Confidential Enquiry Into Maternal Deaths Research Articles

Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different contextof care.

To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.

A synthesis of clinical and health system bottlenecks to implementing new WHO postpartum hemorrhage recommendations: Secondary data analysis of the Kenya Confidential Enquiry into Maternal Deaths 2014-2017.

ObjectiveTo describe maternal deaths from postpartum hemorrhage (PPH) in Kenya by secondary analysis of the Kenya Confidential Enquiry into Maternal Deaths (CEMD) database and clinical audit of a sample of those deaths, and to identify the perceived challenges to implementing country‐specific PPH guidelines.MethodsA retrospective descriptive study using the Kenyan CEMD database and anonymized maternal death records from 2014–2017. Eight standards from the Kenya National Guidelines for Quality Obstetric and Perinatal Care were selected to perform clinical audit. The process of supporting eight Sub‐Saharan African countries to develop country‐specific PPH guidelines was described and perceived challenges implementing these were identified.ResultsIn total, 725 women died from PPH. Most women attended at least one antenatal care visit (67.2%) and most did not receive iron and folate supplementation (35.7%). Only 39.0% of women received prophylactic uterotonics in the third stage of labor. Factors significantly associated with receiving prophylactic uterotonics were place of delivery (χ2 = 43.666, df = 4; P < 0.001), being reviewed by a medical doctor (χ2 = 16.905, df = 1; P < 0.001), and being reviewed by a specialist (χ2 = 49.244, df = 1; P < 0.001). Only three of eight standards had a greater percentage of met cases in comparison to unmet cases. Key concerns about implementation of the new WHO PPH guidance included use of misoprostol by unskilled health personnel, availability of misoprostol and tranexamic acid (TXA) at primary healthcare level, lack of availability of heat‐stable carbetocin (HSC) due to cost, lack of awareness and education about HSC and TXA, and lack of systems to ensure quality oxytocin is available at point of care.ConclusionThere is a need for improved quality of care for women to minimize the risk of mortality from PPH, by implementing updated clinical guidelines combined with focused health system interventions.

Maternal Mortality in Malaysia

Maternal health and well-being have extended to international consideration since the global launching of WHO’s Safe Motherhood Initiative in 1987. In 1990, Malaysia set itself an ambitious vision to achieve high income and developed status by 2020. A relatively low maternal mortality rate (23.2 in 2012), noteworthy increase in the proportion of safe deliveries and antenatal coverage have been achieved. Introduction of Confidential Enquiries into Maternal Deaths (CEMD) in 1991 was an important step towards a full-fledged audit taking into consideration the identification of shortfalls in the care of pregnant mothers and taking cognizance of the remedial measures set forth, thus improving standards of care. The High-Risk Approach system, the introduction of a colour coding system for identification of pregnancies that were at greater risk than average risk, the strengthening of referral systems, and home based maternity assessment cards kept by the patient present at any level of antenatal care were used as additional tools. Swift development of rural infrastructure, increase in skilled personnel to attend deliveries, and recruitment of traditional birth attendants (TBAs) as a short-gap measure was undertaken. In addition, midwives in rural areas were allowed to administer heparin as thromboprophylaxis, antenatal steroids to mothers with preterm labour and intramuscular magnesium sulphate to mothers with hypertension. These drugs are given under guidance by the Ministry of Health protocols and given before transfer to tertiary centres. In addition, partograph use, protocol development and creation of a “red alert system” in hospitals to mobilize specialists and other healthcare personnel were deployed to reinforce existing measures. In 1985, MOH initiated a national quality assurance programme (QAP). This programme was used as a managerial tool to justify the needs for further resources in terms of money, manpower, machinery and materials. Malaysia’s significant decline in maternal mortality has been as a result of development of rural health services (introduction of maternal and child health programmes and TBAs) , adopting specific approaches (strengthening of referral system and colour coding system), assuring quality of care by tracking progress (outcome), providing standardize care, and identifying outliers that needed further improvement.

Promoting Mother's Psychological Health after Fetal Loss-Descriptive Case Reports

Life is the biggest gift of God and the process of giving birth is praise-worthy. Therefore, maternal mortality and morbidity is alarming and need extensive interventions. The psychosocial and psychological perspectives of childbirth need attention and vigorous trainings for health- care workers. Many countries are working to improve standards of their living and to curtail subsequent life threatening illness associated with pregnancy and birth. For that, different reporting, evaluating and practicing guidelines made to check the present practices that have greater impact on health-care industries and on patients. One of the widely eminent is CEMACH (Confidential Enquiry into Maternal and Child Health). According to Weindling [1], CEMACH was established in April 2003. Previously it worked as CESDI (the Confidential Enquiry into Stillbirths and deaths in infancy) and CEMD (the Confidential Enquiry into Maternal Deaths). Formerly, the ministry of health had not reported adequately and timely about the maternal deaths but it started its formalized reporting in the year 1952.

