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Abstract
The latest report of the United Kingdom Confidential Enquiry into Maternal Mortality,
conducted by the MBRRACE-UK collaboration, was published in December 2014. The report
has moved from triennial to annual publication with a chapter on each specific cause of
maternal death included once every three years. In 2010-12, overall maternal mortality fell to
10.1 per 100,000 maternities; a 27% decrease compared to 2003-5. Whilst the maternal
mortality rate from genital tract sepsis more than halved from its 20-year high in 2006-2008,
sepsis per-se accounted for almost 25% of deaths. One in 11 of all deaths were associated
with sepsis related to influenza, the majority 2009/A H1N1 influenza, which, in the presence
of an effective vaccine, were largely preventable. The benefits of influenza vaccination should
be promoted and women offered vaccination at any stage of pregnancy. Thrombosis was the
leading cause of direct death, highlighting the ongoing importance of thromboprophylaxis.
Key words
Maternal mortality; sepsis; influenza, haemorrhage, epilepsy
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Introduction
The UK Confidential Enquiry into Maternal Deaths recognises that every maternal death is a
tragedy; to families, to the staff involved, and to the wider communities left behind. Since the
first report in 1952, the maternal mortality rate in the UK has fallen from approximately 90
per 100,000 to 10 per 100,000 maternities. The Enquiry is now conducted by the MBRRACE-
UK collaboration and the latest report includes for the first time review of the care of women
from Ireland. In addition, there is a move to publication of annual rather than triennial
reports, with a chapter on each specific cause of maternal death included once every three
years, alongside topic specific reviews of episodes of maternal morbidity. In the 2014 report,
chapters reviewed morbidity and mortality relating to maternal sepsis along with deaths
related to haemorrhage, amniotic fluid embolism, anaesthesia-related deaths and deaths
from neurological and other indirect causes.
Between 2009-2012, 357 women died during, or within six weeks of the end of their
pregnancy in the UK. Thirty-six deaths were classified as coincidental, thus there were 321
maternal deaths in 2009-12. The maternal mortality rate of 10.1 per 100,000 maternities in
2010-12 represents a statistically significant reduction of 27% since 2003-5 (relative risk [RR]
0.73, 95% confidence interval [CI] 0.61-0.89). Almost all of this observed reduction is due to
a decline in direct (obstetric) deaths, which fell by 48% over this period (RR 0.52, 95% CI 0.39-
0.69). The mortality rate from indirect deaths has, however, remained unchanged for more
than 10 years (RR 0.90, 95% CI 0.72 – 1.11). This observed reduction in the maternal mortality
rate has occurred on the background of an increase in the number of maternities, and
alongside rising levels of obesity, advancing maternal age, and an increasing proportion of
births amongst women born outside the UK; all of which serve to increase the risk of maternal
death.
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The Women Who Died
Amongst the 321 women who died, 30% were still pregnant at the time of death. Of these,
one third were under 20 weeks’ gestation. Amongst all women: 74% had pre-existing medical
complications; 27% were obese, an independent risk factor for maternal death; almost 1 in 10
received no antenatal care, and 25% received care below the minimum standard defined by
the National Institute of Health and Clinical Excellence (NICE).
Direct and indirect deaths: Key facts
Whilst the maternal mortality rate from genital tract sepsis more than halved from its 20-year
high in 2006-2008 (RR 0.44, 95% CI 0.22-0.87), sepsis from all causes accounted for almost
25% of deaths. In particular, one in 11 of all deaths were associated with sepsis related to
influenza, the majority 2009/A H1N1 influenza, which, in the presence of an effective vaccine,
were largely preventable. The benefits of influenza vaccination should be promoted and
women offered vaccination at any stage of pregnancy. Thrombosis was the leading cause of
direct death, highlighting the ongoing importance of thromboprophylaxis.
General Messages for Care
1) Clinical observations
All women showing any signs or symptoms of ill health require a full set of basic observations,
including heart rate, temperature, respiratory rate and blood pressure; the results should be
documented and acted upon. The reviewers frequently found that the respiratory rate was
not measured. This is as important a physiological measure as the pulse rate, blood pressure
and temperature. Sepsis causes an increased respiratory rate to meet an increased oxygen
demand of the tissues, as well as in possible compensation for metabolic acidosis or due to
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the presence of acute respiratory distress syndrome (ARDS). The threshold for the upper limit
of normal in pregnancy is 20 breaths per minute..
2) Avoid referral delays
Delays in escalating the care of complex cases contributed to poor outcomes in a number of
cases, and it is important to be aware of ‘red flags’ for escalating care such as those highlighted
in relation to sepsis below. Junior medical and midwifery staff should not hesitate to seek
advice from senior colleagues, particularly at night and weekends, when on-site cover may be
limited. Consultant to consultant referral should be undertaken in cases where specialist
advice is required to minimise delays when assessing and treating women.
3) Clinical service configuration
Almost three quarters of women who died from both direct and indirect causes had pre-
existing medical problems, including a wide range of different conditions across all body
systems. Such women represent a high-risk group and need to receive the appropriate
individualised multidisciplinary evidence-based care pre-pregnancy, during pregnancy and
after delivery.
Topic Specific Messages
1) “Think sepsis”
Sepsis refers to an infection with coexisting features of the systemic inflammatory response
(SIRS) (see Box). Eighty-three women died of sepsis related causes (maternal mortality rate
2.04 per 100,000 maternities).
Whilst there were examples of excellent care being provided to women, delays in the
diagnosis and management of sepsis was a recurring theme. Repeated non-specific
presentations to non-obstetric services, may be indicative of sepsis and women should be
evaluated for ‘red flag’ sepsis (see Box). Where sepsis is suspected, a sepsis care-bundle
should be initiated with urgency. National guidance requires that obstetric units have a