Maternal death—a time for reflection

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I write this Editorial as we await the release of the report detailing Maternal deaths in Australia 2000–2002. Whether you read this journal as a midwife, nurse, obstetrician, general practitioner, consumer, sociologist, anthropologist, economist or historian, Maternal deaths in Australia 2000–2002 will have relevance to you. In the previous triennial reports in Australia, avoidable factors associated with the maternal death were thought to be possibly, or certainly present, in 34%¹ and 48%² of the cases. It is possible that similar figures will be presented in the reports for 2000–2002. The learning that we can gain from reading these reports is considerable. Understanding the reasons why women die can help us reform and restructure systems and processes of care to reduce both morbidity and mortality.

In Australia, as in many developed nations, pregnancy is mostly a normal and happy event which culminates in the birth of the baby and a healthy mother. Death at this time is not only unexpected, it is a shocking experience for all involved. It is true that maternal death rates have reduced and that childbirth is considerably safer than in the era of our mothers or grandmothers. Nonetheless, it is still shocking that women die during what is, for the most part, a happy experience, in a country that prides itself on the quality and safety of its maternity services.

Maternal death is defined as the death of a woman while pregnant or within 42 days of the termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. Accidental or incidental causes are when the pregnancy is unlikely to have contributed significantly to the death. In line with current international trends and in recognition of the fact that modern life-sustaining procedures and technologies can delay death, ICD-10 introduced the late maternal death category which is the death of a woman from direct or indirect obstetric causes more than 42 days but less than 1 year after termination of pregnancy.³ Maternal deaths in Australia 2000–2002 will include women who experience both maternal death and late maternal death.

Maternal death can mean the death of the mother or both mother and baby. This duplicate effect adds to the tragedy and has profound implications for the family, friends and community, as well as the health professionals involved.

Internationally, the United Kingdom (UK) are recognised as the leaders in maternal death auditing and reporting, with the Confidential Enquiries into Maternal and Child Deaths.⁴ The process of enquiry has led to changes in practice and national recommendations. In Australia, we need to also ensure that the similar processes around investigation and reporting of maternal deaths leads to improvements in practice. For example, understanding the issues associated with deaths due to mental illness or domestic violence can help in the organisation of early identification, early intervention and support services for those at risk. Each State and Territory in Australia has a committee that investigates these deaths. It is important to have strong midwifery representation on the committees. Systemic changes cannot be accomplished without midwives working together with our medical and other colleagues to improve the system.

Previous maternal death reports in Australia have also highlighted the disparities between death rates in Indigenous women compared with non-Indigenous women. The 1997–1999 report stated that:

“the Maternal Mortality rate (MMR) for Aboriginal and Torres Strait Islander women continues to be higher than the rate for non-Indigenous women. In the current triennium, the MMR for Aboriginal and Torres Strait Islander women was 23.5 deaths per 100,000 confinements compared with 6.7 for non-Indigenous women.¹”

We should all be concerned about this disparity. Midwives and other providers of maternity care in Australia must strive towards better understanding of the needs of women from Indigenous communities, recognising the importance of cultural safety in birthing services and working with Aboriginal and Torres Strait Islander people themselves to achieve these aims. We must work with Indigenous communities to develop models of maternity care that address inequities and disparities.

I urge each of you to read the Maternal deaths in Australia 2000–2002 report and to reflect on the findings and your own practice situations. Fortunately maternal deaths in Australia are rare, though we could argue that the 30 deaths that do occur on average each year is 30 too many. Conversely, anyone working in maternity care would know that ‘adverse events’ or ‘near misses’ are not so rare, though we do not have adequate national data on these events. We need to consider whether the levels of intervention in labour and birth in Australia contribute to morbidity and mortality, as evidence from international studies would suggest. What can we as midwives, both individually and professionally, do to make a difference?

I finish this editorial by announcing that I am stepping down from the role of Deputy Editor of this journal. I have taken on the Project Director role for the ACM Midwifery Practice Review Project and as such, I need to be able to dedicate my time to this project. I am thrilled to have been involved in this Journal through what has been a challenging and exciting transition. I remain strongly supportive of the Journal and look forward to this new journey that we are all taking forward.

The Maternal deaths in Australia 2000–2002 report will be available soon from the National Perinatal Statistics Unit http://www.npsu.unsw.edu.au/Publications.htm

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References 

1. Slaytor E, Sullivan EA, King JF. Maternal deaths in Australia 1997–1999. Canberra: Australian Institute of Health and Welfare; 2004;
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2. NHMRC . Report on maternal deaths in Australia. Canberra: National Health and Medical Research Council; 2001;
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3. WHO . ICD-10 international statistical classification of diseases and related health problems. Geneva: World Health Organization; 1993;(Tenth Revision)
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4. In:  Lewis G editors. Why mothers die, The sixth report of the confidential enquiries into maternal deaths in the United Kingdom, 2000–2002. London: RCOG Press; 2004;
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