Cemach report 2004 why mothers die

In addition, we assessed the robustness of the analysis, given the limitation of the missing data, by undertaking a series of sensitivity analyses. In each case we assumed specific extreme scenarios and apportioned missing values accordingly. We assessed the additive effect of the presence of multiple risk factors on the risk of death in a model including all factors found to be significantly associated.

One hundred maternal deaths from one of the five specific causes under investigation were identified from the CMACE database to have occurred between and The estimated mortality and morbidity rates are shown in Table 2. Among the five conditions, the ratio of survivors to deaths was lowest for AFE, stroke and PE: for every two women with an AFE who die, five have an AFE and survive; for every woman dying of a stroke, three survive; and for every woman dying of a PE 19 survive.

The ratio of survivors to deaths was highest for AFLP and eclampsia: for every woman dying of AFLP, 70 survived and for every woman dying of eclampsia 86 women survived. Increasing maternal age and body mass index were significantly associated with the risk of death Figure 1.

Results from the multivariable models are presented in Table 3. The final model using a missing indicator analysis produced very similar effect estimates to those from the multiple imputation analysis.

Women who were over 30, black Caribbean or African, unemployed or with routine or manual occupation had higher odds of progressing to death Table 3. To explore the role of pre-existing medical conditions further, we undertook a second multivariable analysis including maternal age, smoking, parity, BMI, ethnicity, occupational status and the presence of pre-existing disease Table 5. Odds ratio estimates of the risk of death were not significantly different using missing indicator or multiple imputation models.

Women from unemployed or routine or manual occupational groups appeared to be more likely to progress to death [aOR 3. The presence of a pre-existing medical or mental health condition was not associated with a higher odds of death [aOR 0. To explore the effects of potential biases related to the missing values in the model including all the women who died and survived, we tested the sensitivity of our multivariable model to a series of assumptions about the missing values Table 6.

Women who had a manual occupation or were unemployed, and those who were black Caribbean or African had higher odds of death in all the different analyses used to account for the missing data. The association of women's BMI with maternal death, although resulting in similar odds ratio estimates whatever the hypothesis used to account for the missing values, was inconstantly statistically significant.

Analysis of the combined effects of the risk factors present showed that the odds of death associated with these severe maternal morbidities increased progressively in the presence of more than one of the risk factors identified table 7 , although of note was the high degree of uncertainty around the estimated odds associated with the presence of all four risk factors.

This is the first study to compare on a national basis the characteristics of women who die in pregnancy with those who survive after experiencing one of a series of severe maternal morbidities. This analysis is uniquely possible because of the systems that exist in the UK to collect information about these women [4] , [8].

Although previous maternal death reports have suggested that women with some of these characteristics are at higher risk of dying [9] , these reports have not been able to quantify or assess independent risk factors associated with death. In the context of continuing concerns about maternal mortality [2] , [3] , this demonstrates the benefits of maintaining surveillance of both mortality and severe morbidity in high resource as well as low resource settings.

Our analysis shows that in the UK, women who are older, obese, from manual or unemployed occupational groups and of black Caribbean or African ethnicity are more likely to die from these specific morbidities than women who are young, not obese, from other occupational groups and from white or other ethnic minority groups; the presence of two or more of these factors more than doubles the odds of death.

Our findings highlight key areas for public health action and service provision. Previous analyses have shown, independently, that women from minority ethnic groups are more likely to suffer from a severe morbidity in pregnancy [15] and more likely to die in pregnancy, particularly if they are recent immigrants [4] , [16] , [17] ; this risk diminishes for the following generation [18].

The causes for this increase are not known, but language barriers, lack of familiarity with the health care system, cultural norms, and psychological problems, due for instance to events which occurred in their country of origin, including conflict and sexual assault, may all lead to difficulties in accessing antenatal care [4].

Moreover, poor communication between women and caregivers may result in inadequate care because of undiagnosed early symptoms or poor treatment compliance. In the Netherlands, the most important factors contributing to substandard care of immigrant women who die in pregnancy have been shown to be a delay in recognising symptoms and in referral by the general practitioner [19].

These findings highlight once more the importance of providing culturally sensitive antenatal services with the ready availability of interpreters, facilitating early self-referral and diagnosis for immigrant and ethnic minority women with pregnancy complications, particularly those from Black Caribbean or African groups.

There is a growing trend in developed countries for childbearing to occur at a later time in women's lives [20] , [21]. The influence of increased age on maternal mortality has been clearly observed [4] , [16] , [22]. The most frequently cited explanation for the observed increase in mortality with age is that older women are more likely to suffer from co-existing disease which leaves them with less physiological reserve to cope with the additional insult of morbidity during pregnancy.

