14 - THE LEGACY IN THE UNITED KINGDOM: THE CONCEPT OF ‘NEAR MISS’ AND THE NEED TO KEEP SAVING LIVES

Summary

In 2012 the Enquiry moved to the National Perinatal Epidemiology Unit (NPEU) as part of MBRRACE-UK. CEMD Reports became annual and included near-misses. Life-threatening complications are 100 times commoner than death in pregnancy. In 2005 the NPEU had established a surveillance system through which all obstetric units notify uncommon complications. This facilitated a Confidential Enquiry into Maternal Morbidity, which identified an increase in severe haemorrhage due to abnormal placentation, and inadequate treatment of breast cancer due to withholding drugs in pregnancy. Positive trends included better long-term results of treating psychosis. The Enquiries’ work was hampered by NHS bureaucracy, the need for recommendations to be cost-neutral and a media embargo – even though the CEMD had shown that public information is vital for improving safety. Recently the CEMD revealed an increase in deaths from sudden death in epilepsy (SUDEP) due to withdrawal of medication in pregnancy, and continuing disparity in mortality rates between ethnic groups in the UK. Structural biases in the maternity care system persist, as shown by Black Lives Matter movement and the COVID emergency.