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

December 2014

National Perinatal Epidemiology Unit Nuffield Department of Population Health University of Oxford Old Road Campus Headington, Oxford OX3 7LF

Maternal, Newborn and Infant Clinical Outcome Review Programme

Marian Knight, Sara Kenyon, Peter Brocklehurst, Jim Neilson, Judy Shakespeare, Jennifer J Kurinczuk (Eds.)

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

Saving Lives, Improving Mothers’ Care 2014 i

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 2014ii

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 Chief Medical Officer – England

Dr Michael McBride Chief Medical Officer – Northern Ireland

Dr Tony Holohan Chief Medical Officer – Republic of Ireland

Dr Aileen Keel CBE Acting Chief Medical Officer – Scotland

Dr Ruth Hussey Chief Medical Officer – Wales

Jane Cummings Chief Nursing Officer - England

Charlotte McArdle Chief Nursing Officer – Northern Ireland

Dr Siobhan O’ Halloran Chief Nursing Officer – Republic of Ireland

Ros Moore Chief Nursing Officer - Scotland

Professor Jean White Chief Nursing Officer - Wales

Saving Lives, Improving Mothers’ Care 2014 iii

Key messages from the report

Pre-eclampsia

AFE

Haemorrhage

Thrombosis

Sepsis

32% Epilepsy Heart disease

Cancer

Stroke

Diabetes

68% Suicide

Influenza

Sepsis

Maternal deaths have decreased

Causes of mothers’ deaths Two thirds of mothers died from medical and mental health problems in pregnancy and only one third from direct complications of pregnancy such as bleeding.

Three quarters of women who died had medical or mental health problems before they became pregnant.

Women with pre-existing medical and mental health problems need:

• Pre-pregnancy advice • Joint specialist and maternity care

Think Sepsis

Almost a quarter of women who died had Sepsis (severe infection).

Women with sepsis need:

• Early diagnosis • Rapid antibiotics • Review by senior doctors and midwives

Prompt treatment and action can make the difference between life and death

Prevent Flu

1 in 11 of the women died from Flu

More than half of these women’s deaths could have been prevented by a flu jab.

Flu vaccination will save mothers’ and babies’ lives

10 2010-12

from to per 100,000 women giving birth11 2006-08

Saving Lives, Improving Mothers’ Care 2014iv

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 pat