What has happened to the UK Confidential Enquiry into Maternal Deaths?

On 13 June the Healthcare Quality Improvement Partnership (HQIP) in England and Wales announced that MBRRACE-UK (Mothers and Babies—Reducing Risk through Audits and Confidential Enquiries across the UK) had been appointed to run the national maternal, newborn, and infant clinical outcomes review programme, the latest incarnation of the Confidential Enquiry into Maternal Deaths. MBRRACE-UK is a collaboration of members from the National Perinatal Epidemiology Unit (NPEU) and several universities and charities, and it is now faced with improving the quality of this long running programme and making sure its future recommendations are more evidence based.

The Confidential Enquiry into Maternal Deaths was the world’s longest running clinical audit, originating in the mid-19th century. Local health board audits in the 1920s became a national (England and Wales) three yearly report funded by the Ministry of Health in 1952.1 Its most recent purpose has been to monitor causes of maternal death, improve safety, and reduce mortality using a system of anonymised case records and regional and national assessors, with review, standardisation, and recommendations. The inquiry has engendered loyalty and respect and has been emulated around the globe.

Various structural reincarnations have included expansion to the whole of the United Kingdom (in 1985), inclusion under the umbrella of the National Institute for Health and Clinical Excellence (in 1999), and the adoption of independent charity status while incorporating the Confidential Enquiry into Child Health. In 2003 it became the Centre for Maternal and Child Enquiries (2003). Recently the inquiry was put out to competitive tender and was suspended for more than a year.2 3 In 2011, as the new programme was about to be placed under the umbrella of the National Perinatal Epidemiology Unit (NPEU), the Department of Health initiated a further review.2 The department sought justification for the costs of the inquiry, and for its differences in management compared with other specialties within the framework of generic Department of Health structures.

Among the challenges facing the programme’s new hosts is a requirement to make the audit and its recommendations more robust. Although the UK has one of the lowest rates of maternal mortality in the world, and such deaths are few when set against a vast and rising burden of morbidity, changes in causes of death and demographic changes must still be audited. Some deaths are inevitable, but avoidable ones are unacceptable. The latest Department of Health review concluded, after wide consultation, that it was essential to continue the programme, but that quality improvements—including prompt reporting, multidisciplinary involvement, and inclusion of morbidity measures—were needed.

Despite being highly regarded, highly cited, and linked to 35 national standards in the Clinical Negligence Scheme for Trusts, the old confidential inquiry was widely criticised. Its critics argued that it dealt with “anecdote,” did not fulfil audit criteria, and involved experts giving their opinion on the data collected rather than formal peer review. Thus its recommendations could not be properly implemented.4 Epidemiologists criticised it for its expense, lack of denominators, and scanty scientific evidence of benefit.5 Counter arguments highlighted that evidence does not always lend itself to formal scientific evaluation, and proponents of the inquiry have pointed out that its recommendations are drawn from multiple sources, which is a strength.6

Changing demography and the effect of this on measurable maternal outcomes presents another challenge to the new hosts of the programme. Shifts in the causes of maternal deaths have been identified by recent inquiries, which have highlighted poor mental health, cardiac disease, and sepsis as the major culprits, while deaths after assisted reproduction and elective caesarean section for breech birth, as well as deaths as a result of changes in the management of appendicitis have appeared as emerging problems.7 8 9 10 Evidence of substandard care, especially in the areas of haemorrhage and hypertension, implies that there is room for improvement.11 However, maternal mortality rates are rising in several high income countries and demographic changes, such as age, obesity, and migration from countries where maternal mortality is high, threaten maternal outcomes in the UK.12 A foreseeable lack of improvement in maternal outcomes may in turn affect the perception of success of MBRRACE-UK and its chances for future funding.

Although they have to work within new cost constraints, a higher expectation of quality, and an expectation that they should show evidence of impact, the programme’s new hosts, and their independent advisory groups, must not forget the traditional ethos of the confidential inquiry, which recognised that worthwhile clinical lessons can still be learnt from attending to the detail of individual tragedy and that careful unpicking of the circumstances surrounding avoidable deaths requires the engagement of front line clinicians who deliver care. Expert evaluation, peer opinion, and subjective judgment of substandard care—passed on through powerful narratives innovatively acquired (for example, through requesting relatives’ views)—must still have a place in determining and motivating best practice alongside more quantifiable outcomes. The unique impact of the confidential inquiry that engendered support from clinicians and galvanised the maternity community must not be lost in an inundation of guidelines and performance monitoring.