1. www.cemach.org.uk Julie Maddocks North West & West Midlands Regional Manager for CEMACH Supervisor of Midwivesjulie.maddocks@cemach.org.uk Confidential Enquiry into Maternal and Child Health Improving the health of mothers, babies and children

2. 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

3. 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

4. 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

7. Stillbirths regional variation

8. Neonatal deaths regional variation

9. 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

10. 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

11. Neonatal deaths variation by NHS Neonatal Networks in England

17. Perinatal Enquiry National Reports Regional Reports Trust specific Reports Trust specific work Topic Work Diabetes and pregnancy HIE

18. 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

19. Diabetes and Pregnancy NW dissemination/educational programme 2008 Interactive workshops “ Translating recommendations into practice” 22 nd January 2008 17 th September 2008 Seminar “ Translating recommendations, research and guidelines” 24 th June Lancashire Cricket Club

20. 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

21. www.cemach.org.uk

22. 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

23. 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.

24. Types of Maternal Death Direct Indirect Co-incidental (fortuitous) Late (between 42 -365 days after delivery)

25. Types of Maternal Death Direct Indirect = UK Maternal Mortality Rate

26. “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 ”.

27. Identify cases Collect information Analyse the results Recommendations for action Implement Evaluate and refine The maternal mortality surveillance cycle

28. Maternal Deaths: Numbers and rates per 100,000 maternities by type: UK 1985-2005

29. ONS CEMACH Maternal mortality rates UK 1952-2005 per 100,000 maternities

30. Maternal mortality estimates and lifetime risk: developing countries MMRNumber 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 America16022,000160

31. Direct maternal death rates United Kingdom 1985-2005 0 1 2 3 4 5 6 7 8 9 10 1985-19871988-19901991-19931994-19961997-19992000-20022003-2005 Rate per 100,000 maternities

32. Indirect maternal death rates United Kingdom 1985-2005 0 1 2 3 4 5 6 7 8 9 10 1985-19871988-19901991-19931994-19961997-19992000-20022003-2005 Rate per 100,000 maternities Improved case ascertainment by ONS Improved case ascertainment by CEMACH

33. Direct and Indirect rates UK 1985-2005

34. Leading causes of Direct deaths: UK rates per million maternities 2003-05

35. Leading causes of Indirect deaths: rates per million maternities 2003-05

36. Overall rates per million maternities UK 2003-05

37. Leading causes and rates per million maternities 2000-05

38. Maternal mortality rates by major ethnic group; England only 2003- 05

39. 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

40. Mortality and deprivation 0 5 10 15 20 25 30 35 Least deprived234Most deprived Quintile of the Index of Multiple Deprivation 2004

42. 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

43. Obesity in pregnancy project

44. 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

45. 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?

46. 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

47. Working with Individual Trusts Peer review of perinatal deaths Confidential enquiry approach External assessors Report of findings

48. Reports and Publications So 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 Report To come: OAA project Leaflet for women of childbearing age with diabetes Maternal and Perinatal April2007: Perinatal Mortality 2005 Dec2007: Saving Mother’s Lives To come: Jan2008: Perinatal mortality 2006 April2008 : Why Children Die Available for download from CEMACH website

49. 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

50. Thank You julie.maddocks@cemach.org.uk Tel: 0161 276 6837