Abortion and miscarriage Toxaemia Haemorrhage Puerperal sepsis Puerperal phlebitis, thrombosis and embolism

5. 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 193519401945195019551960196519701975 Source: General Register Office and OPCS, Reproduced inBirth counts, Table A10.1.3 Deaths per 100,000 total births Abortion and miscarriage Toxaemia Haemorrhage Puerperal sepsis Puerperal phlebitis, thrombosis and embolism CEMD

6. Confidential Enquiries into Maternal and Child Health When local audit/CEMDs were introduced Local CEMDs

7. Confidential Enquiries into Maternal and Child Health When the national CEMD was introduced National CEMD

8. Confidential Enquiries into Maternal and Child Health When local audit/CEMDs were introduced Local CEMDs National CEMD

9. 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

10. Confidential Enquiries into Maternal and Child Health Maternal mortality rates UK 1952-2005 per 100,000 maternities

11. Confidential Enquiries into Maternal and Child Health ONS CEMACH Maternal mortality rates UK 1952-2005 per 100,000 maternities

12. Confidential Enquiries into Maternal and Child Health

13. 100 pages Clinical factors

14. Confidential Enquiries into Maternal and Child Health 360 pages Social factors

15. 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

16. Confidential Enquiries into Maternal and Child Health Global recognition

17. Confidential Enquiries into Maternal and Child Health Identify cases Collect information Analyse the results Recommendations for action Implement Evaluate and refine The maternal mortality surveillance cycle

18. Confidential Enquiries into Maternal and Child Health Identify cases Collect information Analyse the results Recommendations for action Implement Evaluate and refine The maternal mortality surveillance cycle

19. Confidential Enquiries into Maternal and Child Health Types of Maternal Death Direct Indirect Co-incidental (fortuitous) Late (between 42 -365 days after delivery)

20. Confidential Enquiries into Maternal and Child Health Direct Indirect = UK Maternal Mortality Rate per 100,000 maternities

21. Confidential Enquiries into Maternal and Child Health Co-incidental deaths count too……..

22. 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…..

23. Confidential Enquiries into Maternal and Child Health

24. Mental health guidelines

25. Confidential Enquiries into Maternal and Child Health Not just professionals either…….

26. Confidential Enquiries into Maternal and Child Health Jessica's Trust

27. 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

28. Confidential Enquiries into Maternal and Child Health Deaths from pulmonary embolism following Caesarean section UK 1985-99, rate per million maternities

29. Confidential Enquiries into Maternal and Child Health National guidelines 2001-2004 1995

30. Confidential Enquiries into Maternal and Child Health 2003-05

31. Confidential Enquiries into Maternal and Child Health YearsNo.RateMaternities 1994-96 1997-99 2000-02 2003-05 158 128 136 149 7.2 6.0 6.8 7.0 2,197,640 2,123,614 1,997,472 2,114,004 Death certificate data alone for international comparison

32. Confidential Enquiries into Maternal and Child Health Maternal Deaths: Numbers and rates per 100,000 maternities by type: UK 1985-2005 Caused Direct Aggravated Indirect Total 94-96 97-99 00-02 03-05 134 106 132 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 Suicide Some Cancers Sub arachnoids Aneurysms

33. Confidential Enquiries into Maternal and Child Health Direct and Indirect rates UK 1985-2005

34. Confidential Enquiries into Maternal and Child Health Direct deaths: rates per million maternities UK1985-05

35. Confidential Enquiries into Maternal and Child Health Leading causes of Direct deaths: UK rates per million maternities 2003-05

36. Confidential Enquiries into Maternal and Child Health Leading causes of Indirect deaths: rates per million maternities 2003- 05

37. Confidential Enquiries into Maternal and Child Health Overall rates per million maternities UK 2003-05

38. Confidential Enquiries into Maternal and Child Health Cardiac causes (per million maternities) maternal mortality 1952-2005

39. Confidential Enquiries into Maternal and Child Health Leading causes and rates per million maternities 2000-05

40. Confidential Enquiries into Maternal and Child Health Why do mothers really die?

41. Confidential Enquiries into Maternal and Child Health Percentage of deaths due to substandard care; UK 1985 - 2005

42. Confidential Enquiries into Maternal and Child Health Maternal mortality by maternal age per million maternities 1985-2005

43. 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.

44. 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

45. Confidential Enquiries into Maternal and Child Health Maternal mortality rates by major ethnic group; England only 2003-05

46. Confidential Enquiries into Maternal and Child Health Direct and Indirect rates; UK and effect of migration 1985-2005

47. Confidential Enquiries into Maternal and Child Health Maternal death rates per 100,000 maternities by employment and partnership status United Kingdom 2003-05

48. Confidential Enquiries into Maternal and Child Health Maternal mortality and deprivation 0 5 10 15 20 25 30 35 Least deprived 234 Most deprived Quintile of the Index of Multiple Deprivation 2004

49. Confidential Enquiries into Maternal and Child Health Attendance for antenatal care (ANC) TotalLate book poor ANC No ANC% of all deaths Direct13211714 Indirect16324820 Direct + Indirect 295351517 Coincidental555416

50. 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 misuse78% Black Caribbean57% Black African57% Single unemployed56% Both partners unemployed47% No English35% Recently arrived in UK26% At least one partner in employment 5%

51. Confidential Enquiries into Maternal and Child Health Top ten recommendations

52. 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.

53. Confidential Enquiries into Maternal and Child Health Commoner conditions Epilepsy Diabetes Cardiac disease Auto-immune disorders BMI > 30 Current / past mental illness

54. 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.

55. 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.

56. 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.

57. 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.

58. 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.

59. 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.

60. 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.

61. 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.

62. 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.

63. 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.

64. 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.

65. Confidential Enquiries into Maternal and Child Health Port Talbot Birth Centre

66. Royal College of Obstetricians and Gynaecologists Setting standards to improve women’s health Risk Management and Medico-Legal Issues In Women’s Health Joint RCOG/ENTER Meeting Please turn off all mobile phones and pagers