Confidential Enquiries into Maternal Deaths and Morbidity 2013–15

Posted by Patricia Wakeford, 8th December 2017

This report looks at lessons learned and is dated 2017. The previous report looked at 2010 to 2012. Please click here to view the report.

The report provided key messages:

  • 8.8 women died per 100,00 in pregnancy or up to 6 weeks post delivery
  • Of these two thirds had pre-existing physical or mental health issues

This death rate has not changed since the 2010-2012 report. However, reducing mortality is very important. The plan is to achieve a reduction of 50% by the year 2030.

The leading cause of maternal death during the 6 weeks post-delivery is thrombosis or thromboembolism. These are considered direct causes of maternal death. I was very surprised to hear that the third highest cause of direct maternal death was maternal suicide. This equates to 1 in 7 women and is a startling statistic.

‘Assessors judged that 35% of women who died, 4% of women with severe morbidity from epilepsy and 26% of women with severe mental illness had good care. However, improvements in care may have made a difference to the outcome for 41% of women who died, 52% of women with epilepsy and 26% of women with severe mental illness’.

There is a focus on ensuring that women with pre-existing conditions receive adequate counselling and advice. It is suggested that funding should be available for women to have a flu vaccination when they attend an antenatal clinic appointment.

Women with epilepsy should be provided with advice pre-pregnancy about their medication and the risks of discontinuing without medical advice and the impact this can have on mother and baby.

Mental health issues, either past or recently diagnosed should be individually assessed and a plan of care put in place.

The conclusion is that there are opportunities to reduce further maternal mortality by planning ahead and considering the issues raised above as well as others detailed in the report itself.

It is good to see plans in place to reduce mortality, but as a midwife for over 20 years; it is still very sad to see that it may take until 2030 to reduce this by a further 50%. I have been asked to assess cases where a mother has died shortly after having her baby. This is a devastating event for a family to go through. I do hope that these plans prevent many more maternal deaths in the future and that the NHS have the funding available to ensure that these recommendations can be actioned.

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