Confidential Enquiry into Maternal and Child Health
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Confidential Enquiry into Maternal and Child Health. Improving the health of mothers, babies and children. www.cemach.org.uk. Julie Maddocks North West & West Midlands Regional Manager for CEMACH Supervisor of Midwives [email protected] Brief overview. Non-NHS organisation

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Confidential Enquiry into Maternal and Child Health

Improving the health of mothers, babies and children

www.cemach.org.uk

Julie Maddocks

North West & West Midlands Regional Manager for CEMACH

Supervisor of Midwives

[email protected]


Brief overview
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
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
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




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



Perinatal enquiry
Perinatal Enquiry England

  • National Reports

  • Regional Reports

  • Trust specific Reports

  • Trust specific work

    Topic Work

  • Diabetes and pregnancy

  • HIE


Diabetes in pregnancy
Diabetes in pregnancy England

  • 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 pregnancy nw dissemination educational programme 2008
Diabetes and Pregnancy EnglandNW 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
Helping to Implement Recommendations England

  • 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



A new title a renewed purpose

New title England

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

A new title: a renewed purpose


Definition of a maternal death
Definition of a maternal death England

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
Types of Maternal Death England

  • Direct

  • Indirect

  • Co-incidental (fortuitous)

  • Late (between 42 -365 days after delivery)


Types of maternal death1
Types Englandof Maternal Death

  • Direct

  • Indirect

    = UK Maternal Mortality Rate


Telling the story
“Telling the story” England

“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”.


The maternal mortality surveillance cycle

Identify cases England

Implement

Evaluate and refine

Collect information

Recommendations

for action

Analyse the results

The maternal mortality surveillance cycle




Maternal mortality estimates and lifetime risk developing countries
Maternal mortality estimates and maternitieslifetime risk: developing countries


Direct maternal death rates united kingdom 1985 2005

10 maternities

9

8

7

6

Rate per 100,000 maternities

5

4

3

2

1

0

1985-1987

1988-1990

1991-1993

1994-1996

1997-1999

2000-2002

2003-2005

Direct maternal death ratesUnited Kingdom 1985-2005


Indirect maternal death rates united kingdom 1985 2005

10 maternities

9

8

7

6

Rate per 100,000 maternities

5

4

3

Improved case

Improved case

2

ascertainment

ascertainment

by ONS

by CEMACH

1

0

1985-1987

1988-1990

1991-1993

1994-1996

1997-1999

2000-2002

2003-2005

Indirect maternal death ratesUnited Kingdom 1985-2005


Direct and indirect rates uk 1985 2005
Direct maternities and Indirect rates UK 1985-2005


Leading causes of direct deaths uk rates per million maternities 2003 05
Leading causes of maternities Direct deaths: UK rates per million maternities 2003-05


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





Sub standard care
Sub-standard care 2003-05

  • 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

35 2003-05

30

25

20

15

10

5

0

Least deprived

2

3

4

Most deprived

Quintile of the Index of Multiple Deprivation 2004

Mortality and deprivation


Obesity
Obesity 2003-05

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



Why an obesity in pregnancy project
Why an obesity in pregnancy project? 2003-05

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 were the questions? 2003-05

  • 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
New Projects 2003-05

  • 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
Working with Individual Trusts 2003-05

  • Peer review of perinatal deaths

  • Confidential enquiry approach

  • External assessors

  • Report of findings


Reports and publications
Reports and Publications 2003-05

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

  • 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 2003-05

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


Thank you

Thank You 2003-05

[email protected]

Tel: 0161 276 6837