I've been looking for a spare window to read the new Saving Mothers’ Lives report since it was released in December (2016). This week I finally got a chance to finish it, fuelled by many cups of tea and slices of toast. It’s a fascinating and moving piece of work.
I want to tell you about this kind of report in general, because they're important and make me proud of maternity care in the UK. They look in detail at the care of every mother that died.
I think that's amazing.
The reports are published every three years and have been running since the 1950s – the longest enquiry into maternal deaths in the world.
The enquiries try to pick up on patterns, to see what could be done to save women and babies in future.
The new title/organisation name ‘MBRRACE’ stands for ‘Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries*’, which makes it sound a bit bureaucratic.
(*In the 50s it was simply called ‘Confidential Enquiries into Maternal Deaths’, but it’s been named many long and/or confusing things since then: in 2008 it was CEMACE (The Centre for Maternal and Child Enquiries), and before that CEMACH (The Centre for Maternal and Child Health), and it’s had many other names, in case you need to go and do some research…)
The teams are given anonymised notes of each woman, which is why these reports are called ‘Confidential Enquires.’
Story telling is important in MBBRACE because the professionals who write it know how effective stories are as opposed to dry facts and figures.
In fact, while reading I found myself telling my partner about particular deaths or events and often had a lump in my throat.
The women's stories are included in small vignettes throughout the text.
Here’s an example:
An anaemic woman had a caesarean section after a very prolonged labour. She was of small stature and lost almost 1000mls at surgery. No blood was ordered. Three hours later she bled 2500mls vaginally from an atonic uterus…She developed pulmonary oedema and was intubated, ventilated and transferred to ITU where she died from ARDS, sepsis and multiorgan failure a month later.
The report is not only readable and moving, it’s motivational. It gets you fired up to make a difference.
And now's there's a move to publish a report like this every year, instead of every three years.
An important philosophy of the report is to avoid blame culture.
It’s all about judging care to improve outcomes. Everything’s kept confidential so the focus can be on making things better, rather than blaming the professionals. Once you start blaming, the negative environment created can be toxic, making policies and behaviours harder to change.
The report has been put together so carefully that it can be used to great effect, even in these difficult times. The thought of this system must give so much comfort to the women's partners and family who are left behind.
I hope this gave you a warm feeling about how brilliant all the professionals are in the maternity services.
Every single one of you, be it midwife in training, applicant, or qualified midwife in the arena, is an incredible person who helps keep mums where they should be - empowered, safe and healthy with their babies and families.