Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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208 16 Issues for midwives Smoking The 2005 Infant Feeding Survey 12 found that 33 per cent of all women in the United Kingdom smoked at some time in the year before pregnancy or during pregnancy. These included 16 per cent who smoked before pregnancy but gave up, mainly on confi rmation of pregnancy and 17 per cent who smoked throughout pregnancy. This was a slight decrease from 2000 when 35 per cent smoked at some time in the year before pregnancy and 20 per cent smoked during pregnancy. The percentage who smoked at some time in the year before pregnancy ranged from 20 per cent of women in managerial and professional occupations to 48 per cent of those in routine and manual occupations and 35 per cent of those who had never worked. Linked to this was differences by age. The percentage of women smoking before or during pregnancy ranged from 68 per cent of women aged under 20 to 21 per cent of those aged 35 or over. A smoking history was not documented for 67 percent of the women who died which makes further analysis of the increased contribution of smoking in pregnancy to maternal mortality impossible. It also highlights the need for better awareness amongst health professionals as well as better record keeping. Accessing care This Report demonstrates that late booking and poor or non attendance for antenatal care are absolute risk factors for maternal death. Table 16.1 shows some of the characteristics of the women who received less than optimal care this triennium. The Recorded Delivery 13 Report reinforces these fi ndings and indeed those of previous Reports where it was demonstrated that women from ethnic groups, a deprived background or who are single parents were more likely to recognise their pregnancy later, access care later and consequently book later for antenatal care. There is a real need for midwives to identify the needs of these women and target and provide care appropriately. Sadly, and despite previous recommendations, only a handful of women in this Report, who were known to be at higher risk and who had defaulted from care were actively followed up.
Table 16.1 Poor or non attenders for maternity care by risk group. Direct and Indirect deaths whose pregnancy was equal to or exceeded 12 weeks’ gestation: United Kingdom; 2003-05. Characteristic Women who were poor or non-attenders at antenatal care Overall number of women n (%) n (%) Domestic abuse 13 (81) 16 (100) Known to Child Protection Services or social services 26 (81) 32 (100) Substance misuse 21 (78) 27 (100) Black Caribbean 4 (57) 7 (100) Single unemployed 19 (56) 34 (100) Both partners unemployed 14 (47) 30 (100) Black African 12 (40) 30 (100) No English 9 (35) 26 (100) White 31 (17) 183 (100) At least one partner in employment 9 (5) 165 (100) Conclusions Although there are lessons to be learnt for midwifery practice, particularly around failure to recognise serious illness, a failure to act appropriately and lack of communication, there is also evidence of positive and innovative responses to the recommendations made in the last Report. Some organisations have developed partnerships with local councils and children centres to develop targeted services aimed at support vulnerable families as shown in Box 16.2 and Box 16.3. Box 16.2 Working in partnership In Liverpool, close partnership working with statutory agencies has led to the development of locally based comprehensive services for women including: • Four midwifery led centres in deprived parts of the city, offering holistic care including ultrasound scans, blood tests, parenting support and specialised midwifery support • The National Society for the Prevention of Cruelty to Children (NSPCC) has fi nancially supported the development of two midwifery posts to offer additional support for women who suffer from domestic abuse and women who misuse substances • The local authority has supported the development of a specialist team of midwives to offer targeted support through local children’s centres for vulnerable women and their families. For further information contact Grace Edwards (Consultant Midwife) Liverpool Women’s NHS Foundation Trust Telephone: 0151 708 9988 This response to the recommendations of the last triennium report is evident across the UK. 209
Page 1 and 2:
Confidential Enquiry into Maternal
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Saving Mothers’ Lives: Reviewing
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Contents Maternal deaths Indirectly
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Foreword Having a baby is a joyous
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The ‘top ten’ key recommendatio
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Migrant women 4. All pregnant mothe
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Clinical skills 7. Maternity servic
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Early warning scoring system 9. The
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References 1 Redshaw M, Rowe R, Hoc
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Working together to save mothers’
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Severe maternal morbidity, “near
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At a national level In every countr
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Table 1 Defi nitions of maternal de
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For the past nine years, ONS have b
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Chapter 1 Which mothers died, and w
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Key fi ndings for 2003-05 Maternal
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Figure 1.1: Overall maternal mortal
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Coincidental deaths The deaths of 5
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Leading causes of maternal deaths:
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Table 1.5 Maternal deaths by gestat
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Table 1.7 Number of maternal deaths
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of note is that every women who die
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Table 1.11 Numbers and percentage o
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These messages are repeated in many
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Doctors may need specifi c training
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Table 1.13 Total number of Direct a
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Ovarian hyperstimulation syndrome (
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The obese women who died From the n
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Pre-pregnancy counselling and weigh
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Table 1.19 Direct and Indirect mate
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double the number of cases in the l
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was ill and he should take her to a
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Table 1.22 Characteristics of the a
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Most staff reported learning clinic
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exception. The health service has a
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17 Shah A, Sands J, Kenny L. Matern
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Country of birth and migration A fa
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Table A1.4 Direct and Indirect deat
