Key Findings MBRRACE 2014–16: Maternal Deaths
Maternal mortality continues to remain high worldwide, despite a 44% drop between 1990 and 2015. Every day, approximately 830 women die from pregnancy- or childbirth-related complications around the world. Almost > 90% of these deaths occur in low-resource settings, and most could have been prevented if the care had been different .
There are large disparities between countries but also within countries, between women with high and low incomes, those women living in rural versus urban areas, and those from different ethnic backgrounds.
In the United Kingdom the maternal mortality is 9.8 per 100 000 and in Sierra Leone, the country with the worst maternal mortality rate, it is 1165 per 100 000 (118 times higher).
Haemorrhage, hypertensive disorders and sepsis continue to be responsible for the majority of maternal deaths in the low-resource setting. In the United Kingdom, the leading causes for maternal deaths are cardiac disease and thromboembolism.
The death of a pregnant woman and/ or her baby is devastating for families, healthcare professionals and society in general. The aim of every maternity care provider should be to ensure that no mother should die during childbirth and to reduce the inequities in the provision of safe and clinically effective maternity care worldwide.
The United Kingdom is determined to reduce the number of women dying during pregnancy and childbirth even further and to cascade any potential learnings from each maternal death. In 1952, the Ministry of Health instituted the National Confidential Enquiry for both England and Wales, initially to reports its findings on a three-yearly basis, and since 2014 on a yearly basis. Since its inception, the overall aims of the enquiry have been to improve the quality of maternity services for the benefit of all pregnant women through the use of guidelines and recommendations, with lessons learned from each case.
The latest report, the 5th MBRRACE-UK Annual Report of the Confidential Enquiry into Maternal Deaths and Morbidity (November 2018), includes surveillance data on women who died during or up to one year after pregnancy between 2014 and 2016 in the UK (9.8 per 100 000, total of 545 women). This report also includes a detailed review of the maternal morbidity, with the Confidential Enquiries focusing on the care of women with major obstetric haemorrhage.
Key Findings MBRRACE 2014–16: Maternal Deaths
There was a statistically non-significant increase in the overall maternal death rate in the United Kingdom between 2011–13 and 2014–16. Most women who died had multiple health problems or other vulnerabilities.
More than two-thirds (68%) were known to have pre-existing medical problems, 24% were known to have pre-existing mental health problems and 8% had pre-existing cardiac problems. Also, more than a third (37%) of the women who died in this triennium were obese and 20% were overweight.
Maternal deaths were not evenly spread across the population. Black women were five times and Asian women twice more likely to die as a result of complications in their pregnancy than white women. Also, older women >40 years of age had a three-fold increased risk compared with the 20–24age group.
Cardiac disease remains the largest single cause of maternal deaths and indirect causes in general represent 56% of all maternal deaths.
Thrombosis and thromboembolism remain the leading cause of direct maternal death during or up to 6 weeks after the end of pregnancy.
Maternal suicide is the third leading cause of direct maternal death occurring during or within 42 days of the end of pregnancy. However, it remains the leading cause of direct deaths occurring within a year after the end of pregnancy, with a mortality rate of 2.8 per 100 000 maternities.
Rates of postpartum haemorrhage (PPH) are known to be increasing in high-resource settings, and alongside this, a near doubling of the maternal death rate from haemorrhage was identified in 2013–15. This was almost entirely due to an increase in the numbers of women dying from haemorrhage in association with abnormally invasive/morbidly adherent placentation (AIP) – placenta accreta, increta or percreta.
The maternal mortality rate from haemorrhage in the UK remains at 0.78 per 100 000 maternities. Improvements in care may have made a difference to the outcome for 38% of women who died and 74% of women with major obstetric haemorrhage who survived.
Caesarean section in advanced labour is associated with a risk of uterine angle extensions which can be difficult to control and which can cause concealed bleeding post operatively. Therefore, appropriate knowledge and skills in interpreting fetal heart rate changes during labour using a cardiotocograph (CTG) trace is essential to differentiate between fetal stress response to intrapartum hypoxia from fetal compromise to avoid unnecessary emergency caesarean sections, especially during late first stage and second stage of labour. In addition, it is essential to improve the skills and competencies in operative vaginal births, especially rotational deliveries to avoid emergency caesarean sections during the second stage of labour which are associated with increased incidence angular tears.
Always exclude each of the four T’s (tone, tissue, trauma and thrombin) when assessing any woman with ongoing bleeding. This would enable clinicians to avoid missing co-existing coagulopathy during a massive PPH due to uterine atony.
Women who have had a previous caesarean section who also have either placenta praevia or an anterior low placenta at 32 weeks of gestation are at increased risk of placenta accreta. Therefore, ultrasound scans with colour Doppler should be performed during the antenatal period, by sonographers or obstetricians who are trained and skilled in detecting abnormal invasion of the placenta.
Any woman with suspected placenta praevia accreta should be reviewed by a consultant obstetrician and consultant anaesthetist in the antenatal period. The different risks and treatment options should have been discussed and an agreed multidisciplinary care plan should be developed, in conjunction with the patient to improve outcomes.
Any woman going to the operating theatre electively with suspected placenta praevia accreta should be attended by a consultant obstetrician who is competent and skilled in managing an abnormal invasion of the placenta and an anaesthetist, who has an expertise in the management of massive obstetric haemorrhage. If the delivery is unexpected, out-of-hours consultant obstetric and anaesthetic staff should be alerted and attend as soon as possible.
Documentation of fluid balance is part of the protocol for monitoring and investigation in major PPH; care must be taken to avoid over-replacement as well as under-replacement.
Stillbirth and Neonatal Deaths
Neonatal deaths: A liveborn baby (born at 20+0 weeks gestational age or later, or with a birthweight of 400 g or more where an accurate estimate of gestation is not available) who died before 28 completed days after birth.
Early neonatal death: A liveborn baby (born at 20+0 weeks gestational age or later, or with a birthweight of 400 g or more where an accurate estimate of gestation is not available), who died before 7 completed days after birth.
Late neonatal: A liveborn baby (born at 20+0 weeks gestational age or later, or with a birthweight of 400 g or more where an accurate estimate of gestation is not available), who died after 7 completed days but before 28 completed days after birth.