Confidential Enquiry into Maternal Deaths in the UK

Last updated

Confidential Enquiry into Maternal Deaths (CEMD)
AbbreviationCEMD
Formation1952;71 years ago (1952)
TypeConfidential Enquiry
Legal statusOperational
Location
Region served
UK and Ireland
Programme Lead
Jenny Kurinczuk
Maternal Programme Lead
Marian Knight
Budget
£352,700 per year
Staff
10
Website www.npeu.ox.ac.uk/mbrrace-uk

The Confidential Enquiry into Maternal Deaths (CEMD) is a national programme investigating maternal deaths in the UK and Ireland. Since June 2012, the CEMD has been carried out by the MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) collaboration, commissioned by the Healthcare Quality Improvement Partnership (HQIP). [1]

Contents

The predecessor to MBRRACE-UK, CMACE (Centre for Maternal and Child Enquiries) produced a report every triennium, analysing all maternal deaths from the previous three years divided into topic-specific chapters. Reports are now published on an annual basis, with each report focusing on a selection of chapters. Furthermore, each MBRRACE-UK report now contains the Confidential Enquiry into Maternal Morbidity (CEMM), a study focusing on women who survived severe pregnancy problems, with the topic chosen in an open application process. [2] The 2014 CEMM topic was maternal sepsis. [3]

The most recent report by the CEMD (and the first by MBRRACE-UK) was published in December 2014, and focused on deaths from AFE, sepsis, haemorrhage, deaths from neurological complications, and deaths from other medical and surgical complications between 2009 and 2012. During the time that the Confidential Enquiry into Maternal Deaths has existed, there has been a fall in overall maternal deaths in the UK, with rates having fallen from 90 per 100,000 women giving birth in 1952 [4] to around 10 per 100,000 at present. [5]

Maternal deaths

According to the United Nations Maternal Mortality Estimation Inter-agency Group, which consists of representatives from the World Health Organization (WHO), United Nations Children's Fund (UNICEF), the United Nations Population Fund (UNFPA), United Nations Population Division, the World Bank and world-renowned academics, maternal death is:

"The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes". [6]

In addition, a late maternal death is one which occurs more than six weeks but less than one year after the end of pregnancy. Maternal deaths can be further divided by cause, typically into: direct deaths, resulting from obstetric complications of the pregnant state (e.g. amniotic fluid embolism, pre-eclampsia); indirect deaths, resulting from medical or medical health conditions exacerbated by pregnancy (e.g. cardiac disease) or coincidental deaths, where the cause is unrelated to pregnancy (e.g. RTA, homicide).

The CEMD reports on all maternal deaths in the UK and Ireland, including those that are late and/or coincidental.

History of the CEMD

The current system of confidential enquiries began in 1952, however, the history of smaller, local enquiries dates back to 1917 in Aberdeen, with national enquiries across England, Scotland and Wales following in the 1920s and 1930s. [7] Maternal deaths during this period were particularly prevalent in poor, working-class families, thus a large part of these early local enquiries was focused on the social backgrounds of the women who died. Further emphasis was placed on educating women and their families on the importance of maternity care as well as an understanding of the warning signs of complications and the importance of seeking help. [7]

Due to the large number of births taking place in non-clinical settings, avoidable clinical factors were not the only consideration. There was an emphasis on the need for health care workers to improve hygiene standards and ensure training in the use of forceps, and to ensure deliveries requiring other forms of intervention were undertaken in hospital. These local enquiries, along with various medical advances (notably the introduction of antibiotics) were credited with a sharp decline in maternal deaths in the 1930s and 1940s. [8]

In 1952 the Ministry of Health instituted the national confidential enquiry for both England and Wales, initially to reports its findings on a three-yearly basis, and since 2014 on a yearly basis. Since its inception, the overall aims of the enquiry have been: [9]

In Northern Ireland, a similar report to the CEMD was published from 1956 to 1984, initially covering four years of maternal deaths at a time. However, due to falling maternal death rates in the country, the final reports covered a larger period of time. The final report covering years 1978-84 covered just 32 deaths. [7] Currently, the agency NIMACH (Northern Ireland Maternal and Child Health) is responsible for collecting and analysing data in support of MBRRACE-UK.

