Maternal mortality is defined in the UK as the death of a mother while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (called coincidental deaths). Deaths are subdivided into those from direct causes those in which the cause of death is directly attributable to pregnancy (eg abortion, eclampsia, haemorrhage) and indirect deaths those resulting from previous existing disease or disease developed during pregnancy, and which were not due to direct obstetric causes but were aggravated by pregnancy (eg heart disease). Late deaths are those occurring between 42 days and 1 year after termination, miscarriage, or delivery that are due to direct or indirect maternal causes.
History
Since 1952 there have been 3-yearly confidential enquiries into maternal deaths. Prior to 1979, as many deaths were considered to have had avoidable factors (this term was used to denote departures from acceptable standards of care by individuals, including patients) but since 1979 the wider term of substandard care has been used to cover failures in clinical care and other factors, such as shortage of resources and back-up facilities.
Maternal mortality has almost halved every decade since reports have been issued (deaths per 100,000 maternities have been 67.1 in 1955-7, 33.3 in 1964-6, 11 in 1973-5, but 13.1 in 2000-2 of which direct deaths were 5.3 per 100,000).1 Rates are lowest for women aged 20-24 years rising markedly in the over-35s. Mortality was highest for first pregnancies. Risk of dying in pregnancy, childbirth or from abortion is 1:65 in developing countries (1:16 in some) as opposed to 1:9000 in the United Kingdom. Note: pregnancy is very protective as all-cause mortality in 15-45 year old women is 58.4:100,000/year (ie rates of death 4 × lower in pregnancy and 1y after).
In 2000-2, 391 UK deaths were recorded including 94 late deaths. Of these 106 were direct obstetric deaths; 155 were indirect and 36 were coincidental (in no way related to pregnancy, eg car accident). Death was increased in non-affluent areas (×1.45); in non-whites (×3 but ×7 if black African or asylum seeker); if both parents unemployed (×20) or single mother (×3) and in those booking late or missing 4 antenatal appointments. Of those dying 14% had reported domestic violence; 35% were obese; 8% were substance abusers.
In 2000-2 thromboembolism was the chief cause of direct death in the UK (28% of deaths). Other direct causes: early pregnancy (14.1%) (mainly ectopic pregnancy at 10.3%); hypertensive disorders (13.2%); genital tract sepsis (12%); amniotic fluid embolism (4.7%); haemorrhage (16.%); fatty liver of pregnancy (2.8%), anaesthetic deaths (5.6%). 33% died before delivery. When unreported deaths were also investigated, suicide was the commonest cause of (indirect) death overall; the mothers tending to be white, older, comfortably off, with other children, and dying by violent means.
The death rate from caesarean section for the 2000-2 period was 1 per 100 thousand operations. 4 direct deaths and 1 later were due to bowel perforation 3 due to Ogilvie's syndrome (pseudo-obstruction leading to perforation; not direct perforation), all in women who had had caesareans.
The maternal mortality rate was higher than in the previous triennium for direct deaths (5.3 vs 5:100,000), and again there were more indirect than direct deaths. Care was considered substandard in 67% of cases of direct death in 2000-2, in 47% this was major ie might have affected outcome. Substandardness includes pregnant women who refuse medical advice.
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