M Knight

Maternal influenza and birth outcomes: systematic review of comparative studies.

Although pregnant women are considered at high risk for severe influenza disease, comparative studies of maternal influenza and birth outcomes have not been comprehensively summarised.

The impact of socioeconomic position on severe maternal morbidity outcomes among women in Australia: a national case–control study

Studies in other developed countries have suggested that socioeconomic position may be a risk factor for poorer pregnancy outcomes. This analysis aimed to explore the independent impact of socioeconomic position on selected severe maternal morbidities among women in Australia.

Experiences, utilisation and outcomes of maternity care in England among women from different socio‐economic groups: findings from the 2010 National Maternity Survey

The objective of this analysis was to explore the healthcare‐seeking behaviours and experiences of maternity care among women from different socio‐economic groups in order to improve understanding of why socially disadvantaged women have poorer maternal health outcomes in the UK.

Maternal and perinatal outcomes in women planning vaginal birth after caesarean (VBAC) at home in England: secondary analysis of the Birthplace national prospective cohort study

To compare vaginal birth rates in women planning vaginal birth after caesarean (VBAC) at home versus in an obstetric unit (OU) and explore transfer rates in women planning home VBAC.

Defining definitions: a Delphi study to develop a core outcome set for conditions of severe maternal morbidity

Develop a core outcome set of international consensus definitions for severe maternal morbidities.

The Australasian Maternity Outcomes Surveillance System: An evaluation of stakeholder engagement, usefulness, simplicity, acceptability, data quality and stability

The Australasian Maternity Outcomes Surveillance System (AMOSS) conducts active, prospective surveillance of severe maternal conditions in Australia and New Zealand (ANZ). AMOSS captures greater than 96% of all births, and utilises an online, active case‐based negative reporting system.

Severe primary autoimmune thrombocytopenia in pregnancy: a national cohort study

To quantify the incidence of severe autoimmune thrombocytopenia (ITP) in pregnancy in the UK, determine current treatment strategies, and establish maternal and neonatal morbidity and mortality associated with severe ITP in pregnancy.

Resident consultant obstetrician presence on the labour ward versus other models of consultant cover: a systematic review of intrapartum outcomes.

Several key policy documents have advocated 24‐hour consultant obstetrician presence on the labour ward as a means of improving the safety of birth. However, it is unclear what published evidence exists comparing the outcomes of intrapartum care with 24‐hour consultant labour ward presence and other models of consultant cover.

2.1 Incidence, Causes and Outcomes of Severe Maternal Sepsis Morbidity in the UK

Background The incidence of severe genital-tract sepsis has increased in the UK and is now the leading cause of direct maternal death. Underlying this trend is a larger number of severe morbidity cases. The aim of this study was to describe, on a national level, the incidence, causes and outcomes of severe maternal sepsis morbidity in the UK. Methods A national population-based study was undertaken using the UK Obstetric Surveillance System (UKOSS) between June 2011 and May 2012. Results 378 women with severe sepsis were identified; an estimated incidence of 5.0 per 10,000 maternities (95%CI 4.6–5.7). Septic shock was diagnosed in 17.5% (N = 66) of women. Sources of infection were: intrauterine (N = 109; 39.9%), urinary-tract (N = 72; 26.4%), wound (N = 35; 12.8%), and respiratory-tract infection (N = 20; 7.3%). Laboratory-confirmed causative organisms were E. coli (31.3%), group A streptococcus (13.9%), group B streptococcus (13.4%), Staphylococcus aureus (10.4%) and polymicrobial growth (9.6%). Causative organisms differed significantly according to diagnosis of septic shock and mode of delivery (P = 0.002; P < 0.001); group A streptococcus was predominant amongst women with septic shock (30.8%) and spontaneous vaginal deliveries (33.3%), while E. coli was predominant amongst women without septic shock (32.6%), operative vaginal deliveries (36.0%) and caesarean sections (37.1%). Of all severely septic women, 73.0% (N = 276) required critical care and five women died. Conclusions For every death from maternal sepsis, there are more than 75 women with severe sepsis morbidity. The pattern of infective organisms appears different amongst women who suffer septic shock. Further work is needed to investigate the risk factors associated with sepsis.

Oxytocin and arterial embolisation: use or overuse?

Inter-country variations in maternal mortality, even in countries where maternal death is rare, can be an important indication that care can be improved. Maternal mortality from postpartum haemorrhage (PPH) is four times higher in France than the UK. Further investigation is clearly needed to identify reasons for this observed difference and to begin to develop preventive actions. This population-based study of all women with PPH at more than 100 hospitals in France includes women who may be regarded as having a ‘near-miss’ maternal morbidity: PPH managed with second and third-line interventions such as arterial embolisation, pelvic vessel ligation, uterine compression sutures and hysterectomy. This approach, studying women with severe morbidity, is recognised as the way forward in countries where maternal death rates are low in order to glean important information to aid prevention. As the authors note, these are observational data, although collected in the context of a trial, and hence any comparison of effectiveness of different therapies has to be interpreted with caution. Nevertheless, some messages for clinical practice are very clear. Six percent of women managed with an invasive treatment for PPH had no prior treatment with uterotonics; a similar observation was made in a national study in the UK (Knight et al, BJOG 2007; 114:1380-7). Fifty-eight percent of the women who had an invasive therapy for PPH had uterine atony as the primary cause of the haemorrhage, and yet overall only 83% of women had a prophylactic uterotonic for the third stage of labour; 73% in women with a vaginal delivery. This contrasts directly to the estimated 60% of women in France who receive oxytocin for augmentation of labour. Oxytocin exposure in labour is known to be associated with risk of PPH and is likely to render third stage prophylaxis less effective. Misuse of uterotonics was a factor identified to be associated with maternal death from PPH in the UK (Paterson-Brown et al, Saving Lives, Improving Mothers’ Care 2014, NPEU. p45-55). Oxytocin, but at the right time, seems then to be the clear message from these data – more cautious use in labour and more liberal use for third stage prophylaxis and PPH treatment. A four times higher mortality rate in one high resource country over another is unacceptable, and universal oxytocin prophylaxis for the third stage of labour should surely become the expected norm in France and elsewhere. The use of uterine artery embolisation for management of PPH is much higher in France than other countries, and the authors speculate that clinicians in France have a lower threshold for its use. Although defining PPH robustly can be difficult given the known inaccuracy of estimation of blood loss (Bose et al, BJOG 2006; 113:919-24), given the high costs of this as an intervention, guidelines must incorporate robust recommendations on when its use is appropriate. The authors speculate that the situation will be improved with prior use of intrauterine balloon tamponade, but its evidence-base is limited, and there are undoubtedly situations when its use exacerbates rather than improves the situation when women are in extremis (Paterson Brown et al, see above). The main message has to be, whatever the circumstances, preventing and controlling the haemorrhage, and controlling it early, is imperative to improve outcomes for women.