CHAPTER 2
Saving mothers' lives: lessons from the Confidential Enquiries

2.1 Introduction

Much of the wisdom in this book has been learned the hard way, some of it in the hardest way of all. When a woman dies as a result of an obstetric complication, the only good thing that can come out of the tragedy is that appropriate lessons are learned. For over 60 years, England and Wales have had a system in place to analyse all maternal deaths, identify the causes and highlight avoidable factors, and over time this system has been expanded to include Scotland and Ireland.

The Confidential Enquiries into Maternal Deaths (CEMDs) have become so familiar to UK obstetricians and midwives that we can hardly imagine life without them. The UK, however, is one of only a few countries with a national system in which experienced clinicians scrutinise cases in detail to work out whether death could be prevented when a similar emergency happens again and, if so, how.

CEMD recommendations carry considerable weight at both political and clinical levels. This chapter will describe the system that produces these recommendations and will then focus on lessons relevant to emergencies and trauma - including those learned in the early years of the programme, which are all too easily forgotten.

2.2 How the enquiries work

England and Wales began collecting confidential data from maternal deaths in 1952 and published reports every 3 years from 1957 until 2008. Similar enquiries began in Northern Ireland in 1956 and in Scotland in 1965. Since 1985, the Confidential Enquiries covered the whole of the UK and, in 2003, it became part of the Confidential Enquiry into Maternal and Child Health (CEMACH), subsequently the Centre for Maternal and Child Enquiries (CMACE), and since 2012 (analysing deaths from 2009 onwards) it is part of the programme of MBRRACE-UK (Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries across the UK), a collaboration based in the National Perinatal Epidemiology Unit in Oxford. Cases from the Republic of Ireland are now included as well.

From the outset, confidentiality was recognised to be essential if staff were to give an honest account of events without fear of litigation or disciplinary action. In this, and in other essentials, the approach initiated in the 1950s is still used today. The process summarised here applies to England, but is similar in the other UK countries.

Reporting

When a maternal death occurs, a form is sent to all the lead professionals involved to obtain anonymous factual information and reflective comments. The forms, along with a copy of the woman's medical records, are returned to the MBRRACE-UK office.

Expert assessment

To ensure confidentiality, the information is kept under lock and key before digitising and storage on a secure server. All records are anonymised and reviewed by expert assessors, who are senior clinicians in obstetrics, midwifery, anaesthetics, pathology, perinatal psychiatry, medicine, cardiology, neurology, infectious diseases, emergency medicine, general practice and intensive care. They look for emerging patterns and lessons for clinical colleagues, managers and politicians. Public health messages are particularly important and denominator data are obtained from the Office for National Statistics (ONS) or equivalents in the devolved nations and Republic of Ireland.

Reports

A report is now published every year, which includes surveillance information as well as topic-specific chapters, each of which appears on a triennial basis. Chapters are drafted by a writing committee including expert assessors from the four UK countries and Republic of Ireland and other relevant experts in the topic area, and discussed by the whole editorial panel, which includes epidemiologists. Once the final report is sent to the printers, any information linked to the identity of the women concerned is destroyed. The published report is available to the public, a fact that surprises doctors in countries that have a less open approach.

A challenge for any report is to ensure that people read it. Recent confidential reports have been entitled Saving Mothers' Lives, Improving Mothers' Care (and before that Why Mothers Die with an emotive cover picture) and launched with a conference. They were bestsellers in the Royal College of Obstetricians and Gynaecologists (RCOG) bookshop, partly because examination candidates knew that they were essential reading. Reports are now available free to download from the MBRRACE-UK website, allowing for wider circulation; the link to the report is distributed through professional and voluntary organisations and the media on the day it is released. The report messages, however, increasingly need to be heard by other specialties and this is more difficult to achieve.

2.3 Lessons from the past

Effective intervention

Before the CEMDs started, maternal mortality had already dropped dramatically in the UK, from 400/100 000 in 1935 to 66/100 000 in 1952-1954 (in fact at this stage there were still problems with case ascertainment and a more realistic estimate was 90/100 000). The most rapid fall had occurred during the Second World War, contradicting the idea that social conditions are the major factor determining the safety of pregnancy. The reasons for the fall were the introduction of effective treatments as follows:

• Antibiotics: puerperal sepsis was the leading cause of maternal death in the 1930s, despite the widespread use of aseptic precautions; when sulphonamides were introduced in 1937 the effect on death rates was spectacular
• Blood transfusion became safe during the 1940s
• Ergometrine, for the treatment and prevention of postpartum haemorrhage, was introduced in the 1940s

In the 1930s, Britain had a well-developed medical infrastructure, so that when effective treatments finally became available their effects were rapidly felt.

Obstetric injury

In the first CEMD report, covering 1952-1954, obstetric injury was the second most common cause of death after hypertensive disease (Table 2.1). It did not, however, warrant its own chapter and Table 2.1 is drawn from the appendix to that report.

Table 2.1 Number of maternal deaths from obstetric injury, 1952-1954

Cause Deaths (n) Prolonged labour 63 Disproportion or malposition of the fetus 23 Other trauma 55 Other complications of childbirth 66 Total 207

Nowadays, we can hardly imagine a woman dying of prolonged labour and we can only guess at what the terms 'other trauma' and 'other complications' conceal (Table 2.1). In the 1950s, the caesarean section (CS) rate was less than 3% and maternity care was quite different from that of today. The 1955-1957 report included 33 women who died from a ruptured uterus, mostly due to intrauterine manipulations. In 1958-1960, there were 43 women who died from obstructed labour, of whom, according to the report for that triennium, 18 gave birth at home and 14 in a general practitioner maternity home. These reports are a useful corrective to the idea that the 1950s were a golden age of non-medicalised childbirth.

2.4 Recent lessons

Obstetric injury today

In 2006-2008 there were, for the first time, no deaths from genital tract trauma and the chapter dealing with these cases was discontinued. Nevertheless, the report commented that genital tract tears were implicated in two women who died of postpartum haemorrhage. The risk of trauma has not disappeared and, indeed, high vaginal tears have become more difficult to deal with because of the current prevalence of obesity. The CEMD recommended that a surgeon faced with life-threatening haemorrhage should routinely ask a colleague to come and help. Genital tract trauma is again featuring in maternal deaths and in the first MBRRACE-UK report covering deaths from 2009 to 2012 there were seven deaths due to haemorrhage following genital tract trauma. In 2013-2015 only one woman died from genital tract trauma but in 2016-2018 a further four women died of that cause. However, when the care of a random sample of 34 women who survived a major obstetric haemorrhage (transfusion of 8 or more units) was reviewed in the 2018 report, 11 women were noted to have had a haemorrhage caused by genital tract trauma, emphasising the substantial burden of morbidity that underlies the small number of deaths.

Who is at risk?

The Enquiry identifies groups at increased risk of complications and with increased awareness, death rates have fallen among, for example, those with a history of thromboembolism. Recognition of risk factors early in pregnancy is essential.

Age

Since the 2006-2008 CEMD report, the maternal mortality rate (MMR) has remained fairly constant up to age 34, but it doubles after age 35 and quadruples after 40 years of age. The same pattern is...