BJA Education, 22(4): 146e153 (2022)

doi: 10.1016/j.bjae.2021.11.009
Advance Access Publication Date: 16 February 2022

Matrix codes: 1I01,

2B05, 3B00

Maternal death: lessons for anaesthesia and critical

care
A. Walls1,*, F. Plaat1 and A.M. Delgado2
1
Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK and 2New
York-Presbyterian Weill Cornell Medical Center, New York, USA
*Corresponding author: alexander.walls@nhs.net

Keywords: anaesthesia, obstetrical; maternal death; maternal mortality

Learning objectives Key points

By reading this article you should be able to:
 Explain how maternal death is defined and
measured along with global and regional trends
in maternal mortality.
 Describe the processes for maternal death
reporting and review in the UK and the USA.
 Identify the key considerations for anaesthetic
practice learned from the current literature and
enquiries into maternal death.
Few occurrences are as tragic as maternal death, which has
wide and permanent effects on children, families, healthcare
staff and wider society. This review examines the current
status of worldwide maternal mortality with a focus on the UK
and USA, and lessons learned from mortality investigations
relevant to anaesthesia and critical care.
Alexander Walls FRCA is a specialist trainee in anaesthesia within
the Imperial School of Anaesthesia, London. His interests are ob-
stetric and regional anaesthesia.
Felicity Plaat FRCA is a consultant anaesthetist at Queen Charlotte’s
and Chelsea Hospital, London. She is immediate past president of the
Obstetric Anaesthetists’ Association and a council member of the
Royal College of Anaesthetists. Her specialist areas are obstetric
anaesthesia, medicolegal and ethical aspects of anaesthesia. She has
been an anaesthetic assessor for MBRRACE-UK.
Angelica Delgado MD is an anaesthesiologist with an interest in
obstetric anaesthesia. She completed her internship and residency
training at New York-Presbyterian Hospital/Weill Cornell Medicine,
including an internship in obstetric anaesthesiology.
 Maternal mortality is decreasing worldwide, but
internationally agreed targets for further reduc-
tion are likely to be missed.
 Maternal mortality is thought to be increasing in
the USA.
 Annual surveillance and reporting of maternal
death in the UK yields lessons for those involved
in caring for pregnant and postpartum women.
 Uterine displacement and perimortem Caesarean
section (resuscitative hysterotomy) are crucial to
successful resuscitation in pregnancy.
 Multidisciplinary cooperation and the involve-
ment of senior clinicians are vital to successful
outcomes in high-risk pregnancies and maternal
emergencies.
Maternal death and its measurement
Maternal death and its subcategories are defined in Table 1.
Estimates of maternal death for each country and region are
produced by agencies such as the WHO, UNICEF and the
World Bank. There are several metrics used to describe
maternal death, defined in Table 2. In 2017 it was estimated
that 295,000 maternal deaths occurred worldwide.1 This is
an improvement on the estimated 451,000 maternal deaths
that occurred in 2000. The concept of ‘obstetric transition’
describes how maternal mortality decreases as a country
develops economically and socially. Low- and middle-
income countries generally have higher levels of maternal
death, consisting largely of direct causes such as haemor-
rhage and communicable diseases. With increasing devel-
opment over time, overall deaths decrease and indirect
causes of maternal death become more predominant.2 A

Accepted: 3 November 2021

© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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146
 Maternal care

Table 1 Definitions of maternal death.1

 Maternal death: the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of
the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from unintentional or incidental causes.
o Direct maternal deaths: deaths resulting from obstetric complications of the pregnant state (pregnancy, labour, puerperium) and from
interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.
o Indirect maternal deaths: deaths resulting from previous existing disease or disease that developed during the pregnancy and not resulting
from direct obstetric causes but were aggravated by the physiological effects of pregnancy.
 Late maternal deaths: direct or indirect maternal deaths occurring from 42 days to 1 yr after termination of pregnancy.
 Coincidental maternal deaths: deaths from unrelated causes which happen to occur during pregnancy or postpartum.

