Saving Mothers’ Lives: the 2006–8 anaesthesia perspective
2011; Elsevier BV; Volume: 107; Issue: 2 Linguagem: Inglês
10.1093/bja/aer222
ISSN1471-6771
Autores Tópico(s)Neonatal Respiratory Health Research
ResumoA single death is a tragedy; a million deaths is a statistic (Kurt Tucholsky: Französischer Witz, 1932). The individual stories of maternal death, documented in Confidential Enquiries into Maternal Deaths, are tragic and compelling, and have informed many recommendations in the past half-century that have improved maternal and neonatal outcomes in the UK and probably, around the world. The individual stories continue with the recent publication of the Eighth Report of the Confidential Enquiries into Maternal Deaths in the UK, ‘Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2006–08’ (hereafter referred to as the Report).1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar In this month's issue of the British Journal of Anaesthesia, Drs McClure, Cooper, and Clutton-Brock, on behalf of the Centre for Maternal and Child Enquiries, have summarized the findings of the Eighth Report.2McClure JH Cooper GM Clutton-Brock TH Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–8: a review.Br J Anaesth. 2011; 107: 127-132Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar In the past, the chapters summarizing deaths attributed directly to anaesthesia and critical care were republished in the British Journal of Anaesthesia, but due to copyright issues, the authors have written a review of the current Report.2McClure JH Cooper GM Clutton-Brock TH Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–8: a review.Br J Anaesth. 2011; 107: 127-132Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Between 2006 and 2008, 261 maternal deaths were reported; 331 existing children and 147 live-born newborns lost their mothers.1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar The good news is that the overall maternal risk ratio (MMR) decreased compared with the 2003–5 report. Since 1985, there is a significant downward trend in the MMR due to direct causes (deaths resulting from obstetric complications). The decrease from the previous triennium is primarily due to a decrease in deaths from pulmonary embolus, and to a lesser extent, obstetric haemorrhage. In all likelihood, this decrease is attributable to the development of protocols to prevent embolism and treat haemorrhage that were developed and implemented after previous reports. A worrying change is the increase in deaths from genital tract infection. According to the latest World Health Organization (WHO) data, the MMR has decreased worldwide by 34% since 1990.3World Health Organization, UNICEF, UNFPA, World Bank Trends in Maternal Mortality: 1990 to 2008. WHO Press, Geneva2010http://whqlibdoc.who.int/publications/Google Scholar Still, an estimated 358 000 women died of pregnancy-related disease in 2008. This rate equates to more than 1000 deaths per day or 42 deaths per hour. The vast majority of these deaths occur in developing countries. The WHO 2000 Millennium Development Goal Five (MDG5) is to reduce MMR by 75% between 1990 and 2015. Unfortunately, at the current rate of decline (2.5% per year), we are making insufficient progress towards this goal.3World Health Organization, UNICEF, UNFPA, World Bank Trends in Maternal Mortality: 1990 to 2008. WHO Press, Geneva2010http://whqlibdoc.who.int/publications/Google Scholar In fact, the MMR is increasing in some countries, including the USA.3World Health Organization, UNICEF, UNFPA, World Bank Trends in Maternal Mortality: 1990 to 2008. WHO Press, Geneva2010http://whqlibdoc.who.int/publications/Google Scholar Better data collection may explain some, but not all of this increase.4Centers for Disease Control National Center for Health Statistics. Maternal mortality and related concepts. 2007http://www.cdc.gov/nchs/data/series/Google Scholar Despite the improved MMR observed in the UK, there is no room for complacency. The MMR trend for indirect deaths (deaths resulting from pre-existing disease, or disease that developed during or was aggravated by pregnancy) is increasing. Of equal concern is the number of cases in which substandard care was judged to be present. For direct deaths, the proportion has hovered between 60% and 70% for the past decade.1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar For the first time, the proportion of indirect deaths in which care was substandard was >50%. The UK is not alone in this regard. The French National Expert Committee on Maternal Mortality (CNEMM) recently published a report summarizing maternal mortality in France from 2001 to 2006, using techniques similar to the Confidential Enquiries.5Report of the National Expert Committee on Maternal Mortality (CNEMM), France, 2001–2006. Institut de veille-sanitaire, Saint-Maurice2011http://www.invs.sante.frGoogle Scholar Almost half (46%) of deaths were judged avoidable. In the Netherlands between 1993 and 2005, care in 55% of women who died was identified as substandard.6Schutte JM Steegers EA