Reality check — Saving mothers’ lives
The new government report on maternal deaths in
What has been appalling is the media coverage. It is difficult to imagine how it’s possible to read the 296-page report and arrive at such portrayals. Before we look at the report’s other findings, it’s important to address what’s most on the minds of millions of women around the world frightened by the headlines.
Reuters headlined with: “Obesity behind half of UK maternal birth deaths.” The Telegraph announced “Over half of new mothers who die are obese,” echoing other mainstream media reports, saying: “More than half of women who die after having a child are overweight, as the obesity epidemic drives up the death rate among new mothers.” And India Times reported: “Obesity has become the greatest threat to the lives of pregnant women.”
The report actually stated that among the maternal deaths, 51% occurred among women who were labeled ‘overweight’ or ‘obese.’ But ... 54.8% of women of childbearing age in Britain were labeled ‘overweight’ or ‘obese.’ In other words, fewer fat women than would be expected had died. In contrast, 48% of maternal deaths were among women with BMIs<25 — 13% higher than the 42.3% they represented in the population.
Another important fact is that the obesity rate in England has not appreciably changed for years. According to the report, based on the Health Survey for England, 21.2% of women were obese in 1998. Seven years later, the rate had not significantly changed — 21.9% of women were labeled obese in 2005, with a high of 23.5% in 2001. This is not the definition of an epidemic.
As with all correlations, weight correlations don’t tell us what the causes of maternal deaths might be. During those years, the demographics of the UK notably changed, bringing new challenges to maternal healthcare. In fact, as we’ll see, weight itself is hardly mentioned among the most significant issues raised in the report.
The media has also failed to mention that the ‘overweight’ and ‘obese’ women were significantly older than those of lower BMIs. Nor has the media reported that the report found the highest rates of maternal deaths among older women — 29.4% among women 40+ as compared to 9.8% among women 20-24.
Rather than scare people about a nonexistent problem and pile on with more obesity scares, if the health of women and good pregnancy outcomes are really the primary concerns, then identifying the most pressing problems is the first step towards making a difference.
The key findings
The report’s key finding was that “maternal deaths are extremely rare in the United Kingdom.” The maternal mortality rate for 2003-05 identified in this report, regardless of the cause, was 14 per 100,000 maternities. Total death rates had not notably changed from 2000, increasing an insignificant 0.89%. In fact, since 1985, only indirect deaths had shown any increase — increasing 4% (from 3.7% to 7.71%).
Even with this perspective, distinct discrepancies were identified — all of which overwhelmingly eclipsed ‘obesity.’
Socioeconomic factors
According to the report:
The underlying root causes of maternal deaths are often underlying social and other non-clinical factors. The link between adverse pregnancy outcomes and vulnerability and social exclusion are nowhere more starkly demonstrated than by this Enquiry.
Among the most notable factors were rising numbers of women “whose lifestyles put them at risk of poorer health, and a growing proportion of women with medically complex pregnancies.”
Immigrants/refugees. Increasing numbers of women are refugees and migrants traveling to the UK to deliver, according to the report. These mothers are often in poor health and suffering from medical conditions, such as HIV and TB, with more complicated pregnancies as a result. A total of 1.5% of maternal deaths, alone, were due to women who had had genital mutilations that hadn’t been recognized and repaired prior to delivery.
Minorities. There were strikingly higher rates of maternal deaths among minorities: 62.4 deaths per 100,000 Black Africans, 41.1/100,000 among Black Caribbeans; 20.3/100,000 among Indians; 23.6/100,000 among Bangladeshi; 32/100,000 among Middle Easterners, compared to 11.1/100,000 among whites.
“Black African women, including asylum seekers and newly arrived refugees, have a mortality rate nearly six times higher than White women,” said the report.
Economic status. Among the maternal deaths, 68.5% of the women were unemployed, compared to 9.2% who were employed; and they were three times more likely to be single. “A third of all women who died were either single and unemployed or in a relationship where both partners were unemployed,” the report found.
