MIDIRS Essence > February 2010 > Midwifery News

Preventing harm: the midwife’s role in preventing maternal morbidity and maternal death

Originally posted on Feb 2010

The CMACE report (Lewis 2007) reported maternal deaths related to pregnancy and childbirth as being 14 deaths per 100,000 maternities.

In Africa, over a similar time period, this was estimated at 230 deaths per 100,000 live births (WHO 2006). Investigation into the background of all these deaths, were it possible, should offer support to those seeking improvements in care provision for each woman.

I consider the work that has been done by the various contributors to maternal mortality reports in England and Wales, Scotland and Northern Ireland, which continues to be refined, to be one of our most valuable assets in achieving safer care for women who rely on the health services in the UK.

For midwives, whose main role is in the care of women without complications (ie ‘normal’), there is also a need to be aware of factors that affect women’s risk of complications arising. Therefore, even if other aspects of pregnancy and childbirth stay within normal limits, the midwife must be competent to give appropriate advice, to refer to other professionals and agencies where needed, and to take part in emergency procedures that might assist in maintaining life (NMC 2004, NMC 2007).

The current CMACE report (Lewis 2007), cites physical conditions (thromboembolism, pre-eclampsia, genital tract sepsis and amniotic fluid embolism) as the most common causes of direct deaths. For the purposes of the report these ‘labels’ help clarify areas where attention is not only needed but vital to the protection of life. Alongside these clinical labels are a whole range of issues around how women live their lives, their social context and what might or might not be within their control to change. The work of midwives involves pre-empting, where this is possible, key components of these issues when they impact on health and well-being in pregnancy.

In her excellent chapter within the report, Grace Edwards sets out a pathway for midwives, which offers clear guidance on attaining this goal. On reading this, (which I would recommend), there is also a feeling of what is or could be an almost unbearable burden on midwives and others caring for women, within the very real legal concept of a duty of care. To some extent this burden is shared, as the report also identifies a range of concerns about provision of care within the health and other services, but there is no doubt that individual health carers carry this duty of care and contribute to reducing the degree to which women are or can be protected from harm.

While we await the publication of the next CMACE report, I looked at what resources might be available to women and to health carers to reduce the occurrence of severe harm or death where risk could and should be identified. At MIDIRS, we collect a range of information aimed at helping anyone who has contact with women around pregnancy, birth and afterwards. Therefore we act mainly as facilitators, and the role of the health care service is to transform that information into meaningful action with regard to the overall context of care provision. Once these are in place, it is then the task of the health carer to facilitate access to these in the form of direct care which, hopefully, will offer some protection and reduction in risk of harm.

The current CMACE (Lewis 2007) report sets out some very clear standards for care but, arguably, identifying where you should be does not ensure that you will get there and as the report identifies, there is a need for national guidelines on several of the factors that contribute to maternal deaths associated with pregnancy and childbirth.

I jotted down three key areas where I felt midwives were pivotal in trying to reduce potential harm from an existing risk factor. For each of these I have identified at least one recent resource to assist direct care and possibly reduce the potential for harm:

· Obesity
· Substance/alcohol abuse (including smoking)
· Domestic violence.

Obesity

With regard to the development of guidelines, CMACE has been undertaking reviews of the evidence and best practice to produce guidelines for the management of women with maternal obesity. Their findings will be presented at a conference held jointly with the Royal College of Obstetricians and Gynaecologists (RCOG) on 19th March 2010. Further information can be obtained from www.rcog.org.uk.

Searching the MIDIRS Reference Database on this topic shows a huge increase in articles, but not necessarily a great deal on interventions; however, a recent review collates some of this while we await the guidelines (Soltani 2009). A recent edition of the British Journal of Midwifery included several articles on this topic which should also serve as an excellent resource (vol 17, no 6, June 2009).

Drug/substance abuse

I have chosen to focus on smoking in relation to ‘drug’ abuse; however, abuse of any substance is problematic. Addiction may be more prevalent in situations of poverty, poor social support, low educational attainment and psychological illness, all of which offer challenges to the uptake and effectiveness of interventions.

