Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-586b7cd67f-dlnhk Total loading time: 0 Render date: 2024-11-23T23:21:44.040Z Has data issue: false hasContentIssue false

Further Reading

Published online by Cambridge University Press:  05 April 2023

James Owen Drife ,
Gwyneth Lewis ,
James P Neilson ,
Marian Knight ,
Griselda Cooper  and
Roch Cantwell
James Owen Drife
Affiliation:
University of Leeds
Gwyneth Lewis
Affiliation:
University College London
James P Neilson
Affiliation:
University of Liverpool
Marian Knight
Affiliation:
National Perinatal Epidemiology Unit, Oxford
Griselda Cooper
Affiliation:
University of Birmingham
Roch Cantwell
Affiliation:
Southern General Hospital, Glasgow
Get access

Summary

A summary is not available for this content so a preview has been provided. Please use the Get access link above for information on how to access this content.
Image of the first page of this content. For PDF version, please use the ‘Save PDF’ preceeding this image.'
Type
Chapter
Information
Why Mothers Died and How their Lives are Saved
The Story of Confidential Enquiries into Maternal Deaths
 , pp. 230 - 240
Publisher: Cambridge University Press
Print publication year: 2023

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Primary Sources

Campbell, JM. Maternity homes. Lancet 1921;198(5017):163–4.Google Scholar
Dunn, PM. The Chamberlen family (1560–1728) and obstetric forceps. Archives of Disease in Childhood: Fetal and Neonatal Edition 1998;81:F232–F235.Google Scholar
Halliday, J, Halliday, S. Zepherina Veitch (1836–94): childbed fever and the registration of midwives. Journal of Medical Biography 2007;15:241–5.CrossRefGoogle ScholarPubMed
Loudon, I. Death in childbirth: an international study of maternal care and maternal mortality 1800–1950. Oxford: Clarendon, 1992.Google Scholar
Shaw, WF. Sir Francis Champneys. BJOG 1948;55(3):312–17.Google Scholar
Shaw, WF. The birth of a college. BJOG 1950;57(6):877–89.CrossRefGoogle ScholarPubMed
Smellie, W. A treatise on the theory and practice of midwifery. London: Bailliere Tindall, 1752. Reprinted by Hansebooks, 2018.Google Scholar
Wilson, A. The making of man-midwifery: childbirth in England 1660–1770. Cambridge, MA: Harvard University Press, 1995.Google Scholar

Secondary Sources

Editorial. The maternal mortality of childbirth and the teaching of midwifery. Lancet 1919;193(4993):802–3.Google Scholar
Editorial. Maternal mortality. Lancet 1934;224(5803):1111–12.Google Scholar
Hogarth, M. Dame Janet Mary Campbell (1877–1854). Oxford Dictionary of National Biography. Oxford: Oxford University Press, 2006. https://doi.org/10.1093/ref:odnb/32267Google Scholar
Holland, E. Maternal mortality. Lancet 1935;225(5926):973–6.Google Scholar
Loudon, I. The transformation of maternal mortality. BMJ 1992;305(6868):1557–60.CrossRefGoogle ScholarPubMed
MacLennan, H. The pioneer spirit. BJOG 1965;72(4):530–4.Google Scholar
Maternal mortality and morbidity: final report of [the] Departmental Committee. BMJ 1932;2(3736):327–9.Google Scholar
Obituary: Andrew Topping. Lancet 1955;266(6888):511–13.Google Scholar
Topping, A. Maternal mortality and public opinion. Public Health 1936;9:342–9.Google Scholar
Anderson, M. Changing childbirth: commentary I. BJOG 1993;100(12):1071–2.CrossRefGoogle ScholarPubMed
Chalmers, I, Enkin, M, Kierse, MJNC. Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989.Google Scholar
Department of Health. Changing childbirth. Part I: report of the Expert Maternity Group. London: Her Majesty’s Stationery Office, 1993.Google Scholar
Dunlop, W. Changing childbirth: commentary II. BJOG 1993;100(12):1072–4.Google Scholar
Editorial. Preventing maternal deaths. Lancet 1957;270(6991):375.Google Scholar
Editorial. The Cranbrook Report. Lancet 1959;273(7069):397–8.Google Scholar
Godber, G. AJ Wrigley (obituary). British Medical Journal 1984;288:415.Google Scholar
Godber, G. The origin and inception of the Confidential Enquiry into Maternal Deaths. BJOG 1994;101(11):946–7.Google Scholar
