13. Confidential Enquiry into Maternal Death:
| a. | the report is triennial | True | |
| b. | the most recent report was published in 2010 and covered the years 2006 - 2008 | True | False |
| c. | hypertensive disease was the commonest direct cause of death | False | |
| d. | sepsis
was the commonest indirect cause death.
|
False | |
| e. | maternal age was identified as a particular risk factor | True | |
| f. | obesity was identified as a particular risk factor | True | |
| g. | in > 80 % of maternal deaths there was no evidence of substandard care | False |
This is being updated to accommodate the 2006 - 2008 data.
See also MCQ5, question 18 and MCQ9, question 1, though they are still to be updated.
See the top 10 recommendations in "Saving Mothers' Lives".
Go to the bottom of the page and other links
SUDEP: Sudden, Unexplained, Death in EPilepsy
MMR: Maternal Mortality Rate: direct and indirect deaths per 100,000 maternities.
MMRat: Maternal Mortality Ratio: direct and indirect deaths per 100, 000 live births.
Go to the bottom of the page and other links
Introduction.
Maternal mortality reports have been produced since the early 1950s.
The most recent was published in 2011 and covered 2006-2008.
There should be a copy in
your medical library. It is called “Saving Mothers’ Lives”.
Go to the bottom of the page and other links
DRCOG essentials.
You will be expected to know that the reports are published three yearly.
And that the most recent was "Saving Mothers' Lives".
It reported the triennium 2006 - 2008 and was published in 2011.
You need to know the main definitions: "direct", "indirect", "coincidental" and "late".
"Direct" is due to pregnancy itself: eclampsia, postpartum haemorrhage etc.
"Indirect" is due to something else, whether or not pregnancy made it worse: congenital heart disease, SUDEP, asthma, coronary artery disease, breast cancer.
"Coincidental" are deaths that would have occurred whether the woman was pregnant or not: e.g. lightning strikes.
"Late" deaths occur from 42 after the end of the pregnancy to 1 year later.
These will be dealt again in later questions. (MCQ5, question 18 and MCQ9, question 1.)
The MMR was 11.39 in 2006 - 2008.
It was 13.95 in 2003 - 2005 per 100,000 maternities.
And 13.1 in 2000-2002
A "maternity" is a pregnancy going to 24 weeks or beyond.
Or one resulting in a live birth before 24 weeks.
Go to the bottom of the page and other links
Expanded information for the MRCOG and the enthusiast.
You will be expected to know that the reports are published three yearly and the years covered by the most recent report: 2006-2008.
You need to know the main definitions: “maternal mortality rate”, "direct", "indirect", "coincidental" and "late".
You need to know the main causes and trends.
You need to know the top 10 recommendations.
Maternal mortality was 11.35 per 100,000 maternities in 2006 - 2008.
The corresponding figure for 2003 - 2005 was 13.95.
The WHO states that while the maternal mortality ratio (the number of direct and indirect deaths per 100,000 live births – “direct” and “indirect” will be defined in later MCQs) is about 14 per 100,000 in developed countries.
But it is up to 1,000 per 100,000 in some developing countries, i.e. 1 in 100.
About 1,000 women die each day!
You can get information about these women and initiatives to help them on the Department for International Development website.
A
substantial reduction in maternal mortality is one of the
Millennium Development Goals.
You
need to know the major causes of death and key recommendations. These will be
covered in the later questions and on the course. Sepsis caused 26 deaths, up
from 18 in the previous Report, making it the leading cause of direct deaths.
VTE had been the leading cause but the numbers declined from 41 in the previous
report to 18. Indeed, VTE numbers fell so much that it went from number one
cause to number 3, with deaths due to pre-eclampsia and eclampsia coming in at
19 and just beating it into second place. The fall in VTE numbers presumably
reflects better and wider use of thromboprophylaxis as the risk factors in the
pregnant population have not reduced and with more obesity and older mothers,
have almost certainly increased.
Black
African and Caribbean women had the highest death rates. They were more than 3
times more likely to die than white women. Chinese and Pakistani women also had
higher risks.
Obesity
was highlighted as a big (no joke intended) risk factor. It had been mentioned
in the 2000 - 2002 and 2003 – 2005 reports, but the findings were stressed
again. Other factors were: social isolation and deprivation, substance abuse,
being known to social and child-protection services, late booking and poor
antenatal attendance. A possible link was noted in the 2003 – 2005 Report
between child case conferences that ended with the child being taken into care
and maternal suicide or death from apparent overdose of a drug of abuse. The
probably explanation is that once the child had been taken into care, support
for the mother from maternity and social services ceased. This was noted again
in the 2006 - 2008 Report.
The
2003 – 22005 Report highlighted the need for early detection of the signs of
possible serious illness. It is lamentable that it had to point out that these
are: heart rate >100 beats / minute, systolic BP >160 mm. Hg. or = to 160 mm.
