The development of clinical audit over the past 10 years has led to questioning of the role of the triennial reports of the confidential inquiries into maternal deaths. Recently, the maternal death rate has been 6-7 per 100 000 maternities, with the proportion of deaths attributed to substandard care remaining around 40%. To investigate the uptake of the recommendations of the confidential inquiries into maternal deaths Hibbard and Milner audited the facilities in consultant maternity units in the United Kingdom in 1993, including the availability of clinical guidelines for two major maternal complications, eclampsia and haemorrhage.1 This audit followed the publication of Maternal Mortality—the Way Forward2 and was published around the time the Royal College of Obstetricians and Gynaecologists produced Deriving Standards from the Maternal Mortality Report3 and the Department of Health the Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1988-1990.4 We investigated whether these national initiatives had had any effect on the implementation of the recommendations.
Subjects, methods, and results
A questionnaire was circulated during November 1996 to the heads of midwifery at all 325 hospitals listed on the unit’s database. The response rate was 100% after one postal reminder and one telephone call to non-respondents during March 1997. We identified 259 consultant maternity units among these 325 hospitals. We excluded data from units that were not led by consultants because they were incomplete, mainly owing to changes occurring as units closed or were redesignated.
Early in 1997, 235 of the 259 units (91%) were on the site of an acute general hospital, compared with 213 out of 248 (86%) in 1993 (table). Overall, 150 maternity units had between 2000 and 4000 deliveries per annum, with 63 having fewer than 2000 and 46 more than 4000. There was an intensive therapy unit on site in 206 of the units (80%) in 1997 compared with 188 (76%) in 1993. In addition, 249 (96%) had blood transfusion services on site compared with 216 (87%) in 1993. The nearest blood transfusion service for the other 10 units was 2-35 km away, with five services being more than 8 km away. Clinical guidelines were available for the management of major haemorrhage in 240 (93%) units and for eclampsia in 243 (94%) units in 1997 compared with 204 (82%) and 225 (91%) respectively in 1993.
In 1997, 239 units had easy access to the Cochrane Library, with 133 having the library available in the clinical area. A total of 244 units had a copy of the confidential inquiry into maternal deaths, with 241 finding it useful for developing guidelines.
Comment
This audit has shown that the availability of services planned to minimise maternal risk are improving. These changes are likely to have at least in part resulted from the audit cycle and the publication and wide distribution of the various recommendations.1–4 These efforts will, we hope, result in a further reduction in maternal deaths, and we believe that continuation of the confidential inquiries is justified. Audit of maternal morbidity is currently being evaluated in several exercises.5
The recommendation to have all consultant maternity units in acute hospitals has now been achieved in Wales and in two English regions, and it has almost been achieved throughout the rest of the United Kingdom apart from Scotland. The availability of blood transfusion services has improved. The availability of guidelines on eclampsia and major haemorrhage has increased, but some units did not have them. Some heads of midwifery did not have access to the reports on confidential inquiries into maternal deaths despite every trust being sent one.
Table.
Facilities by region in 1997 and 1993.1 Values are numbers (percentages) of maternity units
| Northern and Yorkshire | West Midlands | North West | Trent | Anglia and Oxford | South and West* | North Thames | South Thames | Wales | Northern Ireland | Scotland | United Kingdom | ||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Total No of maternity units | 1993 | 36 | 21 | 28 | 16 | 18 | 21 | 30 | 32 | 17 | 17 | 24 | 260 |
| 1997 | 29 | 19 | 31 | 18 | 20 | 23 | 31 | 32 | 16 | 14 | 26 | 259 | |
| Participating maternity units | 1993 | 36 (100) | 20 (95) | 26 (93) | 15 (94) | 18 (100) | 19 (90) | 27 (90) | 29 (91) | 17 (100) | 17 (100) | 24 (100) | 248 (95) |
| 1997 | 29 (100) | 19 (100) | 31 (100) | 18 (100) | 20 (100) | 23 (100) | 31 (100) | 32 (100) | 16 (100) | 14 (100) | 26 (100) | 259 (100) | |
| Acute hospital on site | 1993 | 31 (86) | 20 (100) | 23 (88) | 14 (93) | 16 (89) | 17 (89) | 21 (78) | 26 (90) | 14 (82) | 16 (94) | 15 (63) | 213 (86) |
| 1997 | 25 (86) | 18 (95) | 26 (84) | 17 (94) | 20 (100) | 23 (100) | 29 (94) | 30 (94) | 16 (100) | 12 (86) | 19 (73) | 235 (91) | |
| Intensive care unit on site | 1993 | 29 (81) | 17 (85) | 19 (73) | 11 (73) | 16 (89) | 14 (74) | 21 (78) | 24 (83) | 13 (76) | 11 (65) | 13 (54) | 188 (76) |
| 1997 | 23 (79) | 16 (84) | 23 (74) | 16 (89) | 18 (90) | 21 (91) | 26 (84) | 27 (84) | 13 (81) | 10 (71) | 13 (50) | 206 (80) | |
| Blood bank on site | 1993 | 31 (86) | 20 (100) | 22 (85) | 13 (87) | 16 (89) | 16 (84) | 23 (85) | 26 (90) | 15 (88) | 15 (88) | 19 (79) | 216 (87) |
| 1997 | 28 (97) | 19 (100) | 29 (94) | 18 (100) | 19 (95) | 23 (100) | 29 (94) | 32 (100) | 16 (100) | 12 (86) | 24 (92) | 249 (96) | |
| Eclampsia protocol available | 1993 | 33 (92) | 19 (95) | 26 (100) | 13 (87) | 17 (94) | 18 (95) | 27 (100) | 26 (90) | 17 (100) | 11 (65) | 18 (75) | 225 (91) |
| 1997 | 28 (97) | 17 (89) | 29 (94) | 17 (94) | 20 (100) | 23 (100) | 28 (90) | 30 (94) | 16 (100) | 12 (86) | 23 (88) | 243 (94) | |
| Haemorrhage protocol available | 1993 | 32 (89) | 17 (85) | 25 (96) | 11 (73) | 15 (83) | 18 (95) | 25 (93) | 27 (93) | 15 (88) | 4 (24) | 15 (63) | 204 (82) |
| 1997 | 29 (100) | 17 (89) | 29 (94) | 16 (89) | 20 (100) | 21 (91) | 26 (84) | 28 (88) | 16 (100) | 13 (93) | 25 (96) | 240 (93) | |
| Cochrane Library available† | 1997 | 27 (93) | 18 (95) | 27 (87) | 18 (100) | 18 (90) | 23 (100) | 28 (90) | 31 (97) | 14 (88) | 10 (71) | 25 (96) | 239 (92) |
Includes Channel Islands. †Not audited in 1993.
Footnotes
Funding: Department of Health core clinical audit grant.
Competing interests: None declared.
References
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