Top ten recommendations

The overwhelming strength of successive Enquiry Reports has been the impact their findings have had on maternal and newborn health in the United Kingdom and further afield. Over the years there have been many impressive examples of how the implementation of their recommendations and guidelines have improved policies, procedures and practice and saved more mothers’ and babies’ lives.

The ‘top ten’

Over time, as new specialties have come on board and with the expansion of the Enquiry into the wider social and public health determinants of maternal health, the number of recommendations has inevitably grown. Whilst this is as it should be, the increasing numbers make it difficult for commissioners and service providers to identify those that require action as a top priority. Therefore, in order to ensure the key overarching or most crucial issues are not lost, this Report contains a list of the new ‘top ten’ recommendations which every commissioner, provider, policy maker and other stakeholder involved in providing maternity services should plan to introduce, and audit, as soon as possible.

This new list adds to, but does not replace, recommendations made in earlier Reports.

Baseline data and audit of progress

The data needed to audit these ‘top ten’ recommendations are not currently collected routinely in all units. This Report proposes that baseline data in the form of numbers and percentages are collected continuously from April 2008 onwards. These data can then form the baseline by which progress can be measured.

The more specific individual Chapter recommendations

Whilst these ‘top ten’ recommendations are of general importance, the individual Chapters in this Report contain more targeted recommendations for the identification and management of particular conditions for specific services or professional groups. These are no less important and should be addressed by any relevant national bodies as well as by local service commissioners, providers and individual health care staff.

The Confidential Enquiry into Maternal and Child Health (CEMACH) will be working with key stakeholders, including the Health Care Commission for England, to consider how the implementation and auditing of the ‘top ten’, as well as the more specific recommendations, might best be achieved.

The ‘top ten’ key recommendations

Pre-conception care

Pre-conception counselling and support, both opportunistic and planned, should be provided for women of child-bearing age with pre-existing serious medical or mental health conditions which may be aggravated by pregnancy. This includes obesity. This recommendation especially applies to women prior to having assisted reproduction and other fertility treatments.

Rationale

This Report has identified that many of the women who died from pre-existing diseases or conditions which may seriously affect the outcome of their pregnancies, or which may require different management or specialised services during pregnancy, did not receive any pre-pregnancy counselling. In particular, this was the case for several women with major risk factors for maternal death who received treatment for infertility. This Report has also demonstrated that obese pregnant women with a body mass index (BMI) > 30 are far more likely to die. Where possible, obese women should be helped to lose weight prior to conception or receiving any form of assisted reproductive technologies (ART).

The commoner conditions that should require pre-pregnancy counselling and advice include:

Epilepsy
Diabetes
Congenital or known acquired cardiac disease
Auto-immune disorders
Obesity BMI of 30 or more
Severe pre existing or past mental illness.

Baselines and auditable standards

Maternity service commissioners, maternity trusts and any centre, NHS or private, which provides maternity services and/or assisted reproduction:
- Number and percentage of pregnant women with pre-existing medical conditions for whom specialist pre-conception counselling is offered at April 2008 and then by the end of 2009.
- Number and percentage of pregnant women at booking, or women attending for ART or pre-pregnancy counselling, who have their Body Mass Index (BMI) calculated and noted. Target 100% by April 2008.

Access to care

Maternity service providers should ensure that antenatal services are accessible and welcoming so that all women, including those who currently find it difficult to access maternity care, can reach them easily and earlier in their pregnancy. Women should also have had their first full booking visit and hand held maternity record completed by 12 completed weeks of pregnancy.

Pregnant women who, on referral to maternity services, are already 12 or more weeks pregnant should be seen within two weeks of the referral.

Rationale

Around 20% of the women who died from Direct or Indirect causes either first booked for maternity care after 20 weeks’ gestation, missed over four routine antenatal visits, did not seek care at all or actively concealed their pregnancies. This contrasts starkly with the 98% of women overall who reported having “booked” with NHS maternity services by 18 weeks of gestation in a recent study undertaken by the National Perinatal Epidemiology Unit (NPEU)¹. Identifying and overcoming the barriers to care women face in reaching and staying in touch with maternity services will help improve both the accessibility and continuity of local care for all women and outcomes for maternal and newborn health.

Some of the women who died were let down because, although the GP referral was timely, they did not receive a first maternity service appointment until they were around twenty weeks gestation. This delay denied them the opportunities that early maternity care provides for mother, baby and family.

Baseline and auditable standards

Number and percentage of women who have had an antenatal care “booking visit” and hand held maternity record completed by 12 completed weeks of gestation.
Number and percentage of women referred who were sent a date for their first booking appointment by 12 weeks of their pregnancy, or within two weeks of referral for women with gestations greater than 12 weeks.

Baseline measurement by April 2008, review December 2009, by when 80% coverage should be attained.