Scotland also conducted a series of confidential enquiries, with the first dealing with maternal deaths from 1965 to 1971. [7]

For maternal deaths from 1985 onwards, a single report has been published for the whole of the United Kingdom. [7] Since 2009, maternal deaths from the Republic of Ireland have also been included in the CEMD, with the agency MDE Ireland responsible for all data collection for maternal deaths from the Republic of Ireland. [10]

Since the first CEMD report was published in 1952, maternal deaths have fallen from 90 per 100,000 women giving birth in 1952 to around 10 per 100,000 at present. It is regarded as the 'gold standard' for Confidential Enquiries worldwide. [11] [12]

Confidential enquiry process

A confidential enquiry is an enquiry designed to improve health and health care by collecting data, identifying any shortfalls in the care provided and devising recommendations to improve future care. They are confidential in the sense that the details of the patient/hospital/involved clinicians remain anonymous to those conducting the enquiry.

The CEMD collects and processes anonymous data of every maternal death in the UK and Ireland before they are looked at by several of the MBRRACE-UK expert assessors. MBRRACE-UK has approximately 100 assessors from different specialty groups including obstetrics, anaesthesia, intensive care, midwifery, pathology, psychiatry, general practice, emergency medicine, obstetric medicine, neurology, infectious diseases and cardiology. Each maternal death case is typically looked at by between ten and fifteen expert reviewers. All of the assessors for the CEMD are volunteers who are not remunerated for their work. [13]

Once all data has been collected and each case has undergone review, multi-disciplinary chapter writing groups are convened, where the expert reviews of each case are examined to enable key learning themes to be drawn out for the final report. The lead member of each chapter writing group will then draft the initial chapter, which is then reviewed by the other group members and the Programme Lead before a final version is completed. Where possible, any recommendations by the CEMD are linked to national guidance from organisations such as NICE or SIGN. [14]

Key findings

The latest CEMD was published in 2014 and focused on surveillance of all maternal deaths from the period 2009-12 and confidential enquiries where the cause of death was from haemorrhage, amniotic fluid embolism, anaesthetic-related causes, neurological and other indirect causes. A further sample of survivors of septic shock were also subject to Confidential Enquiry. [13]

Between 2009 and 2012, 357 women died in the UK and Ireland during pregnancy or within six weeks of the end of their pregnancy. 106 of these were considered to be direct maternal deaths, representing a statistically significant decrease. [14] The number of deaths from indirect causes increased however, with 215 women dying over the four-year period. The remaining 36 deaths were classified as coincidental. It was commented in news articles, as well as in the report itself that a significant number of late maternal deaths were attributable to psychiatric causes. [13] [15] [16]

Despite the overall fall, the researchers claimed there are 'key areas that the health service can look to improve in order to reduce the number of maternal deaths from these indirect causes'. [17]

The report urged clinicians to 'Think Sepsis' after almost a quarter of maternal deaths were from sepsis. More specifically, the advice was for staff to take all appropriate observations and act on them when presented with an unwell pregnant (or recently pregnant) woman. Furthermore, rapid administration of intravenous antibiotics and escalating the care of the woman to senior doctors and midwives quickly were considered essential. [14]

Another key recommendation of the report was to encourage clinicians to promote the flu vaccine to all pregnant women, with flu one of the leading causes of preventable death in pregnancy (1 in 11 of the women who died). It was reported that less than half of pregnant women eligible for a free flu vaccine had taken it up. The MBRRACE-UK report notes that of the maternal deaths caused by Flu, more than half could have been prevented had the woman received a flu jab. [14]

In addition to the full report, MBRRACE-UK publishes an executive summary listing separate key areas for action for policy-makers, medical directors, doctors and midwives.

The executive summary, lay report and full MBRRACE-UK report is published online and available publicly. [18]

See also

Related Research Articles

<span class="mw-page-title-main">Maternal death</span> Aspect of human reproduction and medicine

Maternal death or maternal mortality is defined in slightly different ways by several different health organizations. The World Health Organization (WHO) defines maternal death as the death of a pregnant mother due to complications related to pregnancy, underlying conditions worsened by the pregnancy or management of these conditions. This can occur either while they are pregnant or within six weeks of resolution of the pregnancy. The CDC definition of pregnancy-related deaths extends the period of consideration to include one year from the resolution of the pregnancy. Pregnancy associated death, as defined by the American College of Obstetricians and Gynecologists (ACOG), are all deaths occurring within one year of a pregnancy resolution. Identification of pregnancy associated deaths is important for deciding whether or not the pregnancy was a direct or indirect contributing cause of the death.

