NIHR Signal Death in childbirth is rare but women with pre-existing health problems are at greater risk

Published on 30 August 2016

Pregnant women with pre-existing mental health problems or medical conditions, such as high blood pressure, muscular or autoimmune conditions, are at increased risk of dying from pregnancy-related complications like blood clots, high blood pressure or haemorrhage.

Maternal deaths and “near misses” are rare in pregnancy, but there is potential to reduce them further. This major NIHR study used a variety of sources, including comprehensive national databases of cases and interviews with women and their partners, to try and determine the factors and scale of risk associated with these events.

It confirmed that almost half of all maternal deaths could be attributed to pre-existing medical or mental health conditions and further specified what these are. Other associated factors included older women, undergoing caesarean section, from Black or Indian ethnic background, and making less use of antenatal services.

The findings highlight the need for healthcare staff to recognise women at increased risk of pregnancy complications, and counsel them on their risk during pregnancy, including mode of delivery. Such women should also be represented when designing maternity services.

Death in childbirth is rare but women with pre-existing health problems are at greater risk

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Why was this study needed?

In the UK maternal deaths are rare, occurring in three in every 100,000 childbirths (around 30 per year). Severe pregnancy complications needing urgent treatment and carrying risk of death - “near-miss” events – are also uncommon. These events still greatly impact women and their families. For example, the value of clinical negligence claims in 2014/15 was higher for obstetrics than any other specialty.

To understand how to improve services, we need to establish the role of pregnancy-related factors, maternal characteristics and pre-existing illness, how soon complications are identified, and interventions. Research into cases of deaths and “near misses” – severe complications is often limited to reviewing individual cases. Instead, this major NIHR study drew on cases in comprehensive UK-wide databases including the Confidential Enquiry into Maternal Deaths, and on women’s experiences.

The aim of this research was to describe best practice and identify maternity practices that may reduce risk of complications and prevent future deaths and near-misses.

What did this study do?

This study is part of a larger NIHR funded programme of work, while this signal features only the part looking at risk factors related to maternal deaths.

The study used a variety of methods. Data was analysed from national databases, including case reports of specific near-miss morbidities between 2005 and 2014. The experiences of women who had near-miss events and their partners were explored through 47 interviews over 4 years. Findings were compared with women without severe pregnancy complications.

The researchers explored the influence of socioeconomic status, ethnicity and maternal age, and identified factors associated with progression from severe illness to death. They also examined maternity care models that were informed by past patient experiences, compared to maternity services commissioned without patient input.

As data was observational and based on relatively few cases, it is not possible to fully account for all maternal and health-service factors that may have influenced the findings.

What did it find?

  • Pre-existing medical or mental health problems were the greatest contributor to risk of maternal death. Women who died from complications such as pregnancy-related high blood pressure (pre-eclampsia), blood clot in the lungs (pulmonary embolism), or blood infection (sepsis) were almost five times more likely than those who survived to have had existing problems (adjusted odds ratio [aOR] 4.82, 95% confidence interval [CI] 3.14 to 7.40). Associated problems included mental health, asthma, high blood pressure, autoimmune and muscular conditions, infections and blood disorders. Pre-existing medical or mental health conditions were estimated to account for almost half of all maternal deaths.
  • Maternal characteristics associated with risk of death were older age (35 years or over: aOR 2.36, 95% CI 1.22 to 4.56), and being of Black African or Caribbean (aOR 2.38, 95% CI 1.15 to 4.92). Indian ethnic background was specifically associated with risk of death as a direct result of pregnancy complications (aOR 2.70, 95% CI 1.14 to 6.43).
  • Additional factors associated with risk of death included poor uptake of antenatal care, substance misuse, previous pregnancy problems, and pregnancy-related high blood pressure in the current pregnancy.
  • Caesarean section is associated with risk of serious complications both in the current and future pregnancies. The number of previous caesareans, time interval since last pregnancy, and induction of labour may influence risk of rupture of the uterus.