“Women with partners who were unemployed, many of whom had features of social exclusion, were up to seven times more likely to die than women with partners who were employed.”
The report also found a clear gradient in mortality rates between those living in the least and most deprived areas. “In England, women who lived in the most deprived areas were five times more likely to die than women living in the least deprived areas,” it reported.
Substance abuse. Ninety-three of the women 295 who died had problems with substance misuse, 52 were drug addicts, 32 were occasional drug users and the rest were alcoholics.
Domestic abuse. Fourteen percent of the women who died had been victims of domestic abuse and 81% of those in abusive relationships found it difficult to access or maintain contact with maternity services. Others had “domineering partners who disrupted the relationship between the woman and her health care provider.”
Further, 77% of these women were being followed by social services and 64% were known to child protection services, with the vast majority having previous children in care. Similarly, half of the women who were murdered were also known by social services.
“More than 80% of the women who died...did not seek care at all, booked late or failed to maintain regular contact with the maternity services, in the main because of fear that their unborn child might be removed at birth.
Maternity care. Among all of these minority, poor and troubled women, far fewer received early and regular prenatal care. “Vulnerable women with socially complex lives who died were far less likely to seek prenatal care early in pregnancy or to stay in regular contact with maternity services,” said the report. Language and cultural barriers were among the other socio-economic factors identified. Overall, 17% of the women who died began maternity care after 22 weeks of gestational age or missed over four routine antenatal visits, as compared to 5% of women who were employed or had a partner in employment.
And the system failed other women. “Some of the women who died were let down because, although the GP referral was timely, they did not receive a first maternity service appointment until they were around twenty weeks gestation.”
Other maternal-related factors
Of the 104 deaths associated with psychiatric issues in this report, 37 women committed suicide and another 10 died by violence.
Women with higher risk pregnancies, be it social factors or medical conditions, made up the highest percentages of maternal deaths. Beside older mothers, those carrying multiples (twins and triplets) had 2.5-fold higher rates of maternal deaths: 62.38% versus 15.88% among singleton births, the report found.
Thrombosis and thromboembolisms were the leading cause of direct death, most from pulmonary embolisms with a mortality rate of 1.56/100,000 pregnancies. Still, the report concluded, pulmonary embolisms had only increased by 0.24% and “the number of maternal deaths from thromboembolism has hardly changed since 1985-87.”
Multiparity was associated with a 3-fold higher risk for pulmonary embolisms, followed by obesity. But, the report noted that of the eight ‘morbidly obese’ women who had died, six had received no thromboprophylaxis in accordance with clinical guidelines, one had received inappropriate doses and one received it too late.
In fact, the report presented case after case of women with BMIs>40 who had received substandard care, such as one discharged with poorly sutured tears and extremely low hemoglobin levels and collapsed at home; one whose pre-eclampsia wasn’t diagnosed until too late because of the lack of appropriately-sized blood pressure cuffs; and others whose symptoms, such as severe leg pain and breathlessness were attributed to their obesity and their embolisms went untreated.
Medical care factors
While the overall proportions of mothers receiving sub-optimal care was small and hadn’t increased over recent years, the report identified quality of clinical care issues as an area where there is room for much improvement.
Among all of the direct maternal deaths, 64% were among women having received substandard care, the report found. Substandard care also accounted for 40% of all the indirect deaths. The most common problems identified were lack of clinical knowledge and skills among healthcare professionals, who failed to identify and manage common medical conditions or potential emergencies. Even resuscitation skills were considered poor in some cases.
[A] few professionals seemed oblivious to the poor quality of care they had provided, or to have had any understanding of the wider circumstances that may have affected a mother’s life and death. The assessors were also concerned by the apparently culturally dismissive or insensitive remarks made by a few professionals during the course of the reviews.
“In other cases, the early warning signs of impending maternal collapse also went unrecognised,” the report stated.