The most recent Cochrane review of interventions for promoting smoking cessation (Lumley et al 2009) identified that offering women individual support that included incentives and cognitive change related behaviour, was more likely to be effective. The incentives included giving women information about the health status of the fetus, measuring nicotine levels, nicotine replacement therapies and other medications. Such measures resulted in six out of 100 women stopping smoking, but in general were seen to have some positive effects. As noted earlier, negative social influences are key factors in what has been described as a clustering of health risks. Another recent paper underpinned the importance, both from a service and a direct care perspective, of looking at the needs of women as individuals rather than referring to them as risk factors (Gilligan et al 2009).

Midwives have a number of resources that they can refer to when offering to help women to stop smoking, as well as actively discouraging them from continuing to do so. As NHS Trusts are charged with making an impact on smoking rates, it is included in the RCOG’s working party report, Standards for Maternity Care (RCOG, RCM, RCA et al 2008), and is also a government strategy (DH 2009). Many Trusts have dedicated centres which either have specialist midwives or links to specialist workers or services (Lee et al2006). In addition, the NHS helpline and the NHS Stop Smoking service can give assistance to women and their partners as part of an overall health programme, alongside ongoing support from the midwife.

Domestic violence

Some extracts from the CMACE report make for harrowing reading where they are about the extensive abuse of women and where this has contributed to their death. It is recognised that ascertaining a history of domestic abuse is a very difficult area for any health carer, but that this does lead to better outcomes where further support can be obtained. The UK government recently introduced a new strategy initiative called Together we can end violence against women and girls (HM Government 2009). While this is an overall strategy, midwives might find it useful to visit the site to see what wider resources are available to add to those available professionally. The RCM current position statement on domestic abuse (RCM 2006) was apparently due for review last year but I could not find any revisions to it, however, it still remains a useful tool for practice.

If you have not read the report, Saving Mothers’ Lives, I would urge you to do so. The report of course focuses on things that went wrong for these women, resulting in their deaths. The meaning of a profession is that professionals are accountable for their actions, in terms of the law, with regard to their duty of care and there are still too many examples of when the standards for this were lacking. However, I think the report, used in a positive way, can help health care providers of overall services as well as those responsible for giving direct care, to evaluate what they are doing and make use of this information to improve both local services and individual aspects of care and to help women reduce their risk of complications and untimely mortality.

References

Department of Heath (2009). Tobacco – health bill 2009.

Gilligan C, Sanson-Fisher R, Eades S et al (2009). Identifying pregnant women at risk of poor birth outcomes. Journal of Obsetrics and Gynaecology 29(3):181-7.

HM Government (2009). Together we can end violence against women and girls: a strategy. London: Home Office.

Lee M, Hajek P, McRobbie H et al (2006). Best practice in smoking cessation services for pregnant women: results of a survey of three services. Journal of the Royal Society of Health 126(5):233-38

Lewis G ed (2007). Saving mothers' lives: reviewing maternal deaths to make motherhood safer, 2003-2005. The seventh report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH.

Lumley J, Chamberlain C, Dowsell T et al (2009). Interventions for promoting smoking cessation in pregnancy. The Cochrane Database of Systematic Reviews, issue 3.

Nursing and Midwifery Council (2004). Midwives rules and standards. London: NMC.

Nursing and Midwifery Council (2007). The Code: standards of conduct, performance and ethics for nurses and midwives. London: NMC.

Royal College of Midwives (2006). Domestic abuse: pregnancy, birth and the puerperium. Position statement. London: RCM

Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives (RCM), Royal College of Anaesthetists (RCA), Royal College of Paediatrics and Child Health (RCPCH) (2008). Standards for maternity care: report of a working party. London: RCOG.

Soltani H (2009). Obesity in pregnancy: an evidence-based commentary. Evidence Based Midwifery 7(4):140-2.

Wathen CN, Jamieson E, MacMillan HL et al (2008). Who is identified by screening for intimate partner violence? Women's Health Issues 18(6):423-32.

World Health Organization (2006). Country health system fact sheet 2006. South Africa.

Sally Marchant | Editor | MIDIRS | Photo credit: © bilderbox - Fotolia.com

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