Lewis, G, ed. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118 Suppl. 1;1–203. [As of February 2022, this report had been cited 1,857 times in the general literature and in 457 academic papers.]Google Scholar
Lewis, G, Drife, J. Why Mothers Die 1997–99: the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG Press, 2001.Google Scholar
Lewis, G, Drife, J, Botting, B et al. Why Mothers Die: report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994–1996. London: TSO, 1998.Google Scholar
Paintin, D. Commentary: effective care in pregnancy and childbirth. British Journal of Obstetrics and Gynaecology 1990;97(11):967–73.Google Scholar
Weindling, AM. The Confidential Enquiry into Maternal and Child Health (CEMACH): a review of the history of Confidential Enquiries. Archives of Disease in Childhood 2003;88:1034–7.CrossRefGoogle Scholar
Barry, CN. Home versus hospital confinement. Journal of the Royal College of General Practitioners 1980;30(211):102–7.Google Scholar
Editorial. Current practice in obstetrics. British Medical Journal 1964;1(5383): 580.CrossRefGoogle Scholar
Jeffcoate, TNA. Prolonged labour. Lancet 1961;278(7193):61–7.Google Scholar
MacLennan, HR. The management of labour in contracted pelvis. British Medical Journal 1954;2(4892):837–40.Google Scholar
Miller, D. Common obstetrical injuries and their sequelae. British Medical Journal 1936;2(3939):4–6.Google Scholar
O’Driscoll, K, Jackson, RJA, Gallagher, JT. Prevention of prolonged labour. British Medical Journal 1969;2(5655):477–80.Google Scholar
Sheehan, HL. Shock in obstetrics. Lancet 1948;251(6488):1–7.Google Scholar
Wood, LAC. Obstetric retrospect. Journal of the Royal College of General Practitioners 1981;31(223):80–90.Google Scholar
Buddeberg, BS, Aveling, W. Puerperal sepsis in the 21st century: progress, new challenges and the situation worldwide. Postgraduate Medical Journal 2015;91(1080):572–8.CrossRefGoogle ScholarPubMed
Colebrook, L. Prevention of puerperal sepsis: a call to action. British Medical Journal 1936;1:1257–9. [Colebrook had long campaigned for better aseptic practice in childbirth. This heartfelt paper appeared in the BMJ two weeks after his historic Lancet report on prontosil.]Google Scholar
Colebrook, L, Kenny, M. Treatment of human puerperal infections, and of experimental infections in mice, with prontosil. Lancet 1936;227(5884):1279–81.CrossRefGoogle Scholar
Duka, T. Childbed fever, its causes and prevention: a life’s history. Lancet 1886;128(3283 and 3284): 206–8 and 246–8. [These articles about Ignaz Semmelweis were written by Theodor Duka, who restored his reputation.]Google Scholar
Loudon, I. The tragedy of childbed fever. Oxford: Oxford University Press, 2001. [This is the definitive history of puerperal sepsis.]Google Scholar
Lowis, GW, Minagar, A. Alexander Gordon of Aberdeen and the contagiousness of puerperal fever. Journal of Medical Biography 2002;10:150–4.Google Scholar
Noble, WC. Coli: great healer of men. The biography of Dr Leonard Colebrook FRS. London: Heinemann, 1974.Google Scholar
Obstetrical Society of London. Discussion on puerperal fever. Lancet 1875;105(2698):685–92.Google Scholar
Black, MD. Blood transfusion in obstetrics. British Medical Journal 1937;1(3082):903–6. (and correspondence in British Medical Journal 1937;1(3084):1043–4).CrossRefGoogle ScholarPubMed
Hendry, J, Baird, D. Treatment of placenta praevia. Transactions of Edinburgh Obstetrical Society 1937;57:25–44.Google ScholarPubMed
Liang, DYS. The emergency obstetric service, Bellshill Maternity Hospital 1933–1961. BJOG 1963;70(1):83–93.Google Scholar
Lloyd, HN et al. Discussion on [the] emergency obstetrical service (the flying squad): its use and abuse. Proceedings of the Royal Society of Medicine 1949;42:1–10.Google Scholar
Mavrides, E, Allard, S, Chandraharan, E, et al. on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention and management of postpartum haemorrhage. (Green-Top Guideline No. 52.) BJOG 2016;124:e106–e149.Google Scholar
Pavord, S, Rayment, R, Madan, B et al. on behalf of the Royal College of Obstetricians and Gynaecologists. Management of inherited bleeding disorders in pregnancy. (Green-Top Guideline No. 71: Joint with UKHCDO.) BJOG 2017;124:e193–e263.Google Scholar
