Saving mothers' lives.

In the triennium 2006–2008, 261 women in the UK died directly or indirectly related to pregnancy. The overall maternal mortality rate was 11.39 per 100,000 maternities. Direct deaths decreased from 6.24 per 100,000 maternities in 2003–2005 to 4.67 per 100,000 maternities in 2006–2008 (p = 0.02). This decline is predominantly due to the reduction in deaths from thromboembolism and, to a lesser extent, haemorrhage. For the first time there has been a reduction in the inequalities gap, with a significant decrease in maternal mortality rates among those living in the most deprived areas and those in the lowest socio-economic group. Despite a decline in the overall UK maternal mortality rate, there has been an increase in deaths related to genital tract sepsis, particularly from community acquired Group A streptococcal disease. The mortality rate related to sepsis increased from 0.85 deaths per 100,000 maternities in 2003–2005 to 1.13 deaths in 2006–2008, and sepsis is now the most common cause of Direct maternal death. Cardiac disease is the most common cause of Indirect death; the Indirect maternal mortality rate has not changed significantly since 2003–2005. This Confidential Enquiry identified substandard care in 70% of Direct deaths and 55% of Indirect deaths. Many of the identified avoidable factors remain the same as those identified in previous Enquiries. Recommendations for improving care have been developed and are highlighted in this report. Implementing the Top ten recommendations should be prioritised in order to ensure the overall UK maternal mortality rate continues to decline. Our aim is to improve the health of mothers, babies and children by carrying out confidential enquires and related work on a nationwide basis and by widely disseminating our findings and recommendations. Please cite this work as: Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl. 1):1–203. This work was undertaken by the Centre for Maternal and Child Enquries (CMACE). The work was funded by the National Patient Safety Agency, the Scottish Programme for Clinical Effectiveness in Reproductive Health, by the Department of Health, Social Services and Public Safety of Northern Ireland and the States of Jersey and Guernsey, and Isle of Man. The views expressed in this publication are those of the Enquiry and not necessarily those of its funding bodies. Ireland joined the Enquiry in January 2009, at the commencement of the 2009–11 triennium, and its contribution will be included in the Saving Mothers’ Lives report for that triennium. The Irish office is located at the National Perinatal Epidemiology Centre, Cork University Maternity Hospital, Cork. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of CMACE, or in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK (www.cla.co.uk). Enquiries concerning reproduction outside the terms stated here should be sent to CMACE at the address printed on this page. Making duplicate copies of this Report for legitimate clinical or other noncommercial purposes with the UK NHS is permitted provided the CMACE is identified as the originator of the information. Making alterations to any of the information contained within, or using the information in any other work or publication without prior permission, will be a direct breach of copyright and may result in civil action. The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulation and therefore free for general use. Product liability: CMACE can give no guarantee for information about drug dosage and application thereof contained in this guideline. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Published March 2011 CMACE, Chiltern Court, 188 Baker Street, London, NW1 5SD, UK Tel.: + 44 207 486 1191 Fax: + 44 207 486 6226 Email: [email protected] Website: www.cmace.org.uk Acknowledgements a 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 1 Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer—2006–08 The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom Director and Editor Gwyneth Lewis OBE MSc MRCGP FFPH FRCOG FACOG DSc Central Assessors and Authors Roch Cantwell FRCPsych Thomas Clutton-Brock FRCP FRCA Griselda Cooper OBE FRCA FRCOG Andrew Dawson MD FRCOG James Drife MD FRCOG FRCP (Ed) FRCS (Ed) FCOG (SA) FFSRH Debbie Garrod RM, DPSM, BA, MA, PGCE Ann Harper OBE MD FRCOG FRCPI FFSRH Diana Hulbert FRCS FCEM Sebastian Lucas FRCP FRCPath John McClure FRCA Harry Millward-Sadler FRCPath, MHSM James Neilson MD FRCOG Catherine Nelson-Piercy FRCP FRCOG Jane Norman MD FRCOG Colm O’Herlihy MD FRCPI FRCOG FRANZCOG Margaret Oates OBE FRCPsych FRCOG Judy Shakespeare MRCP FRCGP Michael de Swiet MD FRCP FRCOG Catherine Williamson MD FRCP Other authors and contributors Valerie Beale RN RM Dip Man MSc Marian Knight MPH DPhil FFPH Christopher Lennox FRCOG Alison Miller RN RM RDM Dharmishta Parmar BA Hons Jane Rogers BA PhD DPSM SRN RM Anna Springett BSc MSc Acknowledgements 2 a 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203