3: When things go wrong – a review of the MBRRACE‐UK and Ireland Maternity Mortality Reports 2014–17

CHAPTER 3
When things go wrong – a review of the MBRRACE‐UK and Ireland Maternity Mortality Reports 2014–17


3.1 Introduction


In the UK, maternal mortality in the triennium 2013–15 was reported as 8.8 per 100 000 maternities per year. This was slightly up from the 8.5 per 100 000 reported in the previous report. However, these low figures should not give rise to complacency as the death of any woman related to her pregnancy has significant implications for both her family and society. This chapter will focus particularly (but not exclusively) on the ‘lessons learned’ that are relevant to pre‐hospital care including trauma, and will refer to findings from the enquiries of earlier years. The detailed reports can be found by exploring the MBRRACE‐UK (Mothers and Babies – Reducing Risk through Audit and Confidential Enquiries across the UK) home page – https://www.npeu.ox.ac.uk/mbrrace‐uk (accessed February 2018).


From a global perspective, it is important to remember that maternal deaths in resource‐poor countries are astronomically high, with Sierra Leone in West Africa having the highest estimated maternal death rate of 1.36% (or 1360 per 100 000 maternities per year) – see World Bank data reports at http://data.worldbank.org/indicator/SH.STA.MMRT (accessed February 2018).


3.2 Background


The UK Confidential Enquiry into Maternal Deaths (CEMD) has represented the global gold standard for investigation and improvement in maternity care since its inception in 1952. Rigorous investigation of every case of maternal death during and after pregnancy has highlighted where care can be improved. This is vitally important information for staff, health services and for the family and friends left behind. The CEMD published reports triennially from 1957 until 2008. Similar systems began in Northern Ireland in 1956 and in Scotland in 1965. A UK report has been produced since 1985.


The reports were administered through the Confidential Enquiry into Maternal and Child Health (CEMACH) in 2003 and, from 2009, the Centre for Maternal and Child Health (CMACH). Since 2012, the enquiries have been part of the MBRRACE‐UK programme, based at the National Perinatal Epidemiology Unit (NPEU) in Oxford and the enquiries have included data from the Republic of Ireland since then. From 2014, MBRRACE‐UK has published an annual report each December, and these contain topic‐specific reviews of particular interest or concern. Relevant findings will be summarised in subsequent sections. Every reported maternal death is thoroughly scrutinised by an expert panel. There are over 100 independent assessors from many disciplines including emergency medicine. The assessors comment on the ‘quality of care’ in each case, aligning their assessments to any available evidence‐based guidance. The following categories are used:



  • Good care; no improvements identified
  • Improvements in care identified which would have made no difference to the outcome
  • Improvements in care identified which may have made a difference to the outcome

The ‘improvements’ identified mainly involve care offered by various professional groups or teams, but can include instances where the actions of the woman or her family may have been contributory. The confidential enquiries aim to enhance safety by improving the care offered to women in the UK and Ireland, both during and after pregnancy.


Definitions of maternal death


The World Health Organisation (WHO) uses the following international definitions:


















Maternal death Death of a woman during or up to 6 weeks (42 days) after the end of pregnancy (whether the pregnancy ends by termination, miscarriage, ectopic or birth) through causes associated with, or exacerbated by, pregnancy.
Direct deaths Deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and the puerperium (i.e. the 6 weeks following delivery)), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above (e.g. pre‐eclampsia, eclampsia, post‐partum haemorrhage, etc.).
Indirect deaths Deaths resulting from previous existing disease, or disease that developed during pregnancy and which was not the result of direct obstetric causes, but which was aggravated by the physiological effects of pregnancy (e.g. medical and psychiatric disease). (Note: WHO revised the guidance and, from 2016, ‘suicide’ is reported as adirect cause of maternal death.)
Late deaths Deaths occurring between 42 days and 1 year after the end of pregnancy that are the result of direct or indirect maternal causes.
Coincidental Deaths from unrelated causes which happen to occur in pregnancy or the puerperium (e.g. road traffic accidents, homicide, etc.).

Table 3.1 shows the rate of maternal deaths per triennium from 2009 to 2014. There has been a continuing statistically significant reduction in maternal mortality since 2003.


Table 3.1 Summary of maternal mortality statistics, 2009 to 2014








































Triennium Maternal deaths – direct and indirect (up to 42 days) Maternities, n Maternal mortality rate, per 100 000 maternities Additional coincidental deaths (up to 42 days), n (and rate per 100 000 maternities)
2009–11 253 2 379 014 10.63 23 (0.98)
2010–12 243 2 401 624 10.12 26 (1.08)
2011–13 214 2 373 213 9.02 26 (1.10)
2012–14 200 2 341 745 8.54 41* (1.75)
2013–15 202 2 305 920 8.76 38 (1.65)

*Includes nine deaths due to homicide.


The following summaries are based on the four published MBRRACE‐UK reports from 2014 to 2017. General and topic‐specific ‘key messages’ relevant to pre‐hospital care practitioners are presented. The topic‐specific reviews will continue on a 3‐year rolling cycle and the summary reports below include information from the first completed cycle of topic‐specific reviews undertaken by MBRRACE‐UK.