Thomson, AJ, Ramsay, JE, on behalf of the Royal College of Obstetricians and Gynaecologists. Antepartum haemorrhage (Green-Top Guideline No. 63). London: Royal College of Obstetricians and Gynaecologists, 2011.Google Scholar
WHO recommendations for prevention and treatment of postpartum haemorrhage. www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548502/enGoogle Scholar
Eclampsia Trial Collaborative Group. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet 1995;345:1455–63.Google Scholar
Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet 2002;359:1877–90.Google Scholar
National Institute for Health and Care Excellence. Hypertension in pregnancy: diagnosis and management. NICE Guideline 133, 2019. www.nice.org.uk/guidance/ng133Google Scholar
WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548335/enGoogle Scholar
Abortion and maternal deaths. British Medical Journal 1976;2(6027):70.Google Scholar
Anonymous. The statistics of 100 cases of abortion. Lancet 1902;159:1125–6.Google Scholar
Anonymous. Should abortion be legalised? Lancet 1932;219:627.Google Scholar
Anonymous. A charge of illegal abortion: Rex v. Bourne. Lancet 1938;232:220–6.Google Scholar
Baird, D. A fifth freedom? British Medical Journal 1965;2(5471):1411–18.Google Scholar
Davis, A. 2,665 cases of abortion: a clinical survey. British Medical Journal 1950;2(4671): 123–30.Google Scholar
Diggory, PLC. Some experiences of therapeutic abortion. Lancet 1969;293:873–5.Google Scholar
Drife, J. Historical perspective on induced abortion through the ages and its links with maternal mortality. Best Practice & Research Clinical Obstetrics and Gynaecology 2010;24:431–41.Google Scholar
General Medical Council. Deputation on the Midwives Bill. British Medical Journal 1895;1(1796):1244–7.Google Scholar
Malleson, J. Criminal abortion: a suggestion for lessening its incidence. Lancet 1939;233:366–7.Google Scholar
On the frequency of criminal abortion. Provincial Medical Journal 1843;2:471–2.Google Scholar
Rowlands, S (ed.). Abortion care. Cambridge: Cambridge University Press, 2014.Google Scholar
Thomson, AT. Lectures on medical jurisprudence now in the course of delivery at the University of London: Lecture XVII: on abortion. Lancet 1837;27:625–30.Google Scholar
Asher, R. Talking sense. London: Pitman, 1972.Google Scholar
Atlee, HB. Evidence in favour of a more active puerperium: a study of 500 cases. Canadian Medical Association Journal 1935;33(2):144–50.Google Scholar
Bryant, EC. Early ambulation in the practice of obstetrics. Canadian Medical Association Journal 1947;57(3):257–9.Google ScholarPubMed
Drife, J. Deep venous thrombosis and pulmonary embolism in obese women. Best Practice & Research Clinical Obstetrics & Gynaecology 2015;29(3):365–76.Google Scholar
Editorial. Early discharge of maternity patients. British Medical Journal 1964;2(5401):70–1.Google Scholar
Hampton, JR. The end of clinical freedom. British Medical Journal 1983;287(6401):1237–8.Google Scholar
Royal College of Obstetricians and Gynaecologists. Reducing the risk of venous thromboembolism during pregnancy and the puerperium. Third edition. (Green-Top Guideline No. 37a). London: Royal College of Obstetricians and Gynaecologists, 2015.Google Scholar
Salzman, KD. The nature and some hazards of obstetrics in general practice. British Medical Journal 1955;2(4930):15–19.Google Scholar
Thomas, J, Paranjothy, S, RCOG Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. London: RCOG Press, 2001.Google Scholar
Thornton, P, Douglas, J. Coagulation in pregnancy. Best Practice & Research Clinical Obstetrics and Gynaecology 2010;24(3):339–52.Google Scholar
Carapetis, JR. Rheumatic heart disease in developing countries. New England Journal of Medicine 2007;357(5):439–41.Google Scholar
Drife, JO. Breast cancer, pregnancy, and the pill. British Medical Journal 1981;283:778–9.Google Scholar
Head, CEG, Thorne, SA. Congenital heart disease in pregnancy. Postgraduate Medical Journal 2005;81:292–8.Google Scholar
Nelson-Piercy, C. Handbook of obstetric medicine. Sixth edition. London: Routledge, Taylor & Francis, 2021.Google Scholar
