Mothers at risk: Britain's <u>real</u> labour crisis

Sub-standard care, staff shortages and higher levels of obesity are resulting in the highest death rate among new mothers for 20 years, according to a damning report to be published this Tuesday. By Jonathan Owen and Ian Griggs

Record numbers of women are dying during pregnancy or shortly after childbirth, with maternal deaths in the UK at their highest for 20 years.

The findings are revealed in a new report, Saving Mothers' Lives, from the Confidential Enquiry into Maternal and Child Health (Cemach) to be released on Tuesday. Almost 300 women died in childbirth between 2003 and 2005 from conditions relating to pregnancy, leaving 520 children motherless. In a damning verdict on the substandard care that is putting women's lives at risk, the report, seen exclusively by The Independent on Sunday, cites "avoidable factors" that have contributed to the death toll.

It condemns "the number of healthcare professionals who appeared to fail to identify and manage common medical conditions or potential emergencies outside their immediate area of expertise".

It goes on to say that "resuscitation skills were also considered poor in an unacceptably high number of cases" where women died, and that the maternity system allowed "inappropriate delegation to junior staff", which hampered the medical care mothers received.

Cemach also calls for pre-conception counselling and advice for obese women, who are at higher risk of complications during pregnancy.

The report reveals that the mortality rate among mothers giving birth is up to almost 14 per 100,000 people an increase of more than 50 per cent since 1985-87. Repeated reports highlighting fundamental failings in maternity care have failed to reduce the rate of maternal mortality and women continue to die from common and curable infections. The number of women dying from heart disease has more than doubled since Cemach's last report on deaths from 2000-02. It has overtaken thrombosis as the most common cause of maternal death, in what the latest report says "reflects the growing incidence of acquired heart disease in younger women related to poor diets, smoking, alcohol and the growing epidemic of obesity".

A combination of increasing numbers of older mothers, obese women and migrant mothers is thought to be behind the alarming rise in deaths: 261 died between 2000 and 2002, and 295 from 2003 to 2005. But senior doctors have warned that mothers and babies are dying because of staff shortages. They are calling for thousands more midwives and consultants and for a radical overhaul of the way maternity units are run to make them safer.

New guidelines were issued this year by the Royal Colleges of Anaesthetists, of Midwives, of Obstetricians and Gynaecologists, and Paediatrics and Child Health. More doctors are needed desperately, according to Professor Sabaratnam Arulkumaran, president of the Royal College of Obstetricians and Gynaecologists. "We are pressing the Government to increase the number of consultant obstetricians in busy units so that we can provide 24-hour cover," he said. "If there is a consultant present, they are better able to deal with emergencies and prevent disasters."

The rise in deaths is no surprise to Dr Donald Gibb, a consultant obstetrician formerly based at King's College London who now runs his own clinic in Harley Street. "There's a lack of consultant input, not through lack of will, but through lack of numbers and time, as well as the ongoing shortage of midwives," he said. "I think we need to look at systematic failures of the organisation of care. There is a lack of availability of specialist expertise. The standard of 40 hours of consultant cover per week for every obstetrics unit, set eight years ago, has still not been met."

The Government has not acted on repeated warnings, he added. "What really annoys me and other consultants, many of whom work in the NHS, is that in spite of repeated recommendations to increase the consultant cover in labour wards, nobody seems to have done much about this. A lot of consultants are disillusioned and burnt out.

"It seems as if the Department of Health doesn't listen to what doctors tell them. There's a political imperative to run units as cost-effectively as possible. But when things go wrong, for the small number of women that run into trouble, we're talking about life and death. The stakes could not be higher."

While some maternal deaths remain unavoidable, question marks remain over many of them, according to Cemach. It said: "In many cases the care provided was hampered by a lack of cross-disciplinary working and problems with communication... non-existent team-working... [and] inappropriate delegation to junior staff."

Jane Sandall, professor of midwifery and women's health at King's College London, said many deaths could be prevented. "Substandard care accounted for 40 per cent of maternal deaths in the last report and I am fairly sure the same will be true here," she said. "In a very fragmented care system, continuity of care is crucial. The last year has been particularly difficult because of the financial situation in the NHS. Trusts are struggling and the birth rate is going up, as well as the level of complexity of births."

The shadow Secretary of State for Health, Andrew Lansley, said: "These figures are disappointing and they will worry people. We should be moving in a direction where maternal and perinatal deaths are reducing rather than rising." Peter Walsh, chief executive of Action Against Medical Accidents, added: "This is really a very disappointing figure. We would have expected, with modern medicine, for these figures to have reduced and not gone up. We just don't seem to be making progress, and it appears we could even be going backwards."

