CEMACH

Gwyneth Lewis

Statistical analysis by Alison Macfarlane

Summary of key points

• Maternal deaths are extremely rare in the United Kingdom. The maternal mortality rate for 2003-05 calculated from all maternal deaths directly or indirectly due to pregnancy identified by this Enquiry was 14 per 100,000 maternities. Although this is a slight increase from the last Report, it is not statistically significant.
• If, as is the case in other countries, the number of maternal deaths are restricted to those identified by the underlying cause of death given on death certificates alone, the UK maternal death rate was 7 per 100,000 maternities, half that identified by this much more in-depth Enquiry.
• The maternal mortality rate for those mothers’ deaths that could only be due to pregnancy e.g. haemorrhage or eclampsia, i.e. Direct deaths, showed a slight increase for this triennium compared to the last Report. This is not statistically significant.
• The mortality rate for mothers’ deaths from Indirect causes, i.e. from pre-existing or new medical or mental health conditions aggravated by pregnancy such as heart disease, has not changed since the last Report. Although the maternal death rate from Indirect causes was still higher than for deaths from Direct causes, the gap between them was smaller.
• Many possible factors lie behind the lack of decline in the maternal mortality rate. They include rising numbers of older or obese mothers, women whose lifestyles put them at risk of poorer health and a growing proportion of women with medically complex pregnancies. Because of the rising numbers of births to women born outside the UK, the rate may also be influenced by the increasing number of deaths of migrant women.These mothers often have more complicated pregnancies, more serious underlying medical conditions or may be in poorer general health. They can also experience difficulties in accessing maternity care.
• More than half of all the women who died from Direct or Indirect causes, for whom information was available, were either overweight or obese. More than 15% of all women who died from Direct or Indirect causes were morbidly or super morbidly obese.
• The commonest cause of Direct death was again thromboembolism. Despite apparent slight rises in rates of death from thromboembolism, pre-eclampsia/ eclampsia and genital tract sepsis and apparent slight declines in rates of death from haemorrhage and direct uterine trauma, none of these differences were statistically significant. There has also been an apparently inexplicable rise in deaths from amniotic fluid embolism, a rare and largely unavoidable condition.
• Cardiac disease was the most common cause of Indirect deaths as well as of maternal deaths overall. In the main this reflects the growing incidence of acquired heart disease in younger women related to less healthy diets, smoking, alcohol and the growing epidemic of obesity. 
• There has been a decrease in the rate of suicide, the overall leading cause of death in the last Report. If sustained in the next Report, this decline may indicate that the recommendations made in previous Reports concerning identifying women at potential risk in the antenatal period, and developing management plans for them, are having a beneficial effect.
• Whilst there has been no increase in the number of cases associated with sub-standard care, or avoidable factors, a number of health care professionals failed to identify and manage common medical conditions or potential emergencies outside their immediate area of expertise. Resuscitation skills were also considered poor in some cases.
• In many cases the care provided was hampered by a lack of cross-disciplinary or cross-agency working and problems with communication. This included:
  • poor or non existent team working 
  • inappropriate or too short consultations by phone
  • the lack of sharing of relevant information between health professionals, including between GPs and the maternity team
  • poor interpersonal skills.

There were also a number of cases where significant information, particularly regarding a risk of self-harm and child safety, was not shared between the health and social services, and an assumption by social services that their pregnant clients were attending for maternity care.

Vulnerability and other risk factors for maternal deaths

• Vulnerable women with socially complex lives who died were far less likely to seek antenatal care early in pregnancy or to stay in regular contact with maternity services. Overall 17% of the women who died from Direct or Indirect causes booked for maternity care after 22 weeks of gestational age or had missed over four routine antenatal visits compared to 5% of women who were employed themselves, or who had a partner in employment. Of the women who died from any cause, including those unrelated to pregnancy:
  • 14% self-declared that they were subject to domestic abuse
  • 11% had problems with substance abuse, 60% of whom were registered addicts
  • 10% lived in families known to the child protection services.

• A third of all women who died were either single and unemployed or in a relationship where both partners were unemployed.
• Women with partners who were unemployed, many of whom had features of social exclusion, were up to seven times more likely to die than women with partners who were employed. In England, women who lived in the most deprived areas were five times more likely to die than women living in the least deprived areas.
• Black African women, including asylum seekers and newly arrived refugees have a mortality rate nearly six times higher than White women. To a lesser extent, Black Caribbean and Middle Eastern women also had a significantly higher mortality rate.