The Lancet recently published a letter stating that the maternal mortality in London is 19·3 per 100 000 maternities (95% CI 14·0–26·6) versus 8·6 per 100 000 maternities (7·1–10·5) in the rest of the UK. The same letter reported an apparent 27% increase in births in London from 2001 to 2011. Clearly this is important – but hardly surprising. Maternal death is associated with relative social deprivation, minority ethnicity, and obesity. Poor communication secondary to language problems are also a risk factor. London also has significantly higher levels of midwifery vacancies (as illustrated by the Healthcare commissions 2012 report: Healthcare Commision Towards better births: a review of maternity services in England). So comparing London to the “rest of the UK” would seem bound to demonstrate a significant difference. It would seem London may have similar problems to other large cities, and some attempt to compare London statistics to matched “control cities” would have been helpful to ascertain whether there is a “London” problem or not, or whether this afflicts all urban centres. There is also the unusual case of 10 maternal mortalities at Northwick Park hospital – the subject of an investigation in its own right. Northwick Park alone is probably a confounding variable in the data. Hopefully these issues will be factored in by those setting health policy.
The rise in maternal mortality looks alarming in terms of the percentage rise, although the actual numbers are thankfully still small. Even so an avoidable maternal death is tragic. As professionals the details of any maternal death are seared in the memory and never forgotten. There are deaths that are unavoidable, sometimes fate determines someone will have an amniotic fluid embolus or a catastrophic pulmonary embolus. However often when the case is analysed something could have been done. It will come down to a clinical mistake. However looking at the circumstances often shows a coming together of small mistakes that when added together lead to disaster. We have all seen it. There is a locum junior doctor to cover leave. The non-locum junior calls in sick so there are two locum doctors who do not know the system. Nobody tells the consultant on call what has happened, there is a shortage of midwives that night……….it is not hard to see how a set of circumstances come together to lead to error or a poor judgement call. The so called “system error”.
Labour wards are difficult places to manage. Understandably women want a normal process to take its course with minimal intervention. On the other hand, labour wards in London are disproportionately full of women with co-morbidity that makes them “high risk” and likely to run into problems. It would be interesting to know whether the 27% increase in births over the last 10 years is disproportionately made up from the higher risk groups. It is a difficult environment to get right. On the one hand the unit needs to try to provide normal labouring women with 1 to 1 support to enhance their birth experience and chances of a normal delivery. On the other hand the labour ward at times can seem more like an intensive care unit. Labour wards are often trying to be all things to everyone, with predictable problems as a result. Attempts to split units into low and high risk are laudable but sometimes split resources and staff mix. There are no easy answers to this. However the issue of maternal mortality in London illustrates the pressures the capital is under in terms of health care. All women irrespective of their background deserve exactly the same care and the right to expect the same outcomes. The data from London and probably elsewhere in inner city units suggests there is a problem that needs addressing.