3.3 MBRRACE‐UK report 2014 – highlights and take‐home messages


Overview



  1. Title of report: Saving Lives, Improving Mothers’ Care – Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–2012.
  2. This was the first report to include data for the Republic of Ireland as well as confidential enquiries into the care of women with severe complications in pregnancy who survived, with the aim of improving care yet further.
  3. Topic‐specific reviews included: deaths and morbidity due to sepsis, deaths from haemorrhage, amniotic fluid embolism, anaesthetic‐related causes, and neurological and other indirect causes.


Key facts and figures



  • The maternal mortality (MM) rate fell to ten per 100 000 maternities, a statistically significant fall of 27% from 2003–05 – (relative risk (RR) 0.73, 95% confidence interval (CI) 0.61–0.86). This fall was mainly due to a 48% fall in direct (pregnancy‐related) deaths (pre‐eclampsia, etc.) (RR 0.52, 95% CI 0.39–0.69).
  • Overall, 68% of women died from indirect causes, and 32% from direct (i.e. pregnancy‐related) causes. There was no significant decline in indirect (medical and psychiatric) deaths (RR 0.90, 95% CI 0.72–1.11).
  • The MM rate from genital tract sepsis more than halved from 2006–08 to 2010–12 (RR 0.44, 95% CI 0.22–0.87), but still almost a quarter of deaths during pregnancy or up to 42 days after birth were due to sepsis – from influenza and respiratory and urinary infections (one in 11 deaths were due to H1N1 influenza).
  • Venous thromboembolism (VTE) was the leading cause of direct death and the MM rate from hypertensive disease was the lowest ever recorded.


Key messages – general



  • 13% of women who died delivered in an emergency department or an ambulance and 3% delivered at home.
  • Two‐thirds of women died from indirect causes and almost three‐quarters of all women who died had coexisting medical complications:

    • Influenza and other non‐genital causes of sepsis were the main causes of indirect deaths, resulting in a recommendation that influenza vaccination should be actively encouraged.
    • Cardiac, neurological and psychiatric deaths were the next most common indirect causes.
    • 17% had mental health problems, 15% were asthmatic, 22% were overweight and 27% were obese.

  • A recurring theme was that observations were not taken or not responded to. Recommendation – ‘All women with any symptoms or signs of ill health, including those who are postnatal, should have a full set of basic observations taken (temperature, pulse rate, respiratory rate and blood pressure), and the results documented and acted on.’


Topic‐specific key messages – relevant to pre‐hospital care



  • Sepsis – timely recognition and ‘Think Sepsis’. Initiate a sepsis care bundle including prompt administration of intravenous antibiotics.
  • Haemorrhage – acute point of care estimation of haemoglobin can be falsely reassuring. Fluid resuscitation should be implemented when there is evidence of significant blood loss.
  • Amniotic fluid embolism – in hospital, peri‐mortem caesarean section (PMCS/RH) should be considered if cardiopulmonary resuscitation (CPR) does not restore circulation within 4 minutes. Delays in decision making in hospital were highlighted in the report. In cases of cardiac arrest in the pre‐hospital setting, the woman should be transported urgently to the nearest emergency department after initial stabilisation and CPR, where PMCS can be considered. PMCS in the pre‐hospital setting will rarely be appropriate.
  • Neurological and other indirect causes – maternal deaths from epilepsy were higher than deaths from hypertensive disorders of pregnancy and many had not received any pre‐pregnancy advice. Women with subarachnoid haemorrhage (SAH) were not always examined neurologically. New‐onset headaches (especially if atypical) and neck stiffness should elicit suspicion. The report recommended that pregnant women with a suspected stroke should ideally be admitted to a hyperacute stroke unit.


3.4 MBRRACE‐UK report 2015 – highlights and take‐home messages


Overview



  1. Title of report: Saving Lives, Improving Mothers’ Care ‐ Surveillance of maternal deaths in the UK 2011–13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13.
  2. Topic‐specific reviews included: mental health‐related causes, VTE, homicide and domestic abuse, cancer and late deaths (between 42 days and 1 year after the end of pregnancy).


Key facts and figures



  • The MM rate fell from ten to nine per 100 000 maternities, a statistically significant fall of 35% from 2003–05.
  • The leading causes of death were cardiac (indirect: n = 49; rate 2.09 per 100 000) and VTE (direct: n = 24; rate 1.01 per 100 000).
  • Almost a quarter of late maternal deaths (42 days to 1 year after birth) were due to psychiatric causes.
  • Indirect (medical and psychiatric) deaths remained high. There were no deaths from influenza in 2012–13 (related to a fall in influenza activity, not an increase in vaccination).


Key messages – general



  • Of the women who died, the number who delivered in an emergency department or in an ambulance rose from 13% to 18% (3% delivered at home).
  • In general, pre‐hospital care was of a high standard. There were individual cases where care could have been improved. Examples include:

    • Adrenaline was not given when a breast‐feeding woman collapsed despite being indicated.
    • Some interventions were unsuccessful or made the situation worse (e.g. oesophageal intubation).
    • Delay in transporting women to hospital after collapse, with prolonged efforts to resuscitate at the scene (home or other).
    • Poor communication during transport with failure to alert the receiving unit and the receiving obstetrician.

  • Access to antenatal care is lacking in women who died, with only one‐third receiving the nationally recommended level of care. Many women had recurrent presentations to services, often with escalating symptoms. Recommendation – pre‐hospital practitioners should be aware of the increased risk of poor outcome associated with lack of regular antenatal care.

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Mar 9, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on 3: When things go wrong – a review of the MBRRACE‐UK and Ireland Maternity Mortality Reports 2014–17

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