6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

Chapter 12: Deaths apparently unrelated to pregnancyChapter 12: Deaths apparently unrelated topregnancy from Coincidental and Late causesincluding domestic abuseG Lewis (on behalf of the Centre for Maternal and Child Enquiries)National Perinatal Epidemiology Unit (NPEU), University of Oxford, Oxford, UKCorrespondence: Professor Gwyneth Lewis, National Perinatal Epidemiology Unit (NPEU), University of Oxford, Old Road Campus, OxfordOX3 7LF, UK. Email: gwyneth.lewis@npeu.ox.ac.ukKeywords domestic abuse, coincidental, Confidential Enquiry,maternal, mortality.Deaths apparently unrelated to pregnancy: specific recommendations• This Enquiry continues to recommend that routine enquiry, ‘Asking the question’, should be made about domesticabuse, either when taking a social history at booking or at another opportune point during a woman’s antenatalperiod. Midwives should give high priority to ‘Asking the question’ and to giving information to all women aboutdomestic abuse. The antenatal booking appointment may be the appropriate time to ‘ask the question’ or the midwifemay decide to delay until the following appointment when a relationship has already been established.• All women should be seen alone at least once during the antenatal period to facilitate disclosure of domestic abuse.Any member of the maternity team who notices that a woman has an injury, for example a black eye, should asksympathetically, but directly, about how this occurred and be prepared to follow up this enquiry with information,advice and support as needed.• All women should be advised to wear a three-point seat belt throughout pregnancy, with the lap strap placed as lowas possible beneath the ‘bump’ lying across the thighs and the diagonal shoulder strap above the ‘bump’ lying betweenthe breasts. The seat belt should be adjusted to fit as snugly and comfortably as possible, and if necessary the seatshould be adjusted.IntroductionThis chapter considers those deaths reported to the Enquirythat occurred in pregnant or recently delivered mothersfrom causes apparently unrelated to their pregnancy. Suchdeaths, which occur during pregnancy or up to 42 completeddays (6 weeks) after the end of pregnancy are internationallydefined as fortuitous, although this Report usesthe term Coincidental. Deaths occurring between 43 and364 completed days after the end of the pregnancy are classifiedas Late maternal deaths and are not included in thecalculations of mortality rates or ratios (For full definitionssee the Introduction to this Report). Late deaths can besubdivided into those from Late Direct, Late Indirect andLate Coincidental causes. These definitions are discussedfurther in the Introductory section to this Report.As heralded in the last Report, this Enquiry for 2006–08has focused its efforts on assessing Direct and Indirectdeaths occurring within 42 days of delivery, and not allCoincidental deaths will have been identified and assessed.Certainly, most Late Coincidental deaths are not includedbecause they were excluded from assessment this triennium.However, all nine Late Direct deaths from pregnancy-relatedcauses were identified and assessed, as were24 Late Indirect deaths, largely from suicide and cardiomyopathy,which occurred up to 6 months after delivery.These deaths are important to include in this Reportbecause they can be the result of often identifiable andtreatable conditions aggravated or induced by pregnancy.Indeed, in the next update on international definitions formaternal mortality, it is possible that these two causes ofdeath will be classified as being the result of Direct causes.Although Coincidental or Late deaths, in internationalterms, are not considered as true maternal deaths and donot contribute to the calculations for any internationalª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 143