Maternal Mortality

Defined as death of either a pregnant woman or death of woman within 42 days of delivery, spontaneous abortion or termination providing the death is associated with pregnancy or its treatment.¹
In the United Kingdom, maternal mortality rates can be calculated in two ways:

1. Through official death certification to the Registrars General (the Office for National Statistics and its equivalents), or
2. Through deaths reported to the Confidential Enquiry into Maternal and Child Health (CEMACH).² This produces a report every 3 years. The overall maternal death rate for the Enquiry is calculated from the number of deaths assessed as being due to Direct and Indirect deaths.

However, it is not possible to obtain accurate data on total number of pregnancies.
The alternative is to use deaths from obstetric causes/million maternities (i.e pregnancies that have been notified to a doctor).
Direct deaths are defined as those related to obstetric complications during pregnancy, labour or puerperium (6 weeks) or resulting from any treatment received.
Indirect deaths are those associated with a disorder the effect of which is exacerbated by pregnancy.
Late deaths occur ≥ 42 days after end of pregnancy.

In the last reported triennium (2000-2002) 391 maternal deaths were reported to the Enquiry.
There was a slight increase on the 378 cases in 1997-99.
Of the 391 deaths, 106 were classified as Direct and 155 as Indirect deaths.²

Incidence

• Indirect mortality rate has risen to 7.8, from 6.4 per 100,000 maternities in the last Report.
• The Direct maternal mortality rate was 5.3 deaths per 100,000 maternities. This was also higher than the last triennium. By removing the number of Direct deaths of recently arrived refugees or asylum seekers this figure is reduced to 5.1 per 100,000 maternities, which is similar to the rate in the last Report.

The most common cause of Direct deaths was thromboembolism, as in previous reports. The rates remain largely unchanged since 1997-99. There have been increases in the mortality rates from haemorrhage and those associated with anaesthesia and no significant decreases in deaths from other causes. Post-partum haemorrhage (PPH) is the commonest cause of death worldwide, and new initiatives in poorer countries are called for e.g. anti-shock garments and balloon tamponade.³

Most maternal mortality occurs in developing world with >500,000/year.^4,5Risk factors for maternal deaths in the UK include:

• Social disadvantage: Women living in families where both partners were unemployed, where social exclusion was an associated problem, were up to 20 times more likely to die than women from the more advantaged groups. In addition, single mothers were three times more likely to die than those in stable relationships.
• Poor communities: Women living in the most deprived areas had a 45% higher death rate than women living in the most affluent areas.
• Minority ethnic groups: Women from ethnic groups were, on average, three times more likely to die than caucasian women. Black African women, including asylum seekers and newly arrived refugees had a mortality rate seven times higher than caucasian women. These groups were shown to have had major problems in obtaining obstetric care. This disparity in mortality rates between ethnic groups has been noted in other affluent societies.⁶
• Late booking or poor attendance: 20% of the women who died from Direct or Indirect causes booked for maternity care after 22 weeks of gestation, or had missed over four routine antenatal visits.
• Obesity: 35% of the all women who died were obese.
• Domestic violence: 14% of all the women who died declared that they were subject to violence in the home.
• Substance abuse: 8% of all the women who died were substance misusers.
• Suboptimal clinical care: 67% of the women who died were considered to have some form of suboptimal clinical care.
• Lack of inter-professional and/or inter-agency communications: There were many cases where the care provided to the women who died was hampered by a lack of cross-disciplinary working. In several cases crucial clinical information, which may have affected the outcome, was not passed from the GP to the midwifery or obstetric services,or shared between consultants in other specialities.

It is the responsibility of the GP or community midwife to notify the local Director of Public Heath.
If death occurs in hospital a co-ordinator, usually a midwife, should be appointed.
They should perform the following and keep a complete record of all actions:

• Ensure relatives have a suitable member of staff as a single contact point
• Consultant on-call should see relatives as soon as possible and woman's own consultant told of death as soon as next in hospital
• Supervisor of midwives is informed
• Mortuary and pathologist on duty informed
• Try to obtain permission from next-of-kin for post-mortem examination to confirm cause of death (coroner may direct one performed if any doubt). N.B. If there a dead fetus in utero, there is no legal requirement for a death certificate but one can often be supplied if wished
• Ask relatives if they would like to see a culturally appropriate religious adviser
• All relevant documents are sent to the coroner
• Consider offering support to staff involved.

The following should be advised of the death:

• CEO
• Clinical director/managers
• Consumer affairs
• Complaints
• Risk manager
• Community midwife
• GP
• Local Director of Public Heath - will require Confidential Enquiry form to be completed
• Local Supervising Authority Officer.