<span class="mw-page-title-main">Unsafe abortion</span> Termination of a pregnancy by using unsafe methods

An unsafe abortion is the termination of a pregnancy by people lacking the necessary skills, or in an environment lacking minimal medical standards, or both. An unsafe abortion is a life-threatening procedure. It includes self-induced abortions, abortions in unhygienic conditions, and abortions performed by a medical practitioner who does not provide appropriate post-abortion attention. About 25 million unsafe abortions occur a year, of which most occur in the developing world.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. In most cases, maternal health encompasses the health care dimensions of family planning, preconception, prenatal, and postnatal care in order to ensure a positive and fulfilling experience. In other cases, maternal health can reduce maternal morbidity and mortality. Maternal health revolves around the health and wellness of pregnant women, particularly when they are pregnant, at the time they give birth, and during child-raising. WHO has indicated that even though motherhood has been considered as a fulfilling natural experience that is emotional to the mother, a high percentage of women develop health problems and sometimes even die. Because of this, there is a need to invest in the health of women. The investment can be achieved in different ways, among the main ones being subsidizing the healthcare cost, education on maternal health, encouraging effective family planning, and ensuring progressive check up on the health of women with children. Maternal morbidity and mortality particularly affects women of color and women living in low and lower-middle income countries.

<span class="mw-page-title-main">Maternal–fetal medicine</span> Branch of medicine

Maternal–fetal medicine (MFM), also known as perinatology, is a branch of medicine that focuses on managing health concerns of the mother and fetus prior to, during, and shortly after pregnancy.

Immunization during pregnancy is the administration of a vaccine to a pregnant individual. This may be done either to protect the individual from disease or to induce an antibody response, such that the antibodies cross the placenta and provide passive immunity to the infant after birth. In many countries, including the US, Canada, UK, Australia and New Zealand, vaccination against influenza, COVID-19 and whooping cough is routinely offered during pregnancy.

A maternal near miss (MNM) is an event in which a pregnant woman comes close to maternal death, but does not die – a "near-miss". Traditionally, the analysis of maternal deaths has been the criterion of choice for evaluating women's health and the quality of obstetric care. Due to the success of modern medicine such deaths have become very rare in developed countries, which has led to an increased interest in analyzing so-called "near miss" events.

<span class="mw-page-title-main">Maternal health in Uganda</span>

Uganda, like many developing countries, has high maternal mortality ratio at 153 per 100,000 live births.According to the World Health Organization (WHO), a maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. In situations where attribution of the cause of death is inadequate, another definition, pregnancy-related death was coined by the US Centers for Disease Control (CDC), defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.

Maternal health in Angola is a very complicated issue. In the Sub-Saharan region of Africa where Angola is located, poor maternal health has been an ongoing problem contributing to the decreased level of health in the population in the early 21st century.

<span class="mw-page-title-main">Death of Savita Halappanavar</span> Woman who died from sepsis from being denied an abortion in Ireland

Savita Halappanavar was a dentist of Indian origin, living in Ireland, who died from sepsis after her request for an abortion was denied on legal grounds. In the wake of a nationwide outcry over her death, voters passed in a landslide the Thirty-Sixth Amendment of the Constitution, which repealed the Eighth Amendment of the Constitution of Ireland and empowered the Oireachtas to legislate for abortion. It did so through the Health Act 2018, signed into law on 20 December 2018.

A pre-existing disease in pregnancy is a disease that is not directly caused by the pregnancy, in contrast to various complications of pregnancy, but which may become worse or be a potential risk to the pregnancy. A major component of this risk can result from necessary use of drugs in pregnancy to manage the disease.

In reproductive health, obstetric transition is a concept around the secular trend of countries gradually shifting from a pattern of high maternal mortality to low maternal mortality, from direct obstetric causes of maternal mortality to indirect causes, aging of maternal population, and moving from the natural history of pregnancy and childbirth to institutionalization of maternity care, medicalization and over medicalization. This concept was originally proposed in the Latin American Association of Reproductive Health Researchers in analogy of the epidemiological, demographic and nutritional transitions.

Obstetric medicine, similar to maternal medicine, is a sub-specialty of general internal medicine and obstetrics that specializes in process of prevention, diagnosing, and treating medical disorders in with pregnant women. It is closely related to the specialty of maternal-fetal medicine, although obstetric medicine does not directly care for the fetus. The practice of obstetric medicine, or previously known as "obstetric intervention," primarily consisted of the extraction of the baby during instances of duress, such as obstructed labor or if the baby was positioned in breech.

<span class="mw-page-title-main">Neonatal infection</span> Human disease

Neonatal infections are infections of the neonate (newborn) acquired during prenatal development or within the first four weeks of life. Neonatal infections may be contracted by mother to child transmission, in the birth canal during childbirth, or after birth. Neonatal infections may present soon after delivery, or take several weeks to show symptoms. Some neonatal infections such as HIV, hepatitis B, and malaria do not become apparent until much later. Signs and symptoms of infection may include respiratory distress, temperature instability, irritability, poor feeding, failure to thrive, persistent crying and skin rashes.

