Most maternal deaths are caused by deterioration in unrelated medical conditions

Most maternal deaths are caused by deterioration in unrelated medical conditions

Two thirds of women who die during pregnancy or shortly afterwards do not die from complications of pregnancy but from other medical conditions—such as heart disease, neurological conditions, or mental health problems—that have deteriorated because they were not well controlled, a report has shown.1

From 2009 to 2012, 357 women in the United Kingdom died during their pregnancy or within six weeks of it ending. Of these deaths, 36 were coincidental and 321 related to pregnancy complications and other medical causes, said the report from the MBRRACE-UK programme (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK), led by researchers at the University of Oxford. Death rates were higher in women who were older, from deprived areas, or born outside the UK.

The rate of maternal deaths in the UK dropped from 11.39 in 100 000 women giving birth in 2006-08, to 10.12 in 100 000 in 2010-12. The fall was due to an overall decrease in deaths from complications directly related to pregnancy, such as genital tract sepsis, pre-eclampsia and eclampsia, thrombosis, and haemorrhage. The number of deaths from indirect causes, or from medical or mental health problems made worse by pregnancy, has remained relatively steady.

The report said it was clear that maternal deaths from indirect causes “are still not being addressed effectively.”

It added, “Nearly three quarters of women who died had a coexisting medical complication. There has been no significant change in the rate of indirect maternal death over the last 10 years, a time during which direct maternal deaths have halved; the rate of indirect maternal deaths (6.87 per 100 000 maternities) is now twice that of direct deaths (3.25 per 100 000 maternities). Actions are urgently needed to address deaths from indirect causes.”

By looking at the circumstances surrounding maternal deaths in the UK and the Republic of Ireland the researchers identified a number of areas in which care could be improved for women who had pre-existing medical and mental health conditions.

Marian Knight, professor of maternal and child population health at the University of Oxford’s National Perinatal Epidemiology Unit, told a press conference on Monday 8 December, “For example, it was clear that several women had stopped taking their medications when they got pregnant. Their illness then became worse and in some cases this was a direct cause of their death.

“That is why we are recommending that it is really important that women with pre-existing medical or mental health conditions get good pre-pregnancy care, because that allows them to discuss their medicines and plan which ones are best to continue taking when they are pregnant.”

She added that, if a woman with a pre-existing medical or mental health condition found herself pregnant unexpectedly, it was important that she saw her doctor as soon as possible and did not stop taking any medicines unless she had discussed it with her doctor.

The researchers also found that some women with pre-existing medical conditions did not get the care that they needed from specialists. Doctors in obstetrics are often not familiar with the care of specific medical conditions in pregnancy, Knight said, “so we are recommending that there is better training in dealing with medical complications in pregnancy for junior doctors.”

For this particular report the researchers looked in depth at deaths from sepsis and flu. Almost a quarter of maternal deaths were from sepsis, and by comparing differences in care between women who had died and those who had survived, three actions that could prevent sepsis deaths were identified: early recognition of sepsis symptoms and ensuring that basic observations are conducted (temperature, pulse, blood pressure, and breathing rate); rapid provision of antibiotics; and patient care provided by senior doctors and midwives.

In 2009-12 one in every 11 maternal deaths was from flu: 29 women died from flu during pregnancy or within six weeks of giving birth, and another seven died in the next few months. Almost two thirds of these deaths occurred after flu vaccine had been routinely recommended for pregnant women in the UK.

Knight said, “I can’t overemphasise the importance of flu vaccination in pregnancy; it will save both mums’ and babies’ lives.”

Maria Zambon, director of Public Health England’s Reference Microbiology centre, said, “Around 60% of pregnant women in England have yet to get the flu vaccine this winter—and this is of great concern.”

BMJ 2014;349:g7583