There has been continuous audit of maternal deaths in England and Wales since 1952 (and the whole of the UK since 1984), the results of which have been published regularly as reports of the Confidential Enquiries into Maternal Deaths (CEMD). Other countries have established reviews of maternal deaths but none is as well established or complete as the CEMD.
The organisation of the Enquiry has changed in recent years, being administered previously by various bodies including the Confidential Enquiry into Maternal and Child Health (CEMACH) until 2009 and then the Centre for Maternal and Child Enquiries (CMACE). In 2012 a new consortium, MBRRACE-UK (Mothers and Babies - Reducing Risk through Audits and Confidential Enquiries across the UK), was appointed by the Healthcare Quality Improvement Partnership (HQIP) to run the maternal and perinatal death enquiries. The CEMD reports now consist of an annual report into deaths, with a rolling three-year analysis, and chapters focusing on selected topics that rotate over a three-year cycle (e.g. sepsis, psychiatric causes, cardiac disease, anaesthesia); previously a single comprehensive report was produced annually. The 2014 report examined anaesthetic mortality in detail, and this was further reviewed in the 2017 report, which covered the years 2013-15 (see below).
The 2018 CEMD report (covering the years 2014-16) found the following:
• The UK maternal mortality rate (equals number of indirect + direct deaths per 100,000 maternities; see below) was 9.8, which was similar to 2011-13 data, but a 37% decrease since 2003-05.
• The maternal mortality ratio (MMR, the international definition: equals number of indirect + direct deaths (from birth certificates only) per 100,000 live births) was 4.65 (2012-14 data), down from 5.57 (comparable with other northern European countries; in the USA, MMR was 14 in 2015; in sub-Saharan Africa it is around 1000).
• Cardiac disease was the overall leading cause of maternal death, followed by thromboembolism, neurological disease, psychiatric disease and sepsis (Figure 89.1).
Definitions and data collection
A maternal death is any death occurring during or within 42 days of the pregnancy ending. The enquiry into any maternal death is initiated by local reporters in each unit and organised by regional offices. Each death is assessed by obstetric anaesthetic, midwifery and pathology assessors as appropriate.
Figure 89.1 Major causes of death in the 2018 CEMD report (data from 2014-16). Original source: Knight M, Bunch K, TuffnellD, et al.; MBRRACE-UK. Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. Oxford: NationalPerinatal Epidemiology Unit, University of Oxford, 2018
Maternal deaths are classified as:
• Direct (resulting from obstetric complications of pregnancy) - 98 cases in 2014-16.
• Indirect (deaths resulting from previous existing disease or disease that developed during pregnancy and that was not due to direct obstetric causes but was aggravated by the physiological effects of pregnancy) - 127 cases in 2014-16.
• Late (occurring after 42 days and within one year of the pregnancy ending) - 286 cases in 2014-16.
• Coincidental (from unrelated causes, such as road traffic accident) - 34 cases in 2014-16. Since 1994-96 the number of indirect deaths has outnumbered that of direct deaths. Deaths were previously categorised also according to whether they were associated with substandard care, a term used not only to denote failure of clinical care, but also to indicate failure of the woman to take responsibility for her own health (such as refusal of blood transfusion or refusal to be admitted) and inadequate resources for staffing, intensive care and back-up services. More recent reports have moved away from such pejorative terms and focus instead on areas where care could be improved and lessons learned. The reports continue to make recommendations for improved care, and these tend to include similar themes over the years - for example:
• The importance of early recognition of critically unwell parturients
• The importance of early involvement of senior clinicians and referral to other relevant specialists
• The need for local provision of intensive care (not necessarily on the intensive care unit)
• The need for protocols for common, potentially serious conditions, e.g. pre-eclampsia, major haemorrhage
• The need for regular drills and training in life-threatening emergencies and human factors
• The need for better record keeping and communication generally
Anaesthetic deaths
Although anaesthesia is no longer one of the three leading causes of maternal death, as it was in the 1980s, there are still lessons to be learned from the deaths associated with anaesthesia and the cases in which anaesthesia was felt to have contributed to the death. In the 2017 report (2013-15 data), there were two direct anaesthetic deaths as a result of anaphylaxis and pulmonary aspiration (Table 89.1). Recurrent anaesthetic themes in the reports highlighted as learning points include adequate resuscitation before extubation, management of hypotension secondary to aortocaval compression or regional anaesthesia, and appropriate care planning for women with complex needs. Other issues include follow-up of postdural puncture headache and effective communication between team members. Difficulties in airway management including tracheal intubation are regularly highlighted, even though the number of failed intubations is now low.
Table 89.1 Anaesthetic deaths since 1985 in the CEMD reports
Triennium |
Direct anaesthetic deaths |
Proportion of direct deaths |
Rate per 100,000 maternities |
1985-87 |
6 |
4.3% |
0.26 |
1988-90 |
4 |
2.8% |
0.17 |
1991-93 |
8 |
6.3% |
0.35 |
1994-96 |
1 |
0.7% |
0.05 |
1997-99 |
3 |
2.8% |
0.14 |
2000-02 |
6 |
5.7% |
0.30 |
2003-05 |
6 |
4.5% |
0.28 |
2006-08 |
7 |
6.5% |
0.31 |
2009-11 |
3 |
3.6% |
0.12 |
2012-14 |
2 |
3.0% |
0.09 |
2013-15 |
2 |
2.3% |
0.08 |
2014-16 |
1 |
1.0% |
0.04 |
Key points
• Obstetric anaesthesia is high-risk anaesthesia.
• The severity of coexisting medical disease is easily underestimated.
• Adequate monitoring equipment and trained anaesthetic assistance are required for obstetric anaesthesia.
• Intensive care facilities may be required.
• The anaesthetic record is a legal document and is essential for adequate evaluation of morbidity and mortality.
Further reading
Knight M, Bunch K, Tuffnell D, etal.; MBRRACE-UK. Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2018.
Knight M, Nair M, Tuffnell D, et al.; MBRRACE-UK. Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013-15. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2017.
Lucas DN, Bamber JH. UK Confidential Enquiry into Maternal Deaths: still learning to save mothers’ lives. Anaesthesia 2018; 73: 416-20.
Yentis SM. From CEMD to CEMACH to CMACE to ... ? Where now for the confidential enquiries into maternal deaths? Anaesthesia 2011; 66: 859-60.
Pregnancy VI Problems not confined to obstetrics