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

Introduction: Aims, objectives and definitions used in this ReportScottish Confidential Audit of SevereMaternal MorbidityAn audit of a range of defined severe maternal morbiditieshas been carried out continuously in all consultant-ledmaternity units in Scotland since 2003. The methodology issimilar to that of UKOSS, with a designated midwife coordinatorin each unit who identifies cases and sends completeddata to the Reproductive Health Programme of NHSQuality Improvement Scotland, which analyses the dataand produces an annual report. 8 Particularly detailed informationis collected and analysed for all cases of majorobstetric haemorrhage and of eclampsia. For these twoconditions, each unit also provides a self-assessment of thequality of care provided. The continuous nature of theaudit using identical criteria and case definitions over severalyears has allowed the identification of changes in therates of some morbidities, as well as assessment of compliancewith guidelines and changes in clinical management.Appendix 2B is a summary of the findings from SCASMMfor the triennium 2006–2008, and some information fromthe audit is included in other relevant chapters.The aims and objectives of theEnquiryThe overall aim is to save the lives of as many mothers andnewborns as possible through the expert anonymous reviewof the circumstances surrounding and contributing to eachmaternal death in the UK. Apart from the specific issuesand learning points that may emerge from certain cases orcauses of death, the findings from individual cases are alsoaggregated together to learn wider lessons and to formulateand disseminate more general recommendations.Its objectives are:• to improve the care that pregnant and recently deliveredwomen receive and to reduce maternal mortalityand morbidity rates still further, as well as the proportionof deaths caused by substandard care.• to assess the main causes of and trends in maternaldeaths and, where possible, severe morbidity and toidentify any avoidable, remediable or substandard factorsthat could be changed to improve care; to promulgatethese findings and subsequent recommendations toall relevant healthcare professionals and to ensure thattheir uptake is audited and monitored.• to make recommendations concerning the improvementof clinical care and service provision, includinglocal audit, to commissioners of obstetric services andto providers and professionals involved in caring forpregnant women.• to suggest directions for future areas for research andaudit at a local and national level.• to contribute to regular shorter reports on overalltrends in maternal mortality as well as producing amore in-depth triennial Report.The Enquiry’s role in the provision ofhigh-quality clinical careAlthough the Enquiry has always had the support of professionalsinvolved in caring for pregnant or recently deliveredwomen, it is also a requirement that all maternaldeaths should be subject to this confidential enquiry, andall health professionals have a duty to provide the informationrequired.In participating in this Enquiry, all health professionalsare asked for two things:• if they have been caring for a woman who died, toprovide the Enquiry with a full, accurate and unbiasedaccount of the circumstances leading up to her death,with supporting records, and• irrespective of whether they have been caring for awoman who died or not, to reflect on and take anyactions that may be required, either personally or aspart of their wider institution, as a result of the recommendationsand lessons contained within this Report.At a local commissioning level, maternity healthcarecommissioners, such as Primary Care Trusts and LocalHealth Boards, should commission services which meet therecommendations set out in this and previous Reports andensure that all staff participate in the Enquiry if required,as part of their contract.At service provider level, the findings of the Enquiryshould be used:• to ensure that all staff are regularly updated andtrained on the signs and symptoms of critical illness,such as infection, and the early identification, managementand resuscitation of seriously ill women• to develop and regularly update multidisciplinaryguidelines for the management of complications duringor after pregnancy• to review and modify, where necessary, the existingarrangements for the provision of maternity or obstetriccare• to ensure that all Direct and unexpected Indirect maternaldeaths are subject to a local review and critical incidentreport, which is made available to the Enquiry aspart of its own process of review, as well as disseminatingits key findings and recommendations to all localmaternity staff• to introduce an obstetric early warning system chart asrecommended in this and previous Reports• to promote local audit and clinical governance.At a national level—in every country, the findings ofsuccessive Reports have been used to develop nationalª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 25