Schuitemaker NW et al.Rise in maternal mortality in the Netherlands.BJOG. 2009; 117: 399-406Crossref PubMed Scopus (195) Google Scholar In the State of California, USA, the Pregnancy-Associated Mortality Review Committee judged that more than one-third of deaths had a ‘good to strong chance’ of being prevented.7The California Pregnancy-Associated Mortality Review Report from 2002 and 2003 Maternal Death Reviews. California Department of Public Health, Maternal Child and Adolescent Health Division, Sacramento2011http://www.cdph.ca.gov/data/statistics/Google Scholar In South Africa, 304 of 482 (63%) maternal deaths in women with hypertension were ‘clearly avoidable’.8Moodley J Maternal deaths associated with hypertension in South Africa: lessons to learn from the Saving Mothers report, 2005–2007.Cardiovasc J Afr. 2011; 22: 31-35Crossref PubMed Scopus (25) Google Scholar In the developing world, the vast majority of maternal deaths are preventable.3World Health Organization, UNICEF, UNFPA, World Bank Trends in Maternal Mortality: 1990 to 2008. WHO Press, Geneva2010http://whqlibdoc.who.int/publications/Google Scholar Fortunately, direct deaths attributed to anaesthesia care are rare. In the UK between 2006 and 2008, there were seven direct deaths; the MMR was 0.31 per 100 000 maternities (95% confidence interval 0.15–0.64).1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar Anaesthesia deaths constituted 3% of maternal deaths, ranking behind sepsis, pre-eclampsia and eclampsia, thrombosis or thromboembolism, amniotic fluid embolism, early pregnancy deaths, and haemorrhage. In France (2001–6), the MMR attributed to anaesthesia was 0.14/100 000 live births (seven deaths),5Report of the National Expert Committee on Maternal Mortality (CNEMM), France, 2001–2006. Institut de veille-sanitaire, Saint-Maurice2011http://www.invs.sante.frGoogle Scholar in the Netherlands (1993–2005) the rate was 0.1,6Schutte JM Steegers EA Schuitemaker NW et al.Rise in maternal mortality in the Netherlands.BJOG. 2009; 117: 399-406Crossref PubMed Scopus (195) Google Scholar and in the USA (1991–2002) it was 0.1.9Hawkins JL Chang J Palmer SK Gibbs CP Callaghan WM Anesthesia-related maternal mortality in the United States: 1979–2002.Obstet Gynecol. 2011; 117: 69-74Crossref PubMed Scopus (212) Google Scholar It is reassuring that the rates are roughly the same, although not directly comparable because the denominator used for calculating the MMR in the UK is per 100 000 maternities, whereas it is per 100 000 live births in other countries. Additionally, data acquisition differs among countries, for example, the Confidential Enquiries use active surveillance to identify cases, whereas most countries rely on civil records, resulting in significant under-identification of cases. Although the absolute number of deaths attributed to anaesthesia is low compared with other causes, in the UK and elsewhere, the majority of anaesthesia deaths continue to involve substandard care. Six of seven deaths in the 2006–8 Report were judged to involve substandard care, three major (contributed significantly to death) and three minor (relevant factor in death).1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar All five of the anaesthesia-related deaths described in the recent French report were classified as ‘avoidable’.5Report of the National Expert Committee on Maternal Mortality (CNEMM), France, 2001–2006. Institut de veille-sanitaire, Saint-Maurice2011http://www.invs.sante.frGoogle Scholar In the most recent summary of obstetric cases from the American Society of Anesthesiologists Closed Claims Database, 53% of cases in which payment was made for anaesthesia care were judged to have substandard care.10Davies JM Posner KL Lee LA Cheney FW Domino KB Liability associated with obstetric anesthesia: a closed claims analysis.Anesthesiology. 2009; 110: 131-139Crossref PubMed Scopus (163) Google Scholar Over the past several decades, the anaesthesia MMR has not decreased.1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar The number of deaths directly attributed to anaesthesia has ranged from 1 to 8, averaging ∼5 per triennium. The data regarding substandard care imply that anaesthesia-related maternal mortality can and should be lower. In their review, McClure and colleagues argue that anaesthesia is an intervention, not a disease.2McClure JH Cooper GM Clutton-Brock TH Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–8: a review.Br J Anaesth. 2011; 107: 127-132Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Therefore, all deaths could be considered iatrogenic and potentially preventable. Of note, the aetiology of anaesthesia deaths has changed over the past two to three decades. Deaths in the 1980s and early 1990s were primarily related to securing the airway.11Cook TM McCrirrick A A survey of airway management during induction of general anaesthesia in obstetrics: are the recommendations in the confidential enquiries into maternal deaths being implemented?.Int J Obstet Anesth. 