Migrant women

All pregnant mothers from countries where women may experience poorer overall general health, and who have not previously had a full medical examination in the United Kingdom, should have a medical history taken and clinical assessment made of their overall health, including a cardio-vascular examination at booking, or as soon as possible thereafter. This should be performed by an appropriately trained doctor, who could be their usual GP. Women from countries where genital mutilation, or cutting, is prevalent should be sensitively asked about this during their pregnancy and management plans for delivery agreed during the antenatal period.

Rationale

An increasing number of migrant women are seeking maternity care in the UK. Women who have recently arrived from countries around the world, particularly those from Africa and the Indian sub-continent, but also increasingly from central Europe and the Middle East, may have relatively poor overall general health and are at risk from illnesses that have largely disappeared from the UK, such as TB and rheumatic heart disease. Some are also more likely to be at risk of HIV infection. All of these conditions, alone or in combination, contributed to a number of the maternal deaths identified in this Report. None of the women who died of these causes had a routine medical examination during their pregnancy and the opportunity for remedial treatment was lost.

Further, the prevalence of female genital mutilation, or cutting, amongst the pregnant population is increasing due to inward migration of women from countries or cultures where it is still routine practice, despite almost universal international condemnation at government level. It can affect women’s pregnancies in a number of ways and the deaths of at least four women were directly or indirectly associated with the consequences of such procedures in this triennium. Specialist services and reversal procedures are available for these women in their antenatal period, which make childbirth and postnatal recovery easier.

Baseline and auditable standard

Number and percentage of pregnant women new to the UK, and who have not previously had a full medical examination in the UK, who have had a complete medical history taken and physical examination performed during their pregnancy and which is recorded in their notes.

Baseline measurement by April 2008, review December 2009 by when 100% coverage should be attained.

Systolic hypertension requires treatment

All pregnant women with a systolic blood pressure of 160mm/Hg or more require anti-hypertensive treatment. Consideration should also be given to initiating treatment at lower pressures if the overall clinical picture suggests rapid deterioration and/or where the development of severe hypertension can be anticipated.

Rationale

In the current triennium the single most serious failing in the clinical care provided for mothers with pre-eclampsia was the inadequate treatment of their systolic hypertension. In several cases this resulted in a fatal intracranial haemorrhage. Systolic hypertension was also a key factor in most of the deaths from aortic dissection. The last Report suggested that clinical guidelines should identify a systolic pressure above which urgent and effective anti-hypertensive treatment is required. Since then a publication from the US has made a convincing case that that threshold should be 160 mm/Hg². Clinically, it is also important to recognise increases in, as well as the absolute values of, systolic blood pressure. In severe and rapidly worsening pre-eclampsia, early treatment at less than 160 mm/Hg is advisable if the trend suggests that severe hypertension is likely.

Auditable standard

The number and proportion of women with pre-eclampsia and a systolic blood pressure of 160 mm/Hg or more on two or more occasions who were given anti-hypertensive treatment.

Caesarean section

6.1

Whilst recognising that for some mothers and/or their babies caesarean section (CS) may be the safest mode of delivery, mothers must be advised that caesarean section is not a risk-free procedure and can cause problems in current and future pregnancies.

6.2

Women who have had a previous caesarean section must have placental localisation in their current pregnancy to exclude placenta praevia, and if present, to enable further investigation to try to identify praevia accreta and the development of safe management strategies.

Baseline and auditable standards

Number and percentage of women having a CS, its type and underlying indication, as classified in the National Institute for Clinical Excellence guideline on Caesarean Section³
Number and percentage of women who have had a previous CS and who have had a placental localisation scan. Baseline measurement by April 2008 and the % increase by December 2009; target 100%.

Clinical skills

Maternity service providers and clinical directors must ensure that all clinical staff caring for pregnant women actually learn from any critical events and serious untoward incidents (SUIs) occurring in their Trust or practice. How this is planned to be achieved should be documented at the end of each incident report form.

Rationale

In some cases in this Report, where lessons could have been learnt, a critical incident report or serious untoward incident (SUI) review was not undertaken. Without such reviews lessons cannot be learnt and practice cannot improve. Even when reviews were carried out their quality was extremely variable. Although there were many examples of very good internal reviews, this was not always the case. It was also not always evident who was involved in such reviews. In some cases the hospital enquiries were improperly conducted: investigatory panels did not include clinicians from relevant disciplines (including anaesthesia) and therefore lacked clinical insight and relevance, or included clinicians who were directly involved in the death and were therefore potentially biased in their assessments. In other cases, it was clear the review only involved those directly associated with the woman’s care and lessons may not have been widely disseminated to others in the maternity service. Hospital managers should consider whether unbiased external input would assist real learning from individual deaths: it is often only after this has been received that the benefit is realised.

If lessons are to be learnt, it is important that all clinical staff are made aware of the findings of such reviews, particularly those who may not have ready access to internal meetings e.g. GPs and community midwives.

Auditable standards

Every maternal death, and serious untoward incident, should be critically reviewed and the lessons learnt actively disseminated to all clinical staff, risk managers and administrators. The precise educational actions taken as a result must be recorded, audited and regularly reported to the Trust board by the clinical governance lead.
The percentage of staff who have participated or contributed to an SUI review and who confirm having received feedback from the clinical governance lead about the actions taken as a result.

