MBRRACE-UK have published their 2017 report, Saving Lives, Improving Mothers’ Care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013-2015.
MBRRACE-UK is an acronym for ‘Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK’, a national collaborative programme which audits and investigates maternal deaths, stillbirths and infant deaths. The 2017 report forms part of the NHS-funded Maternal, Newborn and Infant Clinical Outcome Review Programme, which aims to promote and increase quality improvement in patient outcomes through clinical audit and review.
The ‘Saving Lives, Improving Mothers’ Care’ report summarises the lessons that a team of leading clinicians believes the NHS should learn from their review of the care of 556 women who died during or up to a year after the end of their pregnancies between 2013-2015.
Maternal deaths are reported to MBRRACE-UK by healthcare staff, coroners and other sources and are cross-referenced against national records. The deceased’s medical records are then anonymised before being reviewed by a pathologist and an obstetrician to establish the cause of death for the purpose of the review. They then undergo detailed scrutiny of the deceased woman’s care by a large panel of obstetricians, midwives, pathologists and other specialists, such as GPs, intensive care or emergency medicine specialists, psychiatrists or physicians, depending on which areas of medicine are relevant to the particular woman’s treatment. The reviews are then further examined by a multi-disciplinary group who identify the main themes and lessons to be learned which they present in their reports, together with their recommendations for future care.
The report combines a statistical analysis of the cases reviewed to facilitate comparison of outcomes year on year. Alongside the stats, we are given brief but more detailed insights into the events leading up to the deaths of some of the women, giving a clinical context to the commentary on their care. However, the most fitting context for the report’s findings is presented in the foreword, by Professor Helen Stokes-Lampard, Chair of the Royal College of General Practitioners, when she says:
“It is impossible to read a report of this nature, including the details of the women affected, and not feel a pressing need to act. We owe it to the 359 motherless children, and countless other family members and friends of the women whose deaths are reported here, to do all we can to try to prevent women from dying in the future.”
In 2013-2015, out of every 100,000 maternities in the UK there were 8.8 maternal deaths (during pregnancy or up to six weeks after the end of the pregnancy).
The figures suggest that there was no change in the overall maternal death rate since MBRRACE’s report on UK maternal deaths between 2010-2012 – a worrying finding which prompted a call for urgent further action if the government is to achieve its target of reducing maternal deaths in England by 50% by 2030.
Equally concerning was the assessors’ finding that 41% of the women who died might have had a different outcome with improvements in their care.
Two thirds of the women who died had pre-existing physical or mental health problems. Whilst these patients are at higher risk, they should also be easier to identify at an earlier stage as needing specialist maternity care. The recurring, dominant theme was that there are multiple opportunities to reduce women’s risk of complications through early and forward planning of the care of women who are known to have pre-existing medical problems. It must be seen as the responsibility of all health professionals to use these multiple opportunities opportunistically and resources should be made available for them to do so. The report cited provision of appropriate advice and optimal medication before pregnancy, specialist referral in early pregnancy and planning of antenatal, intrapartum and postnatal care, along with postnatal advice about risks and planning for future pregnancies as the key improvements which are needed to prevent women from dying or experiencing severe complications.
Specific recommendations were also made for improvements in the care of women with various conditions, including epilepsy (which accounted for 52% of the cases in which better care would have altered the outcome), sepsis, stroke, haemorrhage and mental health problems.
The report recommended that all maternity units should have escalation policies for periods of high activity including plans to obtain more (including more senior level) obstetric and anaesthetic assistance as well as increasing midwifery staffing levels.