The MBRRACE report is incredible. Confidential Enquiries have reduced maternal deaths from 90/100,000 to 10/100,000 since the 1950s, which is a huge achievement.

MBRRACE is also put together by prestigious, multidisciplinary teams.

So it might seem strange that I'm putting up a post finding fault with it.

But midwives have a duty to assess recommendations as part as advocacy for women. It’s why midwifery degrees cover how to critique guidelines and research.

It can feel really frightening going against the grain. But midwives time and again have changed practice for the better. (Click here for Mary Cronk's wonderful account of refusing to do routine episiotomies).

There are 2 main questionable areas of the MBRRACE report I've noticed so far:

1. The Flu Vaccine Recommendation:

Pregnant women are more at risk of getting flu, and of complications.

MBRRACE states: 'Increasing immunisation rates in pregnancy against seasonal influenza must remain a public health priority'.

This sounds like very good advice.

But we don't know for sure how effective the vaccine is.

Sara Wickham, in particular, has mentioned on her wonderful blog that there isn't evidence to say all the flu-related maternal deaths were preventable. This is because a recent Cochrane report found protection from the vaccine was only mild; there was ‘no appreciable effect on hospital admissions or working days lost.’

MBRRACE argues the deaths were preventable, as it would have been better for these women to at least try the vaccine.

There are some specialists that argue the Cochrane data was too ‘finely cut’ to show any overall message, and quote trials which show the vaccine is very effective.

It seems there’s a lack of information from the research.

The best approach may be to tell women the vaccine is recommended by a high-quality report/specialists, but that evidence doesn’t show clearly how effective the it is.

2. The 'Think Sepsis' Obs Recommendation

Like with flu, pregnant women are more at risk of sepsis. We think this is because their immune system is a bit suppressed during pregnancy, so the baby doesn't get treated like an invader.

MBRRACE says ‘Think Sepsis’ at an early stage when presented with an unwell pregnant or recently pregnant woman, take all appropriate observations and act on them.’

But this is controversial just because it’s sometimes very hard to tell when a woman is unwell.

We might screen women needlessly…and then end up with false positives.

Sepsis comes with lots of different symptoms. Women can have the typical ones like a fever, shivering (rigors) or nausea and vomiting.

But they can also have headaches, painful urination, and light-headedness.

Should we do a set of obs on every woman who has any those symptoms?

We’d end up doing obs for pretty much everyone, as headaches can be caused by crying babies, passing urine can be painful because of stitches, and light-headedness can be caused by tiredness.

Doing obs on every woman means eventually we'll get a dodgy result. So we'll end up sending at least some healthy women into hospital for a check….and we medicalise, which can do more harm than good.

I'm totally biased, but wouldn't a better conclusion be: midwives and others need more time and more continuity with women?

It’s a lot easier to tell if someone’s sick if you're not meeting them for the first time.

It could be argued that a one midwife, one woman system of care would help prevent a lot of these flu/sepsis deaths. Better communication between professionals and women, and continuity of care would help nearly every case.

Currently, this is hard to achieve as time = money.

For now, we just have to try our best to give a balanced opinion about the flu, and Think Sepsis.

Heavy stuff! But important.

See part one: Before Their Time
See part two: 5 Lessons I Learnt