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

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LewisThere were cases where a major failure of communicationbetween healthcare workers may have contributed to thewoman’s death. Notably, these included GPs not beingasked for information or not being consulted about furtherreferral and, in some cases, the GP not being informed thatthe woman was pregnant. The converse was also true, withthe GP not passing on information relevant to the woman’shealth and well-being. In addition, the assessors have beenstruck by the lack of further referral by hospital obstetriciansto senior specialists of potentially high-risk cases.Underlying health statusAgeAs in previous Reports, the recognised association betweenmaternal age and risk of pregnancy-related death, as shownin Table 1.15 and Figure 1.5, remains. In this, as in previoustriennia, the highest maternal mortality rates are among theolder mothers. In this Report, the youngest mother who diedwas aged 15 and the oldest was 47 years of age. Four girlswho died were aged between 15 and 16, two of whom diedfrom Direct causes, one of which occurred later in the postnatalyear. Two of these were living in the care of social servicesand another was well known to them. Four of the tenyoung mothers aged between 17 and 19 years were alsoknown to social services. Two were also described as being‘learning disabled’, two used illegal drugs and one was consideredto be homeless, having been recently discharged fromthe care of social services.ParityThe parity of the women who died is given in Table 1.16.Because there are no reliable population denominator datafor parity, it is not possible to calculate specific maternalmortality rates. Rates are, however, available for singletonand multiple births, and these are shown in Table 1.17.These show that the increased maternal mortality rate associatedwith multiple births in the previous two triennia ismaintained. Women with multiple pregnancies appear tobe four times (95% CI 2.3–6.6) more likely to die of apregnancy-related complication than women expecting onlyone child, but care should be taken in interpreting thisbecause of the very small numbers involved.Assisted reproductionEight women whose deaths are counted in this Report wereknown to have undergone assisted reproductive techniques(ART), including in vitro fertilisation, for infertility, four ofwhom died from Direct or Indirect causes, compared withnine in the previous Report. Because it is not possible toseparate UK citizens from visitors from overseas who underwentprivate in vitro fertilisation treatment, it is not possibleto obtain specific denominator data and therefore provide amaternal mortality rate for UK citizens only. Furthermore, itis not possible to calculate an overall mortality rate for ART,because many of the overseas women will have gone back totheir own countries to give birth and are lost to UK followup. But, based on the findings of earlier Reports where thedata were analysed irrespective of citizenship and place ofTable 1.15. Total number of Direct and Indirect deaths by age (in years) of the women who died and rate per 100 000 maternities; UK: 1985–2008Under 20 20–24 25–29 30–34 35–39 40 and over Not stated All agesNumbers1985–87 15 47 53 60 35 13 0 2231988–90 17 38 74 57 31 18 3 2381991–93 7 30 87 61 36 7 1 2291994–96 15 40 71 70 53 11 8 2681997–99 19 34 60 66 50 13 0 2422000–02 16 30 70 79 47 19 0 2612003–05 15 39 66 91 64 20 0 2952006–08 13 36 59 58 71 24 0 261Rates per 100 000 maternities1985–87 7.6 7.1 6.7 13.6 22.8 48.4 9.81988–90 8.8 6 8.9 11.5 18.7 57.4 10.11991–93 4.2 5.5 10.6 10.9 19.1 20.6 9.91994–96 10.2 9 9.6 11.5 24.1 29.1 12.21997–99 11.7 8.9 9.3 10.5 19.2 29.0 11.42000–02 10.6 8.2 13.0 13.2 16.2 35.6 13.12003–05 9.9 9.8 12.4 14.5 19.1 29.4 14.02006–08 8.6 8.2 9.7 9.2 18.8 29.2 11.444 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203
Chapter 1: The women who died 2006–2008Rate per 100 000 maternities50454035302520151050Under 20 20–24 25–29 30–34 35–39 40 and overMaternal ageFigure 1.5. Maternal mortality rates by age group; UK: 2006–08.Table 1.16. Parity of the women who died; UK: 2006–08Parity Direct Indirect Direct andIndirectn % n % n %Nulliparous 46 43 49 32 95 36Multiparous 61 57 105 68 166 641–4 58 54 99 64 157 605–10 3 3 6 4 9 3All 107 100 154 100 261 100delivery, there appeared to be no appreciable increase in thematernal mortality rate associated with ART. The smallnumbers in this Report suggest that it does not seem to havebeen the case in this triennium either.ObesityObesity is defined by a woman’s Body Mass Index (BMI).This is calculated by the person’s weight in kilogramsdivided by the square of their height in metres (kg/m 2 ).Box 1.5 shows how the National Institute for Health andClinical Excellence (NICE) 9 and the NHS Information Centre(NHSIC) 10 classify BMI into the categories used in thisReport.Table 1.17. Direct (including Late Direct) and Indirect deaths and rates per 100 000 maternities for singleton and multiple births; UK: 1997–2008Direct and Indirect deaths Relative risk 95% CI Maternities (n)n Rate 95% CI2006–08Singleton 232 10.28 9.04–11.69 1.0 2 256 298Multiple 14 39.74 23.54–67.11 3.9 2.3–6.6 35 226Not known 24Total 270Singleton1997–99 234 11.17 9.83–12.70 1.0 2 093 9652000–02 255 12.96 11.46–14.65 1.0 1 967 8342003–05 295 14.17 12.64–15.88 1.0 2 082 429Multiple1997–99 8 26.16 13.26–51.62 2.3 1.2–4.7 30 5782000–02 6 20.24 9.28–44.17 1.6 0.7–3.5 29 6382003–05 11 34.84 19.45–62.38 2.5 1.4–4.5 31 575Sources: CMACE, Office for National Statistics, General Register Office for Scotland, Northern Ireland Statistics and Research Agency.ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 45
Page 1: Volume 118, Supplement 1, March 201
Page 4 and 5: AcknowledgementsSaving Mothers’ L
Page 6 and 7: AcknowledgementsAcknowledgementsCMA
Page 8 and 9: Forewordbeen written jointly by a m
Page 10 and 11: ‘Top ten’ recommendationsServic
Page 12 and 13: ‘Top ten’ recommendationscommun
Page 14 and 15: ‘Top ten’ recommendationsof suc
Page 16 and 17: ‘Top ten’ recommendationsMarch
Page 18 and 19: Oates et al.Back to basicsM Oates 1
Page 20 and 21: Oates et al.BreathlessnessBreathles
Page 22 and 23: Oates et al.appropriate pathway of
Page 24 and 25: LewisIntroduction: Aims, objectives
Page 26 and 27: LewisAn important limitation of ran
Page 28 and 29: Lewismaternal and public health-pol