Powrie, RO, Greene, MF, Camann, W, eds. De Swiet’s medical disorders in obstetric practice. Fifth edition. Chichester: Wiley-Blackwell, 2010.Google Scholar
Schaufelberger, M. Cardiomyopathy in pregnancy. Heart 2019;105:1543–51.Google Scholar
Soma-Pillay, P, Nelson-Piercy, C, Toppanen, H, Mebazaa, A. Physiological changes in pregnancy. Cardiovascular Journal of Africa 2016;27(2):89–94.Google Scholar
Yarris, JP, Hunter, AJ. Roy Hertz MD (1909–2002): the cure of choriocarcinoma and its impact on the development of chemotherapy for cancer. Gynecologic Oncology 2003;89:193–8.CrossRefGoogle Scholar
Yentis, SM, Steet, PJ, Plaat, F. Eisenmenger’s syndrome in pregnancy: maternal and fetal mortality in the 1990s. British Journal of Obstetrics and Gynaecology 1998;105(8):921–2.Google Scholar
Sykes, WS. Essays on the first hundred years of anaesthesia. Volume 2. 1982. Edinburgh: E&S Livingstone.Google Scholar
Grieff, JMC, Tordoff, SG, Griffiths, R et al. Acid aspiration prophylaxis in 202 obstetric anaesthetic units in the UK. Int J Obstet Anesth. 1994;3:137–42.Google Scholar
Interim report of Departmental Committee on Maternal Mortality & Morbidity. London: His Majesty’s Stationery Office, 1930.Google Scholar
Thomas, J, Paranjothy, S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit: The National Sentinel Caesarean Section Audit Report. London: RCOG Press; 2001.Google Scholar
Cantwell, R. Perinatal mental health service development across the UK: many achievements, growing challenges. Irish Journal of Psychological Medicine. (2022): 1–4. https://doi.org/10.1017/ipm.2022.1CrossRefGoogle Scholar
Howard, LM, Molyneaux, E, Dennis, C-L, Rachat, T, Stein, A, Milgrom, J. Non-psychotic mental disorders in the perinatal period. Lancet 2014;384 :1775–88.Google Scholar
Jones, I, Chandra, PS, Dazzan, P, Howard, LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet 2014;384:1789–99.Google Scholar
Khalifeh, H, Hunt, IM, Appleby, L, Howard, LM. Suicide in perinatal and non-perinatal women in contact with psychiatric services: 15 year findings from a UK national inquiry. Lancet Psychiatry 2016;3:233–42.Google Scholar
Oates, M. The development of an integrated community service for severe postnatal mental illness. In Motherhood and Mental Illness 2: causes and consequences, ed. Kumar, S and Brockington, IF, pp. 133–58. London: Wright, 1988.Google Scholar
Prettyman, RJ and Friedman, T. Care of women with puerperal psychiatric disorders in England and Wales. British Medical Journal 1991;302:1345–6.Google Scholar
Department of Health. Inequalities in Health: report of an independent enquiry chaired by Sir Donald Acheson. London: Her Majesty’s Stationery Office, 1998.Google Scholar
Department of Health and Social Security. Inequalities in Health: report of a research working group chaired by Sir Douglas Black. London: Department of Health and Social Security, 1980.Google Scholar
Godber, G. The Confidential Enquiry into Maternal Deaths: A limited study of clinical results. In: A Question of Quality? Roads to assurance in medical care. Nuffield Provincial Hospitals Trust, ed. McLachan, G, pp. 23–34. Oxford: Oxford University Press, 1976.Google Scholar
Gray, A M. Inequalities in Health. The Black Report: a summary and comment. https://pubmed.ncbi.nlm.nih.gov/7118327Google Scholar
Lewis, G, ed. Saving Mothers’ Lives: the seventh report of the Confidential Enquires into Maternal Deaths in the UK. CEMACH. December 2007. www.cmace.org.ukGoogle Scholar
Lewis, G, ed. Saving Mothers’ Lives: the eighth report of the UK Confidential Enquiries into Maternal Deaths. Centre for Maternal and Child Health Enquiries. March 2011. Published as BJOG 2011;118Suppl1: 1–203. https://doi.org/10.1111/j.1471-0528.2010.02847.xGoogle Scholar
Marmot, M. Health equity in England: the Marmot review ten years on. BMJ 2020;368:m693.Google Scholar
Marmot, M, Allen, J, Boyce, T, Goldblatt, P, Morrison, J. Health equity in England: the Marmot review 10 years on. London: Institute of Health Equity, 2020. www.instituteofhealthequity.org/the-marmot-review-10-years-onGoogle Scholar
