Age
Since the 2006–2008 CEMD report, the maternal mortality rate (MMR) has remained fairly constant up to age 34, but it doubles after age 35 and quadruples after 40 years of age. The same pattern is seen in the latest 2016–2018 report. The average age of childbearing in the UK has risen ‐–in 2008 it was 29.3 years with 20% of births being to women aged 35 years or over, while in 2018 it was 30.6 years with 23% to women aged 35 years or over.
Obesity
This problem continues to grow. In the 2016–2018 report, 119 of 196 women who died whose body mass index (BMI) was known (i.e. 61%) were overweight compared with 49% in 2009–2012. Of these overweight women, 57 (29%) had a BMI of 25–29.9 and 62 (32%) were obese (with a BMI >30). This compares with 22% and 27%, respectively, in 2009–2012.
Socioeconomic classification
In 2016–2018, the MMR among women living in the most deprived areas was 15.3 compared with 5.7 for women living in the most affluent areas, a close to threefold difference. Attention should also be focused on women who book late or are poor attenders for antenatal care. In 2016–2018, 22% of women who died booked late, 61% did not receive the recommended level of antenatal care and 27% did not receive the minimum level of antenatal care as defined by National Institute for Health and Care Excellence (NICE) guidance.
Ethnicity
In the 2016–2018 report black women have more than fourfold higher MMRs than white women, a disparity which has been evident for many years and has been worsening more recently. The increase is less among other ethnic groups (Table 2.2), but is also significantly higher in women from Asian and mixed ethnic backgrounds. Women recently arrived from overseas often have communication difficulties and are at particular risk.
Table 2.2 Estimated maternal mortality rates by ethnic group, England 2016–2018
| Ethnic group (England only) | Total maternities | Deaths (n) | Rate/100 000 (95%CI) | Relative risk (95%CI) |
|---|---|---|---|---|
| White (inc. not known) | 1 486 428 | 117 | 7.87 (6.51–9.43) | 1 (Ref.) |
| Asian | 191 145 | 28 | 14.65 (9.73–21.17) | 1.86 (1.19–2.83) |
| Black | 81 704 | 28 | 34.27 (22.77–49.53) | 4.35 (2.77–6.62) |
| Chinese/others | 75 270 | 6 | 7.97 (2.93–17.35) | 1.01 (0.36–2.27) |
| Mixed | 31 823 | 8 | 25.14 (10.85–49.53) | 3.19 (1.35–6.50) |
2.5 Direct deaths
Hypertensive disease
The number of deaths from pre‐eclampsia is a fraction of what it was in 1952–1954 (Table 2.3) and most recently has fallen dramatically from 19 in 2006–2008 to 10 deaths in 2009–2011, nine deaths in 2010–2012 and then six deaths in 2014–2016. This reduction is largely due to the introduction of guidelines on fluid management and none of the recent deaths have been due to pulmonary or cerebral oedema. However, there is a continuing problem with failure to control systolic hypertension, and preventing intracranial haemorrhage remains a challenge. Among the recent recommendations the following points are emphasised:
Epigastric pain in the second half of pregnancy should be considered to be the result of pre‐eclampsia until proved otherwise
Keep blood pressure (BP) below 150/100, and very high systolic BP is a medical emergency with urgent treatment needed
Neuroimaging should be performed if a woman with hypertension or pre‐eclampsia has focal neurology, severe or atypical headache or incomplete recovery from a seizure
Stabilising the mother including controlling her BP is vital prior to intubation
New‐onset hypertension or proteinuria needs prompt referral with clear communication between health professionals
Table 2.3 The changes in direct deaths reported to the CEMDs, 1952–2018
| Cause | 1952–1954 (England+Wales) | 2006–2008 (UK) | 2009–2011 (UK and Ireland) | 2010–2012 | 2014–2016 | 2016–2018 |
|---|---|---|---|---|---|---|
| Hypertensive disease | 246 | 19 | 10 | 9 | 6 | 4 |
| Obstetric injury | 197 | 0 | 7 | 7 | 1 | 4 |
| Haemorrhage | 188 | 8 | 14 | 11 | 17 | 10 |
| Early pregnancy/abortion | 153 | 0 | – | 7 | 3 | 7 |
| Thromboembolism | 138 | 18 | 30 | 26 | 32 | 33 |
| Anaesthesia | 49 | 7 | 3 | 4 | 1 | 1 |
| Genital tract sepsis | 42 | 26 |
15
|