Risk factors for maternal death revisited.

For many years the UK Confidential Enquiry into Maternal Deaths (CEMD) has reported increased risks of pregnancy-associated death in certain groups of women, such as older mothers and substance abusers. The CEMD, however, lacks a control group, so these conclusions have had to be based on comparisons with data from other sources, e.g. the Office for National Statistics or Hospital Episode Statistics. Comparison between deaths and ‘near miss’ events became possible after the UK Obstetric Surveillance System (UKOSS) was established to study uncommon disorders of pregnancy. Conditions such as eclampsia and pulmonary embolism feature in reports from both CEMD and UKOSS, allowing researchers to compare women who died and those who survived. Kayem et al. (PLoS ONE 2011;6:e29077) found that the risk of death was increased by older age, black ethnicity, obesity and unemployment. In a similar, larger study, Nair et al. (BJOG. 2015;122:653-62) identified six risk factors, such as inadequate use of antenatal care, which together accounted for 70% of the increased risk of death. UKOSS also collects details on controls—one or more women delivering in the same hospital immediately before the near-miss case was delivered. These now provide an opportunity for the long-awaited comparison between women who died and women with uncomplicated pregnancies. In this issue, Nair et al. compare 383 maternal deaths reported to MBRRACE-UK in 2009–2013 and 1516 controls from UKOSS studies between 2010 and 2012. The two groups, drawn from the same national population over similar time periods, are as closely comparable as possible. This study is ground-breaking in several ways. First, it combines data from two well-established and accurate surveillance programmes. Their reliability contrasts with much of our global information on maternal mortality, which is derived either from estimates by international bodies or from national registers—notoriously subject to under-reporting. Secondly, the study includes maternal deaths from both direct and indirect causes. This is important because in the UK indirect deaths have outnumbered direct deaths since 1997. Worldwide, however, direct causes still account for 73% of maternal deaths (Say et al. Lancet Global Health. 2014;2:e323-33). This difference is one example of why lessons for reducing maternal mortality must be learned at a national level. Thirdly, the study challenges our ideas about risk factors. Of the 13 factors examined, only seven were found to be associated with maternal mortality. They include inadequate utilisation of antenatal care, medical comorbidities and, surprisingly for the UK, anaemia. Missing from the list are ethnicity, parity, body mass index and cigarette smoking, all of which were significant on initial analysis but not after adjustment for other factors. The clinical implications of this study are important. It confirms the risks associated with unemployment and increasing maternal age. The authors point out that women from black African backgrounds should still be considered high risk, but their analysis strongly suggests that the excess mortality in this and other at risk groups can be substantially reduced by targeted interventions, such as attention to medical co-morbidities and improved access to antenatal care. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Maternal Death Surveillance and Response in East and Southern Africa.

Maternal death surveillance and response (MDSR) is one of several low cost, high impact strategies to reduce maternal mortality. This initiative is supported in eastern and southern Africa by the United Nations Population Fund (UNFPA) and other partners. Currently, South Africa is the leading country in the institutionalization of MDSR through the Confidential Enquiry into Maternal Deaths (CEMD). With the support of UNFPA and other partners, at least 15 countries in the region have introduced MDSR into maternal and newborn health care programs. The report from the knowledge-sharing meeting and the findings of the evaluation of the South African MDSR show that MDSR is still not at an optimal level in most countries in sub-Saharan Africa, despite the efforts of national authorities and support from a number of development partners. Additional work is required on the part of national authorities, communities, and development organizations, and the challenges being faced were highlighted at the knowledge-sharing meeting.

The Confidential Enquiry into Maternal Deaths in South Africa: a case study.

The Confidential Enquiry into Maternal Deaths (CEMD) in South Africa has been operational for 15years. This case study describes the process of notification and independent assessment of maternal deaths, predominantly in facilities. In the earlier years of the Enquiry, institutional maternal mortality ratio increased and was 176.2 per 100000 live births in the 2008-10 triennium; thereafter it decreased to 146.7 in the 2011/12 period. The slow progress was due to the significant contribution of HIV/AIDs to maternal mortality and challenges in implementing the recommendations that were devised from the findings of the Enquiry. Nevertheless, the CEMD process has been maintained and strengthened so it is currently able to perform routine maternal death surveillance at both national and district levels, identify deficiencies within the health system, generate reports and also provide early warning about alarming trends such as the increasing numbers of deaths due to caesarean-section-associated haemorrhage.