1994; 3: 143-145Abstract Full Text PDF PubMed Scopus (22) Google Scholar 12Hawkins JL Koonin LM Palmer SK Gibbs CP Anesthesia-related deaths during obstetric delivery in the United States, 1979–1990.Anesthesiology. 1997; 86: 277-284Crossref PubMed Scopus (605) Google Scholar Only one of seven deaths in the current report involved failure to ventilate during induction of anaesthesia.1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar Indirect evidence from the USA also suggests that airway disasters are becoming less common. The case fatality risk ratio for general compared with neuraxial anaesthesia between 1985 and 1990 was 16.7.12Hawkins JL Koonin LM Palmer SK Gibbs CP Anesthesia-related deaths during obstetric delivery in the United States, 1979–1990.Anesthesiology. 1997; 86: 277-284Crossref PubMed Scopus (605) Google Scholar The majority of general anaesthesia deaths were related to airway management and respiratory events. Between 1997 and 2002, the risk ratio decreased to 1.7 and there was no difference between the two anaesthetic techniques (P = 0.2).9Hawkins JL Chang J Palmer SK Gibbs CP Callaghan WM Anesthesia-related maternal mortality in the United States: 1979–2002.Obstet Gynecol. 2011; 117: 69-74Crossref PubMed Scopus (212) Google Scholar Given that the incidence of failed intubation does not appear to have changed during this time interval,13Lyons G Failed intubation. Six years’ experience in a teaching maternity unit.Anaesthesia. 1985; 40: 759-762Crossref PubMed Scopus (133) Google Scholar 14McDonnell NJ Paech MJ Clavisi OM Scott KL Difficult and failed intubation in obstetric anaesthesia: an observational study of airway management and complications associated with general anaesthesia for caesarean section.Int J Obstet Anesth. 2008; 17: 292-297Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar these findings suggest that the emphasis on failed intubation algorithms, new airway devices, and simulation and practice have improved airway rescue techniques and skills in maternity units. However, airway events are still being reported, suggesting that we must continue to practise the management of a difficult airway in this high-risk population.15Mhyre JM Healy D The unanticipated difficult intubation in obstetrics.Anesth Analg. 2011; 112: 648-652Crossref PubMed Scopus (65) Google Scholar Indeed, this is a specific anaesthesia recommendation of the current Report.1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar Given that we have shown that we can improve outcomes by developing and implementing new protocols, it is imperative that we use the current mortality data to develop and implement protocols to address the preventable causes of death identified in the current Report. Respiratory deaths in the postoperative period have been reported in several recent case series. The current Report describes a woman who aspirated on emergence from general anaesthesia and a second death was likely to have resulted from an overdose of opioid analgesia;1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar three of six deaths in the previous triennial report involved respiratory events in the immediate post-partum period.16Lewis G Confidential Enquiry into Maternal and Child Health (CEMACH) Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer—2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. CEMACH, London2007http://www.cmace.org.ukGoogle Scholar In the State of Michigan in the USA, five of eight anaesthesia-related deaths between 1985 and 2004 were due to postoperative hypoventilation and airway obstruction.17Mhyre JM Riesner MN Polley LS Naughton NN A series of anesthesia-related maternal deaths in Michigan, 1985–2003.Anesthesiology. 2007; 106: 1096-1104Crossref PubMed Scopus (141) Google Scholar These cases suggest that better post-partum monitoring and management are necessary. A 2009 survey of obstetric post-operative care practices in the USA confirmed that post-operative care in most US maternal units was provided solely by perinatal nurses, not perianaesthesia [postanaesthesia care unit (PACU)] nurses.18Wilkins KK Greenfield ML Polley LS Mhyre JM A survey of obstetric perianesthesia care unit standards.Anesth Analg. 2009; 108: 1869-1875Crossref PubMed Scopus (15) Google Scholar Almost half of respondents indicated that their institutions had no specific post-anaesthesia recovery training for perinatal nurses. In many institutions, including my own, perinatal nurses are currently not required to have Advanced Cardiac Life Support (ACLS) training. This will soon change. Other problem areas may benefit from implementing new protocols. In the current Report, one woman who underwent uneventful spinal anaesthesia died from acute haemorrhagic disseminated leucoencephalitis, a rare disease that may be triggered by vaccination or infection. The autopsy revealed thoracolumbar spinal canal empyema. Last year, the US Centers for Disease Control (CDC) reported a series of five women (two from one institution/one anaesthetist and three from another institution/one anaesthetist) who developed meningitis within 13–22 h after the initiation of neuraxial labour analgesia (spinal or combined spinal-epidural).19Bacterial meningitis after intrapartum spinal anesthesia'New York and Ohio, 2008–2009.Morb Mortal Wkly Rep. 2010; 59: 65-69PubMed Google Scholar One woman died. In four of five cases, Streptococcus salivarius was identified in the cerebrospinal fluid of the patient. The anaesthetist was thought to be the source of the infection in all cases. The AAGBI20Infection control in anaesthesia.Anaesthesia. 