www.cemach.org.uk julie maddocks north west & west midlands regional manager for cemach...
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www.cemach.org.uk
Julie Maddocks North West & West Midlands Regional Manager for CEMACH
Supervisor of Midwives
[email protected]@cemach.org.uk
Confidential Enquiry into Maternal and Child HealthImproving the health of mothers, babies and children
Brief overview
• Non-NHS organisation• Funded mainly by NPSA• Central Office in London • 7 Regional offices in England, affiliated offices in
Wales and N Ireland• Strong support by clinicians
– Panel assessors and chairs– Advisory group members
Work programme
• Maternal and perinatal surveillance– Maternal deaths during pregnancy up to 1
year – Late fetal losses from 22 weeks, stillbirths and
neonatal deaths up to 28 days
• Child health– Children from 28 days to 18 years old
• Topic-specific projects related to morbidity
APPROACH
• Mortality Surveillance– Mothers to one year after delivery– Babies from 22 weeks gestation to 28 days
• Topics– Descriptive study– Organisational survey– Clinical audit
• Trust-specific feedback– Trust specific work
Stillbirths regional variation
5.5
4.4
5.0
6.3
5.8
5.6
4.6
4.4
6.1
6.3
5.5
4.0
5.4
5.50
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0
Central South Coast
East of England
East Midlands
London
North East
North West
South East Coast
South West
West Midlands
Yorkshire and Humberside
England
Northern Ireland
Wales
England, Wales and Northern Ireland
Mat
erna
l reg
ion
of
resi
denc
e
Stillbirth rate (per 1000 total births)
Neonatal deaths regional variation
2.2
2.1
2.7
2.6
2.3
2.8
2.2
2.4
4.1
3.1
2.7
3.9
2.3
2.7
0.8
0.4
0.8
0.9
0.9
1.1
0.5
0.8
0.9
0.7
0.8
0.8
0.7
0.8
0.0 1.0 2.0 3.0 4.0 5.0 6.0
Central South Coast
East of England
East Midlands
London
North East
North West
South East Coast
South West
West Midlands
Yorkshire and Humberside
England
Northern Ireland
Wales
England, Wales and Northern Ireland
Mat
ern
al r
egio
n o
f re
sid
ence
Neonatal mortality rate (per 1000 live births)
Early neonatal mortality rate Late neonatal mortality rate
Stillbirth rate, 5.3per 1000 total births
0
2
4
6
8
10
12
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
Total births
Sti
llb
irth
ra
te (
pe
r 1
00
0 t
ota
l b
irth
s)
Trust
Adjusted stillbirth rate
95% confidence interval
Note: due to high variance in rates calculated using events numbering less than five, data presented in the graph are for trusts with 1000 or more live births and 5 or more deaths in 2005. The national stillbirth rate has been adjusted accordingly
Note: due to high variance in rates calculated using events numbering less than five, data presented in the graph are for trusts with 1000 or more live births and 5 or more deaths in 2005. The national neonatal mortality rate has been adjusted accordingly
Neonatal mortality rate, 3.4per 1000 live births
0
1
2
3
4
5
6
7
8
0 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
Live births
Neo
nat
al m
ort
alit
y ra
te (
per
100
0 liv
e b
irth
s)
Trust
Adjusted neonatal mortality rate
95% confidence interval
Neonatal deaths variation by NHS Neonatal Networks in England
Figure 6b: Neonatal mortality rates from 22+0 weeks gestation by neonatal networks, England, 2005
Neonatal Death Rate, 2.9per 1000 live births
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
- 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000
Live Births
Ne
on
ata
l D
eath
Ra
te (
pe
r 1
000
Liv
e B
irth
s)
Note: Data presented in figure 6b are for all neonatal deaths with gestational age of 22 weeks or more, and the clustering effects of the Networks are taken into consideration, so the neonatal death rate reported is adjusted for this
Perinatal Enquiry
• National Reports
• Regional Reports
• Trust specific Reports
• Trust specific work
Topic Work
• Diabetes and pregnancy
• HIE
Diabetes in pregnancy
• 3876 babies over 18 months• Findings so far:
– Stillbirths 5x, neonatal deaths 3x, major malformations 2x
– T2 more common than expected; outcomes as bad– Preparation for pregnancy very poor– Preconception services haven’t improved– Low breastfeeding rates– Separation of mother and baby
Diabetes and PregnancyNW dissemination/educational
programme 2008
Interactive workshops
“Translating recommendations into practice”22nd January 2008
17th September 2008
Seminar“Translating recommendations, research and guidelines”
24th June
Lancashire Cricket Club
Helping to Implement Recommendations
• Joint RCGP/Diabetes UK leaflet to GPs and primary care team
• Interactive workshops– Extended case studies– Translating findings into practice
• Collaborative research projects– Barriers to accessing diabetes preconception care– BEADI project
www.cemach.org.uk
A new title: a renewed purpose
• New title
• Top 10 recommendations and auditable standards
• Near misses UKOSS
• GP and EMD chapters
• Better statistical rigour
• Separate reports for GPs, ED, Path, Psych and Midwives
Definition of a maternal death
A maternal death is a death occurring during pregnancy or within 42 days of delivery, miscarriage, termination of pregnancy or ectopic pregnancy from any cause related to, or aggravated by, the pregnancy or its management.
