Chapter 3 Maternal and perinatal mortality

Reports from the Confidential Enquiries into Maternal Deaths in the UK have appeared every 3 years since 1952 and are the first example of audit by the medical profession. The Department of Health document A First Class Service – Quality in the New NHS (1998) states that all health workers are required to participate in these enquiries. Information and case notes must be made available for enquiry assessors and reports completed within 9 months of the death. The 1994–1996 triennia audit emphasised awareness of social and public health issues. These issues include advice for seatbelt usage, identification and coordinated care for psychiatric disorders especially postnatal depression, impact of social sequestration from access to help and contribution from domestic violence.

These enquiries have led to substantial improvement in care and safety for childbirth. The direct maternal death rate for the 1994–1996 triennium is 6.1 per 100 000 maternities (total of 12.2 per 100 000 maternities). Women older than 40 years, high parity, thromboembolism, pregnancy hypertension, amniotic fluid embolism, sepsis, haemorrhage and uterine rupture remain as salient but often avoidable causations. There is no room for complacency. In the 2000–2002 triennium the direct death rate is 3.5 per 100 000 maternities. In the past 6 years indirect causes have exceeded direct causes of maternal deaths, emphasising the need for coordinated multidisciplinary care when a woman has an existing psychiatric or medical condition. Inadequate contribution and support from experienced senior obstetricians, and inappropriate delegation and treatment emphasise the need for protocols, teamwork and drills to address emergencies. The continuing challenge is to achieve year on year improvement in the safety and satisfaction of childbirth, using evidence-based practice.

MATERNAL MORTALITY

Maternal mortality is defined by the International Classification of Diseases, Injuries and Causes of Death – Ninth Revision (ICD9; World Health Organization (WHO) 1993) as ‘death of a woman while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.’ This is further subdivided into the following in which maternities are defined as pregnancies which result in a live birth at any gestation or a stillbirth occurring at or after 24 completed weeks’ gestation. (Note statement for twin pregnancies.)

• Direct obstetric death results from obstetric complications of the pregnancy state.

• Indirect obstetric death is where existing or pregnancy precipitated medical disorders led to or is associated with maternal mortality, for example following diabetes mellitus, cardiac diseases, vascular aneurysm, epilepsy or suicides.

• Fortuitous obstetric death is when pregnancy is incidental to the causation, for example road traffic accident, murder or unrelated malignancies.

• Late obstetric death. The ICD10 revision (WHO 1993) introduced inclusion of direct and indirect deaths ‘occurring between 42 days and one year after abortion, miscarriage or delivery.’ The last two Confidential Enquires included late deaths in their figures.