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Learning from Ireland: establishing a confidential maternal death enquiry in a low maternal mortality context

Ireland has recorded a low maternal death rate for several years now, but it was still important for the country to introduce confidential maternal death enquiry.

Edel Manning – the MDE Ireland Co-ordinator, tells us why and how they recently introduced confidential enquiries. Edel outlines the inspiration, the challenges and the results that this new system achieved for Ireland’s mothers.

In recent decades, Ireland has been credited with a low maternal death rate: 4 per 100,000 live births. This was based on data derived from the Irish civil death registration system. However, in acknowledging national and international evidence, it was considered that in the absence of active case ascertainment, under-reporting and misclassification of maternal deaths occur, even in countries with advanced civil registration systems.

The aim of establishing a confidential enquiry into maternal deaths in Ireland was not just to ascertain numbers, but principally to promote safer pregnancy by learning how such tragedies could be avoided in the future. This could make a major contribution to informing and improving standards of care in maternity services.

Establishing MDE Ireland had many challenges. First, engaging and establishing support at governance level with stakeholders in the Irish maternity service including: the national health authority, maternity service providers, multidisciplinary health professionals and academics proved more protracted than expected.

This process was driven by a dedicated Maternal Mortality in Ireland Working Group, a joint Institute of Obstetricians and Gynaecologists in Ireland/Health Service Executive initiative which helped to garner the required support. Inviting multidisciplinary representatives from relevant stakeholders to join the Working Group, in the development stage, was considered key to establishing commitment for the project.  Although support for the ethos of the project was widely considered as laudable, issues of concern related to data protection, potential adverse litigation and anticipated review of cases by agencies out with MDE Ireland.

Jeyheich, Flickr (Creative Commons license)

Jeyheich, Flickr (Creative Commons license)

The confidential Maternal Death Enquiry (MDE) Ireland was officially established in 2009, with the stated objective of linking with the UK Confidential Enquiry into Maternal Deaths (CEMD). Given the relatively small number of maternities in Ireland (70,709 in 2012) there was much to be gained from pooling Irish data with data from the UK.  Joining a larger cohort of maternal death case reviews would help to preserve confidentiality and allow for more meaningful analysis and recommendations.  The UK, our nearest neighbour, has a similar maternity service and a respected and validated methodology in the 60 year old CEMD, which could easily be adapted to the Irish context.

The UK CEMD is part of the national Maternal, Newborn and Infant Clinical Outcomes Review Programme, which was previously conducted by the Centre for Maternal and Child Enquiries (CMACE), and was transferred to Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries (MBRRACE-UK) in 2012. MBRRACE-UK has revised and streamlined the process of data collection and analysis on maternal deaths, which will result in reports being published annually.

The first MBRRACE-UK report including data on maternal deaths occurring in Ireland was published in December 2015: ‘Saving Lives, Improving Mother’s Care: Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2009 – 2012’ 1.  Surveillance data on maternal deaths occurring in Ireland is not included in the MBRRACE-UK report.  Irish maternal mortality rates (MMR) are published independently in annual data briefs and in more detailed triennial MDE Ireland reports (available on the MDE Ireland website).

Since the inception of MDE Ireland in 2009, there have been many challenges in implementing the enquiry process nationally. It was clear to us that confidence and ‘buy-in’ for the confidential enquiry process was paramount at service level as it was a ‘top down’ approach.  We attempted to build this by:

  • Raising awareness and support for the MDE through presentations at the service level, articles in multidisciplinary journals and a national workshop;
  • Establishing a national reporting network to the MDE at service level and collaboration with coroners.
  • Promoting awareness that the MDE process is independent of clinical incident reporting and local review of serious adverse incidents;
  • Alleviating concerns regarding potential litigation.  Confidentiality is assured through a process of anonymisation of data submitted prior to multidisciplinary assessment of cases. There is no disclosure of information to any outside agency.

Similar to experience in the UK and other European countries, a key learning point was that a proactive approach to case ascertainment identified maternal deaths that were not captured by the civil death registration system.  However, achieving this has been labour intensive and, despite support letters from governing bodies, was challenging.  Participation in the Enquiry is policy but not statutory for publicly funded health care providers.  Further, the dedicated time of a national co-ordinator and the support and guidance of the Maternal Mortality in Ireland Working Group has been essential to implementing the enquiry process in Ireland.

A fundamental component of the UK CEMD process is dissemination of recommendations from enquiry reports.  Since its inception, MDE Ireland has promoted this element of the audit cycle through a series of organised educational events.

MDE Ireland’s most recent report was published in February 20152.  To improve the power of analysis and to facilitate direct comparisons with the UK, Irish MMR is presented over a rolling three year period.  Although the overall MMR identified by MDE Ireland (outlined in Table 1), compares favourably with the UK (MMR = 10.1 per 100,000 maternities for the years 2010-2012) and other developed countries, it is important to avoid complacency.  The ongoing enquiry process and collaboration with the UK CEMD will provide learning points for health professionals in advancing quality and safety within the Irish maternity services. As in the UK, our findings were that maternal deaths in Ireland during the years 2010-2012 were predominately due to indirect causes (70%) with the remainder (30%) due to direct obstetric causes.

The increasing number of pregnant women presenting in Ireland with co-morbidities has highlighted the ongoing need for appropriate assessment of women at the booking visit to a maternity unit, allocation of appropriate pathways of care and pre-conception counselling. Also, the disproportionately high representation of ethnic minorities in this cohort challenges us to address health seeking behaviours of immigrant pregnant women in a country which provides free maternity services for all pregnant women.

Table 1: Direct and Indirect Maternal Mortality rates per 100,000 maternities in Ireland: rolling three year average 2009 – 2012

Ireland_maternal death rates_tablesNB: The apparent increase in the MMR 2010 – 2012 is not statistically significant.

Acknowledgements:

This case study was written by Edel Manning – a trained midwife and currently the MDE Ireland Co-ordinator who is responsible for the co-ordination of the maternal death enquiry process and dissemination of MDE recommendations. This is an updated version of a case study originally published in our May 2014 issue of the MDSR Action Network newsletter.

For further information on MDE Ireland please visit their website – https://www.ucc.ie/en/mde/

References:

  1. Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2014. Available at: https://www.npeu.ox.ac.uk/mbrrace-uk/reports
  2. O’Hare MF, Manning E, Greene RA on behalf of MDE Ireland. Confidential Maternal Death Enquiry in Ireland, Report for 2009 – 2012. Cork: National Perinatal Epidemiology Centre, February 2015. Available at: http://www.ucc.ie/en/mde/publications/