MBRRACE-UK: Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK

THIS IS NOT THE MBRRACE-UK ONLINE REPORTING SYSTEM. IF YOU WISH TO REPORT A CASE PLEASE GO TO: www.mbrrace.ox.ac.uk

MBRRACE-UK release: Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2013–15
December 2017

In this, the latest MBRRACE-UK Confidential Enquiry into Maternal Deaths and Morbidity, we report on the care of 124 women who died and 46 women who had severe illness during or after pregnancy in the UK and Ireland between 2013 and 2015. In this report we examined in particular the care for women with severe epilepsy and women who had severe mental illness, as well as the care for women who died.

A key findings was that forward planning of care and optimising medication doses for women with physical and mental health problems could make a major difference to women’s risk of complications during and after pregnancy. In particular pregnant women and those who are planning pregnancy who are on medication should not discontinue their treatment without consulting a specialist. 

We found that that a number of women who died from epilepsy had stopped their treatment early in pregnancy. In some instances this was because either they or their treating doctors were not aware that this could leave them and their unborn babies being at increased risk from the effects of seizures. Women who consulted for specialist advice either before pregnancy or early in pregnancy and changed their medication where needed to medication which was best for both them and their baby had the least complications in pregnancy. There is an urgent need to ensure pregnant women and women planning pregnancy can access this type of specialist care.

The report also highlights the positive impact that forward planning can have for women who have severe mental illness after giving birth. Women who have had an episode of psychosis after giving birth (so called postpartum psychosis) should be recognised as ‘high risk’ in a subsequent pregnancy. It was evident that good care - when mental health and maternity teams recognised and discussed this risk and put in place preventive treatment and plans for action - prevented relapse in future pregnancies. However, we also noted that for some women there was confusion over what medication was safe for them and their baby during pregnancy, emphasising the importance of seeking specialist advice before stopping or changing treatment. 

We also report on the national rate of maternal deaths and show that in 2013-15, 8.8 women per 100,000 died during pregnancy or shortly after giving birth. There has been no significant change in the overall national maternal death rate since our last report in December 2016.

To read more you can download the full report, the lay report and infographic on the reports page.

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MBRRACE-UK release “Perinatal Confidential Enquiry: Term, Singleton, Intrapartum Stillbirth and Intrapartum Related Neonatal Death”

The rate of term, singleton, intrapartum stillbirth and intrapartum-related neonatal death has more than halved since these deaths were last reviewed nationally in 1993. This represents a reduction of about 220 intrapartum deaths per year.

Despite the fall in the mortality rate these deaths remain an important group for concern not least because, in the vast majority, the mother was directly receiving maternity care when the baby died or when the event in labour or birth occurred which led to the baby’s death.

In this latest MBRRACE-UK perinatal confidential enquiry we report on the quality of care for stillbirths and neonatal deaths of singleton babies born at term who were alive at the start of care in labour, and who were not affected by a major congenital anomaly.  This type of death occurred in 225 pregnancies in the UK in 2015 and represents about 5% of perinatal deaths overall.

We selected a representative sample of 78 of eligible deaths of babies born in 2015. The care provided for these mothers and babies was reviewed in detail against national guidelines and standards by a panel of clinicians, including midwives, bereavement midwives, obstetricians, neonatologists, neonatal nurses and pathologists who considered every aspect of care. In the panels’ view for 80% of the deaths different care may have resulted in a different outcome for the baby.

The main findings from the panel enquiries were that:

  • in at least a quarter of the deaths there were problems with inadequate staffing and resources to provide safe care;  
  • heavy workload contributed to delays in induction in one third of women being induced;
  • not all women who had had a caesarean section in a previous pregnancy had had a clear discussion about their birth plan;
  • there were problems recognising when women moved from early to established labour and appropriate monitoring wasn’t instituted as a consequence;
  • guidelines weren’t followed when monitoring the baby’s heart rate leading to delays when babies needed to be delivered urgently;
  • for most babies where resuscitation was attempted it was delivered effectively by clinical staff present at the delivery based on the Neonatal Life Support programme;
  • overall the quality of bereavement care was variable, with a lack of joint midwifery, obstetric and neonatal input;
  • one in three neonatal deaths did not have a post-mortem examination or placental histology carried out;
  • the majority (95%) of intrapartum-related deaths were reviewed, however, nine in ten of the reviews were of poor quality and didn’t follow guidance for serious incident reviews.

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To read more you can download the full report, executive summary and the lay report on the reports page.

 Call for topic proposals for the ‘maternal morbidity’ confidential enquiry in 2019 – now open

In addition to carrying out confidential enquiries into maternal deaths, we are undertaking confidential enquiries into a rolling programme of selected maternal morbidity topics.

We would like to invite new proposals from individuals and organisations for the maternal morbidity confidential enquiry which will run during 2019 and report in 2020. This invitation will be open from now until 31st December 2017.

More information is available on the topic proposal page.

'MBRRACE-UK' is the collaboration appointed by the Healthcare Quality Improvement Partnership (HQIP) to run the national Maternal, Newborn and Infant clinical Outcome Review Programme (MNI-CORP) which continues the national programme of work conducting surveillance and investigating the causes of maternal deaths, stillbirths and infant deaths.

The aim of the MNI-CORP MBRRACE-UK programme is to provide robust national information to support the delivery of safe, equitable, high quality, patient-centred maternal, newborn and infant health services.

MBRRACE-UK achieves this by:

The scope MNI-CORP is a national programme which encompasses England, Wales, Scotland, Northern Ireland, Jersey, Guernsey and the Isle of Man

Duration of the programme: MBRRACE-UK were commissioned to run the programme from May 2012 to March 2017; following a further competitive re-commissioning round the programme has been extended to run until 30th September 2021.  

Funding: The MNI-CORP programme is commissioned by HQIP on behalf of NHS England, NHS Wales, the Health and Social Care Division of the Scottish government, the Department of Health, Social Services and Public Safety, Northern Ireland (DHSSPS), the States of Jersey, Guernsey, and the Isle of Man.

Notifications of maternal deaths should be made by ringing the Oxford MBRRACE-UK office on 01865 289715.

Reporting of stillbirths, perinatal deaths and infant deaths is via the MBRRACE-UK online reporting system available here: www.mbrrace.ox.ac.uk. Guidelines for using the system can be downloaded here: MBRRACE online data entry guidebook (release April 2013 v101) .

Units are asked to review their access to the internet to ensure that the web browser they are using meets the specifications required to enter data via the MBRRACE-UK system; older versions of software are not suitable as they do not meet NHS data security requirements. Please view the IT specification page to check this for your Unit.

Please also view the MBRRACE-UK IT deployment page which outlines more information about the deployment of the MBRRACE-UK data collection system and may be helpful for IT staff in Units.

Information about why we are collecting non-anonymised information and details about the approvals we have to collect this information is provided on the 'Why we need identifiers' page.

The topics selected for future confidential enquiries are available on the Topics page.

Please also see our Frequently Asked Questions page.

Assessors for the Confidential Enquiries into Maternal and Infant Deaths

With the exception of a small number of specific specialties we have recruited most assessors for the Confidential Enquiries into Maternal Death and the current perinatal confidential enquiry. Any future positions will be advertised here.

Contact details