However, we found no such association in our analysis; a fifth of both survivors and those who died had at least one significant past or pre-existing medical condition when they became pregnant. Thus whilst a pre-existing medical condition may increase the risk of developing severe maternal morbidity, this was not associated with an increased likelihood of dying.

Furthermore, the increased risk of progressing from severe morbidity to death associated with age persisted after adjustment for known pre-existing medical conditions. It is possible that some of these women had undiagnosed pre-existing diseases contributing to death, since late or no antenatal care has been reported as a factor associated with maternal death [4].

However, it seems likely that older maternal age confers a health disadvantage, reflecting a lack of physiological robustness to respond to pregnancy pathology which is not fully appreciated by women or their clinicians. There is a clear need for public health action to reverse the rising trend in maternal age at childbirth by highlighting to clinicians, women and their partners the implications of decisions to delay child-bearing.

In the meantime, clinical services need to appreciate that whilst older maternal age is now common, older mothers remain at higher risk. Obese women were also more likely to die following severe maternal morbidity in our analysis. The analysis was limited by missing data but the association of obesity with death was significant when the analysis was performed including only the group of women who died between and , when the data were more complete, even after adjustment for the presence of pre-existing medical conditions.

Obesity is an increasingly important public health problem throughout the developed world. Obese pregnant women generally require care from a wide range of health professionals, have more complex pregnancies and require more interventions [23]. They also need specific high weight capacity equipment which is not necessarily widely available [23].

Critical care, which may be urgently needed in cases of severe maternal morbidity, can be particularly challenging in obese women. Anatomic changes associated with obesity can lead to specific difficulties related to emergency intubation and mechanical ventilation or catheterization procedures [24]. Obesity has been clearly shown to impact on mortality and morbidity associated with other complications in pregnancy, for example in the context of the recent AH1N1 influenza pandemic [25] , [26].

Together these data serve to reinforce the need to address the problem of obesity in pregnancy; a wider perception of the additional pregnancy risks associated with obesity may provide an additional incentive for obese women who are planning pregnancy to lose weight. Currently evidence on the risks or benefits of weight loss or maintenance during pregnancy, and the optimal methods to encourage weight loss prior to, during or following pregnancy is lacking, and there is an urgent need for further research in this area.

In the interim, appropriate hospital facilities should be available for obese pregnant women, and their care should be carefully planned, involving the multidisciplinary team, in order to evaluate and prevent additional complications.

Few studies have compared socioeconomic differences in mortality according to the cause of death [27] , and none have studied risk factors for maternal death amongst women with severe maternal morbidity.

Members of occupational groups associated with higher incomes have access to a wider array of psychosocial and other resources. Conversely, individuals who cannot rely on informal social structures when encountering problems report worse health; this effect is related to dysfunction of social structures, socioeconomic deprivation, and lack of perceived control [28] , [29].

Our analysis suggests that the differences we found are not related to pre-existing medical conditions and may thus be linked to care or access to care. It is interesting to note that the converse is observed amongst infants born very preterm [30] ; there are no socioeconomic differences in neonatal care or survival after very preterm birth, although mothers from the most deprived areas were nearly twice as likely to have a preterm infant than those from less deprived areas.

Why mothers are less likely than their infants to receive equitable care clearly requires further investigation. This study has highlighted two factors previously unreported as being linked with progression from morbidity to death, depressive illness and learning or intellectual disability. Women with depressive illness were over-represented by five-fold amongst the women who died from severe obstetric morbidity. Recent reports [4] , [9] have highlighted suicide as an important cause of maternal death, leading to recommendations to maternity services that all women with a history of psychiatric disorder should be identified at their first antenatal visit, and that women with a previous history of serious affective disorder or other psychoses should be referred in pregnancy for psychiatric assessment and management even if they are currently well.

It has also been recommended that psychiatric services should have in place a rapid referral system for women who are pregnant or postpartum. Our findings suggest that the converse should also be the case; maternity services should have a system for rapid referral and management of women with a history of depressive illness presenting with obstetric morbidity in pregnancy, because of their higher risk of death.

Although our findings suggesting a risk of death associated with intellectual disability are based on a very small number of cases, we believe there is also a place for a similar rapid referral pathway for pregnant women with learning disabilities, alongside individually personalised antenatal care for this group of extremely vulnerable women.

Our analysis assumes that severe morbidity per se is a better outcome than mortality, whereas the morbidity itself may also represent a failure of management of less severe morbidity. Severe morbidity may be associated with long-term disability as a consequence of, for example, stroke associated with hypertensive disorders of pregnancy, or hypoxic brain injury following resuscitation from amniotic fluid embolism [31] , [32] , and it is important that every effort continues to be made to prevent both severe morbidity and mortality through, for example, strict control of blood pressure.