Hg., systolic BP <90 mm. Hg., temperature >38o C., respiratory rate
>21 breaths per minute and a respiratory rate >30 per minute as probably
indicating serious illness. The 2006 – 2008 Report repeated these and came in
line with NICE in recommending treatment for systolic BP ≥ 150 in women with
hypertension, indeed advising that women with PET and this level of hypertension
be admitted for urgent treatment.
The
2003 – 2005 Report had two new sections: one for General Practitioners, the
other for Emergency Medicine Practitioners and these were retained in 2006 –
2008.
Go to the bottom of the page and other links
One thousand women die each day as a result of pregnancy.
The pregnancy-related mortality for women in less-developed countries is horrendous.
And most of it could be prevented without high-tech intervention.
The WHO states that the MMRat was about 14 per 100,000 in developed countries in 2008.
But it was about 290 per 100,000 in developing countries.
And up to 2,000 per 100,000 in some developing countries, mostly in sub-Saharan Africa, i.e. 1 woman in 50.
The greatest mortality is among children under the age of 15.
HIgh mortality rates and greater numbers of pregnancies give women in developing countries a high risk of dying of a pregnancy-related condition.
With risks as high as 1 in 10 being estimated.
The maternal mortality ratio is the number of direct and indirect deaths per 100,000 live births.
In the UK we mainly talk about the MMR: the number of direct and indirect deaths per 100,000 maternities.
This is more accurate.
“Direct” deaths are those caused by pregnancy: e.g. from postpartum haemorrhage, amniotic fluid embolism or eclampsia.
“Indirect” deaths are due to things that are not due to pregnancy.
For example, epilepsy and SUDEP, asthma, congenital heart disease.
Pregnancy might make some of them worse, but it was the underlying problem, not pregnancy, that caused the death.
You can get information about these women and initiatives to help them on the Department for International Development website.
Millennium Development Goal 5, accepted by the internal community in 2000, is to produce a 75% reduction in maternal mortality by 2015 compared with the 1990 figures.
By 2008 MM had only reduced by a third.
A key part of reducing mortality is to audit it so that the causes can be identified and recommendations made for improvements.
Maternal mortality reports have been produced in the UK since the early 1950s.
The most recent was published in 2011 and was for 2006 -2008.
There should be a copy in your medical library.
Go to the bottom of the page and other links
Maternal mortality rates for women in less developed countries are horrendous.
The rate for women in Northern Nigeria is about 2,000 per 100,000 births.
And their lifetime risk of dying of a pregnancy-related disorder in ~ 1 in 10.
You can get information about these women and initiatives to help them on the Department for International Development website.
You need to know the major causes of death and key recommendations.
These will be covered in the later questions (MCQ5, question 18 and MCQ9, question 1) and on the course.
You should know that Black African and Caribbean women had the highest death rates.
They were approximately 6 times and 4 times more likely to die respectively than white women.
Obesity was highlighted as a big (no joke intended) risk factor.
It had been mentioned in the 2000 - 2002 report, but the findings were stressed again.
Other factors were:
social isolation and deprivation,
substance abuse,
being known to social and child-protection services,
late booking,
poor antenatal attendance.
A possible link was noted between child case conferences and maternal suicide or death from apparent overdose of a drug of abuse.
A possible reason was that once the child had been taken into care, support for the mother from maternity and social services ceased.
The report highlighted the need to detect the signs of possible serious illness.
It is lamentable that it has to point out that these are:
heart rate > 100 beats / minute,
systolic BP > 160 mm. Hg. or = to 160 mm. Hg.,
systolic BP < 90 mm. Hg.,
temperature > 38o C.,
respiratory rate > 21 breaths per minute,
and a respiratory rate > 30 per minute as probably indicating serious illness.
The report has two new sections:
one for General Practitioners,
the other for Emergency Medicine Practitioners.
The authors mentioned that they would like to include analysis of "near misses".
They did not have the resources to do so.
So, as second best, they included data from the Scottish Confidential Audit of Severe Maternal Morbidity.
I'll include the relevant data in later questions.
See
MCQ5, question 18 and
MCQ9, question 1.
See the top 10 recommendations in "Saving Mothers'
Lives": MCQ12, question 23.
Maternal mortality reports have been produced since the early 1950s. The most
recent was published in 2011 and covered 2006 – 2008. There should be a copy in
your medical library. It is called “Saving Mothers’ Lives”.
DRCOG essentials.
You
will be expected to know that the reports are published three yearly and the
years covered by the most recent report. You need to know the main definitions:
“maternal mortality rate”, "direct", "indirect", "coincidental" and "late". See
(MCQ
paper5, q.18 and
MCQ paper 9, q.1.)
Maternal mortality was 11.35 per 100,000 maternities in 2006 - 2008. A
"maternity" is a pregnancy going to 24 weeks or beyond. Or one resulting in a
live birth before 24 weeks. The corresponding figure for 2003 - 2005 was 13.95.
You
need to know the major causes of death and key recommendations. These will be
covered in the later questions and on the course. Sepsis caused 26 deaths, up
from 18 in the previous Report, making it the leading cause of direct deaths.
