1. SCASMM Sociodemographic factors and severe maternal morbidity: the risk of being less deprived Leslie Marr Reproductive Health Programme Manager November 2014

2. A continuous audit of the factors associated with, and the incidence, causes and management of severe maternal morbidity in Scotland, 2003 – 2012 SCOTTISH CONFIDENTIAL AUDIT OF SEVERE MATERNAL MORBIDITY (SCASMM) WHAT WAS IT?

3. To generate information and provide feedback to clinicians in maternity services in order to improve clinical management, particularly in relation to national guidelines, and to inform service provision. SCASMM – WHAT WAS ITS PURPOSE?

4. SCASMM – HOW WAS IT DONE? Basic information for 14 severe morbidities, gathered locally by a designated co-ordinator (usually a senior midwife) in each obstetric consultant led maternity unit Data analysed by the Reproductive Health Programme (RHP) of Healthcare Improvement Scotland Annual reports, including recommendations for practice produced and disseminated. Maternity unit level reports since 2010

5. CATEGORIES OF SEVERE MORBIDITY Major (obstetric) haemorrhage Eclampsia Renal/liver dysfunction Cardiac arrest Pulmonary oedema Respiratory dysfunction Coma Cerebrovascular event Status epilepticus Anaphylaxis Septicaemic shock Anaesthetic problem Pulmonary embolism ITU/CCU admission (Information on interventional radiology collected from January 2010) Mantel GD, Buchmann E, Rees H, Pattinson RC. BJOG 1998;105:985-90.

6. SCASMM FORMS

7. RCOG GUIDELINES

8. ANNUAL PUBLICATION: SCASMM

9. healthcareimprovementscotland.org SCASMM REPORTS ON HEALTHCARE IMPROVEMENT SCOTLAND WEBSITE

10. SCASMM DEFINITION OF MAJOR OBSTETRIC HAEMORRHAGE (MOH) One or more criteria: Estimated blood loss ≥ 2500 ml Transfused 5 or more units of blood Received blood products

11. RATES OF WOMEN WITH MOH AND OTHER MORBIDITIES 2004 - 2012

12. AGGREGATED RATES OF SEVERE MATERNAL MORBIDITY 2006 -2012

13. NUMBER OF REPORTED CASES OF ECLAMPSIA IN SCOTLAND, 2003-2012

14. RATES OF INFREQUENT SEVERE MATERNAL MORBIDITIES 2003 - 2012

15. PERINATAL MORTALITY RATES FOR SEVERE MATERNAL MORBIDITY 2005-12

16. MODE OF DELIVERY, ALL BIRTHS (2010-12) AND MOH (2003-11)

17. TIME OF EVENT (2012)

18. CONSERVATIVE SURGICAL TREATMENT OF MOH, 2003-12

19. HYSTERECTOMY FOR MOH, 2003-2012

20. MORBIDITY IN CONTEXT (2006-08) Maternal mortality*:1 in 9,000 births Maternal morbidity Ϯ :1 in 170 births (1 in 137 in 2012) Mortality/morbidity Ϯ :1/79 * SML UK data Ϯ SCASMM data

21. DIRECT INVOLVEMENT OF CONSULTANT OBSTETRICIAN AND ANAESTHETIST IN CARE OF MOH, 2003-2012

22. PROPORTION OF WOMEN WITH MOH IN 2011 AND 2012 ATTENDED OR NOT ATTENDED BY A CONSULTANT OBSTETRICIAN IN RELATION TO TIME OF DAY OR NIGHT

23. QUALITY OF CARE FOR WOMEN WITH MOH AS ASSESSED BY MATERNITY UNIT, 2003-2012

24. SOCIO DEMOGRAPHIC ASSOCIATIONS: DATA COLLECTED FROM JANUARY 2009 Deprivation (SIMD) Body mass index Smoking

25. PERCENTAGE OF WOMEN WITH SEVERE MATERNAL MORBIDITY AND OF ALL WOMEN GIVING BIRTH IN SCOTLAND IN AGE BANDS, 2009-2012.

26. OBESITY Increased risk with BMI >35 (12% of those with severe maternal morbidity, compared with 6.5% of all women giving birth in Scotland )

27. BODY MASS INDEX OF WOMEN WITH SEVERE MATERNAL MORBIDITY AND WOMEN GIVING BIRTH IN SCOTLAND, 2009-2012

29. SMOKING At Antenatal booking (where known) reported by : 21% of women with severe maternal morbidity from 2009 – 2012 20.4% of women giving birth in Scotland between 2009 - 2012 However, Women < 20 years of age with severe maternal morbidity were significantly more likely to smoke and come from the most deprived quintile

30. DEPRIVATION

31. DEPRIVATION QUINTILE OF WOMEN WITH SEVERE MATERNAL MORBIDITY AND OF ALL WOMEN GIVING BIRTH IN SCOTLAND 2009-2012

32. Obesity increases the risk of severe maternal morbidity Smoking does not appear to influence severe maternal morbidity Women in the most and least deprived quintiles are those most likely to experience severe maternal morbidity. Further work to assess the impact of maternal age and deprivation on severe maternal morbidity is required CONCLUSIONS AND FUTURE ANALYSIS

33. Chris Lennox – Reproductive Health Programme (RHP) Clinical Advisor, Healthcare Improvement Scotland (HIS) Angus K MacFadgen – Statistician Naomi Fearns – Clinical Audit Coordinator (RHP) (HIS) Kenny Gifford – Administrator (RHP) (HIS) Frank Dixon – National Records Scotland Kirsten Monteith - Information Analyst, Information Services Division ACKNOWLEDGEMENTS