A review of maternal mortality in Malaysia

There has been a significant decline in maternal mortality from 540 per 100,000 live births in I957 to 28 per 100,000 in 2010. This decline is due to several factors. Firstly the introduction of the rural health infrastructure which is mainly constructing health centres and midwife clinics for the rural population. This provided the accessibility and availability of primary health care and specially, antenatal care for the women. This also helped to increase the antenatal coverage for the women to 98% in 2010 and it increased the average number of antenatal visits per women from 6 in 1980 to 12 visits in 2010 for pregnant women. Along with the introduction of health centres, another main feature was the introduction of specific programmes to address the needs of the women and children. In the 1950s the introduction of Maternal and Child Health (MCH) programme was an important step. Later in the late 1970s there was the introduction of the High Risk Approach in MCH care and Safe Motherhood in the 1980s. In 1990, an important step was the introduction of the Confidential Enquiry into Maternal Deaths (CEMD). Another significant factor in the reduction is the identification of high risk mothers and this is being done by the introduction of the colour coding system in the health centres. Other factors include the increase in the number of safe deliveries by skilled personnel and the reduction in the number of deliveries by the Traditional Birth Attendants (TBAs). The reduction in fertility rate from 6.3 in 1960 to 3.3 in 2010 has been another important factor. To achieve the 2015 Millennium Development Goals (MDG) to further reduce maternal deaths by 50%, more needs to be done especially to identify maternal deaths that are missed by omission or misclassification and also to capture the late maternal deaths. IeJSME 2012: 6 (Suppl 1): S142-S151

SIMULATION TRAINING FOR OBSTETRIC PROCEDURES AND EMERGENCIES

The World Health Organisation (WHO) has estimated that 1500 women die every day from preventable complications of pregnancy and childbirth. While barriers to accessing healthcare are undoubtedly multi-factorial, studies have repeatedly shown that providing skilled healthcare workers can result in untold benefits for women and babies in developing countries. The phenomenon of preventable maternal and fetal morbidity and mortality is not limited to the developing world. The Confidential Enquiries into Maternal Deaths (CEMD) and Stillbirths and Infant Deaths (CESDI) in the UK have repeatedly identified substandard care as a major contributor to maternal and neonatal mortality. In 2008 The King's Fund publishedSafe Births: Everybody's business,an independent enquiry into the safety of maternity services in England. This recommended that simulation-based training to assess clinical, communication and team skills should be available to all maternity staff, and that training should form a core activity. Many hospitals in the UK have been running in-house courses for staff for over a decade with measurable improvements in neonatal outcomes. The value of these training schemes is recognised and rewarded through reduced insurance premiums for participating hospital trusts as part of clinical negligence schemes. Gaining competence in managing obstetric emergencies presents particular challenges for trainees. Most emergencies are, thankfully, uncommon but some constitute life-threatening events where management naturally falls to the most experienced available clinician. The skills required are often particular to emergencies and therefore novel to trainees. Utilising emergencies as training opportunities is further complicated by the presence of a conscious patient.

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

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).

Maternal mortality in Denmark, 1985–1994

Objectives In Denmark, maternal mortality has been reported over the last century, both locally through hospital reports and in national registries. The purpose of this study was to analyze data from national medical registries of pregnancy-related deaths in Denmark 1985–1994 and to classify them according to the UK Confidential Enquiry into Maternal Deaths (CEMD). Study design All deaths of women with a registered pregnancy within 12 months prior to the death were identified by comparing the Danish medical registries, death certificates, and relevant codes according to International Classification of Diseases (ICD-10). All cases were classified using the UK CEMD classification. Cases of maternal death were further evaluated by an audit group. Results 311 cases were classified. 92 deaths (29.6%) occurred ≤42 days after termination of pregnancy. Of these, 30 were classified as direct obstetric deaths, 30 as indirect obstetric deaths, and 32 as fortuitous deaths. Among the late pregnancy-related deaths (>42 days), 1 woman died from a direct obstetric cause, 46 from indirect causes, and 172 from fortuitous causes. Hypertensive disorders of pregnancy were the major cause of direct maternal deaths. The rate of maternal deaths constituted 9.8/100,000 maternities (i.e. the number of women delivering registrable live births at any gestation or stillbirths at 24 weeks of gestation or later). Conclusion This is the first systematic report on deaths in Denmark based on data from national registries. The maternal mortality rate in Denmark is comparable to the rates in other developed countries. Fortunately, statistics are low, but each case represents potential learning. Obstetric care has changed and classification methods differ between countries. Prospective registration and registry linkage seem to be a way to ensure completion. This retrospective study has provided the background for a prospective study on registration and evaluation of maternal mortality in Denmark.

