It’s one of the dirty little secrets of midwifery care in countries in which midwives provide primary obstetrical care. Midwives are often responsible for a disproportionate share of deaths.
As I noted in A stunning indictment of midwives in the Netherlands, a study in the BMJ in November 2010 produced a deeply shocking result:
We found that delivery related perinatal death was significantly higher among low risk pregnancies in midwife supervised primary care than among high risk pregnancies in obstetrician supervised secondary care. This difference was even greater among the cases that were referred from primary to secondary care during labour… (my emphasis)
Now the latest triennial review of maternal deaths in the UK reveals that midwives are responsible for a major proportion of maternal deaths. Indeed, the problem is so worrisome, that an entire chapter is devoted to the role of midwives in maternal deaths.
The report, Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008, was compiled by the Centre for Maternal and Child Enquiries. Chapter 13 is devoted to the role of midwifery in maternal deaths.
During this triennium, a total of 261 women died from Direct or Indirect causes. In 31 of the 107 Direct deaths (29%), the midwifery assessors considered midwifery care to be substandard, as well as in 27 of the 154 (16%) Indirect deaths. This gives a rate of 22% overall for the 261 women who died of Direct and Indirect causes …
As a general matter, maternal deaths in developed countries occur overwhelmingly among women who are high risk patients. Midwives, of course, care only for low risk patients. Therefore, it is unexpected and disturbing that nearly 1/3 of women who died from direct pregnancy complications were under the care of midwives, and more than 15% of deaths from indirect causes (pre-existing medical conditions) occurred under a midwife, who, by the rules of the UK system, should not have been caring for the patient in the first place.
Why are midwives presiding over so many maternal deaths? Midwives failed to:
• Carry out, record and act upon basic observations for both women at low and higher risk of complications.(emphasis in the original)
• Recognise and act on symptoms suggestive of serious illness, including sepsis …
• Provide pregnant women and new mothers with information about the prevention and signs and symptoms of possible genital tract sepsis …
• Assess the mother’s risk adequately throughout the continuum of pregnancy and the postnatal period, re-assessing as needed if circumstances change.
• Refer and escalate concerns to a medical colleague of appropriate seniority…
In other words, midwives, charged with the care of low risk women and referral of high risk women, did not act upon evidence of complications.
In a remarkable passage, the authors note:
It was evident from some of the situations reviewed for this Report that midwives need to develop clear boundaries between advocacy and collusion. There were instances where midwives should have taken a supportive but challenging approach to ensure that women received appropriate care that was in the best interests of themselves and their babies.
Midwives colluded with patients in pretending that high risk situations were not high risk.
Midwives failed to refer low risk patients who became high risk. For example:
A woman in the postnatal period … reported having felt unwell for a week with symptoms of breathlessness and pain on breathing; she also had swelling in one leg and calf and thigh pain. She was advised by the midwife to attend hospital or a walk-in centre. Some hours later she arrived at the Emergency Department where she collapsed, was intubated, ventilated and transferred to the Intensive-Care Unit. A diagnosis of pulmonary embolism/deep vein thrombosis was made. She went on to have several cardiac arrests later that day. She continued to deteriorate and died some days later.
In addition:
… Similar lessons can be learned from some of the 25 Indirect deaths where the women were booked for midwife-led care. Some of these women who died had co-morbidities that were either missed by the midwife or deemed to be unimportant.
That bears repeating: 25 mothers died of pre-existing medical conditions that the midwives failed to diagnose or understand!
The authors note:
There were many examples of failure to make or act upon basic observations. For instance, a woman with several risk factors for pre-eclampsia arrived at hospital with a fully dilated cervix and promptly gave birth. She was given Syntometrine and, over the next few hours, was observed to have at least four abnormal features symptomatic of pre-eclampsia. These were not acted upon until she suffered a cerebral haemorrhage as a result and died.
The authors point out that these deaths could have been prevented by “getting the basics right.”
Midwives are the experts in the care of healthy, low-risk women. They have a clear duty, however, to be equally skilled in the recognition of early signs of problems and to make prompt referral for appropriate senior medical input.
The chapter concludes:
If there is a single ‘take-home’ message for midwives it is this: listen to the woman and act on what she tells you.
I would go one step further and point out that the relentless “promotion of normal birth” has distorted midwifery. The only thing that should be promoted is the health of mothers and babies. It is grossly inappropriate to promote a process at the expense of outcome. When you privilege process over outcome, as contemporary midwifery theory does, women and babies die.