Page 30 and 31: Lewisresult in a live birth at any
Page 32 and 33: LewisChapter 1: The women who died
Page 34 and 35: Lewiswho would not have been identi
Page 36 and 37: Lewis1098Rate per 100 000 materniti
Page 38 and 39: LewisTable 1.4. Numbers and rates o
Page 40 and 41: Lewis2.50Rate per 100 000 materniti
Page 42 and 43: LewisTable 1.9. Number of maternal
Page 44 and 45: LewisTable 1.12. Numbers and percen
Page 48 and 49: LewisBox 1.5. Classifications of Bo
Page 50 and 51: LewisTable 1.20. Number and estimat
Page 52 and 53: LewisNew countries of the European
Page 54 and 55: LewisTable 1.23. Direct and Indirec
Page 56 and 57: LewisTable 1.26. Characteristics* o
Page 58 and 59: Lewis4 Lewis G (ed). The Confidenti
Page 60 and 61: DrifeTable 2.1. Direct deaths from
Page 62 and 63: Drifewomen who died in 2006-08 had
Page 64 and 65: Drifedelivery she became breathless
Page 66 and 67: DrifePathological overviewFourteen
Page 68 and 69: NeilsonChapter 3: Pre-eclampsia and
Page 70 and 71: Neilsontrue, and what might be the
Page 72 and 73: NeilsonConclusionThe number of deat
Page 74 and 75: NormanBackgroundIn the UK, major ob
Page 76 and 77: Normanwhich there was catastrophic
Page 78 and 79: Normanrecommendations made in succe
Page 80 and 81: DawsonBox 5.1. The UK amniotic flui
Page 82 and 83: Dawsontry despite an extensive sear
Page 84 and 85: O’HerlihyTable 6.1. Numbers of Di
Page 86 and 87: O’Herlihytoxic shock syndrome aft
Page 88 and 89: HarperGroup A b-haemolytic streptoc
Page 90 and 91: Harperthe 6-week postnatal period,
Page 92 and 93: Harpera major intrapartum haemorrha
Page 94 and 95: HarperBox 7.1. Signs and symptoms o
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Harperwoman was given several litre
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Harper2 Lamagni TL, Efstratiou A, D
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LucasTable A7.1 Proposed new catego
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Lucasthe same infection scenario as
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McClure, CooperChapter 8: Anaesthes
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McClure, Cooperaddress, but protoco
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McClure, CooperPostpartum haemorrha
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McClure, CooperWorkloadA number of
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Nelson-PiercyTable 9.1. Indirect ma
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Nelson-Piercynary arteries. In view
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Nelson-Piercynormal left ventricle
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LucasAnnex 9.1. Pathological overvi
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Lucasdiac death that is non-ischaem
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de Swiet et al.causes but are aggra
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de Swiet et al.died of SUDEP before
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de Swiet et al.for 6 weeks after de
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de Swiet et al.mised. The obstetric
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de Swiet et al.CancerPregnancy does
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de Swiet et al.a thorough autopsy w
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Oates, CantwellChapter 11: Deaths f
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Oates, CantwellTable 11.1. Timing o
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Oates, CantwellTable 11.5. Maternal
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Oates, CantwellChild protection iss
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Oates, CantwellAll women who are su
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Oates, Cantwell4 Kendel RE, Chalmer
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Lewismaternal mortality rates or ra
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Annex 12.1. Domestic abuseAnnex 12.
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Annex 12.1. Domestic abuseshe could
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Garrod et al.supportive but challen
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Garrod et al.• Culture and system
Page 156 and 157:
Garrod et al.the second stage and s
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Garrod et al.through the still heal
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ShakespeareChapter 14: General prac
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Shakespeareemergency caesarean sect
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ShakespeareCardiac diseaseDeaths fr
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Shakespearereduce the risks to the
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ShakespeareManaging a maternal deat
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Hulbertin the ED was of a high qual
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HulbertPre-eclampsia/eclampsia: lea
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HulbertTransfersWhen the obstetric
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Clutton-Brocksimply the case that s
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Clutton-BrockDiagnosis of sepsisTak
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Clutton-Brockpulseless electrical a
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Clutton-BrockImprovement Scotland (
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Lucas, Millward-Sadler95 mmHg. This
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Lucas, Millward-Sadleran agreed mai
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Annex 17.1. The main clinico-tholog
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MillerAppendix 1: The method of Enq
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MillerDatanotificationNotificationR
Page 194 and 195:
Knight• investigating different m
Page 196 and 197:
Knightbaseline incidence against wh
Page 198 and 199:
LennoxAppendix 2B: Summary of Scott
Page 200 and 201:
LennoxEvidence of effective managem
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Appendix 3: Contributors to the Mat
Page 204 and 205:
Appendix 3: Contributors to the Mat
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6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

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