Oliver, A. Reflections on the development of health inequalities policy in the United Kingdom. Working Papers 11/2008. LSE Health. London: School of Economics and Political Science, 2008.Google Scholar
Oxley, WH, Phillips, MH, Young, J. Maternal mortality in Rochdale. British Medical Journal 1935;1(3867):304–7.Google Scholar
Socialist Health Association. The Black Report. 1980. www.sochealth.co.uk/national-health-service/public-health-and-wellbeing/poverty-and-inequality/the-black-report-1980Google Scholar
https://healthtalk.org/conditions-threaten-womens-lives-childbirth-pregnancy/overview. This is a website with women describing their near-miss experiences.Google Scholar
Hinton, L, Locock, L, Knight, M. Experiences of the quality of care of women with near-miss maternal morbidities in the UK. BJOG. 2014 Sep;121 Suppl 4 (Suppl4): 20–3. https://doi.org/10.1111/1471-0528.12800. PMID: 25236629; PMCID: PMC4312976.Google Scholar
Knight, M, Acosta, C, Brocklehurst, P et al. Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity. Southampton: NIHR Journals Library, 2016. PMID: 27386616.Google Scholar
Knight, M, Bunch, K, Vousden, N et al. A national cohort study and confidential enquiry to investigate ethnic disparities in maternal mortality. EClinicalMedicine. 2021 Dec. 13;43:101237. https://doi.org/10.1016/j.eclinm.2021.101237. PMID: 34977514; PMCID: PMC8683666.Google Scholar
Knight, M, Lindquist, A. The UK Obstetric Surveillance System: impact on patient safety. Best Pract Res Clin Obstet Gynaecol. 2013 Aug;27(4):621–30. https://doi.org/10.1016/j.bpobgyn.2013.03.002. Epub 2013 Mar 30. PMID: 23548471.Google Scholar
www.thelancet.com/series/maternal-health-2016Google Scholar
Marshall, O, Blaylock, R, Murphy, C, Sanders, J. Risk messages relating to fertility and pregnancy: a media content analysis. Wellcome Open Res. 2021 May 14;6:114. https://doi.org/10.12688/wellcomeopenres.16744.1. PMID: 34286102; PMCID: PMC8276184.Google Scholar
Borchert, M, Bacci, A, Baltag, V, Hodorogea, S, Drife, J. Improving maternal and perinatal health care in the Central Asian Republics. International Journal of Gynecology and Obstetrics 2010;110:97–100.Google Scholar
Fathalla, M. Human rights aspects of safe motherhood. Best Practice and Clinical Research in Clinical Obstetrics and Gynaecology 2006;20(3):409–19.Google Scholar
Fathalla, M. Reproductive rights and reproductive wrongs. Current Women’s Health Reports 2001;1(3):169–70.Google Scholar
Lewis, G. Reviewing maternal deaths to make pregnancy safer. Best Practice & Research Clinical Obstetrics and Gynaecology 2008;22(3):447–63.Google Scholar
Lewis, G. Saving mothers’ lives: the continuing benefits for maternal health from the United Kingdom (UK) Confidential Enquires into Maternal Deaths. Seminars in Perinatology 2012;36(1):19–26.Google Scholar
Lewis, G. The cultural environment behind successful maternal death and morbidity reviews. BJOG 2014;121 Special issue 4 (International Reviews: Quality of Care):24–31.Google Scholar
Rosenfield, A, Maine, D. Maternal mortality, a neglected tragedy: where is the M in MCH? Lancet 1985;326(8446):83–5.Google Scholar
Say, L, Chou, D, Gemill, A et al. Global causes of maternal deaths: a WHO systematic analysis. Lancet Global Health 2014;2:e323–e233.Google Scholar
Thaddeus, S, Maine, D. Too far to walk: maternal mortality in context. Social Science and Medicine 1994;38(8):1091–110.Google Scholar
World Health Organization. Trends in Maternal Mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization, 2019.Google Scholar
World Health Organization, Lewis, G. Beyond the Numbers: reviewing maternal deaths and complications to make pregnancy safer. Geneva: World Health Organization, 2004.Google Scholar
For those interested in more details of the South African experience with CEMDs, the articles by Moodley and colleagues (2014) and Moodley and colleagues (2018) give more details. In an attempt to make the Saving Mothers reports more accessible, a number of the chapters from the seventh Saving Mothers Report 2017–2019 related to conditions were published in the Obstetrics and Gynaecology Forum (https://journals.co.za/toc/medog/30/4).Google Scholar
