CEMACH 2003–5 Saving Mothers' Lives: lessons for anaesthetists

Abstract

The Confidential Enquiry into Maternal and Child Health (CEMACH) reviews every death in the UK occurring during pregnancy and up to 42 days post-partum. Originally titled Confidential Enquiries into Maternal Deaths (CEMD), this series of Reports is the longest running audit in the world. It covers every triennium since 1952, with sequential Reports having established the leading causes of maternal mortality and recommended change where appropriate. Up to 1985, only deaths in England and Wales were considered; thereafter, the whole UK was included. The maternal mortality rate (MMR) is defined as the number of maternal deaths per 100 000 maternities. This has markedly reduced over the last 50 yr. In 1952–4, there were 1094 maternal deaths (MMR 53.29), whereas the latest Report 2003–5 records 295 deaths (MMR 13.95) of which 132 were direct and 163 were indirect. However, most of this dramatic improvement in MMR occurred early and was mainly attributable to advances in public health and medicine (Fig. 1). Unfortunately, if we compare total deaths (223) and MMR (9.83) for the 1985–7 Report with those in the current Report 2003–5, we see that over the last 20 yr, there has been an increase in both total deaths and MMR. Suggested explanations for the failure of MMR to decline since the last (2000–2) CEMACH Report include increasing maternal age at delivery, obesity, poor overall health status, difficulty in accessing maternity care, and the increase in immigrant mothers. One in four mothers now delivering in the UK has been born outside the UK. Whether these factors can explain the increase in MMR since 1985 is not known. In addition, the Scottish morbidity data indicate that for every maternal death, there are 60 ‘near-misses’ (rate of severe morbidity 5.3/1000 maternities). CEMACH historically divides maternal deaths into direct deaths from conditions directly related to pregnancy and indirect deaths from conditions unrelated to pregnancy but exacerbated by it. Deaths occurring during pregnancy or within 6 weeks of birth, which were not due to or affected by pregnancy are called coincidental deaths. Deaths from any cause that occurred between 6 weeks and 1 yr after delivery are termed late deaths. Most late deaths are unrelated to pregnancy and therefore termed late coincidental deaths. This complex structure sometimes obscures causality. A ‘late’ death beyond the arbitrary 42-day post-natal period is often not counted in the quoted figures, even though the death is clearly attributable to the initial event after the patient has survived for a protracted period on the intensive therapy unit (ITU). Figure 2 therefore shows the less familiar—but more informative— leading causes of maternal deaths as direct/ indirect plus relevant late deaths, with the proportion receiving major substandard care (defined as treatment—or lack of—which contributed significantly to the death of the mother, and where different treatment may have altered the outcome).