CEMACH

Chapter 14: Coincidental and Late deaths 

Summary of key findings for 2003-2005

Coincidental deaths

In this triennium, the deaths of 55 women who died of Coincidental causes either during their pregnancy or within 42 days of delivery were reported to this Enquiry compared to 39 for the previous triennium. This rise is due to better case ascertainment by the CEMACH regional managers and is not significant. As in the past, and as shown in Table 14.1, the largest overall category were deaths due to “unnatural” causes including murder and road traffic accidents. Deaths from cancer form the second largest overall category and the deaths of 16 women who died from cancers unaffected by their pregnancy are discussed in Chapter 11.

Table 14.1 Coincidental deaths occurring during or up to, and inclusive of, 42 days after, the end of pregnancy; United Kingdom: 2003-05.

Cause of Death
Number
Unnatural Deaths  
          Road Traffic Accident 23
          Murder 10
          Overdose of street drugs  4
          House fire 1
Cancer (see Chapter 13) 16
Medical condition 1
All Coincidental deaths 55

 

As with previous Reports, and other causes of death, many of the women whose deaths are counted in this Chapter were vulnerable and socially excluded. The general lessons to be drawn from this category of women have been discussed in Chapter 1. Coincidental deaths associated with domestic abuse and murder are considered in Chapter 13.

Road traffic accidents during and after pregnancy

Twenty-three women died from road traffic accidents, including pedestrian accidents, whilst pregnant or within six weeks of delivery. Another seven women are counted as Late deaths in that their accidents occurred two months or more after childbirth.  Twelve women died undelivered and eight women died despite intense cardio-pulmonary resuscitation and perimortem caesarean section. None of the eight babies delivered in this way survived even though their gestational ages ranged between 24 and 38 weeks. One woman who died some weeks after childbirth may have intentionally killed herself in a road traffic accident, and her case is discussed in Chapter11 - Psychiatric deaths.

Thirteen of the women who were drivers or passengers in moving vehicles were wearing seat belts, six were not and in two cases the evidence was not clear. The characteristics of the six women who did not wear seat belts are remarkably similar in that they were all vulnerable and had complex lives.  Two of these six women, who died near term or shortly after delivery, had sought no care at all due to their chronic drug and/or alcohol misuse and domestic abuse, and another two women, with similar characteristics, had been seen only once or twice. Another woman, who had been repeatedly subject to domestic abuse, was killed by her drunken partner whilst in the front passenger seat of their car.

Eight of the women who died were pedestrians hit by oncoming vehicles. Of these, six also led socially complex lives and all but one were either regular or occasional drug users and most suffered domestic abuse. Several had high levels of street drugs at autopsy. One was an extremely young girl and another was a recent immigrant who spoke no English. 

Twelve of the fourteen women who were either involved in pedestrian accidents whilst crossing a road, or who were not wearing seat belts whilst travelling in moving vehicles, had features suggestive of significant social exclusion. Seven of them were receiving support from social services and the four women who had not sought maternity care, or were very poor attenders, were also known to the Child Protection Services. Between these four women alone, 17 older children were already in care.

Box 14.1

Recommendations for the use of seat belts in pregnancy
“Above and below the bump, not over it”

Three point seat belts should be worn throughout pregnancy with the lap strap placed as low as possible beneath the “bump” lying across the thighs with the diagonal shoulder strap above the bump lying between the breasts. The seat belt should be adjusted to fit as snugly as comfortably possible, and if necessary the seat should be adjusted.

Late deaths

Late maternal deaths are defined as those deaths which occur in women more than 42 days, but less than one year after miscarriage, abortion or delivery. The International Classification of Maternal Deaths (ICD10) only classifies Late deaths due to Direct or Indirect maternal causes, whereas this report also includes Late Coincidental deaths from which educational, public health or other messages and recommendations may also be drawn. For this reason all Late deaths reported to the Enquiry are counted, and some are discussed in this Chapter, but none are included in the overall maternal mortality rate as defined in Chapter 1.

