Review shows maternal deaths under-reported
[Posted: Fri 23/11/2012 by Niall Hunter, Editor www.irishhealth.com]
Ireland’s maternal mortality rate is twice as high as has been previously reported, new figures show.
The first report from the recently-established Maternal Death Enquiry – MDE Ireland system shows that our maternal death rate is 8 per 100,000 births, compared with 4 per 100,000 reported by the Central Statistics Office (CSO).
The MDE Ireland report, which uses wider criteria for defining maternal death than that used by the CSO, found that in the years 2009 to 2011 inclusive, 25 mothers who attended maternity hospitals with their pregnancies died.
The Irish report adopted the more comprehensive British classification system for determining maternal death, and collated detailed data on mortality from hospitals. It classified two of the deaths in the period as being due to suicide.
In the wake of the death of Savita Halappanavar, assurances have been made by health authorities and the medical profession that Ireland has one of the lowest maternal death rates in the world. However, the new report shows that while our maternal death rate is still relatively low by international standards, it is higher than has been previously reported in official statistics.
According to the report, seen by irishhealth.com, six of the 25 deaths were classified as direct maternal deaths, 13 as indirect maternal deaths, while the remaining six were attributed to ‘coincidental cause’. Forty per cent of the deaths recorded were in women not born in Ireland.
It says of the 25 deaths MDE Ireland recorded between 2009 and 2011 inclusive, among the six direct maternal deaths, three were due to pulmonary embolism, one from amniotic fluid embolism, one due to uterine rupture and one due to multi-organ failure secondary to the HELLP syndrome, a life-threatening pregnancy complication related to pre-eclampsia.
The report says of the 13 indirect maternal deaths recorded during the period, five were due to heart disease, two due to suicide, two were due to swine flu, two due to epilepsy, one due to serious lung disease and one due to an oesophageal bleed.
Of the six ‘coincidental’ deaths, two were due to metastatic cancer, one due to a road traffic accident, one due to lymphoma and two due to substance abuse.
The MDE Ireland system, set up in 2009 and run by leading medical and midwifery experts, is linked to the Confidential Maternal Death Inquiry system for England and Wales. This system is regarded as the ‘gold standard’ for confidential maternal death inquiry.
MDE Ireland classifies maternal deaths under the criteria of:
* ‘Maternal’ deaths of women while pregnant or within 42 days of the end of pregnancy, from any cause related to or aggravated by the pregnancy.
* ‘Direct’ deaths resulting from obstetric complications of pregnancy, from ‘interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above’.
* ‘Indirect’ deaths resulting from a previous existing disease, or a disease developing during pregnancy and which was not due to obstetric causes, but where the disease was aggravated by the physical effects of the pregnancy.
* ‘Coincidental’ maternal deaths, from unrelated causes which happen to occur in pregnancy or the during or just after childbirth.
* ‘Late’ deaths occurring between 42 days and one year after abortion, miscarriage or delivery that are the result of direct or indirect maternal causes.
Figures used by the CSO for maternal deaths rely on the cause of death as recorded on the coroner’s death certificate alone, which experts believe limits the definition of a maternal death and has led to under-reporting of the true rate.
The most recent CSO figures recorded only one maternal death in 2010 and three in 2009.
The MDE Ireland report says its aim is to investigate why some women die during or shortly after pregnancy, and to learn how such tragedies can be avoided in the future.
The new figures mean our maternal mortality rate is on the same level as that of France, it is still less than that of the UK and the US, but is higher than that of Sweden and Norway.
Referring to the significant number of maternal deaths in Ireland among women born outside the country, the report says the issue of how these women engage with our maternity services needs to be dealt with, and highlighted the importance of the availability of interpretive services.
A particular concern, the report says, is the issue of engagement with maternity services by non-national patients getting alternative medical advice from outside the country.
The MDE Ireland report says there was reluctance in some hospitals to share maternal death data due to concerns over data protection, potential litigation and anticipated review of cases by other agencies.
It says pregnant women with pre-existing medical and mental health disorders should have risk assessment on booking into a maternity hospital, and they should be afforded high priority when referred for assessment by doctors in other medical disciplines.
The report recommends that a question on pregnancy status at time of death, similar to that on the medical death cert, should be included on the coroner’s death cert.