Update on maternal mortality and morbidity: the role of the anaesthetist Mike Paech, Professor and Chair of Obstetric

Anaesthesia, The University of Western Australia, Perth, Western Australia I currently represent The Australian and New Zealand College of Anaesthetists (ANZCA) on the Australian Institute of Health and Welfare National Advisory Committee on Maternal Mortality (NACMM), which prepares triennial reports on Maternal Deaths in Australia, based on data provided by the 6 states and 2 territories. The 2000-02 report was released in 2006 (1) and the 2003-2005 report release is planned for late 2007. Personal involvement in a maternal death (The death of a woman while pregnant or within 42 days from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes) is very stressful to us all. For those working only in Australasia, the chances of encountering a maternal death are small. This contrasts dramatically with much of the rest of the world. The World Health Organisation estimates the world total maternal mortality ratio (MMR, deaths per 100,000 births) is 400 per 100,000. The life-time risk of dying during pregnancy is 1 in 74. The estimates for Australia are 11 per 100,000 and 1 in 5,800, contrasting dramatically with countries such as Afghanistan, which has figures of 1,900 per 100,000 and 1 in 6 (2). The Indonesian maternal mortality figures are not known accurately, but Indonesian Demographic and Health Survey data for the period 1998-2002 suggest 300 per 100,000 and lifetime risk of 1 in 65, with marked regional variation and the lowest rates in central Java (250 per 100,000) (3). Irrespective of the country, most maternal deaths are due to obstetric haemorrhage, infection and preeclampsia/eclampsia. Anaesthetic complications (of both general and spinal anaesthesia) cause about 5% of deaths in both developed and developing countries. Reports from all countries consistently show that general anaesthesia confers a much higher risk of both serious morbidity and fatal complications. The UK triennial reports (now Confidential Enquiry into Maternal and Child Health or CEMACH) are highly instructive and have shaped clinical practice, examples being the promotion of regional anaesthesia for caesarean section in the 1980s and the introduction of thromboprophylaxis guidelines in the late 1990s. With respect to anaesthesia, it was astonishing to read in the CEMACH Why Mothers Die 2000-2002 report that three deaths resulted from undetected oesophageal intubation (two with failure to use capnography) (4). From a country considered to have anaesthetic services of the highest quality, this raises issues about training standards, supervision and compliance with monitoring standards. The Australian triennial reports have not been widely publicized. They detail only a small cohort of cases, but reflect local circumstances reasonably accurately. The most striking features of the Australian report, covering the same time period, were the markedly increased risk of death (approximately 5-fold above overall risk) faced by indigenous women; women who were not born in Australia and women over 40 years of age. This highlights the strong influence risk, irrespective of country, of population demographic and epidemiological factors. Direct maternal deaths are defined as those resulting from obstetric complications of the pregnant state. Indirect deaths are those resulting from pre-existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiological effects of pregnancy. The leading direct causes currently in Australia are amniotic fluid embolism, obstetric haemorrhage, infection, hypertensive disorders