Continued monitoring of physiological parameters in all mothers, particularly post-delivery, through the use of early warning scoring systems is now being advocated to detect and manage morbidity early in its course [9] , although there is currently little evidence in pregnancy about what thresholds in physiological parameters are appropriate to trigger actions.

Collection of the cases was performed nationally across the UK for both the women who died and those who survived. The UK is, to our knowledge, the only country where both the necessary data collection systems exist to allow this type of analysis. In this analysis we took advantage of data which had already been collected to allow us to rapidly investigate the progression from morbidity to death without the need to carry out a new study which would take several years to complete.

However, the use of existing data has limitations. Some major causes of direct maternal death such as sepsis were not included because data were not collected by the UK Obstetric Surveillance System during the time period for which maternal death data were available. Cases of indirect maternal death were not included; these results are therefore only generalizable to women suffering from direct obstetric morbidity.

Ongoing surveillance of a full range of disorders causing both maternal mortality and morbidity would allow analysis of a wider range of conditions in the future; however, the marginal benefits of such an approach need to be weighed against the expense and burden to clinicians of reporting a much larger number of cases, compared with the current targeted approach focusing on specific morbidities in a changing programme. However all the UKOSS data were collected during the — CMACE data collection period and we believe that significant bias associated with these different data collection timings is unlikely.

As maternal deaths are rare, this approach maximizes the statistical power of these analyses and therefore improves the validity of the results. However, the two sets of data were collected separately and therefore the number of comparable data items is limited.

It is also possible that there was differential case ascertainment between the two systems, although since both systems use several methods to ensure maximal case ascertainment, we believe this is unlikely to have led to significant bias. Data about BMI and occupational status were missing for a substantial proportion of women, particularly for those who died; we therefore performed multiple imputation analyses assuming that data were missing at random.

As more data were missing in the CMACE collection we included the outcome death or severe maternal morbidity in the multiple imputation model as this method has been shown to provide the best results when dealing with missing data [33].

Additionally, we performed sensitivity analyses to explore the effects which may potentially bias our results; these observed associations were consistent with those found after the multiple imputation procedure. However, even under the most extreme hypothesis in the sensitivity analysis, the same trends were found, thus this observation may represent limited statistical power.

The messages from this study can be used to inform actions to reduce maternal mortality throughout the developed world. Ongoing high quality national surveillance programmes still have an important role to play in addressing new challenges in maternal health and care. Women from vulnerable populations in high resource countries remain at increased risk of maternal death in the presence of severe maternal morbidities.

This study has identified that women with a history of depressive illness and intellectual disability are over-represented amongst women who die, suggesting a need for rapid referral systems for women with these co-morbidities and pregnancy morbidity. There is a clear place for public health action to reverse the rising trends in maternal age at childbirth and clinical action to mitigate its effects, and to reduce the burden of obesity in pregnancy.

Further research is needed to address weight management prior to, during and after pregnancy. In addition, development and evaluation of services to mitigate the risk of dying associated with being of black Caribbean or African ethnicity and being unemployed or from routine or manual socioeconomic groups is essential. It is not clear whether the increased risk of death is related to difficulties in access to maternal care through physical location or cultural factors.

There is thus a place for more in depth studies to determine exactly why the presence of these factors makes women more likely to die. As the latest figures from the World Health Organisation indicate [2] , even in the developed world this is no time for complacency. Definitions of Severe Acute Maternal Morbidities included in this analysis.

We would also like to thank Matthias Pierce and Maria Quigley for their statistical advice. Performed the experiments: MK. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Background Women continue to die unnecessarily during or after pregnancy in the developed world. Methods and Findings We conducted a national cohort analysis using data from two sources obtained between and the Centre for Maternal and Child Enquiries maternal deaths database and the United Kingdom Obstetric Surveillance System database.

Conclusions Ongoing high quality national surveillance programmes have an important place in addressing challenges in maternal health and care. Introduction Globally, reducing maternal mortality has been recognised as an important challenge facing all governments and international agencies [1].

Data collection Data concerning women who died and women who survived from five specific maternal conditions were analysed: eclampsia, antenatal pulmonary embolism, amniotic fluid embolism, acute fatty liver of pregnancy, and antenatal cerebral stroke. Download: PPT. Table 1. Number of women who died and number who survived from specific causes of severe maternal morbidity.

CMACE data collection The methodology of the confidential enquiries into maternal deaths has been described in detail previously [9].

Results One hundred maternal deaths from one of the five specific causes under investigation were identified from the CMACE database to have occurred between and Table 2. September — Diabetes in Pregnancy: caring for the baby after birth. Findings of a national enquiry February — Diabetes in Pregnancy: are we providing the best care? March — February Executive Summary. February Diabetes in Pregnancy: are we providing the best care? Findings from a national project March — February Sign up to be notified when this resource is updated and to receive updates about other related quality improvement resources, events and news from HQIP.

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