There also some other spin-offs from a CEMD which are often not recognised, but very important. The system set-up allows for rapid recognition of complications which are rare but in a large enquiry become apparent, for example the article by Fawcus and colleagues (2016) highlighted the problem of deaths due to bleeding at or after caesarean delivery, which led to an immediate response. The system also can be used to rapidly report on new diseases such as COVID-19. Here the CEMD was able to produce quarterly reports to the ministerial committee working on COVID-19 and highlight for the committee the higher mortality of COVID-19 in pregnancy, putting pregnant women in the high-risk category and stressing their need for vaccination.Google Scholar
Finally, a CEMD is an integral part of the audit cycle. Poor-quality emergency care was identified early as a problem in maternal deaths by the CEMD in South Africa. Thus permission was obtained from Professor Nyncke van den Broek and the Royal College of Obstetricians and Gynaecologists to adapt their ‘Life Saving Skills’ course to South African circumstances. The adapted course, ‘Essential Steps in Managing Obstetric Emergencies’, was tested in South Africa. Twelve of the worst-performing districts were identified using the CEMD. In partnership with the Liverpool School Tropical Medicine and their volunteers, the adapted course was scaled up in these 12 districts such that at least 80% of all healthcare professionals dealing with pregnant women were trained in emergency obstetric care. The impact was assessed using the CEMD of the 12 districts and the control group of the remaining 40 districts. It showed a 39.5% overall drop in mortality, mainly due to reduction in deaths due to complications of HIV infection, but also a 17.5% reduction in direct maternal deaths, mainly those due to obstetric haemorrhage and hypertensive disorders of pregnancy (Pattinson et al. 2019). This is a good illustration of the audit cycle and the part a CEMD plays in it.Google Scholar
Fawcus, S, Pattinson, RC, Moodley, J et al. Maternal deaths from bleeding associated with caesarean delivery: a national emergency (a review). SAMJ: South African Medical Journal 2016 May;106(5):472–6.Google Scholar
Moodley, J, Fawcus, F, Pattinson, R. Improvements in maternal mortality in South Africa. South African Medical Journal 2018 Mar 2;108(4):s4–s8.Google Scholar
Moodley, J, Pattinson, RC, Fawcus, S, Schoon, MG, Moran, N, Shweni, PM. The confidential enquiry into maternal deaths in South Africa: a case study. BJOG: An International Journal of Obstetrics & Gynaecology 2014;121(s4):53–60.Google Scholar
Pattinson, RC, Bergh, AM, Ameh, C et al. Reducing maternal deaths by skills-and-drills training in managing obstetric emergencies: a before-and-after observational study. South African Medical Journal 2019 Mar 29;109(4):241–5.Google Scholar
Pattinson, RC, Fawcus, S, Gebhardt, GS, Soma-Pillay, P, Niit, R, Moodley, J. The impact of COVID-19 on use of maternal and reproductive health services and maternal and perinatal mortality. South African Health Review 2021: 106–19.Google Scholar
Chatterjee, A, Paily, VP. Achieving Millennium Development Goals 4 and 5 in India. BJOG 2011;118Suppl 2:47–59.Google Scholar
Paily, VP, Ambujam, K, Rajasekharan, V, Nair, VR, Thomas, B. Confidential review of maternal deaths in Kerala: a country case study. BJOG 2014;121Suppl 4:61–6. https://doi.org/10.1111/1471-0528.13000Google Scholar
Paily, VP, Ambujam, K, Thomas, B et al., eds. Why Mothers Die: Kerala 2010–2020: observations and recommendations. Thrissur: Kerala Federation of Obstetrics and Gynaecology, 2021.Google Scholar
Paily, VP, Ambujam, K, Thomas, B, Sekharan, PK, Nair, VR. Measures to reduce maternal mortality: Kerala experience. In press.Google Scholar
CMQCC Improving Health Care Response to Hypertensive Disorders of Pregnancy Toolkit, Version 2.0. www.cmqcc.org/resources-tool-kits/toolkits/HDP[6]Google Scholar
