Saving mothers' lives: the 2006-8 anaesthesia perspective.

The individual stories of maternal death, documented in Confidential Enquiries into Maternal Deaths, are tragic and compelling, and have informed many recommendations in the past half-century that have improved maternal and neonatal outcomes in the UK and probably, around the world. The individual stories continue with the recent publication of the Eighth Report of the Confidential Enquiries into Maternal Deaths in the UK, ‘Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2006–08’ (hereafter referred to as the Report). In this month’s issue of the British Journal of Anaesthesia, Drs McClure, Cooper, and Clutton-Brock, on behalf of the Centre for Maternal and Child Enquiries, have summarized the findings of the Eighth Report. In the past, the chapters summarizing deaths attributed directly to anaesthesia and critical care were republished in the British Journal of Anaesthesia, but due to copyright issues, the authors have written a review of the current Report. Between 2006 and 2008, 261 maternal deaths were reported; 331 existing children and 147 live-born newborns lost their mothers. The good news is that the overall maternal risk ratio (MMR) decreased compared with the 2003–5 report. Since 1985, there is a significant downward trend in the MMR due to direct causes (deaths resulting from obstetric complications). The decrease from the previous triennium is primarily due to a decrease in deaths from pulmonary embolus, and to a lesser extent, obstetric haemorrhage. In all likelihood, this decrease is attributable to the development of protocols to prevent embolism and treat haemorrhage that were developed and implemented after previous reports. A worrying change is the increase in deaths from genital tract infection. According to the latest World Health Organization (WHO) data, the MMR has decreased worldwide by 34% since 1990. Still, an estimated 358 000 women died of pregnancy-related disease in 2008. This rate equates to more than 1000 deaths per day or 42 deaths per hour. The vast majority of these deaths occur in developing countries. The WHO 2000 Millennium Development Goal Five (MDG5) is to reduce MMR by 75% between 1990 and 2015. Unfortunately, at the current rate of decline (2.5% per year), we are making insufficient progress towards this goal. In fact, the MMR is increasing in some countries, including the USA. Better data collection may explain some, but not all of this increase. Despite the improved MMR observed in the UK, there is no room for complacency. The MMR trend for indirect deaths (deaths resulting from pre-existing disease, or disease that developed during or was aggravated by pregnancy) is increasing. Of equal concern is the number of cases in which substandard care was judged to be present. For direct deaths, the proportion has hovered between 60% and 70% for the past decade. For the first time, the proportion of indirect deaths in which care was substandard was .50%. The UK is not alone in this regard. The French National Expert Committee on Maternal Mortality (CNEMM) recently published a report summarizing maternal mortality in France from 2001 to 2006, using techniques similar to the Confidential Enquiries. Almost half (46%) of deaths were judged avoidable. In the Netherlands between 1993 Volume 107, Number 2, August 2011