Types of Maternal Death
• Direct
• Indirect
• Co-incidental (fortuitous)
• Late (between 42 -365 days after delivery)
Types of Maternal Death
• Direct
• Indirect
= UK Maternal Mortality Rate
“Telling the story”
“Whose faces are behind the numbers? What were their stories? What were their dreams? They left behind children and families. They also left behind clues as to why their lives ended so early”.
Identify cases
Collect information
Analyse the resultsRecommendations
for action
ImplementEvaluate and refine
The maternal mortality surveillance cycle
Maternal Deaths: Numbers and rates per 100,000 maternities by type:
UK 1985-2005
1994-1996 134 6.1 134 6.1 268 12.21997-1999 106 5 116 6.4 242 11.42000-2002 106 5.3 155 7.8 261 13.12003-2005 132 6.2 163 7.7 295 14
Total Direct Indirect Caused Aggravated
0
10
20
30
40
50
60
70
80
1954 56 60 64 68 72 76 80 84 88 92 96 2000
Triennia
Ra
te p
er
10
0,0
00
ma
tern
itie
s
ONS CEMACH
Maternal mortality rates UK 1952-2005 per 100,000
maternities
Maternal mortality estimates and lifetime risk: developing countries
MMR Number of deaths
Lifetime risk of death
Africa
Sub Sahara
Northern
830
920
130
251,000
247,000
4600
20
16
210
Asia
South-central
S E
West
330
520
210
190
253,000
207,000
25,000
9,800
94
46
140
120
S America 160 22,000 160
Direct maternal death ratesUnited Kingdom 1985-2005
0
1
2
3
4
5
6
7
8
9
10
1985-1987 1988-1990 1991-1993 1994-1996 1997-1999 2000-2002 2003-2005
Rat
e p
er 1
00,0
00 m
ate
rniti
es
Indirect maternal death ratesUnited Kingdom 1985-2005
0
1
2
3
4
5
6
7
8
9
10
1985-1987 1988-1990 1991-1993 1994-1996 1997-1999 2000-2002 2003-2005
Rat
e p
er 1
00,0
00 m
ate
rniti
es
Improved case
ascertainment
by ONS
Improved case
ascertainment
by CEMACH
Direct and Indirect rates UK 1985-2005
0
2
4
6
8
10
12
14
16
85-89 88-90 91-93 94-96 97-99 00-02 2003-5
Direct
Indirect
Total
Leading causes of Direct deaths: UK rates per million maternities
2003-05
0
5
10
15
20
25
Leading causes of Indirect deaths: rates per million
maternities 2003-05
0
5
10
15
20
25
Overall rates per million maternities
UK 2003-05
0
5
10
15
20
25
Leading causes and rates per million maternities 2000-05
0
5
10
15
20
25
30
2003-05
2000-02
Maternal mortality rates by major ethnic group; England only 2003-
05
0
10
20
30
40
50
60
70
80
Sub-standard care
• Lack of clinical knowledge and skills• Lack of senior support• Poor identification and management of higher
risk women• Communications
– Lack of communication– Lack of communication skills– Telephone conversations– Referral letters and information
Mortality and deprivation
0
5
10
15
20
25
30
35
Least deprived 2 3 4 Most deprived
Quintile of the Index of Multiple Deprivation 2004
Obesity
52% of mothers who had booked for antenatal care died were overweight or obese c/f estimates of 11-10% in the general population.
• 25% overweight• 12% obese (BMI 30-34.9)• 15% were morbidly obese (BMI greater than 35)
8% had BMI greater than 40
Obesity in pregnancy project
Why an obesity in pregnancy project?
There are services and clinical interventions which would help to improve outcomes for women with obesity and their babies
• Preconception care• Multidisciplinary antenatal care• Equipment• Screening and management of co-morbidities• Management of labour and delivery• Minimising the risk of complications
What were the questions?
• What is the prevalence of obesity in pregnancy in the UK?
• Are health care services appropriately organised for the care of pregnant women with obesity?
• Are consensus standards of care for obesity in pregnancy being met in the UK?
• What are the outcomes for women and their babies?
New Projects
• Obesity in pregnancy– Increased perinatal mortality and congenital
anomalies– Maternal deaths– Significant morbidity e.g. postpartum haemorrhage
• Neonatal encephalopathy– Important contributory factor to medical negligence
claims– Significant neurological morbidity– Intrapartum-related perinatal mortality rate has
remained unchanged
Working with Individual Trusts
• Peer review of perinatal deaths
• Confidential enquiry approach
• External assessors
• Report of findings
Reports and PublicationsSo far: Diabetes and Pregnancy• April 2004 : Organisational Survey• Oct 2005 : Descriptive Study• July 2006 : BMJ Publication• Sept 2006 : Primary Care Leaflet• Feb 2007 : “Are we providing the best care?”• Oct 2007 : Neonatal Enquiry Findings ReportTo come:• OAA project• Leaflet for women of childbearing age with diabetes
Maternal and Perinatal• April 2007 : Perinatal Mortality 2005• Dec 2007 : Saving Mother’s Lives
To come:• Jan 2008 : Perinatal mortality 2006• April 2008 : Why Children Die
Available for download from CEMACH website
Mission
Our aim is to improve the health of mothers, babies and children by carrying out confidential enquiries on a nationwide basis and by disseminating our findings and recommendations as widely as possible