Many women were not seen by an appropriately trained senior or consultant doctors in time, and a few never saw a consultant doctor at all, despite, in some cases, being in a Critical Care unit. The reasons for this were, generally, a lack of awareness of the severity of the woman’s illness by more junior or locum maternity staff, both doctors and midwives. In a few cases, but in smaller numbers than in previous Reports, the consultant(s) did not attend in person until too late and relied on giving advice over the phone.
“Whilst most midwives are autonomous practitioners of normal birth, they do need to recognize professional boundaries and refer appropriately for advice to ensure true woman centred care,” the report concluded. “This was not always the case.”
Another recurrent issue identified in the report, was the lack of multidisciplinary care for women with pregnancies complicated by medical or psychiatric problems. Numerous high-risk cases had received poor management or active follow-up. Poor communication was identified as a factor in poor or nonexistent teamwork, inappropriate consults by phone, and a lack of sharing of relevant information among health professionals.
“Although there were many examples of excellent care provided by health care staff this triennium, there were also a few examples of what the assessors described as ‘breathtaking’ ‘callous’ and ‘dreadful’ behaviour on the part of some other health care workers.” One case illustrated commendable actions on the part of a nurse who proactively attempted to get a doctor’s care for a critically-ill women who was miscarrying in the critical care unit before dying:
The Critical Care staff thus called the obstetric Senior House Officer who declined to attend because s/he had never delivered a baby and the locum obstetric registrar said the staff should “just get on with it as the baby was dead”. No midwives could be spared from the delivery suite and the consultant obstetrician was not informed. Eventually the EPU nurse managed to find cover, attended and delivered a dead baby. She then stayed to comfort and support both the woman, her partner and the nursing staff, who had been very traumatised by the events. The mother died shortly afterwards.
The “shocking aspects of this case,” said the report, was the indifference, poor decision-making, and lack of care from an appropriately trained obstetrician. One assessor said: “I find it extraordinary that an extremely ill pregnant woman can be transferred to Critical Care without being seen either by a consultant in obstetrics or gynaecology, internal medicine or Critical Care.”
But the report also recognized that the system failed both the patients and the healthcare professionals at times, stating:
In some cases staff appeared to take the blame upon themselves despite providing the best possible care. In these cases the Enquiry assessors were saddened as they considered the care these professionals had provided was exemplary and that the failings in the system were totally outside the control of these workers.
Recommendations
The report concluded with a list of ten recommendations for improving maternity services. They included timely and early prenatal care; medical care for migrant women; ensuring all women with systolic blood pressures of 160mm/Hg2 and higher receive treatment; care with caesarean sections and recognition of the risks; improving clinical skills of all staff caring for pregnant women; standards to help recognize, treat and refer women developing a critical condition and impending collapse; and care guidelines to improve care for pregnant women with sepsis, pain, bleeding and obesity.
Going back to the media stories, it’s difficult to see that they’re even talking about the same report, isn’t it? The news seems to see everything through obesity-hysteria glasses, anymore. But obesity is hardly the “greatest threat to the lives of pregnant women” identified in this report.
Instead, the report highlighted that being among the most disadvantaged in our culture is the greatest risk factor for disparities in health and healthcare. Blaming fat women will get us nowhere towards most effectively improving things for women and their babies, and helping to prevent as much needless deaths and suffering as possible.
© 2007 Sandy Szwarc. All rights reserved.
Postscript: There have been some comments that this post didn't report on what happened among the mothers who didn't die, but a writer cannot report on information that doesn't exist. The paper, Saving Mothers' Lives was an investigation of the maternal deaths.
Definitions of maternal deaths in this report Maternal deaths Deaths of women while pregnant or within 42 days of the end of the pregnancy (includes delivery, ectopic pregnancy, miscarriage or termination of pregnancy) from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Direct Deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above. Indirect Deaths resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiologic effects of pregnancy. Examples of causes of Indirect deaths include epilepsy, diabetes, cardiac disease and, in the UK only, hormone dependent malignancies. The Enquiry also classifies most deaths from suicide as Indirect deaths Late Deaths occurring between 42 days and one year after abortion, miscarriage or delivery that are due to Direct or Indirect maternal causes.
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