The crisis in maternity care is hitting the poorest women the hardest, with Cemach researchers stating: "The stark inequalities demonstrated by the risk factors for maternal deaths continue to highlight that a disproportionate number of the women who died came from the most vulnerable and excluded groups of our society." Women in most deprived areas are five times more likely to die; black African women are six times more likely; and women with unemployed partners are seven times more likely to die.

Researchers are calling for counselling of obese women who are considering having children. "More than half of all the women who died were overweight or obese. Where possible, obese women should be helped to lose weight prior to conception or any form of assisted reproduction." A national obstetric early-warning chart is needed to help to prevent deaths, and antenatal services need to be "accessible and welcoming", with women who are at least 12 weeks pregnant being seen within two weeks.

Doctors and nurses need to be trained in how to deal with serious medical conditions that may affect pregnant women, and to improve their basic life-saving skills, said Cemach. It said guidelines are urgently needed for dealing with sepsis severe infection in pregnancy, pain and bleeding in early pregnancy, and pregnant obese women.

A national investigation into maternity care standards is to be undertaken by the Healthcare Commission, after a major survey of 26,000 mothers found that more than a third said they had not been offered antenatal classes and 26 per cent reported being alarmed by being left alone during labour or after birth. The commission said that at one hospital, 18 per cent of women said they had not been treated with "kindness and understanding".

Anna Walker, the organisation's chief executive, said: "The results do highlight specific areas of concern and wide variations with issues including postnatal care, communication, food and cleanliness." Government figures released earlier this year revealed that 63,801 "adverse events" were reported by maternity staff in 2006-07, a steep rise on the 44,001 cases reported the previous year. Thousands of women suffered botched diagnoses, scans, tests and assessments. Almost 3,000 were given the wrong medication, and there were more than 4,500 cases of medical records being lost or mixed up; 1,617 mothers suffered an avoidable accident on the ward, up almost a half on the year before.

Louise Silverton, deputy general secretary of the Royal College of Midwives, said that at least 5,000 more midwives are needed. "We have got to aim for all women to be happy with their care, but we will struggle to make this happen unless the chronic and worsening shortage of midwives is addressed," she said.

Government policies are failing to make a real impact, said Net Mums co-founder Sally Russell. "The pressure newly qualified midwives are under is terrible. Some are dealing with three pregnant women in one shift, which is when things become dangerous," she said.

Health minister Ann Keen said: "The report clearly shows that maternal deaths are extremely rare in the UK. The UK rate of maternal deaths is seven per 100,000 pregnancies, which is lower than both France and the US. I am aware that many of these women are in very poor health during pregnancy and have not accessed early antenatal care. Having a full check-up and assessment by 12 weeks of pregnancy, or as soon as possible, is essential."

But her words come as little comfort to those who have lost loved ones. Ben Palmer, whose wife Jessica died of blood poisoning six days after giving birth to his daughter Emily in 2004, said: "Politicians look at it as statistics, but it's real lives and it's unnecessary deaths. There are a lot of fine words, but there's no action. It's all hollow."

'My children cry because they lost their mother. I cry for them both'

Ben Palmer, 37, became a single father when his wife Jessica died of blood poisoning six days after giving birth to their second child, Emily, in 2004. Doctors and midwives had failed to spot the signs of sepsis until it was too late.

"There isn't a day that goes by that I don't think of Jessica. The sense of loss will never go away. There have been so many low points, but it's having the children that keeps you putting one foot in front of another. I try to remember the good times, particularly for them. We talk about her a lot and I tell them what she was good at and what she liked."

Jessica was one of 18 women who died of genital tract sepsis between 2003 and 2005. Her husband has made it his mission to find out everything he can about the condition. "It is my way of making sure her death wasn't in vain. Having been through our own misery, even if I can stop just one mother dying then it's worth it. With 'childbed fever', people need to acknowledge and accept that it's still a killer. It's easy to spot and it should ring alarm bells immediately."

Jessica should never have died, says Ben, an IT consultant from London, who won a High Court negligence case against the NHS. "My son cries because he misses his mother. My daughter cries because she never knew her mother. I cry for them both. I cry for the lovely girl I met when I was 22, and for the wonderful mother she never got a proper chance to be."

While his three-year-old daughter never had the opportunity to know her mother, his five-year-old son did. "Sometimes at night I'll find Harry sitting on the stairs holding the two pictures of his mummy he keeps by his bed. I'll give him a cuddle and we'll talk about Jessica and maybe cry a little, as we remember the wonderful woman who was his mother."

Jonathan Owen

Further reading: 'The New Experience of Childbirth' by Sheila Kitzinger (Orion Publishing, 10.99)

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