This triennium, the CEMACH regional managers have been proactively starting reviews on a large proportion, but not all, of the 273 Late deaths either notified to the Enquiry via the CEMACH regional managers or through the record linkage system derived by the Office for National Statistics (ONS). This system identifies all women who have died within a year of giving birth from whatever cause. Whilst this has meant an increase in the number of deaths assessed, it does not reflect an increase in actual numbers of maternal deaths and this has been discussed in detail in Chapter 1. The classification of these deaths is shown in Table 14.2. Apart from the Late Direct and some Late Indirect deaths related to pregnancy notably puerperal psychosis and cardiomyopathy, from which important lessons for maternity care can still be drawn, it is not the intention of the Enquiry to assess all late cases in future.

When considering the findings of this Report it must be noted that the figures for the deaths counted in this Chapter, apart from the eleven directly associated with pregnancy in this triennium, cannot be compared to figures given in previous Reports due to an increase in extended case assessment.

Late Direct deaths

Some of the mothers who died 42 days or more after delivery actually died of maternal causes but, due to the limitations of the ICD 10 classification system for maternal deaths, cannot be counted as such in maternal mortality statistics. This is regrettable as they do contain important lessons for clinical care, especially in developed countries such as the UK, where these women often have prolonged support in a Critical Care unit before succumbing to their illness. There were 11 such Late Direct cases for this triennium, shown in Table 14.2 and discussed in depth in the relevant Chapters of this Report. Thus, for example, three Late Direct deaths from thromboembolism are discussed in Chapter 2, two from amniotic fluid embolism in Chapter 5, three from sepsis in Chapter 7 and three from choriocarcinoma in Chapter 11.

Late Indirect deaths

Similarly some 71 mothers who died later in their first postnatal year died from conditions that might have been aggravated by pregnancy. These are classified as Late Indirect deaths and the main causes in Table 14.2 are shown. The largest categories of Late Indirect deaths are those due to cancer, mental illness and cardiac disease. Lessons from deaths from cardiac disease or malignancies are discussed in Chapters 9 and 11 respectively. In this triennium 18 cases of suicide were reported and are discussed in full in the chapter on psychiatric causes. There appeared to be very few cases of substandard care in the other causes of Late Indirect deaths.

Late Coincidental deaths

The cause of deaths for the 125 women who died from Late Coincidental causes are also listed in Table 14.2. Where appropriate, the lessons for the Enquiry from these deaths are discussed in the relevant chapters of this Report. Three women who died from suicide were judged to have had a serious underlying, long-standing mental illness which was the precipitating cause, and these deaths were not associated with pregnancy or a puerperal mental illness.

Table 14.2 Late deaths known, or notified to, the Enquiry by the Office for National Statistics (ONS); United Kingdom: 2003-05.

Underlying  condition Chapter Cause of death Assessed Not assessed Total
      Late
Direct
Late
Indirect
Late
Coincidental
   
Central nervous
system 
10 Cerebral haemorrhage 0 1 7 6 14
    Epilepsy 0 0 3 1 4
Cardiac  9   0 20 14 6 40
Respiratory  2, 10 Asthma 0 0 4 2 6
    Pulmonary embolism 3 0 1 2 6
Gastrointestinal, 10 Pancreatitis 0 0 3 0 3
    Liver disease 0 0 3 1 4
    Peritonitis 0 0 0 2 2
Infectious  7, 10 Pneumonia 0 0 9 9 18
    Meningitis 0 0 4 2 6
    HIV 0 2 0 1 3
    Sepsis  3 0 0 0 3
    Other 0 1 0 1 2
Psychiatric  12 Suicide  0 18 3 4 25
    Substance Abuse/Alcohol 0 0 21 2 23
Unnatural causes 13, 14 Accidents 0 0 6 0 6
    Murder 0 0 10 1 11
    Road traffic accidents  0 0 6 4 10
Endocrine/Diabetes   10   0 2 1 0 3
Cancer  11   3 27 26 13 69
Autoimmune 10   0 0 0 2 2
Other  5, 10   2 0 4 7 13
Total     11 71 125 66 273