Maternal Death (1193)

Maternal death is defined by the World Health Organisation (2) as:

‘Deaths of women while pregnant or within 42 days of delivery, miscarriage or termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.’

Direct – deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above.

Indirect – deaths resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetrics causes, but which was aggravated by the physiological effects of pregnancy.

Late – Deaths occurring between 42 days and one year after termination of pregnancy, miscarriage or delivery that are due to direct or indirect maternal causes.

Coincidental – deaths from unrelated causes which happen to occur in pregnancy or the puerperium.

All deaths occurring during pregnancy and up to one year following the end of pregnancy must be reported to MBRRACE, irrespective of the nature of the pregnancy or the cause/circumstances of the death. These deaths may occur within Maternity services, in other departments within the hospital, or in the community.

Immediate Actions

A maternal death in hospital may occur in settings out with the Maternity Unit, for example in the Emergency Department or the Intensive Care Unit. In such circumstances, the Midwifery Hospital Co-ordinator provides the necessary support to non-maternity departments, advising on the appropriate management in the event of a maternal death.

Further Actions and Support

The Named Consultant will arrange to meet with relatives and provide appropriate follow up.

The Local MBRRACE Coordinator (Risk Midwife) reports maternal death to MBRRACE who send a notification pack to the unit for completion. The surveillance form requires completion within one month of the death. A full copy of the woman’s medical records must be included with the MBRRACE submission.

After submission of the notification pack the MBRRACE team send report forms to the clinical staff involved in the woman’s care to seek staff perspectives and to identify any lessons for future care. There documents are anonymised and are used in the independent assessment by MBRRACE assessors. There is an aim for all the data to be ready for assessment 3 months following the date of the woman’s death.