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Body mass index varies with age, be
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2 Thrombosis and thromboembolism Ja
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Pulmonary embolism Of the 33 women
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Family history In two deaths there
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vigilance and take symptoms serious
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Deaths after caesarean section Seve
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of pregnancy, seven had identifi ab
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Annex 2.1 Summary of the key recomm
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The grades of recommendations (B or
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High risk patients Patients assesse
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Table 3.2 Numbers of deaths from pr
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publication from the United States
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References 1 Knight M, Kurinczuk JJ
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obstetricians and anaesthetists rou
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Detailed guidelines for the managem
Page 111 and 112:
acute bleeding situation although i
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References 1 Brace V, Penney G, Hal
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Table 5.1 Direct deaths attributed
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of over ten litres. Despite a hyste
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References 1 Clark SL, Pavlova Z, G
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The women who died The ages of the
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A woman who had not been long in th
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7 Genital tract sepsis Ann Harper G
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Sepsis in early pregnancy Six women
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Box 7.3 Learning points: Sepsis in
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Risk factors for, and the identifi
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Box 7.7 Features of septicaemic sho
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8 Anaesthesia Griselda Cooper and J
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The third case also highlights the
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A woman suffered a concealed haemor
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Sepsis Poor anaesthetic or resuscit
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What did you learn from this case a
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9 Cardiac disease Catherine Nelson-
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Table 9.2 Causes of maternal death
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an estimated incidence of 1.1 per 1
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Quality of care Care was considered
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y a doctor, with a systolic blood p
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Box 9.3 Learning points: peripartum
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Infectious endocarditis Two women d
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10 Other Indirect deaths Michael de
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Table 10.1 Causes of Other Indirect
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Fifty-eight of the eighty-seven wom
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Previous Reports have emphasised th
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Aspergillosis usually occurs in imm
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Liver disease There were four mater
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Diseases of the circulatory system
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11 Cancer and other tumours Gwyneth
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her delivery, but her case should h
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Severe abdominal and back pain, sci
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References 1 Drife, J O. The contri
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Psychiatric deaths: Specifi c recom
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cut off point for maternal deaths,
Page 185 and 186: Report, 26 deaths from suicide were
Page 187 and 188: Current psychiatric treatment In th
Page 189 and 190: 12 Deaths from psychiatric causes S
Page 191 and 192: caring for the woman. Nonetheless,
Page 193 and 194: Commentary on deaths related to dru
Page 195 and 196: It is known that women presenting w
Page 197 and 198: antibiotics nor returned to her gen
Page 199 and 200: It is still evident that there is a
Page 201 and 202: 13 Domestic abuse Gwyneth Lewis Dom
Page 203 and 204: The mothers affected: 2003-05 Durin
Page 205 and 206: Of the women who were murdered: •
Page 207 and 208: Annex 13.1 The recommendations of t
Page 209 and 210: Road traffi c accidents during and
Page 211 and 212: Table 14.2 Late deaths known, or no
Page 213 and 214: Table 15.2 Quality of autopsy repor
Page 215 and 216: Haemorrhage Thirteen of the sevente
Page 217 and 218: association with obesity as eight o
Page 219 and 220: Obesity was present in 55% of these
Page 221 and 222: Toxicology showed non-lethal citalo
Page 223 and 224: Box 15.6 Pathology learning points:
Page 225 and 226: References 1 Royal College of Patho
Page 227 and 228: 16 Issues for midwives Grace Edward
Page 229 and 230: effective service for women who may
Page 231 and 232: Professional accountability and com
Page 233 and 234: Box 16.1 Key physical signs that ma
Page 235: Midwives’ responsibility for vuln
Page 239 and 240: Action checklist for midwifery prac
Page 241 and 242: 17 Issues for General Practitioners
Page 243 and 244: Box 17.1 Summary of the key issues
Page 245 and 246: Box 17.3 Risk factors for venous th
Page 247 and 248: headaches. The indications for emer
Page 249 and 250: Box 17.8 GP learning points: Heartb
Page 251 and 252: medication after delivery and been
Page 253 and 254: Women with mitral stenosis may seem
Page 255 and 256: signifi cance in the pregnancy. It
Page 257 and 258: References 1 RCOG. Thromboprophylax
Page 259 and 260: Introduction For the fi rst time in
Page 261 and 262: measures were of a good or excellen
Page 263 and 264: A woman collapsed at home following
Page 265 and 266: never preclude requesting opinion f
Page 267 and 268: admissions represented 0.9% of all
Page 269 and 270: Modifi ed early warning scoring sys
Page 271 and 272: Box 19.3 Critical care learning poi
Page 273 and 274: her initial collapse she was transf
Page 275 and 276: Chapter 19 Annex A This Annex is av
Page 277 and 278: Table 20.1 Inclusion criteria used
Page 279 and 280: Table 20.3 Numbers and rates of sev
Page 281 and 282: References 1 Baskett TF,.O’Connel
Page 283 and 284: The Director of the Maternal Death
Page 285 and 286: Verifi cation of Ascertainment Asce
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Scotland A single panel of assessor
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CEMACH Regional Managers East of En
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Regional Assessors in Pathology Eas
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NORTHERN IRELAND Department of Heal
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