2008; 63: 1027-1036Crossref PubMed Scopus (95) Google Scholar and the American Society of Anesthesiologists21Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques.Anesthesiology. 2010; 112: 530-545Crossref PubMed Scopus (86) Google Scholar have both recently published guidelines stating the masks should be worn during neuraxial procedures. Alcoholic chlorhexidine solution20Infection control in anaesthesia.Anaesthesia. 2008; 63: 1027-1036Crossref PubMed Scopus (95) Google Scholar 21Practice advisory for the prevention, diagnosis, and management of infectious complications associated with neuraxial techniques: a report by the American Society of Anesthesiologists Task Force on infectious complications associated with neuraxial techniques.Anesthesiology. 2010; 112: 530-545Crossref PubMed Scopus (86) Google Scholar or alcoholic povidone iodine solution20Infection control in anaesthesia.Anaesthesia. 2008; 63: 1027-1036Crossref PubMed Scopus (95) Google Scholar should be used for skin asepsis. In the current Report, one woman died from acute anaphylaxis from an antibiotic administered during labour,1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar and in the French report, two women died from anaphylaxis from succinylcholine.5Report of the National Expert Committee on Maternal Mortality (CNEMM), France, 2001–2006. Institut de veille-sanitaire, Saint-Maurice2011http://www.invs.sante.frGoogle Scholar The Report ‘learning point’ is that anaphylaxis charts should be available in all clinical areas.1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar It may also be helpful to simulate (‘fire drills’) response to anaphylactic reactions along with other obstetric emergencies. Developing interventions to decrease the MMR directly attributed to anaesthesia, although important to our speciality, will play a small role in decreasing the overall MMR because the absolute number of these deaths is low. However, in the current Report, anaesthesia management was found to contribute to adverse outcome in 18 women; in a further 12 cases, failure to consult the anaesthesia service in a timely fashion was thought to have contributed to death.1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar Anaesthesia services were involved in 127 of 261 women who died in the current triennium. Although anaesthesia care was not thought to be contributory to death for most of these women, anaesthetists were members of the care team. Presumably, they could positively affect outcome by participating in the early recognition and care of high-risk women with pre-eclampsia and eclampsia, sepsis, haemorrhage, and chronic co-morbidities such as cardiac and respiratory disease. Anaesthetists and intensivists are trained to care for high-risk patients. It is our responsibility, as members of the obstetric care team, to positively contribute to their care. There are a number of specific ways in which anaesthetists might contribute to improving obstetric care. Top Ten Recommendation No. 5 from the current Report suggests that clinical skills and training, including basic, intermediate, and advanced life support skills, should be updated regularly.1Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’. Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG. 2011; 118: 1-203Google Scholar In the USA, closed-claims analysis of data from a large insurance company suggests that we need to improve knowledge and management of cardiac arrest in obstetric patients.22Lofsky A Doctors company reviews of maternal arrests cases. Anesthesia Patient Safety Foundation. 2007http://www.apsf.org/Google Scholar In a survey study, a large proportion of anaesthetists, obstetricians, and emergency medicine physicians lacked knowledge of basic concepts of resuscitation of obstetric patients.23Cohen SE Andes LC Carvalho B Assessment of knowledge regarding cardiopulmonary resuscitation of pregnant women.Int J Obstet Anesth. 2008; 17: 20-25Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar Multiple deficits in resuscitation procedures by multidisciplinary teams were noted in simulated maternal cardiac arrest.24Lipman SS Daniels KI Carvalho B et al.Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises.Am J Obstet Gynecol. 