Maternal, Newborn and Infant Clinical Outcome Review Programme Saving Lives, Improving Mothers’ Care Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012 December 2014 Maternal, Newborn and Infant Clinical Outcome Review Programme Saving Lives, Improving Mothers’ Care Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012 Marian Knight, Sara Kenyon, Peter Brocklehurst, Jim Neilson, Judy Shakespeare, Jennifer J Kurinczuk (Eds.) December 2014 National Perinatal Epidemiology Unit Nuffield Department of Population Health University of Oxford Old Road Campus Headington, Oxford OX3 7LF Design by: Sarah Chamberlain and Andy Kirk Cover artist: Tana West Printed by: Oxuniprint This report should be cited as: Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf of MBRRACE- UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014. ISBN 978-0-9931267-1-0 Individual chapters from this report should be cited using the format of the following example for chapter 4: Paterson-Brown S, Bamber J on behalf of the MBRRACE-UK haemorrhage chapter writing group. Prevention and treatment of haemorrhage. In Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014: p45-55. © 2014 National Perinatal Epidemiology Unit, University of Oxford Foreword This report continues the longest running programme of Confidential Enquiries into maternal deaths worldwide, and shows a welcome decrease in the overall rate of maternal death across the United Kingdom. In addition, it includes, for the first time, Confidential Enquiries into maternal deaths occurring in Ireland. The importance of this report lies in going “beyond the numbers” and recognising the death of every woman during or after pregnancy as a tragedy from which it is incumbent upon us, as health professionals, service planners or policy- makers to learn lessons to improve future care. We must recognise that each woman included in this report leaves behind a bereaved family on whom the impact of her death will be lifelong. We owe it to those left behind to learn from the death of their mother, partner, daughter or friend and to make changes for the future to prevent other women from dying. The focus of this report is therefore clearly to the future, on the actions, small and large, that we as a community or an individual can make to continue to improve the quality of maternity care across the UK and Ireland. As such, it is also enhanced by the inclusion, for the first time, of Confidential Enquiries into the care of women with severe complications in pregnancy, but who survived, thus broadening the messages to improve care yet further. As always, the focus is not in attributing blame, but on improving future mothers’ care. Maternal deaths from genital tract sepsis have fallen significantly, but as this report shows, infections from all causes are an important cause of maternal death. This report spans the period of the influenza A/H1N1 pandemic, which severely affected pregnant women in particular. Some women died before immunisation was introduced, but a number of unvaccinated women died after the vaccination programme began, and, more recently, some women died from non-pandemic type seasonal influenza. The compelling message for the future has to be the importance of continuing the programme of vaccination against influenza in pregnancy in the UK and Ireland, working to maximise uptake and hence to ensure we prevent future influenza-related maternal deaths. At the same time, and as highlighted across many areas of the health service, early identification of pregnant and postpartum women whose medical condition is deteriorating and rapid actions to diagnose and treat pregnant and postpartum women with suspected sepsis will save lives. The importance of routine measurements such as pulse, temperature, respiratory rate and blood pressure in any ill pregnant women cannot be over-emphasised. Pregnant women can appear relatively well and yet become seriously ill with sepsis very quickly. Midwives, doctors and other health professionals need to “think sepsis” and implement sepsis bundles, including giving antibiotics within an hour of the diagnosis being suspected. The consistent year on year decrease in direct maternal deaths is evidence of commitment to and success in improving the care of women with obstetric complications in pregnancy throughout the health service. However, we still need to plan for the care of women with known co-existing medical complications in pregnancy. The majority of women who die during or after pregnancy in the UK and Ireland die from indirect causes, that is, from an exacerbation of their pre-existing diseases. Commitment to improve care for these women is needed across all professional organisations and groups, working alongside researchers to provide the evidence to ensure that we can provide the best care for women pre-pregnancy, during and after pregnancy. Throughout the report, areas of guidance where care can be improved have been clearly highlighted; an obvious area in which specific guidance is lacking is for the care of women with epilepsy in pregnancy. As Chief Medical and Nursing Officers we are committed to ensuring the development of such guidance and hence optimal care for mothers with epilepsy. Saving Lives, Improving Mothers’ Care 2014 i This report would not be possible without the dedication and commitment of health professionals throughout the UK and Ireland. In particular, we would like to thank the dedicated assessors who review each individual woman’s death in order to identify actions to improve care in the future. This work is carried out without remuneration and in the assessors own time, because of their commitment to continuous quality improvement. It behoves health service provider organisations including hospitals, health boards, executives and trusts to continue to recognise the importance of this work at both a national and local level and allow assessors dedicated time for it to continue. We therefore welcome the findings in the report that will ultimately help improve outcomes for mothers and their families across the UK and Ireland. Professor Dame Sally C Davies Dr Michael McBride Chief Medical Officer – England Chief Medical Officer – Northern Ireland Dr Tony Holohan Dr Aileen Keel CBE Chief Medical Officer – Republic of Ireland Acting Chief Medical Officer – Scotland Dr Ruth Hussey Jane Cummings Chief Medical Officer – Wales Chief Nursing Officer - England Charlotte McArdle Dr Siobhan O’ Halloran Chief Nursing Officer – Northern Ireland Chief Nursing Officer – Republic of Ireland Ros Moore Professor Jean White Chief Nursing Officer - Scotland Chief Nursing Officer - Wales ii Saving Lives, Improving Mothers’ Care 2014 Key messages from the report Maternal deaths have decreased from 11 to 10 per 100,000 women giving birth 2006-08 2010-12 Causes of mothers’ deaths AFE Two thirds of mothers died from medical and mental Pre-eclampsia Heart disease health problems in pregnancy and only one third from Epilepsy direct complications of pregnancy such as bleeding. 32% Thrombosis Suicide Three quarters of women who died had medical or Haemorrhage mental health problems before they became pregnant. Sepsis 68% Stroke Women with pre-existing medical and mental health problems need: Influenza Cancer Diabetes • Pre-pregnancy advice Sepsis • Joint specialist and maternity care Think Sepsis Prevent Flu Almost a quarter of women who died had Sepsis (severe infection). Women with sepsis need: • Early diagnosis 1 in 11 of the women died from Flu • Rapid antibiotics More than half of these women’s deaths • Review by senior doctors and midwives could have been prevented by a flu jab. Prompt treatment and action can make Flu vaccination will save mothers’ and the difference between life and death babies’ lives Saving Lives, Improving Mothers’ Care 2014 iii Executive Summary Key areas for action For Policy-makers, Service Planners and Commissioners, Public Health and Professional Organisations • Two thirds of women died from indirect causes and almost three quarters of all women who died had co- existing medical complications. High level actions are needed to ensure that physicians are appropriately trained in, and engaged with, the care of pregnant women, and that services are designed for women with medical conditions which provide appropriate and evidence-based care across the entire pathway, including pre-pregnancy, during pregnancy and delivery, and postpartum. • One in eleven women died from influenza. Increasing immunisation rates in pregnancy against seasonal influenza must remain a public health priority. • Access to antenatal care remains an issue amongst women who died and ensuring access to appropriate care for all groups must remain part of service planning. More than two thirds of women who died did not receive the nationally recommended level of antenatal