CMQCC Improving Health Care Response to Obstetric Hemorrhage Toolkit, Version 2.0. www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit[5]Google Scholar
Main, EK, Cape, V, Abreo, A et al. Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative. Am J Obstet Gynecol. 2017;216(3):298.e1–298.e11.[9]Google Scholar
Main, EK, Dhurjati, R, Cape, V et al. Improving maternal safety at scale with the mentor model of collaborative improvement. Jt Comm J Qual Patient Saf. 2018;44(5):250–9.[7]Google Scholar
Main, EK, Goffman, D, Scavone, BM et al. National partnership for maternal safety: consensus bundle on obstetric hemorrhage. Obstet Gynecol. 2015;126(1):15562.[10]Google Scholar
Main, EK, McCain, CL, Morton, CH, Holtby, S, Lawton, ES. Pregnancy-related mortality in California: causes, characteristics and improvement opportunities. Obstet Gynecol. 2015 Apr;125(4):938–47.[1]Google Scholar
Morton, CH, Seacrist, MJ, Van Otterloo, LR, Main, EK. Quality improvement opportunities identified through case review of pregnancy-related deaths from preeclampsia/eclampsia. J Obstet Gynecol Neonatal Nurs. 2019 48:275–87.[3]Google Scholar
Morton, CH, Van Otterloo, LR, Seacrist, MJ, Main, EK. Translating maternal mortality review into quality improvement opportunities in response to pregnancy-related deaths in California. J Obstet Gynecol Neonatal Nurs. 2019 48:252–62.[2]Google Scholar
Rosenstein, MG, Chang, S-C, Sakowski, C et al. Hospital quality improvement interventions, statewide policy initiatives and rates of nulliparous term singleton vertex caesarean deliveries in California. JAMA 2021;325(16):1631–9.[8]Google Scholar
Seacrist, MJ, Van Otterloo, LR, Morton, CH, Main, EK. Quality improvement opportunities identified through case review of pregnancy-related deaths from obstetric hemorrhage. J Obstet Gynecol Neonatal Nurs. 2019 48:288–99.[4]Google Scholar
For those interested in more details of the South African experience with CEMDs, the articles by Moodley and colleagues (2014) and Moodley and colleagues (2018) give more details. In an attempt to make the Saving Mothers reports more accessible, a number of the chapters from the seventh Saving Mothers Report 2017–2019 related to conditions were published in the Obstetrics and Gynaecology Forum (https://journals.co.za/toc/medog/30/4).Google Scholar
There also some other spin-offs from a CEMD which are often not recognised, but very important. The system set-up allows for rapid recognition of complications which are rare but in a large enquiry become apparent, for example the article by Fawcus and colleagues (2016) highlighted the problem of deaths due to bleeding at or after caesarean delivery, which led to an immediate response. The system also can be used to rapidly report on new diseases such as COVID-19. Here the CEMD was able to produce quarterly reports to the ministerial committee working on COVID-19 and highlight for the committee the higher mortality of COVID-19 in pregnancy, putting pregnant women in the high-risk category and stressing their need for vaccination.Google Scholar
Finally, a CEMD is an integral part of the audit cycle. Poor-quality emergency care was identified early as a problem in maternal deaths by the CEMD in South Africa. Thus permission was obtained from Professor Nyncke van den Broek and the Royal College of Obstetricians and Gynaecologists to adapt their ‘Life Saving Skills’ course to South African circumstances. The adapted course, ‘Essential Steps in Managing Obstetric Emergencies’, was tested in South Africa. Twelve of the worst-performing districts were identified using the CEMD. In partnership with the Liverpool School Tropical Medicine and their volunteers, the adapted course was scaled up in these 12 districts such that at least 80% of all healthcare professionals dealing with pregnant women were trained in emergency obstetric care. The impact was assessed using the CEMD of the 12 districts and the control group of the remaining 40 districts. It showed a 39.5% overall drop in mortality, mainly due to reduction in deaths due to complications of HIV infection, but also a 17.5% reduction in direct maternal deaths, mainly those due to obstetric haemorrhage and hypertensive disorders of pregnancy (Pattinson et al. 2019). This is a good illustration of the audit cycle and the part a CEMD plays in it.Google Scholar