What does current guidance say on this issue?

Maternity services are national and local priorities for service improvement and there is a strong focus on service quality.

Royal College of Gynaecologists’ standards from 2008 recommend multidisciplinary care is available for all women with pre-existing medical, psychological or social problems that may require specialist advice during pregnancy.

2014 NICE guidance recommends low-risk women be advised that a midwifery-led unit (or home birth if not first child) is particularly suitable. If a caesarean section is the safest option, for example because of another health condition, NICE recommends explaining the risks and benefits so women can make an informed decision.

What are the implications?

To further reduce maternal deaths and “near misses”, this research highlights that maternity service professionals need to recognise the increased risk for women with pre-existing medical or mental health conditions.

Women of older age and those with previous or planned caesarean section should be counselled about their risk and planned mode of delivery.

When designing or commissioning maternity services it is important to fully engage service users, including representation of minority ethnic groups and women who have experienced near-miss events, and their partners or families.

Citation and Funding

Knight M, Acosta C, Brocklehurst P, et al. Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity. Programme Grants Appl Res. 2016;4(9).

This project was funded by the National Institute for Health Research Programme Grants for Applied Research (project number RP-PG-0608-10038).

Bibliography

NHSLA. NHS Litigation Authority report and accounts 2014/15.London: National Health Service Litigation Authority; 2015.

NICE. Caesarean section. CG132. London: National Institute for Health and Care Excellence; 2011.

NICE. Intrapartum care for healthy women and babies. CG190. London: National Institute for Health and Care Excellence; 2014.

Knight M, Kenyon S, Brocklehurst P, et al. Saving lives, improving mothers’ care - lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. Oxford: Maternal, Newborn and Infant Clinical Outcome Review Programme, National Perinatal Epidemiology Unit, University of Oxford; 2014.

RCOG. Standards for Maternity Care. London: Royal College of Obstetricians and Gynaecologists; 2008.

Why was this study needed?

In the UK maternal deaths are rare, occurring in three in every 100,000 childbirths (around 30 per year). Severe pregnancy complications needing urgent treatment and carrying risk of death - “near-miss” events – are also uncommon. These events still greatly impact women and their families. For example, the value of clinical negligence claims in 2014/15 was higher for obstetrics than any other specialty.

To understand how to improve services, we need to establish the role of pregnancy-related factors, maternal characteristics and pre-existing illness, how soon complications are identified, and interventions. Research into cases of deaths and “near misses” – severe complications is often limited to reviewing individual cases. Instead, this major NIHR study drew on cases in comprehensive UK-wide databases including the Confidential Enquiry into Maternal Deaths, and on women’s experiences.

The aim of this research was to describe best practice and identify maternity practices that may reduce risk of complications and prevent future deaths and near-misses.

What did this study do?

This study is part of a larger NIHR funded programme of work, while this signal features only the part looking at risk factors related to maternal deaths.

The study used a variety of methods. Data was analysed from national databases, including case reports of specific near-miss morbidities between 2005 and 2014. The experiences of women who had near-miss events and their partners were explored through 47 interviews over 4 years. Findings were compared with women without severe pregnancy complications.

The researchers explored the influence of socioeconomic status, ethnicity and maternal age, and identified factors associated with progression from severe illness to death. They also examined maternity care models that were informed by past patient experiences, compared to maternity services commissioned without patient input.

As data was observational and based on relatively few cases, it is not possible to fully account for all maternal and health-service factors that may have influenced the findings.

What did it find?

