ArticleBMJ open2019
Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014: a case note review study.
Article in BMJ open, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.
What it found
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The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
1 citing paper in PubMed.
- Role of ethnicity in high-level obstetric clinical incidents: a review of cases from a large UK NHS maternity unit.BMJ open quality · 2022Review
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
4 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectivesLocal reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews.
designAnonymised case notes review.
participantsAll 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012-2014.
main outcome measuresThe number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed.
resultsThe care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140).
conclusionsThis systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time.
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