2010; 203: 179.e1-179.e5Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar These findings suggest that simulation drills of maternal cardiac arrest, with participation of all members of the team, might improve care. The current Report continues to emphasize the need for specialist input in the management of high-risk women. This includes the early request for help from senior medical staff. Although not specifically stated, this recommendation should apply to both the anaesthesia and obstetric services. Sick women, day or night, will benefit from the collective wisdom and skill set of senior staff. The immediate availability of skilled senior personnel is not a problem unique to the UK. However, currently in the UK, the standards for obstetric consultant presence on maternity units25Royal College of Obstetricians and Gynaecologists Responsibility of Consultant On-call. RCOG Press, London2009http://www.rcog.org.ukGoogle Scholar exceed those for anaesthesia consultant presence.26OAA/AAGBI Guidelines for Obstetric Anaesthesia Services. Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists’ Association, London2005http://www.oaa-anaes.ac.ukGoogle Scholar If we are to argue that our knowledge and skill set are important to the safe provision of care on maternity units, then we must work to optimize our availability and presence on these units. On a global level, anaesthetists can also influence outcome. Volunteer anaesthetists from North American and Europe have enthusiastically participated in multiple medical missions to developing countries. Kybele (http://www.kybeleworldwide.org) is a humanitarian organization dedicated to improving childbirth conditions worldwide by establishing medical education partnerships in host countries. Although the teams are multidisciplinary, the organization's founder and most volunteers are anaesthetists, including many from the UK. Over the past decade, the Kybele team has made remarkable progress at both the local and the national level, particularly in Ghana, and data are now accumulating showing improved neonatal and maternal outcomes.27Engmann C Olufolabi A Srofenyoh E Owen M Multidisciplinary team partnerships to improve maternal and neonatal outcomes: the Kybele experience.Int Anesthesiol Clin. 2010; 48: 109-122Crossref PubMed Scopus (13) Google Scholar How do we measure whether what we are doing has an effect? Fortunately, in the UK and other developed countries, maternal death is unusual. Therefore, it is difficult to measure whether interventions (e.g. simulation) positively affect outcome. The last two Confidential Enquiries have proposed measurement of baseline and auditable standards for each of the Top Ten recommendations. However, these standards are of necessity intermediate outcomes. The development of obstetric surveillance systems which track ‘near-miss’ events, which occur much more frequently than death, is one method of assessing whether interventions affect outcome. Results of two UK systems, the UK Obstetric Surveillance System (UKOSS) and the Scottish Confidential Audit of Severe Maternal Morbidity, are summarized in the Eighth Report. Anaesthetists should work to ensure that these or similar systems include data important to anaesthesia care. At the risk of being presumptuous, because I do not practice in the UK, I believe that anaesthetists should actively participate in implementation of many, if not most of the recommendations from the current Report, both in the UK and abroad.2McClure JH Cooper GM Clutton-Brock TH Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–8: a review.Br J Anaesth. 2011; 107: 127-132Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar We are vital members of the safety net of care on maternity units. These recommendations, outlined in the review,2McClure JH Cooper GM Clutton-Brock TH Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–8: a review.Br J Anaesth. 2011; 107: 127-132Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar include using professional interpretation services when communicating with non-English-speaking patients, being available for antenatal referrals for women with anticipated complicated anaesthesia care, participation in multidisciplinary care teams, routine training and maintenance of clinical skills, supporting the routine use of early obstetric warning scores, aggressive treatment of severe hypertension, and recognition and early treatment of genital tract infection or sepsis. Finally, anaesthetists should be active participants in high-quality serious incident reviews. They can even help improve maternal autopsies (another goal) by directing the pathologist to the relevant organ systems. The Safe Motherhood Initiative of the World Health Organization is founded on the premise that we already know what needs to be done to save the lives of mothers and newborns.3World Health Organization, UNICEF, UNFPA, World Bank Trends in Maternal Mortality: 1990 to 2008. WHO Press, Geneva2010http://whqlibdoc.who.int/publications/Google Scholar The challenge is to put these solutions into operation in many different environments at home and around the world, in the presence to varying degrees, of limited resources. Anaesthetists should, and do, have an essential role to play in this important endeavour. C.A.W. is a member of the State of Illinois Maternal Mortality Review Committee.
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