It’s MBRRACE reading time again. (If you’re not sure what this is, please scroll down).
One of the key points for me to consider was how little I remember about epilepsy. I studied it at Uni, we had a particularly good research tutor who was interested in how best to manage care for clients with complex medical conditions and I’ll be going back to her book (Medical Disorders in Pregnancy: A Manual for Midwives, by Robson, E.)
Having specialist midwives for women with epilepsy may be a good idea, or at least knowing who to contact for a multidisciplinary team approach.
There’s been an increase in Sudden Unexpected Death in EPilepsy (SUDEP).
As usual, the vignettes did their work in making the learning sink in. Night seizures are a red flag, and very sadly one woman died as a result of a seizure she had when her partner was on nightshift. I wonder whether this death may have been linked to poverty. The review points out a GP letter allowing day shift for the partner might have been life-saving but maybe this wasn't seen as an option for the family involved.
This report records that 3 women died from SUDEP in the bath at home; I remember being told during training that baths could be dangerous for patients with epilepsy. Social services may be able to help install a wet room but this can take a while. I was discussing all this with Jason and he pointed out that he grew up with just a bath and one of those £10 shower heads you attach to the tap. Could be a good interim if women aren’t able to install a proper shower.
Many women and professionals are concerned about using sodium valproate in pregnancy as there is a risk of congenital malformations but there are other options. Also, uncontrolled epilepsy is so dangerous that sometimes sodium valproate may in rare cases still be considered. Expert input is needed for these clients. Sub-therapeutic levels of antiepileptic drugs were often found at autopsy in clients who died from SUDEP.
The ‘constellation of biases’ notes in the review includes poverty and, of course, being from a minority ethnic group.
In comparison to white women:
- Black women are 4.35x more likely to die during the perinatal period
- Asian women are 2x more likely to die during the perinatal period
It could be concluded that we're making some steps in the right direction, as in the last MBRRACE report black women were 5x more likely to die during childbearing.
But the reduction is described as ‘non-significant’. We can't see this as a solved problem.
My own thinking and learning about unconscious bias continues and I’ve invested in some ‘play the race cards’ which you can see more about on the playtheracecard.co.uk website.
The NHS Long Term Plan sets out the aim that by 2024, 75% of women from Black and minority ethnic communities and a similar percentage of women from the most deprived groups should be offered continuity of care. The Best Start in Scotland says something similar.
There’s plenty more to be learnt from the MBRRACE report but other things I’ll also take with me are:
- Cardiac disease is still one of the most dangerous conditions for childbearing women
- If you get a loss of fundal height without delivering the placenta you need to consider uterine inversion
- Anaesthetists are incredibly useful during complex emergencies and can often identify illnesses that have gone undiagnosed
- Sepsis can be missed, especially in women with complex care needs. MBRRACE made the recommendation that community midwives carry a thermometer.
As the report says:
‘‘The conversation has changed and it is now recognised that disparity in maternal mortality simply because of a woman’s ethnicity is unacceptable. The conversation now also has to encompass the recognition that it is equally unacceptable for women with pre-existing medical conditions such as epilepsy to receive a lower standard of care simply because they are pregnant.’’
And clients who are from ethnic minority groups AND have pre-existing conditions will be even more at risk.
What is MBRRACE?
If you’re just starting out with these reports, this is my take on what’s going on with MBRRACE.
This is the report on maternal morbidity and mortality that UK professionals draw on to improve practice.
I’ve explained what it is a few times on the blog so I’ll borrow from my last post:
MBRRACE is the bit of the NPEU that do Confidential Enquiries; it stands for 'Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries'. Since the UK started to run Confidential Enquiries into Maternal Death in 1952, the maternal mortality rate has dropped from 90/100,000 to 10/100,000.
The 'Saving Lives, Improving Mothers’ Care' report is out annually, but as (thankfully) only 200ish women die from maternity causes each year, MBRRACE has to wait for three years to get enough data to assess.
This means MBRRACE publishes on different topics each year.
This is the bit students find confusing, it's kind of like one of those magic tricks with the three cups and the ball but the reports go like this:
|2014||Severe morbidity and deaths from sepsis, deaths from haemorrhage, amniotic fluid embolism (AFE), anaesthesia,
neurological, respiratory, endocrine and other indirect causes
|2015||psychiatric causes, deaths due to thrombosis and thromboembolism, malignancy, homicides and late deaths.|
|2016||cardiac causes, deaths from pre-eclampsia and eclampsia and related causes and deaths in early pregnancy, messages for critical care.|
|2017||psychosis, severe morbidity and deaths from epilepsy, deaths from haemorrhage, amniotic fluid embolism (AFE), anaesthesia, stroke, respiratory, endocrine and other indirect causes.|
|2018||psychiatric causes, deaths due to thrombosis and thromboembolism, malignancy and homicides, and
morbidity from major obstetric haemorrhage.
|2019||deaths from cardiac causes, deaths from pre-eclampsia and eclampsia and related causes, accidental deaths and deaths in early pregnancy, morbidity from newly diagnosed breast cancer and messages for critical care|
|2020||pulmonary embolism and deaths from epilepsy, stroke, haemorrhage, amniotic fluid embolism (AFE), anaesthesia, respiratory, endocrine and other indirect causes.|
You can see there’s a topic cycle. It’s like if you watched a news programme that covered everything that happened each month but grouped together with different themes in specific episodes.
There's be a bit of a delay while each episode gets made, but every day and every topic would eventually get covered.
The 'Saving Mothers Lives' reports give details about the death rate as a whole, particular lessons learned from expert opinion, and also 'maternity morbidity' themes are chosen and addressed.
Storytelling is important in MBBRACE because the professionals who write it know how effective stories are as opposed to dry facts and figures.
I'm looking forward to reflecting in more depth, asking my trust and colleagues what their thoughts are and catching up with MBRRACE insights from The Practising Midwife, Dr Sara Wickham, AbuelaDoula (Mars Lord) and more.
A full reference is here: MBRRACE. (2021). Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016-18. Available: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10.pdf.
Leave me a comment below! What are your takeaways from the 2020 MBRRACE report?
Image used with kind permission from Rob Durant.