Fawcus, S, Pattinson, RC, Moodley, J et al. Maternal deaths from bleeding associated with caesarean delivery: a national emergency (a review). SAMJ: South African Medical Journal 2016 May;106(5):472–6.Google Scholar
Moodley, J, Fawcus, F, Pattinson, R. Improvements in maternal mortality in South Africa. South African Medical Journal 2018 Mar 2;108(4):s4–s8.Google Scholar
Moodley, J, Pattinson, RC, Fawcus, S, Schoon, MG, Moran, N, Shweni, PM. The confidential enquiry into maternal deaths in South Africa: a case study. BJOG: An International Journal of Obstetrics & Gynaecology 2014;121(s4):53–60.Google Scholar
Pattinson, RC, Bergh, AM, Ameh, C et al. Reducing maternal deaths by skills-and-drills training in managing obstetric emergencies: a before-and-after observational study. South African Medical Journal 2019 Mar 29;109(4):241–5.Google Scholar
Pattinson, RC, Fawcus, S, Gebhardt, GS, Soma-Pillay, P, Niit, R, Moodley, J. The impact of COVID-19 on use of maternal and reproductive health services and maternal and perinatal mortality. South African Health Review 2021: 106–19.Google Scholar
Chatterjee, A, Paily, VP. Achieving Millennium Development Goals 4 and 5 in India. BJOG 2011;118Suppl 2:47–59.Google Scholar
Paily, VP, Ambujam, K, Rajasekharan, V, Nair, VR, Thomas, B. Confidential review of maternal deaths in Kerala: a country case study. BJOG 2014;121Suppl 4:61–6. https://doi.org/10.1111/1471-0528.13000Google Scholar
Paily, VP, Ambujam, K, Thomas, B et al., eds. Why Mothers Die: Kerala 2010–2020: observations and recommendations. Thrissur: Kerala Federation of Obstetrics and Gynaecology, 2021.Google Scholar
Paily, VP, Ambujam, K, Thomas, B, Sekharan, PK, Nair, VR. Measures to reduce maternal mortality: Kerala experience. In press.Google Scholar
CMQCC Improving Health Care Response to Hypertensive Disorders of Pregnancy Toolkit, Version 2.0. www.cmqcc.org/resources-tool-kits/toolkits/HDP[6]Google Scholar
CMQCC Improving Health Care Response to Obstetric Hemorrhage Toolkit, Version 2.0. www.cmqcc.org/resources-tool-kits/toolkits/ob-hemorrhage-toolkit[5]Google Scholar
Main, EK, Cape, V, Abreo, A et al. Reduction of severe maternal morbidity from hemorrhage using a state perinatal quality collaborative. Am J Obstet Gynecol. 2017;216(3):298.e1–298.e11.[9]Google Scholar
Main, EK, Dhurjati, R, Cape, V et al. Improving maternal safety at scale with the mentor model of collaborative improvement. Jt Comm J Qual Patient Saf. 2018;44(5):250–9.[7]Google Scholar
Main, EK, Goffman, D, Scavone, BM et al. National partnership for maternal safety: consensus bundle on obstetric hemorrhage. Obstet Gynecol. 2015;126(1):15562.[10]Google Scholar
Main, EK, McCain, CL, Morton, CH, Holtby, S, Lawton, ES. Pregnancy-related mortality in California: causes, characteristics and improvement opportunities. Obstet Gynecol. 2015 Apr;125(4):938–47.[1]Google Scholar
Morton, CH, Seacrist, MJ, Van Otterloo, LR, Main, EK. Quality improvement opportunities identified through case review of pregnancy-related deaths from preeclampsia/eclampsia. J Obstet Gynecol Neonatal Nurs. 2019 48:275–87.[3]Google Scholar
Morton, CH, Van Otterloo, LR, Seacrist, MJ, Main, EK. Translating maternal mortality review into quality improvement opportunities in response to pregnancy-related deaths in California. J Obstet Gynecol Neonatal Nurs. 2019 48:252–62.[2]Google Scholar
Rosenstein, MG, Chang, S-C, Sakowski, C et al. Hospital quality improvement interventions, statewide policy initiatives and rates of nulliparous term singleton vertex caesarean deliveries in California. JAMA 2021;325(16):1631–9.[8]Google Scholar
Seacrist, MJ, Van Otterloo, LR, Morton, CH, Main, EK. Quality improvement opportunities identified through case review of pregnancy-related deaths from obstetric hemorrhage. J Obstet Gynecol Neonatal Nurs. 2019 48:288–99.[4]Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×