of pregnancy; pulmonary thromboembolism; anaesthetic complications and early pregnancy deaths, in that order. The leading causes of indirect deaths are cardiac disease; infection; psychiatric illness (suicide); non-obstetric haemorrhage; cancer and asthma, in that order. In this presentation I plan to reflect on the situation in Indonesia and to present Australian data that suggest strategies by which anaesthetists might contribute to maintaining or improving our standards. In Australia, fatal complications of anaesthesia are exceptionally rare (estimate 1 in 250,000 births). There were no deaths from airway complications in the most recent triennium, but the declining use of general anaesthesia during pregnancy behooves us to optimise the teaching and training of new anaesthetists and of general practitioners (and in some countries, other health professionals). Anaesthesia contributes to more deaths than it causes directly, but the most influential role that anaesthetists can play is in reducing morbidity and possibly mortality from non-anaesthetic causes of death. In most countries, including Indonesia and over the past 30 years in Australia, obstetric haemorrhage is the leading cause of death. Although many such deaths in Indonesia probably occur before health personnel are involved, including from unsafe abortion (3,5), the role of the anaesthetist in the hospital management of obstetric haemorrhage is clearly critically important. For example, aggressive early intervention improves the likelihood of a successful outcome after severe or intractable postpartum haemorrhage (PPH). Prognostic factors for outcome associated with PPH are the 24-hour availability of anaesthetic personnel and the size of the maternity unit, because larger units are more likely to have on-site anaesthetists and obstetricians and blood bank services (6). The anaesthetist has the opportunity to improve outcomes by means of their aggressive resuscitation and team leadership. The latter should incorporate early and continuing dialogue with haematology laboratories and specialists; and with anaesthetic, obstetric, surgical, midwifery, nursing and operating room colleagues. As anaesthetists, our skills in airway management and circulatory monitoring and management allow us to contribute to the multidisciplinary management of hypertensive disorders and eclampsia. We are in a good position to drive compliance with local policies on prophylaxis of thromboembolism, especially at caesarean section. Amniotic fluid embolism is unpredictable and can be rapidly fatal, but early recognition, resuscitation and transfer to a tertiary centre appears the best hope of survival. In the UK, death from cardiac disease now exceeds the leading cause of direct death, and in Australia cardiac disease has been the leading indirect cause over the 30 year period from 19732002, with 15 deaths in the last triennium. Congenital heart disease, myocardial infarction and peripartum cardiomyopathy all feature as underlying pathologies of concern. The failure of carers to recognize symptoms and signs of preeclampsia in Indonesia is a problem (5), and in the UK the failure of medical staff, including anaesthetists, to appreciate the severity of maternal illness was highlighted (7). The difficulties of dealing with women with morbid obesity was also featured. A third of women who died in the UK were obese, a situation mimicked in the USA (8) and a factor likely to become significant in many countries. Can future improvements be made so that maternal mortality falls? It is evident from the Australian, as well as the CEMACH report, that many women who die are economically and socially disadvantaged. The wealth of a country does not necessarily correlate with its maternal mortality ratio, so is not indicative of the quality of its health services. Improvement in health services are likely to be far more important than the introduction of new therapies or technologies (4,5). This means political will is required to achieve improvement, with governments needing to promote high-quality care and access to it, especially in rural areas (9).

The Indonesian Millenium Development Target for improving maternal health (which includes reducing the MMR by three-quarters between 1990 and 2015) suggests strategies such as improved access and coverage of care; building more effective partnerships; empowering women and families by improving knowledge and attitudes; and involving communities in the provision and utilization of services (3). At a hospital level, cost-effective resource allocation and clinical governance are likely to represent the best means of minimising critical incidents and adverse outcomes. The accurate collection of near miss and specific morbidity data could have an educational impact similar to that apparent from the UK triennial reports and is being considered currently by the NACMM in Australia. References Australian Institute of Health and Welfare National Perinatal Statistics Unit, Canberra. Maternal Deaths in Australia 2000-2002. http://www.npsu.unsw.edu.au (accessed 26 June 2007) 2. www.who.int/reproductive-health/publications/maternal_mortality_2000/ (accessed 26 June 2007) 3. see www.undp.or.id/pubs/imdg2004/English/MDG-IDN_English_Goal5.pdf (accessed 14 November 2007) 4. Confidential Enquiry into Maternal and Child Health. Why Mothers Die 2000-2002: The Sixth Report of the Confidential Enquiries into Maternal Death in the United Kingdom. http://www.cemach.org.uk (accessed 26 June 2007) 5. Iskandar M, Utomo B, Hull T et al. Unravelling the mysteries of maternal death in West Java: re-examining the witnesses. Depok, Indonesia: Centre for Health Research, University of Indonesia, 1996 6. Bouvier-Colle MH, El Joud DO, Varnoux N et al. Evaluation of the quality of care for severe obstetrical haemorrhage in three French regions. BJOG 2001; 108:898-903 7. Cooper GM, McClure JH, on behalf of the Editorial Board. Maternal deaths from anaesthesia. An extract from Why Mothers Die 2000-2002, The Confidential Enquiries into Maternal Deaths in the United Kingdom. Br J Anaesth 2005; 94:417-423 8. Mhyre JM, Riesner MN, Grigorescu V. Anesthesia-related maternal mortality in Michigan: 1985-2003 (abstract). Anesthesiology 2006;104;Supp 1 SOAP Abstracts A-19 9. Weeks A., Maternal mortality: Its time to get political (editorial). BJOG 2007; 114:125126
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