Maternal mortality in the UK and the need for obstetric physiciansBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4993 (Published 09 August 2011) Cite this as: BMJ 2011;343:d4993
- Catherine Nelson-Piercy, professor of obstetric medicine and consultant obstetric physician1,
- Lucy Mackillop, consultant obstetric physician2,
- David J Williams, consultant obstetric physician3,
- Catherine Williamson, professor of obstetric medicine4,
- Michael de Swiet, emeritus professor of obstetric medicine4,
- Christopher Redman, professor of obstetric medicine2
- 1Guy’s and St Thomas’ Foundation Trust, St Thomas’ Hospital, London SE1 7EH, UK
- 2John Radcliffe Hospital, Oxford, UK
- 3University College Hospital, London, UK
- 4Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare Trust, London, UK
Since the first report of the Confidential Enquiry into Maternal Deaths in 1952, the maternal death rate in the United Kingdom has decreased dramatically.1 This has been due to an impressive fall in deaths with direct obstetric causes, including obstetric haemorrhage, ectopic pregnancy, and venous thromboembolism. This has partly been achieved through better understanding of obstetric complications, advances in medical treatments, and the use of evidence based guidelines that implement recommendations made in previous reports.2 However, almost 60 years since the first Confidential Enquiry into Maternal Deaths report, the most recent report, published in March 2011, highlights a worrying trend in the causes of maternal mortality in the UK.1
The report states that most maternal deaths in the UK now occur in women with pre-existing or new onset medical and psychiatric conditions (“indirect causes”). The leading cause of maternal death remains cardiac disease; the second is neurological disease. Most worryingly, the number of maternal deaths due to indirect causes has significantly increased over the past 20 years (table⇓). Furthermore, most of these deaths are associated with substandard care, and in one third of cases this is classified as major substandard care, where different care might have prevented death of the mother. These failings require urgent attention.
Much has been written about the failure to achieve the United Nations’ fifth millennium development goal to reduce the maternal mortality ratio by three quarters by 2015.3 But it is under-appreciated that even in the UK women die in pregnancy or shortly after delivery from preventable and treatable medical causes such as epilepsy, diabetes, heart failure, and asthma.
Past and present Confidential Enquiry into Maternal Deaths reports have repeatedly shown that factors contributing to substandard care include failure to appropriately diagnose, investigate, and treat women with new onset chest pain, headache, or other medical symptoms.1 This often arises when well meaning clinicians prioritise the health of the fetus over that of the mother, but it can result in the death of both mother and fetus.
Obstetricians and midwives alone cannot reduce indirect maternal deaths—they need support from physicians and general practitioners. But many doctors are unfamiliar with the interaction between pregnancy and medical disease, the safety of radiological investigations in pregnancy, and the risk-benefit ratio for the use of different drugs in pregnancy. During the three years that the current report is based on (2006-8), one woman died from asthma after her general practitioner advised her to stop taking oral prednisolone.1 In many cases pre-pregnancy counselling was not given to women with pre-existing medical conditions, so that they entered pregnancy not understanding their risks or how their management could be optimised.
Specific recommendations from the latest report include:
All women planning pregnancies that are likely to be complicated by potentially serious medical conditions should have pre-pregnancy counselling
Women whose pregnancies are complicated by potentially serious medical conditions should be referred to appropriate specialist centres of expertise, where both care for their medical condition and their obstetric care can be optimised
Doctors who do not work directly with pregnant women need to know more about the interaction between the conditions that they are treating and pregnancy1
Doctors and general practitioners looking after pregnant women in clinics or in acute settings need to have the skills to assess the common symptoms of pregnancy including breathlessness, headache, and epigastric pain. These are mostly benign, but they can herald or represent fatal disease. A “back to basics” section of the latest report highlights the “red flags” for these symptoms.4 It is not clear who is going to provide the pre-pregnancy counselling recommended in the report—the general practitioner, the woman’s own doctor, or an obstetrician?
Increasing numbers of women with often complex medical conditions are now becoming pregnant or seeking fertility treatment. Women are delaying childbearing until later in life, and the menopause is no longer a barrier to pregnancy. Older women are more likely to be obese, have hypertension, or be predisposed to gestational diabetes and thromboembolism. The success of modern medicine, surgery, and transplantation in treating conditions that previously would have precluded pregnancy has led to increasing numbers of “high risk” pregnancies in women with chronic medical disorders. Furthermore, migrant women present with disorders such as rheumatic heart disease or tuberculosis that can cause complications in pregnancy. These women require expert and informed pre-pregnancy counselling and expert multidisciplinary care during and after pregnancy to optimise both maternal and fetal outcomes.
The data and recommendations from the confidential enquiries report suggest that the training of obstetric physicians and their numbers should be expanded and that the subspecialty should be formally recognised. Obstetric physicians specialise in the care of women with pre-existing and new onset medical problems in pregnancy, and much of their work involves specialised pre-pregnancy counselling. Most surgical specialties have medical counterparts (neurosurgery, urology, cardiac surgery), but not obstetrics. Moreover, many other countries, including Canada, the United States, Australia, and New Zealand, recognise the importance of obstetric medicine and have well developed training programmes.5
The expansion of obstetric anaesthesia was associated with an impressive fall in anaesthesia related deaths in pregnancy. The current maternal death figures show a need to involve medical skills. An expansion in the number of obstetric physicians would be a positive step towards reducing deaths from medical disorders in pregnancy. Not every obstetric unit needs an obstetric physician, but they all need access to one, perhaps within maternity networks. Such a specialist in each region would ensure that when obstetricians, physicians, or general practitioners confront difficult or complex medical problems in pregnancy they will have easy access to an expert opinion. In addition, obstetric medicine should form part of the postgraduate training curriculum of general practitioners and physicians, as already happens in the US, Canada, Australia, and New Zealand.
Cite this as: BMJ 2011;343:d4993
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, CN-P, CW, and MdS are central assessors for the Confidential Enquiries into Maternal Deaths, UK.
Provenance and peer review: Not commissioned; externally peer reviewed.