All clinical staff must undertake regular, written, documented and audited training for:

The identification, initial management and referral for serious medical and mental health conditions which, although unrelated to pregnancy, may affect pregnant women or recently delivered mothers
The early recognition and management of severely ill pregnant women and impending maternal collapse
The improvement of basic, immediate and advanced life support skills. A number of courses provide additional training for staff caring for pregnant women and newborn babies.

There is also a need for staff to recognise their limitations and to know when, how and whom to call for assistance.

Rationale

A lack of clinical knowledge and skills amongst some doctors, midwives and other health professionals, senior or junior, was one of the leading causes of potentially avoidable mortality. This triennium the assessors were particularly struck by the number of health care professionals who failed to identify and manage common medical conditions or potential emergencies outside their immediate area of expertise. Resuscitation skills were also considered poor in an unacceptably high number of cases.

Auditable standards

The provision of courses and a record of attendees should be regularly audited to reinforce, familiarise, and update all staff with local procedures, equipment and drugs.
Number and percentage of staff who have their training requirements in relation to safety and clinical skills identified and addressed in their annual appraisal report. Target 100%.
Number and percentage of all cardiac arrest teams who know where the maternity unit is and how to gain immediate access to it. Target 100%.

Early warning scoring system

There is an urgent need for the routine use of a national obstetric early warning chart, similar to those in use in other areas of clinical practice, which can be used for all obstetric women which will help in the more timely recognition, treatment and referral of women who have, or are developing, a critical illness. In the meantime all Trusts should adopt one of the existing modified early obstetric warning scoring systems of the type described in the Chapter on Critical Care, which will help in the more timely recognition of woman who have, or are developing, a critical illness. It is important these charts are also used for pregnant women being cared for outside the obstetric setting for example in gynaecology, Emergency Departments and in Critical Care.

Rationale

In many cases in this Report, the early warning signs of impending maternal collapse went unrecognised. The early detection of severe illness in mothers remains a challenge to all involved in their care. The relative rarity of such events combined with the normal changes in physiology associated with pregnancy and childbirth compounds the problem. Modified early warning scoring systems have been successfully introduced into other areas of clinical practice and a system which has been modified for obstetric mothers is discussed in Chapter 19, together with an example of such a chart. These should be introduced for all obstetric admissions in all clinical settings.

In developing this recommendation, a consultant from a hospital where staff are trying to get such a scheme introduced said “we have had three near misses related to unrecognised sepsis in the last two months, all of which would have been picked up by this chart. All three women came close to featuring in the next edition of your Report”.

Auditable standards

A National Modified Obstetric Early Warning System (MEOWS) chart developed and piloting started by December 2008.
In the interim, the number of trusts who have adopted a version of any existing MEOWS charts and trained all staff in its use by the end of 2008.

National guidelines

10. Guidelines are urgently required for the management of:

The obese pregnant woman
Sepsis in pregnancy
Pain and bleeding in early pregnancy

Rationale

National clinical guidelines are especially useful where there are unexplained variations in practice, emerging problems, and the recognition of persisting sub-standard care. The increasing prevalence of obesity in the UK has been widely publicised, and the risks of maternal death among pregnant obese women have been highlighted in this Report. There are many aspects of the care of overweight women in pregnancy, beyond maternal risks, that require guidance including the difficulties of prenatal diagnosis, the enhanced risk of gestational diabetes, the increased chance of caesarean section and the challenges of analgesia and anaesthesia. With deaths from sepsis and ectopic pregnancies the issues are different and there are persisting failures to recognise these conditions promptly. These have been highlighted in several Reports and guidelines would help by addressing diagnostic issues in a more extensive, evidence-based format, than is possible in this Report.

Additionally

International definitions

The next revision of the International Classification of Diseases, ICD 11, should recognise that, in more developed countries at least:

The current arbitrary cut off point for the definition of a maternal death, 42 days postpartum, is unhelpful and Enquiries limited by this definition will miss learning lessons from some important Direct and Indirect deaths which occur later than this.
Deaths from peripartum cardiomyopathy, ovarian hyper-stimulation syndrome (OHSS) and suicide from puerperal psychoses, at any time after pregnancy, should be recognised as Direct maternal deaths. These deaths would not have occurred if the woman had not been, or sought to become pregnant.

References

Redshaw M, Rowe R, Hockley C, Brocklehurst, P. Recorded delivery: a national survey of women’s experience of maternity care 2006. National Perinatal Epidemiology Unit. Oxford; NPEU; 2007. ISBN 978 0 9735860 8 0. www.npeu.ac.uk
Martin Jr JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May W. Stroke and pre-eclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol 2005;105:246-54.
National Institute for Clinical Excellence. National Collaborating Centre for Women’s and Children’s Health. Caesarean section: clinical guideline. Royal College of Obstetricians and Gynaecologist Press. April 2004. www.nice.org.uk or www.rcog.org.uk