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Learning from maternal death reviews Saving Mothers’ Lives

Royal College of Obstetricians and Gynaecologists April 30 th. Learning from maternal death reviews Saving Mothers’ Lives. Dr Gwyneth Lewis National Director of maternal health CEMACH Clinical Director Maternal Death Enquiry. Short history

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Learning from maternal death reviews Saving Mothers’ Lives

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

  2. Short history • How Confidential Enquires into Maternal Deaths have helped in the past • Why we continue • Recent findings and recommendations Confidential Enquiries into Maternal and Child Health

  3. Confidential Enquiries into Maternal and Child Health

  4. Maternal deaths by major cause England and Wales, 1935-78 350 300 Abortion and miscarriage 250 Toxaemia 200 Haemorrhage Deaths per 100,000 total births Puerperal sepsis 150 Puerperal phlebitis, 100 thrombosis and embolism 50 0 1935 1940 1945 1950 1955 1960 1965 1970 1975 , Table A10.1.3 Source: General Register Office and OPCS, Reproduced in Birthcounts Confidential Enquiries into Maternal and Child Health

  5. Maternal deaths by major cause England and Wales, 1935-78 350 CEMD 300 Abortion and miscarriage 250 Toxaemia 200 Haemorrhage Deaths per 100,000 total births Puerperal sepsis 150 Puerperal phlebitis, 100 thrombosis and embolism 50 0 1935 1940 1945 1950 1955 1960 1965 1970 1975 , Table A10.1.3 Source: General Register Office and OPCS, Reproduced in Birthcounts Confidential Enquiries into Maternal and Child Health

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

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

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

  9. “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 Confidential Enquiries into Maternal and Child Health

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

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

  12. Confidential Enquiries into Maternal and Child Health

  13. Clinical factors 100 pages Confidential Enquiries into Maternal and Child Health

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

  15. 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 Confidential Enquiries into Maternal and Child Health

  16. Global recognition Confidential Enquiries into Maternal and Child Health

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

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

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

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

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

  22. 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….. Confidential Enquiries into Maternal and Child Health

  23. Confidential Enquiries into Maternal and Child Health

  24. Mental health guidelines Confidential Enquiries into Maternal and Child Health

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

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

  27. The first fifty years1952-54 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 Confidential Enquiries into Maternal and Child Health

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

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

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

  31. Death certificate data alone for international comparison Confidential Enquiries into Maternal and Child Health

  32. Maternal Deaths: Numbers and rates per 100,000 maternities by type: UK 1985-2005 Suicide Some Cancers Sub arachnoids Aneurysms UK Indirect Confidential Enquiries into Maternal and Child Health

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

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

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

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

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

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

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

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

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

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

  43. 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. Confidential Enquiries into Maternal and Child Health

  44. 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 Confidential Enquiries into Maternal and Child Health

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

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

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

  48. 35 30 25 20 15 10 5 0 Least deprived 2 3 4 Most deprived Quintile of the Index of Multiple Deprivation 2004 Maternal mortality and deprivation Confidential Enquiries into Maternal and Child Health

  49. Attendance for antenatal care (ANC) Confidential Enquiries into Maternal and Child Health

  50. Percentage of women who were poor or non-attenders for antenatal care Domestic abuse 81% Known to CPS 81% Substance misuse 78% Black Caribbean 57% Black African 57% Single unemployed 56% Both partners unemployed 47% No English 35% Recently arrived in UK 26% At least one partner in employment 5% Confidential Enquiries into Maternal and Child Health

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