Table 2 Measures of maternal mortality.1

 Maternal mortality ratio (MMR): the number of maternal deaths during a given time period per 100,000 live births during the same time period.
In 2017, the global MMR was estimated as 211 maternal deaths per 100,000 live births.*
 Maternal mortality rate (MMRate): the number of maternal deaths divided by person-years lived by women of reproductive age in a popu-
lation. This statistic reflects both the risk of maternal death per pregnancy and the level of fertility in the population.
 Proportion maternal (PM): reflects the proportion of deaths among women of reproductive age (15e49 yrs) that are attributable to maternal
causes.
 Adult lifetime risk of maternal death: the probability that a 15-yr-old girl (in the year of the estimate) will eventually die from a maternal
cause. In 2017 the global probability was 1 in 190.
 Pregnancy-related mortality ratio: an estimate of the number of pregnancy-related deaths for every 100,000 live births (used in US literature).

*In the USA the term ‘maternal mortality rate’ can be used to describe maternal mortality ratio as defined above.

2014 review by the WHO indicated that approximately 73%
of global maternal deaths between 2003 and 2009 were as a
result of direct causes. The main causes of death were
haemorrhage (27.1%), hypertensive disorders (14%), sepsis
(10.7%), abortion (7.9%), embolism (3.2%) and other direct
causes (9.6%).3
In the UK there has been a gradual decrease in the number
of maternal deaths. Between 2016 and 2018 there were 217
deaths, compared with 295 between 2003 and 2005. Direct
deaths decreased by 39% and indirect deaths by 22% over this
period. Some 42% of maternal deaths are now from direct
causes, of which thrombosis and thromboembolism are the
most common. Fifty-eight percent of deaths are from indirect
causes with cardiac disease being not just the most common
indirect cause but the single most common cause of death
overall (Fig. 1).4
Presently, the USA does not have a uniform system for
collecting maternal morbidity and mortality data at a national
level. The current system relies on reporting from individual
states. The heterogeneous quality of data makes it difficult to
compare maternal mortality rates internationally. Despite
having a system that can provide some of the most advanced
healthcare worldwide, maternal mortality rates have risen in
the USA over the period of 2000e2017 (Figs. 2 and 3).1

Direct
25%
Indirect
20%

15%

10%

5%

0%
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is

ct

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ia

ed
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ag

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ar

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hi

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ta
lo

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in

or
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ig

la
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er
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em

ae
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eu

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bo

ae

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e-
id

na
N

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eg
ro

ic
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rly

Am
Ea

Fig 1 Causes of maternal death in the UK for the 2016e18 triennium. Green bars show direct causes of death, red bars show indirect causes of death. Adapted from
the 2020 CEMD report.4

BJA Education - Volume 22, Number 4, 2022 147

Maternal care

30%
25%
20%
15%
10%
5%
0%
ac

is

es
nt

er
ag

si
ps

lis

lis
di

us
he
de

rd
rh
se

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ar

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ac

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ar
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Fig 2 Causes of pregnancy-related death in the USA for 2014e7 (CDC PMSS).13

20 UK
18 USA
per 100,000 live births)
MMR (Maternal deaths

16
14
12
10
8
6
4
2
0
2000 2005 2010 2015 2017
Year

Fig 3 Trend in the estimated maternal mortality ratio (MMR) for the UK and USA between 2000 and 2017. Data obtained from the WHO report ‘Trends in maternal
mortality’.1

Improving global outcomes maternal and newborn healthcare that is universally available,
accessible and acceptable to women is essential. It is recognised
Global variation in maternal death rates is stark. In 2017 the
that in order to achieve a sustained reduction in maternal
lifetime risk of maternal death for women in Sub-Saharan Africa
deaths, individual countries need to have an effective political,
was one in 37, compared with one in 7800 for women in Australia
social and financial infrastructure that will support high-
and New Zealand.1 The United Nations Sustainable Develop-
performing health systems.5 Lack of accurate death registra-
ment Goal 3.1 aims to reduce the average global maternal mor-
tion and misclassification of causes of death make it difficult for
tality rate to <70 per 100,000 live births by 2030. At the current
countries and organisations to fully comprehend the extent of
slow trajectory of improvement this goal will be missed,
maternal mortality, especially in low- and middle-income
resulting in one million additional maternal deaths by then.1
countries. The WHO recommends international stand-
The WHO’s 2015 strategy for ending preventable maternal
ardisation of death certification and recording pregnancy status
mortality is based on strengthening the position of women in
on death certificates.5
society and involves empowering women and girls to make
decisions about their health and education and encouraging
Confidential enquiry into maternal deaths in
greater gender equality within societies.5 Lower levels of edu-
cation amongst women have been associated with increased
the UK
risk of adverse outcomes in pregnancy and maternal death, The UK’s National Surveillance and Confidential Enquiry into
especially in the developing world.6 High quality reproductive, Maternal Deaths (CEMD) began in 1952. Since 2012, the

