Tuesday, December 04, 2007

Maternal mortality in the UK

CEMACH (the Confidential Enquiry into Maternal and Child Health) has published it's biennial report on maternal mortality. It has been getting a lot of press, for two reasons. Maternal mortality in the UK has risen slightly and the authors of the review put a lot of the blame on obesity.

The report is long, 296 pages, and I just finished reading it. It is sad and sobering reading and I have some preliminary thoughts. First, the title of the report has been changed. Until this version, it was called "Why Mothers Die" which is apt and to the point. Now, the title has been changed, presumably for political reasons to Saving Mothers Lives. It is not about lives saved; it is about lives lost and it seems disingenuous to change the title.

Second, the report presents so much data, and slices and dices it in so many different ways, that it is bit difficult to figure out what is going on. Nonetheless, we can say certain things about it.

It is unclear whether maternal mortality is truly rising or whether the risk profile of the patients is rising. Pregnant women are older and many have serious pre-existing medical conditions. Older women and women with pre-existing medical conditions are known to have substantially increased risk of maternal mortality.

While obesity is certainly a factor, the report dramatically overplays its significance. It lumps overweight (BMI greater than 25) with obesity (BMI greater than 30) and morbid obesity (BMI greater than 40). A substantial proportion of the population is overweight and it is not clear whether the increase in maternal mortality among this group represents increased risk or increased numbers (probably the latter).

Every case of maternal death is reviewed and categorized based on whether it was a direct obstetric death, and indirect death (caused by pre-existing medical conditions) or a coincident death (such as auto accident). An effort was made to determine whether each death was preventable and whether substandard care played a role in the death.

The majority of preventable deaths occured after substandard medical or midwifery care. To a certain extent, this is a sign of progress in that most life threatening complications were recognized and then treated appropriately. Of course, it also means that many of the women who died did not have to die. The common thread in these potentially preventable deaths is the failure to recognize risk factors and complications. The medical personnel involved insisted that everything was normal when it was not. There were repeated attempts to minimize the seriousness of alarming signs and symptoms. In contrast, as far as I can tell, there were no maternal deaths related to over use of interventions or technology.

The bottom line is that maternal mortality may have risen in the UK, but probably because the risk profile of the patients rose. As a general matter, serious complications are identified and successfully treated. To the extent that there is need for improvement, it is that medical personnel need to be more vigilant about the dangers of childbirth. Modern obstetrics has become so successful in reducing maternal mortality that some people have become complacent, and women die unnecessarily as a result.


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