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is a registered charity based in London. Dr Marisa Mason is the Chief Executive and Ian Martin is the Chair of the Trustees. The organisation started from a pilot study of mortality associated with anaesthesia in five regions in England, Wales and Scotland published in 1982. A joint venture was established between surgery and anaesthesia named the Confidential Enquiry into Perioperative Deaths. It became the National Confidential Enquiry into Perioperative Deaths (NCEPOD) in 1988 and published its first report in 1990. It now covers all specialities and covers all outcomes as well as deaths.

<span class="mw-page-title-main">Maternal mortality in the United States</span> Overview of maternal mortality in the United States

Maternal mortality refers to the death of a woman during her pregnancy or up to a year after her pregnancy has terminated; this metric only includes causes related to the pregnancy, and does not include accidental causes. Some sources will define maternal mortality as the death of a woman up to 42 days after the pregnancy has ended, instead of one year. In 1986, the CDC began tracking pregnancy-related deaths to gather information and determine what was causing these deaths by creating the Pregnancy-Related Mortality Surveillance System. According to a 2010-2011 report although the United States was spending more on healthcare than any other country in the world, more than two women died during childbirth every day, making maternal mortality in the United States the highest when compared to 49 other countries in the developed world.

<span class="mw-page-title-main">Maternal mortality in India</span> Overview of maternal mortality in India

Maternal mortality in India is the maternal death of a woman in India during pregnancy or after pregnancy, including post-abortion or post-birth periods. Different countries and cultures have different rates and causes for maternal death. Within India, there is a marked variation in healthcare access between regions and in socioeconomic factors, accordingly, there is also variation in maternal deaths for various states, regions, and demographics of women.

Marian Knight is a British physician who is a Professor of Maternal and Child Population Health at the University of Oxford. She is an Honorary Consultant of Public Health for Public Health England. During the COVID-19 pandemic Knight studied the characteristics and outcomes of pregnant women who tested positive for COVID-19.

Black maternal mortality in the United States refers to the death of women, specifically those who identify as Black or African American, during or after child delivery. In general, maternal death can be due to a myriad of factors, such as how the nature of the pregnancy or the delivery itself, but is not associated with unintentional or secondary causes. In the United States, around 700 women die from pregnancy-related illnesses or complications per year. This number does not include the approximately 50,000 women who experience life-threatening complications during childbirth, resulting in lifelong disabilities and complications. However, there are stark differences in maternal mortality rates for Black American women versus Indigenous American, Alaska Native, and White American women.

Gwyneth Helen Lewis is a British physician who is a professor at University College London. She previously served as National Clinical Director for Maternal Health and Maternity Services for the Department of Health. Lewis helped to write Maternity Matters, a strategy that outlined the future of maternity care in the United Kingdom.

References

  1. "MBRRACE-UK appointed to conduct MNI-CORP".
  2. "MBRRACE-UK topic proposal". Archived from the original on 19 January 2015. Retrieved 11 May 2015.
  3. Knight, M.; Lewis, G.; Acosta, CD; Kurinczuk, JJ (2014). "Maternal near-miss case reviews: the UK approach". BJOG: An International Journal of Obstetrics & Gynaecology. 121: 112–116. doi:10.1111/1471-0528.12802. PMC   4314674 . PMID   25236644.
  4. Report on Confidential Enquiries into Maternal Deaths in England and Wales 1952-1954, p. viii
  5. "MBRRACE-UK 2014 Report Lay summary" (PDF).
  6. "Maternal mortality data definitions". Archived from the original on 14 October 2013.
  7. 1 2 3 4 5 Why Mothers Die – CEMD in the United Kingdom 1997 – 1999, appendix 3
  8. Report on Confidential Enquiries into Maternal Deaths in England and Wales 1982-84, Appendix A
  9. Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008, p.25
  10. "About MDE Ireland".
  11. "RCOG statement on appointment of MBRRACE-UK".
  12. World Health Organisation 2004
  13. 1 2 3 SAVING LIVES, IMPROVING MOTHERS' CARE – Lessons learned to inform future maternity, p.3
  14. 1 2 3 4 "SAVING LIVES, IMPROVING MOTHERS' CARE Executive Summary" (PDF).
  15. Siddique, Haroon (9 December 2014). "(The Guardian) Better care urged for pregnant women with mental health problems – study". The Guardian.
  16. "(NHS) Around 1 in 10 maternal deaths due to flu". 9 December 2014.
  17. "UK sees a fall in maternal deaths".
  18. "MBRRACE-UK reports".