148 BJA Education - Volume 22, Number 4, 2022


enquiry has been conducted by a collaboration called
‘Mothers and babies: reducing risk through audits and confi-
dential enquiries across the UK (MBRRACE-UK). Before 2014
reports were published every 3 yrs, but since then they are
produced annually to enable faster changes in clinical practice
to be made in response to the findings.7 Each annual report is
still based on data from the previous 3 yrs. For example, the
2020 report uses data from maternal deaths occurring be-
tween 2016 and 2018. This allows analysis of more cases of
rare causes of death whilst maintaining patients’ anonymity.
Specific causes of maternal death are the subject of chapters
every 3 yrs, with anaesthesia being covered in the 2014, 2017
and 2020 reports. The CEMD reports contain anonymised case
vignettes to highlight key issues in the care received by
women who died. An expedited review into maternal deaths
during the global pandemic caused by SARS-CoV-2, has
recently been published.8
It is not possible to demonstrate a statistical effect of the
CEMD reports on maternal death rates because maternal
death is a rare occurrence. The clinical impact is likely to be
highly significant because maternal death is only the ‘tip of
the iceberg’ of adverse events in pregnancy. Therefore, any
lessons implemented from the enquiry may reduce the
morbidity experienced by women in the future.9
Maternal death in the USA
As previously mentioned, the USA does not have a single
comprehensive reporting process for maternal death. Infor-
mation on maternal mortality is collated by the National
Center for Health Statistics (NCHS) which collects data on
deaths within pregnancy and 42 days postpartum based on
death certificates and the International Classification of Dis-
eases (ICD) code listed for the cause of death.10 In 2019, the
NCHS reported a maternal mortality rate of 20.1 per 100,000
live births, compared with 17.4 in 2018.11 Whether an
apparent increase in deaths is genuine or reflects improving
data capture is uncertain as variability in reporting and data
collection persists, despite the best efforts of the Centers for
Disease Control and Prevention (CDC), which receives and
publishes maternal mortality data.12 The Pregnancy Mortality
Surveillance System (PMSS) is a separate national surveillance
system covering all 50 states and also separately New York
City and the District of Columbia for a total of 52 locations. The
PMSS uses different sources of data and includes late deaths
within 1 yr of the end of pregnancy (13e14% of all deaths) to
generate a pregnancy-related mortality ratio.13 The
pregnancy-related mortality ratio has increased steadily from
14.5 per 100,000 live births in 2000 to 17.3 in 2017.13
In the USA, in contrast to mortality data, there are reliable
morbidity data that reveal the increasing prevalence of
obesity and chronic medical conditions such as heart disease,
hypertension and diabetes in obstetric patients. There is an
association between comorbidity and increasing risk of
maternal morbidity and mortality, as demonstrated by the
Bateman Comorbidity Index for use in obstetric patients.14
This may reflect a growing tendency to delay childbearing
until later in life.15 In response to the increase in maternal
deaths and marked racial disparities, the CDC has initiated
several projects aimed at facilitating the creation and
improving the function of existing maternal mortality review
committees (MMRCs).16 Several states are now collaborating
Maternal care
to produce recommendations to prevent future maternal
morbidity and mortality based on the amalgamated findings
of their individual MMRCs. Through data sharing amongst
these organisations, it is hoped that a better understanding of
maternal mortality is gained and high impact recommenda-
tions can be disseminated nationwide.17
Racial disparities in maternal death in the
USA and UK
A disproportionate number of deaths occur amongst
women from ethnic minority backgrounds in both the UK
and US. Rates are particularly high amongst US-born Black
women compared with US-born White women.10 In the USA
in 2014, the ratio of pregnancy-related mortality was found
to be between three to four times higher for Black women as
compared with White women.18 The difference in both
morbidity and mortality is independent of age and socio-
economic status. Such disparities highlight issues of both
access to medical care and variation in the quality of care
available to non-White women in the USA.10 Black women
access antenatal care later in pregnancy and attend fewer
antenatal appointments than White women. The hospitals
used by Black women often have higher rates of maternal
morbidity and mortality and are less frequently used by
White women.19
In the UK between 2016 and 2018, the risk of maternal
