Mortality data delivers surprising results


A Cork-based body is combining information on maternal deaths here with data from the UK in an effort to reduce such tragedies, writes JOANNE HUNT

THE DEATH of a pregnant woman or new mother with hopes and dreams of a happy future is one of the most poignant tragedies of all.

Defined by the WHO as the death of a woman while pregnant or within 42 days of the end of pregnancy, maternal death is rare in the developed world.

While 600,000 such deaths occur worldwide every year, predominantly in developing countries, cases in Ireland number just a handful – and perhaps it is their rarity that makes them so shocking.

The death last week of a woman in her late 30s, shortly after giving birth to a girl at Our Lady of Lourdes Hospital in Drogheda, brings the topic to the fore.

So too did the death of 34-year-old Tania McCabe, who in March 2007 died after giving birth to twins, also at Our Lady of Lourdes Hospital. One of Ms McCabe’s twin boys died too.

The HSE admitted negligence in that case and damages were recently paid to her family, but ensuring that broader lessons are learned from these and other maternal deaths is the job of a Cork-based body.

The Centre for Maternal and Child Enquiries (CMACE) was established in April 2009. Located in the National Perinatal Epidemiology Centre at Cork University Maternity Hospital, CMACE Ireland works closely with its long established UK counterpart and, from January 2009, all Irish maternal mortality data is included in the CMACE UK triennial report.

The combining of UK and Ireland data is a welcome development, according to Dr Michael O’Hare, consultant obstetrician and gynaecologist, and chairman of the CMACE Ireland working group.

According to Dr O’Hare, with “no more than between one and 12 per annum out of about 75,000 deliveries” in Ireland, there may just be one or two deaths in a particular diagnostic group.

“Merging the data from both countries enables us to accumulate enough cases of one condition from which to draw conclusions and recommendations,” he says.

So what are the main causes of maternal death? Published in March, the most recent CMACE report, which captures UK maternal mortality data between 2006 and 2008, held some surprises, according to Dr Declan Keane, former master of the National Maternity Hospital, Holles Street.

The UK report, long used as a source of learning by Irish medics, classifies a maternal death as the death of a pregnant woman or a new mother who has died of any cause for up to 365 days after giving birth.

“One of the greatest surprises was that sepsis has now become the greatest cause of maternal death in the UK,” says Dr Keane.

He says the type of sepsis referred to – the virulent Group A streptococcus organism – is something that is acquired in the community, “in other words, perhaps from children at home who had sore throats”.

Dr Keane says while it has long been recognised as a potentially serious condition for pregnant women and new mothers, “I would think the causes ranking second and third in Britain – clotting disorders and haemorrhage – would still rank as the number one and two direct causes of death in Ireland with sepsis not as high.”

He describes the finding as “a wake-up call for all of us in the profession . . . you think of sepsis as being more a cause of maternal death in developing countries”.

He says the listing of haemorrhage as one of the top causes of maternal death is also noteworthy, particularly its link to Caesarean sections.

“The more C-sections a woman has had, the more likely she is going to haemorrhage and also the more likely it is on a subsequent pregnancy that the placenta is going to embed itself over the site of the previous scar.

“This is something we feel could be a big issue going forward,” he says.

Dr Keane says that if ultrasound or MRI scanning during pregnancy reveals that the placenta has adhered to the uterus, then you must “adequately forewarn the woman before delivery that she has a significant chance of requiring a Caesarean hysterectomy”.

Other findings in the UK report place emphasis on the importance of caring for the mental health of the mother.

“We know that suicide is one of the fasting growing causes of maternal death,” says Patricia Hughes, director of midwifery at the Coombe Women and Infants University Hospital.

“We ask every mother at the book-in stage about their history to help identify those who might be more at risk of developing mental health issues throughout the pregnancy or immediately afterwards,” says Ms Hughes. “We put in place referral services for them to mental health or psychiatry services.”

Working closely with maternity hospitals, emergency consultants and the coroners, Ms Hughes says CMACE will also now record cases where a woman takes her own life in the weeks or months after birth – a step that will, for the first time, highlight the frequency of maternal deaths that occur by suicide.

In the meantime, Ms Hughes is calling for a mother and baby unit where mothers with severe postnatal depression can be best cared for.

Better interpretation services for women who do not speak English was another key finding of the UK report. Ms Hughes says with 25 per cent of mothers giving birth in the Coombe themselves born in other countries (though not all unable to speak English), access to translation services is key. “It’s number two in the top 10 recommendations in the UK report,” says Ms Hughes.

She says while there can be a tendency for family members in large communities to seek to do the interpreting for a mother, “you don’t know what their level of understanding is, you can’t ascertain if they are able to convey the message”.

According to Ms Hughes and Dr Keane, most Irish maternity hospitals now have very good translation services in place. “We can get someone who can speak one of up to 40 languages within five minutes of making the call,” says Dr Keane.

Overall, Ireland’s CMACE reporting should put fears that maternal deaths in Ireland are under-reported to rest.

“For the last 25 years, there hasn’t been a systematic audit undertaken in Ireland on maternal mortality,” says Dr Michael O’Hare.

He says while some maternal deaths occurred in maternity hospitals, those that occurred in non-maternity hospitals, at home or elsewhere, “may not have come to the attention of obstetricians and therefore not have been recorded as a maternal death”.

He says CMACE’s work with maternity hospitals, general hospitals, coroners, public health nurses, psychiatrists and GPs will aim to record 100 per cent of maternal deaths.

It’s a pledge that means the tragedy of the death of an expectant or new mother is something we can learn from.