Recent Enquiries

Saving Mothers’ Lives

A Confidential Enquiry into Maternal and Child Health

It is a government requirement that the death of any woman during pregnancy should be subject to a careful and thorough investigation. Since 2005 the National Patient Safety Agency (NPSA) has commissioned a triennial report called The Confidential Enquiry into Maternal and Child Health (CEMACH). The latest CEMACH report gathered information from 2003-2005 and was published in December 2007

2,891,892 women became pregnant between 2003-2005 of which 295 women died. In many cases the death was unavoidable but in some cases there was substandard care. The health professionals involved were requested to provide a full and accurate account of the circumstances leading to the woman’s death and to reflect on any clinical or other lessons that had been learned. The causes from these individual deaths were then gathered together and the results published along with national recommendations in an attempt to improve maternity care and hopefully prevent such tragedies from happening again.

There has been a persistent failure to recognise ‘ectopic pregnancy’ and hence one of the ‘top-ten’ key recommendations from the latest CEMACH report was that there should be national guidelines for the management of pain and bleeding in early pregnancy. The Ectopic Pregnancy Foundation attempts to provide patients and doctors with information in order to help manage this potentially dangerous condition.

Findings of the CEMACH report

Deaths in pregnancy are divided into those causes that are directly related to being pregnant (these are called Direct deaths), and those where there was already an underlying medical/psychiatric condition such as heart disease or depression that was made worse by the pregnancy (these are called Indirect deaths)

Number/Rate of Deaths per 100,000 maternities Direct deaths Indirect deaths Indirect
1985-1987 139 6.13 84 3.70 223 9.83
1988-1990 145 6.14 93 3.94 238 10.08
1991-1993 128 5.53 100 4.32 228 9.851
1994-1996 134 6.10 134 6.10 268 12.19
1997-1999 106 4.99 136 6.40 242 11.40
2000-2002 106 5.31 155 7.76 261 13.07
2003-2005 132 6.24 163 7.71 295 13.95

Interpreting the results of the CEMACH Report
Since the mid 1980s the number of women dying from direct deaths has remained relatively constant with only small random fluctuations, but deaths from Indirect causes have more than doubled. Interpreting the trends in maternal mortality is extremely complex and although the actual number of direct deaths in pregnancy increased very slightly in 2003-2005 compared to previous years, this rise from 106 to 132 is not statistically significant.

Many possible explanations have been put forward for the rising mortality rate. These include the rising numbers of older or obese mothers, women whose lifestyles put them at risk of poorer health and a growing proportion of women with medically complex pregnancies. Women born outside the UK often have more complicated pregnancies, more serious underlying medical conditions and may be in poorer health. They can also experience difficulties in accessing maternity care.

Early Pregnancy and Ruptured Ectopic Pregnancy
TThe rate of ectopic pregnancy has remained stable at 11 per 1000 maternities. Of the 2,891,892 pregnancies in 2003-2005 there were 32,100 ectopic pregnancies. The vast majority was treated safely but sadly 14 women died in early pregnancy, of which ten were a result of ruptured ectopic pregnancy.

1985-87 88-90 91-93 94-96 97-99 00-02 03-05
Ectopic pregnancy 11 15 9 12 13 11 10
Miscarriage 4 6 3 2 1 1 1
Legal termination 1 3 5 1 2 3 2
Other 0 0 2 0 0 0 3
Total Early Deaths 16 24 17 15 17 15 14

The CEMACH report clearly concludes that:

“Clinicians in primary care and Emergency Departments need to be aware of atypical clinical presentations of ectopic pregnancy and especially the way in which it may mimic gastrointestinal disease.

Fainting in early pregnancy suggests the possibility of ectopic pregnancy and conservative approaches to the treatment of ectopic pregnancy should not blind clinicians to the dangers of this condition.

Laparoscopy or laparotomy should be undertaken without delay if there are clinical signs suggestive of tubal rupture. Medical treatment of ectopic pregnancy should be based on strict adherence to protocols, with women having immediate access to in-patient facilities if complications occur.”

Early pregnancy deaths: Specific Recommendations

In women of reproductive age who present to practitioners with diarrhoea and vomiting and/or fainting, the possibility of ectopic pregnancy should be considered.

Medical treatment of ectopic pregnancy should be based on strict adherence to protocols, with women having immediate access to in-patient facilities if complications occur.

Mr Patrick Bose BSc, PhD, MBBS, DFFP, MRCOG.