LEARNING FROM ADVERSE OUTCOMES: A SYSTEM FOR IDENTIFICATION AND ASSESSMENT OF SEVERE MATERNAL MORBIDITY

Traditionally, the maternal mortality ratio has been used as a measure of the quality of maternity care and review of individual cases of maternal death has provided information for professional learning in order to improve patient care. In the United Kingdom, this process of multidisciplinary review has been carried out for over 50 years in the form of the Confidential Enquiry into Maternal Deaths (CEMD). The Confidential Enquiry is well respected internationally and has been used as a model for confidential enquiries in other countries, such as South Africa.

Reports on Confidential Enquiries into Maternal Deaths: management strategies based on trends in maternal cardiac deaths over 30 years

In the latest Report of the Confidential Enquiries into Maternal and Child Health (CEMACH; formerly Confidential Enquiries into Maternal Deaths (CEMD)), cardiac disease was the second commonest cause of maternal mortality. Currently there is much emphasis on appropriate referral and multidisciplinary planning for women with known cardiac disease. However, examining all maternal cardiac deaths in the CEMACH/CEMD reports over the last 30 years, to see whether the condition was known before pregnancy or developed during pregnancy, suggests that while reported maternal mortality due to cardiac disease overall has approximately doubled, the number due to known disease has changed little. Thus significant and increasing numbers of deaths occur in women without known disease, either in those with risk factors or in those who develop conditions in the absence of risk factors. Therefore, while there is a continuing need to counsel, refer and appropriately manage women with known pre-existing cardiac disease, attention must also be paid to screening women before pregnancy for evidence of cardiac disease or risk factors, and also to cardiac disease that develops de novo during pregnancy, since early screening and referral strategies alone will not prevent units from encountering such cases. All units therefore require processes for monitoring and managing women for the development of cardiac disease throughout their pregnancies.

Thromboprophylaxis after vaginal delivery: A district generalhospital experience

SummaryThe Confidential Enquiries into Maternal Deaths (RCOG ) recommends risk assessment and appropriate thromboprophylaxis after vaginal delivery. This study examines the risk group and the need for thromboprophylaxis after vaginal delivery in our local population and the cost implications for the same. It is a retrospective study of women who delivered in the month of November 2003. There were 307 deliveries, of these 251 (81.7%) were vaginal deliveries. Confidential Enquiries into Maternal Deaths (CEMD) risk classification was possible for 243 women. A total of 170 women were low risk, 66 (27.16%) moderate risk and 7 (2.88%) high risk. The costs of thromboprophylaxis for the year in our unit were calculated as £7,339.71 for unfractionated heparin (UFH) 5,000 IU twice daily and £7,098.27 for 40 mg enoxaparin once daily. A total of 30% of our District General Hospital population were classified as moderate or high risk for thromboprophylaxis after vaginal delivery. It is less expensive to use enoxaparin compared with unfractionated heparin for thromboprophylaxis.

Maternal mortality

Worldwide maternal mortality is the health index that shows greatest disparity between developing and affluent countries. Many of the deaths in developing countries could be avoided by improving the availability of simple clinical interventions. In the UK, maternal deaths are infrequent, but many are associated with sub-standard care and avoidable deaths still occur. The Confidential Enquiry into Maternal Deaths (CEMD) had been instrumental in highlighting causes and possible solutions for more than 50 years. Recent reports have highlighted the importance of suicide and high-risk social and personal features.

