APPENDIX 33
Memorandum by Professor James Drife, Medical
Director, Confidential Enquiry into Maternal Deaths in the UK
(MS 40)
SUMMARY
Black and Asian women have a higher risk of
death in pregnancy than white women. Women from the most deprived
circumstances appear to have a 20 times greater risk of dying
of causes directly or indirectly related to pregnancy than women
from social classes 1 and 2. The maternal mortality rate has long
been recognised as an indicator of the quality of maternity care.
Policies for provision of maternity services should be directed
at reducing ethnic and social differences in quality of care.
INTRODUCTION
1. I am a professor of obstetrics and gynaecology
at the University of Leeds. I am also Medical Director of the
Confidential Enquiry into Maternal Deaths in the UK ("CEMD"),
and I wish to draw the sub-committee's attention to certain findings
in the most recent report of this Enquiry ("Why Mothers Die
1997-99").
2. The Confidential Enquiry into Maternal
Deaths in England and Wales has been running continuously for
over 50 years and is now part of the National Institute for Clinical
Excellence (NICE). The CEMD makes detailed enquiries into every
death of a pregnant or recently pregnant woman in the UK and publishes
reports every three years. The most recent report, published in
2001, included 242 deaths directly or indirectly due to pregnancy.
3. Maternal mortality in the UK has of course
fallen over the last 50 years. In 1952-54 there were 1,812 deaths
directly or indirectly due to pregnancy, compared to the 242 in
1997-99. Most of the fall, however, occurred between 1952 and
1985. Since 1985 there has been relatively little improvement,
and it has recently become clear that pregnancy is much safer
for some British women than for others.
Findings relevant to the provision of maternity
services, and in particular to variation in service provision.
ETHNICITY
4. The Enquiry first examined the effect
of ethnic origin in the 1990s. In 1994-96, black women had three
times the risk of death compared to white women, with Asian women
somewhere between. In 1997-99 it was Asian women who had three
times the mortality rate of white women, with black women falling
between.
5. There is no single disease or group of
diseases that account for this increase. The Enquiry found that:
"In some cases, the care received by women from ethnic
minority groups was of an exceptionally high standard. In other
cases it was poor. Some of these women were recently arrived immigrants
pregnant on arrival in the UK and many did not speak English.
Several were late in booking and others were poor attenders at
antenatal clinics. A number constantly moved address during their
pregnancy making community follow up difficult."
SOCIAL CLASS
6. The Enquiry first examined the effect
of social class in 1997. The findings were disturbing. Of the
242 deaths in 1997-99, no fewer than 97 (40%) occurred in the
most deprived group, "social class 9", which includes
the unemployed and people of no fixed address. The maternal mortality
rate in this group is similar to that in a developing country.
7. The report, "Why Mothers Die 1997-99"
includes vignettes illustrating some case histories. One described
a young teenager who had had a miscarriage. She was discharged
from hospital after a "day case" procedure but had no
home to go to, having run away. She froze to death under an eiderdown
in a front garden.
CONCLUSION
8. The women in greatest need of support
from the maternity services are also those least able to give
evidence to the sub-committee.
RECOMMENDATIONS FOR
FURTHER ACTION
9. The CEMD's key recommendations include:
— Antenatal services should be flexible
enough to meet the needs of all women. The needs of those from
the most vulnerable and less articulate groups in society are
of equal if not more importance. Many women in this Report found
it difficult to access or maintain access with the services, and
follow-up for those who failed to attend was poor.
— When planning new methods of service
provision it is helpful to involve women who might have difficulties
in using the services. Where this has been done, antenatal clinic
attendances have significantly improved. Such flexibility may
require imaginative solutions in terms of the timing and setting
for antenatal clinics and the provision of outreach services.
— Health professionals who work with
disadvantaged clients need to be able to understand a woman's
social and cultural background, act as an advocate for women,
overcome their own personal and social prejudices and practise
in a reflective manner.
— All healthcare professionals should
consider whether there are unrecognised but inherent racial prejudices
within their own organisations, in terms of providing an equal
service to all users.
— Interpreters should be provided for
women who do not speak English. The use of family members, including
children as interpreters, should be avoided if at all possible.
REFERENCE
"Why Mothers Die 1997-99". The Confidential
Enquiries into Maternal Deaths in the United Kingdom. London:
RCOG Press, 2001. Pp 39-45.
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