VTE had been the leading cause but the numbers declined from 41 in the previous
report to 18. Indeed, VTE numbers fell so much that it went from number one
cause to number 3, with deaths due to pre-eclampsia and eclampsia coming in at
19 and just beating it into second place. The fall in VTE numbers presumably
reflects better and wider use of thromboprophylaxis as the risk factors in the
pregnant population have not reduced.
Black
African and Caribbean women had the highest death rates. They were more than 3
times more likely to die than white women. Chinese and Pakistani women also had
higher risks.
Obesity
was highlighted as a big (no joke intended) risk factor. It had been mentioned
in the 2000 - 2002 and 2003 – 2005 reports, but the findings were stressed
again. Other factors were: social isolation and deprivation, substance abuse,
being known to social and child-protection services, late booking and poor
antenatal attendance. A possible link was noted in the 2003 – 2005 Report
between child case conferences that ended with the child being taken into care
and maternal suicide or death from apparent overdose of a drug of abuse. A
possible reason was that once the child had been taken into care, support for
the mother from maternity and social services ceased. This was noted again in
the 2006 - 2008 Report.
The
2003 – 22005 Report highlighted the need for early detection of the signs of
possible serious illness. It is lamentable that it had to point out that these
are: heart rate >100 beats / minute, systolic BP >160 mm. Hg. or = to 160 mm.
Hg., systolic BP <90 mm. Hg., temperature >38o C., respiratory rate
>21 breaths per minute and a respiratory rate >30 per minute as probably
indicating serious illness. The 2006 – 2008 Report repeated these and came in
line with NICE in recommending treatment for systolic BP ≥ 150 in women with
hypertension, indeed advising that women with PET and this level of hypertension
be admitted for urgent treatment.
The
2003 – 2005 Report had two new sections: one for General Practitioners, the
other for Emergency Medicine Practitioners and these were retained in 2006 –
2008.
Go to the bottom of the page and other links
MRCOG.
You need to know a lot more, which will be covered in later questions (MCQ5, question 18 and MCQ9, question 1).
Ethnicity is a risk factor you need to know.
Make out cards!
Black African women had the highest overall risk of death.
They were 6 times more likely to die than their white counterparts.
Black Caribbean and women from the Middle East were also at increased risk.
The table below gives an indication of the risks faced by different ethnic groups.
Relative risk of death by ethnicity.
Figures for England, 2003 - 2005.
| Background | Relative risk. (RR) |
| White | 1 |
| Black African | 5.6 |
| Black Caribbean | 3.7 |
| Middle East | 2.9 |
| Bangladeshi | 2.1 |
| Indian | 1.9 |
| Chinese /Asian | 1.3 |
| Pakistani | 0.8 |
Some of the numbers of women are small e.g. 7,146 for the Chinese group.
Remarkably, this number was the same for the "other" group.
The small numbers cast some doubts on the figures for relative risk.
The table suggests that women of mixed race and Pakistani women have the lowest risk.
It is a bit unlikely that women of mixed race have half the risk of white women.
But the small numbers mean that their relative risk compared to white women could be anything from:
0.1 to 3.4 for women of mixed race
and 0.4 to 1.9 for women of Pakistani background.
So they could be at significantly more or significantly less risk.
In the 2000-2002 report, Pakistani women had a relative risk of 1.2, with a spread of 0.6 - 2.2.
It would be nice if the figures represented a real fall in their risk.
On the other hand, the figures for black women are worrying, regardless of the numbers.
Black Caribbean women have a 3.7 relative risk, with a spread from 1.9 - 7.3.
And Black African women have an appalling 5.6 relative risk, with a spread from 3.8 to 8.3.
So there is no way these numbers can be tweaked to make their risks other than awful.
Death rates by Age.
It has been known for ages that the risk of death rises with age.
The figures for 2003 - 2005 for the whole of the UK were as follows:
As you can see, the risk trebles from teens to forties.
Death rates by parity.
It has been traditional to teach that maternal mortality increased with parity.
The classic curve was "J-shaped".
The rate for the primigravida was low.
It was even lower for those having second and third babies.
And then started to rise, doing so quite quickly for those having fifth or subsequent babies.
In the 2000-2002 report the following was stated:
"...the association with parity is now much less clear.
This may be due to the smaller number and proportion of women women having four or more children in the 21st. century".
Based on that report and the three that preceded it, the Report concluded:
"The mortality rate for women with one previous maternity has been about 3/4 of the overall rate.
The rates for women whose parity is three or more have been about 1/3 higher than the overall rate".
It went on to qualify even these guarded comments.
It pointed out that the numbers were small and the rates varied considerably between Reports.
The rates by parity were not calculated for the 2003-05 Report.
If asked in the exam, you would give the views of the 2000-2002 report, that the rates rise from 4th. babies on.
Obesity is highlighted as a particular risk factor in the 2003-05 report.
More than half of those who died had a BMI > 25.
15% had BMIs > 35.
And ~ 7% had BMIs > 40.
Systolic hypertension (160 mm. Hg. or more) is highlighted as a risk factor for intra-cranial haemorrhage.
It merits the bald statement that hyptotensive treatment must be introduced.
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