This week has seen the publication of the latest triennial ‘Confidential Enquiries’ report: 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. This triennium’s enquiries also looked into the care of women who experienced severe complications but survived, which the team felt would further enhance the investigation’s ability to improve the care of women in the future.
The key findings from this report included that:
- In the 2009-2102 period, 357 women died during or within six weeks of the end of their pregnancy. This was equivalent to 10 in every 100,000 women giving birth, and a significant reduction from the 2006-2008 period in which 11 in every 100,000 women died during or in the six weeks following pregnancy.
- The reduction from the last triennium to this one is mostly explained by a reduction in deaths which were the direct result of a pregnancy-related complication, such as bleeding.
- In the 2009-2012 period, a third of the women who died did so as a direct result of a pregnancy complication, and two thirds of the women who died did so because of a pre-existing medical or mental health problem.
- Three-quarters of mothers who died had pre-existing medical or mental health problems when they became pregnant, and the report’s authors recommend ‘high-level actions’ to ensure that women with medical conditions are offered appropriate and evidence-based care throughout the childbearing year.
- More than two-thirds of the women who died did not receive the nationally recommended level of antenatal care, and a quarter did not receive the recommended minimum level of care.
- Almost a quarter of the women who died had a severe infection, and one in 11 of the women who died did so from flu, which has led the report’s authors to include the promotion of flu vaccination in their recommendations.
- Lastly, one ongoing statistic which never seems to get highlighted in the way that it should but which I feel ought to get more attention is that maternal mortality rates continue to be higher amongst older women, women living in the most deprived areas and women from some ethnic minority groups.
I’m still going through the report, and so I am very open to discussion on the questions that I am going to raise here. I am a big fan of Confidential Enquiries; I know that midwives and doctors in some other countries are very envious of it, I refer to it a lot in my work and I see huge value in our being able to unpack and analyse tragic situations in order to try and improve the care we give to women in the future. I also understand that most practitioners do not have the luxury (as I do) of being able to get to know every woman very well, which does make it easier to determine when a woman is unwell or when things may be going awry, so population-level recommendations are needed. But there are a couple of elements of this report that I think warrant further debate.
The flu vaccination debate
Firstly, the statistic that ‘one in 11 of the women who died did so from flu’ has been linked with the statements that ‘more than half of these women’s deaths could have been prevented by a flu jab’ and ‘flu vaccination will save mothers and babies’ lives’. Yet, when I looked for the evidence to support this statement in the report, all I could find was the following paragraph:
I realise that I am biased, in that I tend to want evidence before suggesting intervention (which includes prophylactic intervention such as vaccination) rather than the other way around, but I am finding it hard to see how we can really know that these women’s deaths were preventable. If we were to have good trial or meta-analysis data showing the unequivocal effectiveness of flu vaccination, then that would be different (although there would still be a need for women to weigh up the pros and cons of the intervention within their own context). But the Cochrane review that looked at the effectiveness of flu vaccination in healthy adults (including pregnant women) concluded that ‘influenza vaccines have a very modest effect in reducing influenza symptoms and working days lost in the general population, including pregnant women.’ (Demicheli et al 2014). These reviewers also found that 35.4% of the trials were funded by industry, so bias is most certainly an issue that needs consideration… For these reasons, I fully understand why some midwives and doctors are concerned about being told that they need to recommend flu vaccination to women.
Presuming or measuring normality?
My second concern sits within the context of a finding which I wholeheartedly agree with and, in fact, often speak about in my workshops. I unequivocally share the reviewers’ concerns that we need to be vigilant for sepsis, and I will be sharing their recommendation to ‘keep the possibility of sepsis in mind at all times, ensuring women with any symptoms or signs of ill health in pregnancy have a full set of basic observations – such as temperature, blood pressure and breathing rate – and ensuring that women get access to available care.’
I am, however, less enamoured with one sentence in the document, and I will share it with you in the context in which it appears. It is the first recommendation under the key areas for action by doctors, midwives and allied health professionals:
‘All women with any symptoms or signs of ill health, including those who are postnatal, should have a full set of basic observations taken (temperature, pulse rate, respiratory rate and blood pressure), and the results documented and acted upon. Normality cannot be presumed without measurement.’
I understand the sentiment behind why this sentence has been included here, and that it was probably intended to relate solely to women ‘with any symptoms or signs of ill health’ but I am concerned because it is not clear whether it refers only to women who are feeling unwell. If this was not the intention, then I find this an incredibly problematic statement. It is absolutely vital that we learn from tragedies and take every opportunity to improve the care that is offered to pregnant, birthing and postnatal women and babies, but surely not at the cost of the understanding that pregnancy and birth, for the vast majority of women, are healthy and happy parts of their life journey and certainly not to be put on trial and decreed to be normal or healthy only after measurement by a health professional?
I don’t want my concerns to detract from the importance of this report and from the value of its contents. I highly recommend that all practitioners read it and see for themselves where they might be able to reflect upon and/or make changes to their practice. But I believe that we need to read even the most eminent sources with a reflective and questioning mind, and those are some of the questions that mine will be pondering over the next few weeks. I look forward to hearing and reading others’ thoughts.
Demicheli V, Jefferson T, Al-Ansary LA, Ferroni E, Rivetti A, Di Pietrantonj C. Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD001269. DOI: 10.1002/14651858.CD001269.pub5.
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 2009-2012. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014.