  • Pre-existing medical or mental health problems were the greatest contributor to risk of maternal death. Women who died from complications such as pregnancy-related high blood pressure (pre-eclampsia), blood clot in the lungs (pulmonary embolism), or blood infection (sepsis) were almost five times more likely than those who survived to have had existing problems (adjusted odds ratio [aOR] 4.82, 95% confidence interval [CI] 3.14 to 7.40). Associated problems included mental health, asthma, high blood pressure, autoimmune and muscular conditions, infections and blood disorders. Pre-existing medical or mental health conditions were estimated to account for almost half of all maternal deaths.
  • Maternal characteristics associated with risk of death were older age (35 years or over: aOR 2.36, 95% CI 1.22 to 4.56), and being of Black African or Caribbean (aOR 2.38, 95% CI 1.15 to 4.92). Indian ethnic background was specifically associated with risk of death as a direct result of pregnancy complications (aOR 2.70, 95% CI 1.14 to 6.43).
  • Additional factors associated with risk of death included poor uptake of antenatal care, substance misuse, previous pregnancy problems, and pregnancy-related high blood pressure in the current pregnancy.
  • Caesarean section is associated with risk of serious complications both in the current and future pregnancies. The number of previous caesareans, time interval since last pregnancy, and induction of labour may influence risk of rupture of the uterus.

What does current guidance say on this issue?

Maternity services are national and local priorities for service improvement and there is a strong focus on service quality.

Royal College of Gynaecologists’ standards from 2008 recommend multidisciplinary care is available for all women with pre-existing medical, psychological or social problems that may require specialist advice during pregnancy.

2014 NICE guidance recommends low-risk women be advised that a midwifery-led unit (or home birth if not first child) is particularly suitable. If a caesarean section is the safest option, for example because of another health condition, NICE recommends explaining the risks and benefits so women can make an informed decision.

What are the implications?

To further reduce maternal deaths and “near misses”, this research highlights that maternity service professionals need to recognise the increased risk for women with pre-existing medical or mental health conditions.

Women of older age and those with previous or planned caesarean section should be counselled about their risk and planned mode of delivery.

When designing or commissioning maternity services it is important to fully engage service users, including representation of minority ethnic groups and women who have experienced near-miss events, and their partners or families.

Citation and Funding

Knight M, Acosta C, Brocklehurst P, et al. Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity. Programme Grants Appl Res. 2016;4(9).

This project was funded by the National Institute for Health Research Programme Grants for Applied Research (project number RP-PG-0608-10038).

Bibliography

NHSLA. NHS Litigation Authority report and accounts 2014/15.London: National Health Service Litigation Authority; 2015.

NICE. Caesarean section. CG132. London: National Institute for Health and Care Excellence; 2011.

NICE. Intrapartum care for healthy women and babies. CG190. London: National Institute for Health and Care Excellence; 2014.

Knight M, Kenyon S, Brocklehurst P, et al. Saving lives, improving mothers’ care - lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–13. Oxford: Maternal, Newborn and Infant Clinical Outcome Review Programme, National Perinatal Epidemiology Unit, University of Oxford; 2014.

RCOG. Standards for Maternity Care. London: Royal College of Obstetricians and Gynaecologists; 2008.

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Published on 1 July 2016

Knight M, Acosta C, Brocklehurst P, Cheshire A, Fitzpatrick K, Hinton L, Jokinen M, Kemp B, Kurinczuk JJ, Lewis G, Lindquist A, Locock L, Nair M, Patel N, Quigley M, Ridge D, Rivero-Arias O, Sellers S, Shah A on behalf of the UKNeS coapplicant group.

Programme Grant for Applied Research , 2016

Background Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed. Funding The National Institute for Health Research Programme Grants for Applied Research programme.

Expert commentary

This programme demonstrates the value of addressing complex clinical problems from a range of disciplinary perspectives. It supports the direction of maternity care resources towards marginalised and older women, and those with co-morbidities. The strong message about aggressive antibiotic treatment for women showing signs of infection is important, but is not balanced against population risks of consequent ‘just-in-case’ antibiotic use. Service providers should act on the findings on the adverse effects of unnecessary instrumental interventions in labour for healthy women and babies; and commissioners can build on the positive outcomes of experience based commissioning, including both professionals and service users.

Soo Downe, Professor in Midwifery Studies, University of Central Lancashire