This isn't an easy topic to write about, but following Panorama's "One Born Every 40 Seconds" shown on BBC1 on Monday 25th July, I felt it was something I wanted to explore further. I can understand if you do not wish to read further, its not pleasant subject matter. However, what concerned me, is that the documentary only focussed on one possible cause of these deaths, and that is the failure of the NHS to provide adequate midwifery resources. I feel that this is only part of the story, and wanted to look at the role of patient education and awareness. In this post I only focus on maternal death, not the death of the baby, that is another post for another day.
The bulk of the source information that Panorama used was from the Saving Mother's Lives report - reviewing maternal deaths 2006-2008.* You can find the link to the report in its entirety here, it makes for sobering reading. I am just a mum, I'm not a researcher, or a doctor or a clinician. But I am passionate about awareness and education. Scaremongering is one thing, but empowerment is another. And what worried me about the Panorama reporting is that it didn't empower, it frightened. What can a pregnant woman do to ensure she is safe in pregnancy and childbirth? She can educate and empower herself, and her partner.
I think its important to note that the actual numbers we are talking about are very small, in the three year period the report covers, 261 women died in pregnancy. Now this figure covers direct and indirect maternal deaths, and for the purposes of this discussion the number I am interested in is the direct maternal deaths, 107 in total, of conditions or situations that only arose due to pregnancy. I think the indirect number is significant too and may be a subject for another post.
The main cause of direct maternal death is sepsis/genital tract infection. I had no idea that this was the case. The report talks about the link between sore throat and genital tract infection. How many women know, that if they are pregnant and have a sore throat, they should consult their doctor or midwife. I certainly didn't. The second main cause is pre-eclampsia/eclampsia, haemorrhage is way down the list at number 6.
Until I was pregnant, I had very little awareness of pre-eclampsia. I knew, from my job authorising procedures for a medical insurer, that pre-eclampsia necessitates swift delivery usually be caesarean section, but didn't really know any more than that. I certainly did not expect to get it, and I did not think it could be fatal, not really. But its very clear that pre-eclampsia/eclampsia is killing women in England in the 21st century.
It's important to remember that the numbers are small, 19 died in the three year period as a result of pre-eclampsia/eclampsia and as its a very common condition, its clear that it is managed, in the most part, very well. It is also clear that initiatives in this area are working. The number of women dying of these conditions in the reporting periods of 1985-87 and 1988-1990 was 27 in both periods, so clearly we are making progress.
Alarmingly though, the rate of women dying as a result of sepsis (and one of the cases featured in last nights programme was sepsis) is increasing. I certainly didn't realise that infection can kill women in pregnancy or shortly after delivery, and I am not sure I would have given a sore throat a second thought. I think, alarmingly, One of the ten recommendations of the report is that there should be more education about genital tract infection and sepsis. I would have even shrugged off a urinary tract infection as being annoying, not necessarily a source of danger. And I do not think I am alone in this.
What is clear from the report is the role that antenatal care plays in preventing maternal death. A significant number of the mortalities were women who either did not have any antenatal care, or sought antenatal care late in their pregnancies.I think also, whilst this doesn't come out in the report, is the quality of antenatal care. Surely a shortage of hospital midwives equates to a shortage of community midwives. I think laying the blame at the door of midwives in particular is wrong. The situation is a lot more complex than that.
I remain convinced that education, awareness and empowerment is important. Being aware of any pre existing conditions and ensuring you get proper consultant input is essential. Being aware of signs and symptoms of consitions like sepsis and pre-eclampsia is vital. Listen to your body, and have your voice heard, don't allow yourself to be fobbed off. Follow things up yourself, if you have been referred and not heard anything, ring - all hospitals in England have a PALS (patient advisory liaison) service, use it.
In a busy, and at times understaffed system being aware and assertive is important.
*Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternal
deaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl. 1):1–203.