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Introduction

 
     

Health professionals involved in caring for pregnant women and their babies have long been at the forefront of clinical audit in the UK. Mortality rates are fundamental to the audit process: death is undeniably important, the diagnosis is unarguable and the figures are easily collectable. At its crudest level, monitoring mortality rates is one of the most basic ways of checking the effectiveness of a clinical service.

Clearly there is much more to modern maternity care than ensuring that mother and baby survive pregnancy and childbirth. Practising healthcare professionals across the country now contribute to a wide range of Confidential Enquiry activity that extends beyond the remit of mortality. Nevertheless, safety remains paramount. In developing countries, maternal and perinatal mortality rates are the main indicators of the quality of maternity services and they demand constant vigilance even in developed countries.

This report represents the first annual perinatal mortality surveillance report conducted under the auspices of the Confidential Enquiry into Maternal and Child Health (CEMACH). Its primary focus is perinatal mortality surveillance, although reference is made to other CEMACH studies and activities which have previously been reported or are planned for the future. This report is also intended to stimulate discussion at unit meetings in order to identify local issues, which these data may highlight, so that measures can be put in place to address areas of concern.

CEMACH is the successor organisation to two previous national confidential enquiries, the Confidential Enquiry into Maternal Deaths (CEMD) and the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI). It has taken on the programme of national confidential enquiries started by CEMD in 1952 and by CESDI from 1992 and is building on this well-established foundation by extending its remit to encompass morbidity and the establishment of a new national enquiry into child health. In essence, CEMACH runs three programmes: maternal health, perinatal health and child health. More information on this work can be found in Sections 8 and 9 of this report.

CEMACH is run as a self-governing body and is managed by its own Board with members from seven Royal Colleges (RCOG, RCPCH, RCM, FPH, RCPath, RCA and RCGP) and an independent Chair. There is a national advisory panel for each of its major programmes of work (maternal, perinatal and child health) and extensive lay and voluntary sector involvement. Multidisciplinary involvement is at the centre of the Enquiry's work.

Why confidential? Confidentiality is a fundamental principle in the way CEMACH operates. The aim is to learn lessons for general application by enquiring into individual cases. This is based on a non-blaming approach, where individuals can be frank in discussing what went wrong and make suggestions about how care can be improved. The results of CEMACH enquiries are made available in national reports, which do not identify individual patients, clinicians or the units in which care has been provided.

Full copies of recent reports can be found on the CEMACH website www.cemach.org.uk.

And finally, THANK YOU! The CEMACH programme is only possible because of the commitment and involvement of practising health professionals throughout the nations covered by the enquiry, by providing data, by participating as assessors and finally closing the loop by advocating the implementation of recommendations into trust practice. CEMACH cannot thank enough the many clinicians and staff who continue to provide this support for our work.