Last December, the long awaited and much anticipated most recent confidential enquiry into maternal mortality in the UK was published by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK). The full title ‘Saving Lives, Improving Mothers’ Care: Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–2012’ highlights two of the developments that the new report style brings, namely the inclusion of maternal deaths from the Republic of Ireland as well as the UK and a review of care of some women with severe morbidity in pregnancy.
The report continues the longest running programme of Confidential Enquiries into maternal deaths worldwide. It is essential reading for anyone working in maternal health and is downloadable from https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/Saving%20Lives%20Improving%20Mothers%20Care%20report%202014%20Full.pdf
From now on there will be annual reports instead of the previous triennial reports, and deaths from specific causes will be considered in depth once every three years. Surveillance data on all causes will be published annually. The current report includes topic-specific reviews of deaths and morbidity due to sepsis, and deaths from haemorrhage, amniotic fluid embolism, anaesthetic-related causes, neurological and other indirect causes.
Care is reviewed against national guidance, such as from the National Institute of Health and Care Excellence, where such guidance exists. The executive summary includes key areas for action for different groups (policy makers, medical managers and clinicians) and topic-specific messages for care. Each chapter also highlights further key messages.
The headline of the report is that there has been an overall reduction in maternal mortality (to 10.12 per 100,000 maternities) but that this is mostly due to a fall in deaths from direct obstetric causes, such as pre-eclampsia and genital tract sepsis, without any change in death rates from indirect causes. In the past 10 years, the rate of direct deaths has halved and that of indirect deaths has remained unchanged. Cardiac disease remains the leading cause of maternal death and venous thromboembolism is the commonest direct cause. The death rate from epilepsy in pregnancy (0.40 per 100,000) is now higher than the death rate from hypertensive disorders in pregnancy (0.38 per 100,000).
The first key area for action for Policy-makers, Service Planners and Commissioners, Public Health and Professional Organisations in the MBRRACE report states:
Two thirds of women died from indirect (medical and psychiatric) causes and almost three quarters of all women who died had co-existing medical complications. High level actions are needed to ensure that physicians are appropriately trained in, and engaged with, the care of pregnant women, and that services are designed for women with medical conditions which provide appropriate and evidence-based care across the entire pathway, including pre-pregnancy, during pregnancy and delivery, and postpartum.
This statement has far-reaching implications for the role of obstetric physicians and training in the management of medical problems in pregnancy for all physicians.
Two key areas for action for Medical Directors, Clinical Directors, Heads of Midwifery and Clinical Service Managers in the MBRRACE report are;
Women with pre-existing medical conditions should have pre-pregnancy counselling by doctors with experience of managing their disorder in pregnancy.
Women with medical disorders in pregnancy should have access to a coordinated multidisciplinary obstetric and medical clinic, thereby avoiding the need to attend multiple appointments and poor communication between senior specialists responsible for their care.
Another key recommendation from the report states:
Appropriately trained senior physicians should be involved in the care of pregnant and postpartum women with new onset symptoms suggestive of or known underlying medical disorders.
In the UK, at least, it would appear that the current system of sub-specialty training in maternal fetal medicine for obstetricians and the assumption that specialist physicians have the necessary training and expertise to help manage women with medical problems in pregnancy is insufficient to meet the needs of all pregnant women with pre-existing or new onset medical problems. The recommendations from the report support better training in obstetric medicine for physicians. This is difficult to reconcile within a system that does not recognize obstetric medicine as a specialty. But trainee physicians themselves do recognize the need and welcome the opportunity to access training opportunities.
Ironically, despite this acknowledgement that training and expertise need to be rolled out so more women can benefit from multidisciplinary expert care, our reapplication to have Obstetric Medicine, the journal, included in Medline was unsuccessful. At the journal’s editorial board meeting in New Orleans in October, it was decided that we would not reapply or appeal this decision. On a positive note, this means that we have a degree of freedom about what we can now include in the journal and have therefore decided to publish the abstracts from the ISOM 2014 meeting in this issue. Many thanks to Ghada Bourjeilly for overseeing their preparation.
Also in this issue, two contrasting reviews of HIV in pregnancy: one from the developed world and one from South Africa where for many years there was political resistance to any form of maternal screening, treatment or prevention of vertical transmission, contributing to the current 30% of pregnant women who are HIV positive.
Obstetric Medicine remains the only journal addressing the specialised needs of obstetric physicians and other health care professionals committed to the expert management of women with medical disorders of pregnancy. We will continue to develop the Journal to publish research, clinical cases and topic reviews of interest to you, our readers. We would like to hear from you about proposals for future content and any ‘themed issues’ you think may be appropriate.
Declarations: none