Thrombosis and pregnancy

Ten women die from thrombosis in pregnancy every year in the UK. Thromboembolism is the leading cause of maternal mortality in the UK with 25 deaths from pulmonary embolus and 5 deaths from cerebral vein thrombosis reported in the most recent Confidential Enquiry into Maternal Deaths (CEMD) 2000–2002. Substandard care was identified in over 50% of cases. Pregnancy itself is a procoagulant state, there is a 6- to 10-fold increase in the risk of venous thromboembolism compared to the non-pregnant situation. This risk is increased further in some women because of pre-existing (e.g. age >35, obesity, previous venous thromboembolism, medical conditions) or transient pregnancy-related additional risk factors (e.g. hyperemesis, pre-eclampsia, prolonged labour, excessive blood loss). Risk assessment for venous thromboembolism during the pregnancy should be undertaken, ideally prior to pregnancy or early in the first trimester and this assessment should be repeated subsequently if the woman is admitted to hospital, or develops antecedent problems. The use of appropriate thromboprophylaxis throughout the antenatal period and following delivery whether by caesarean section or vaginal delivery must be considered in the context of these risk factors. The most important aspect of substandard care in the most recent CEMD was the failure to recognise these risk factors. The diagnosis of acute venous thromboembolism using diagnostic imaging and prompt treatment with adequate dosages of anticoagulation are key issues in the subsequent prevention of maternal morbidity and mortality.

Shifting the balance of care—or imaginative healthcare accounting?*

The UK has tended recently to centralise treatment of complex medical disorders in tertiary care centres. In parallel there have been moves to increase healthcare delivery by consultants and extend the role of nurses and midwives to include duties previously undertaken by doctors in training. The idea is both to improve patient care and make the best use of limited resources but such shifts may pose difficulties for obstetric practice. How do we safely define low and high risk pregnancy when we know that a patient’s condition can change rapidly? Where are the limits of responsibility for a midwifery profession that is determined to reverse the unrelenting increase in rates of obstetric intervention and an obstetric profession that is focussed on minimising maternal and perinatal morbidity and mortality? Oettle et al. (p. xx) have proposed an approach to the management of severe early onset pre-eclampsia that is a direct challenge to the direction we are taking in the UK. With increasing pressures on their tertiary care centre, they have allowed complex patients to be cared for in the secondary care setting. A single obstetrician with expertise in high risk care provides the medical lead and the unit works to a protocol determining timing of delivery and criteria for transfer to the tertiary care centre. Perinatal mortality was higher in the secondary care centre despite a lower risk patient profile, but the authors interpret this as an acceptable outcome. This is worrying. Either more training is needed, or it may reflect the complexity in evaluating changing patterns of care. A full evaluation would include not only the impact on the health of those who are transferred early and late, but also the effect on low risk patients in the secondary and tertiary units whose care will be altered by staff trying to care for additional high risk patients. There will also be an impact on the members of obstetric teams and neonatal intensive care facilities. Such complex evaluations of the remote effects of policy changes are difficult. Evaluating maternal mortality and morbidity is also difficult. The authors followed the approach of the confidential enquiries into maternal deaths (CEMD) in the UK and recorded individual adverse outcomes with care. We must also wonder at a service that relies on only one specialist with the necessary expertise to care for such complex cases. The European working time directive would not allow this in the UK. We are faced with the additional challenge of a future workforce with shortened training and limited exposure to complex obstetric care. The UK will then have to face up to the issue of who will care for preeclamptic women in secondary care centres on a daily basis? Will they all have to be transferred to tertiary care centres? If not who will recognise that the mother or fetus is decompensating and requires stabilisation and delivery?

Learning lessons from ‘Why Mothers Die’

The ‘Why Mothers Die’ Report (2000 – 2002) from the Confidential Enquiry into Maternal and Child Health (CEMACH) (RCOG, 2004), was launched on 12 November 2004 at the Royal College of Obstetricians and Gynaecologists (RCOG). This is the latest report by the Confidential Enquiry into Maternal Deaths (CEMD), the first having been published in 1957 when the risk of a mother dying was 1 in 1500.

Pregnant women with significant medical conditions: anaesthetic implications

Anaesthetic assessment plays a vital role in the successful management of the pregnant patient with coexisting medical diseases. This has been highlighted by successive reports of the Confidential Enquiries into Maternal Deaths (CEMD). Advances in medical care have resulted in an increasing number of women with concomitant diseases becoming pregnant. The effects of the physiological changes of pregnancy on the disease must be given due consideration in patient evaluation and management. In this review, some of the common problems will be discussed.

Small babies and substandard anaesthesia: the Confidential Enquiries into Stillbirths and Deaths in Infancy 27/28 report

The Confidential Enquiries into Stillbirths and Deaths in Infancy (CESDI) were established in 1992 to determine how death in late fetal life and infancy (from 20 weeks’ gestation to one year after birth) could be decreased. Patterns of care and service provision have been monitored in defined areas so that recommendations can be made to attempt to improve fetal and neonatal outcome. The scale of mortality is much larger than for mothers, as reported by the Confidential Enquiries into Maternal Deaths (CEMD); the overlap of deficiencies that include maternal care has previously been reported by CESDI.1