death was more than four-fold higher for women from Black
ethnic minority backgrounds compared with White women.
Women from Asian and mixed ethnic backgrounds were also
at higher risk of death.4 Although further research is needed
to fully understand the causes of these disparities, it is likely
to be multifactorial in both countries. In a recent review,
Howell suggested a conceptual model for understanding the
poorer outcomes in pregnancy within some ethnic groups in
the US.19 This consists of:
(i) patient-related factors (biological and genetic de-
terminants of health and disease, socioeconomic cir-
cumstances, personal beliefs and behaviour);
(ii) community and neighbourhood-related factors (hous-
ing, social networks);
(iii) provider-related factors (implicit bias, communication
issues); and
(iv) system-related factors (presence of structural racism
[defined below], social and political policy, ease of access
to healthcare and its quality).
The 2020 UK Confidential Enquiry report highlighted the
‘constellation of biases’ faced by many women who died.4
These included a mixture of physical, mental and social
problems, with ‘siloed’ systems of care that prevented women
from receiving all the help they needed. In addition, women
from ethnic minority backgrounds encounter models of care
that may not take account of cultural differences. Structural
racism refers to the unfair disadvantage suffered by racial and
ethnic groups that is perpetuated by current rules, policies and
laws.20 The potential effect on healthcare outcomes has
recently captured wider interest of both public and healthcare
professionals on both sides of the Atlantic. In response to these
concerns, there are now advocacy groups to raise awareness
and bring about change, such as ‘Five X More’ in the UK.
BJA Education - Volume 22, Number 4, 2022 149
Maternal care
Anaesthesia as a cause of maternal death in
the UK
Anaesthesia is classed as a direct cause of maternal death.
Between 2000 and 2017, there were 25 anaesthetic deaths,
representing only a small percentage of total maternal deaths
during this period.21 Between 2016 and 2018, only one
anaesthetic-related death was reported. This is in contrast to
the first triennial report in 1952e4 where 49 deaths were
directly attributed to anaesthesia and a further 20 deaths
where anaesthesia was a contributing cause. Anaesthetists
play a broad role in the care of pregnant women beyond
simply providing anaesthesia and analgesia, allowing lessons
derived from many sections of the enquiry to be applied to
anaesthetic practice. There were frequently deaths where
input from anaesthetists, or lack of it, was felt by enquiry
assessors to have contributed to the poor outcome.22
Lessons for airway management and induction of
anaesthesia
Although failures in airway management continue to feature
in recent reports in the UK, failed intubation itself is not a major
cause of maternal death despite much anxiety regarding this
topic amongst anaesthetists. The joint 2015 Obstetric Anaes-
thetists’ Association (OAA) and Difficult Airway Society guid-
ance for management of difficult or failed tracheal intubation
in obstetrics aims to standardise approaches to the obstetric
airway against a background of reduced provision of general
anaesthesia in obstetrics and therefore reduced practical
experience, especially for trainee anaesthetists.23 Fixation er-
ror, also known as ‘anchoring’ or ‘tunnel vision’, has been
repeatedly identified in airway crises. It refers to situations
where clinicians focus on one possible explanation for a
problem without consideration of other possible causes.24 An
example from the 2014 report was of an anaesthetist repeat-
edly focussed on replacing a tracheal tube because of the loss of
end-tidal CO2 measurement without consideration of other
potential diagnoses such as bronchospasm. It is recommended
that all staff should be made aware of the potential for fixation
error and the need for ‘standing back’ and reviewing acute
situations with other team members, for example through
simulation training. Based on a case where an inappropriately-
sized tracheal tube may have complicated intubation during a
crisis situation, the 2017 report recommended that the largest
tracheal tube used in obstetric patients should be a size 7.0,
with smaller tubes being available.25 An individualised risk
assessment for pulmonary aspiration, that takes into account
risk factors such as obesity or acute illness, should be formu-
lated for each woman. The benefit of antacid medication in
reducing the risk of a low gastric pH before anaesthetic in-
duction is highlighted.25
Lessons for neuraxial anaesthesia
26
Serious complications of neuraxial techniques are rare. The
2014 CEMD report stated that two women died after accidental
dural puncture, one with a subdural haematoma and one a
cerebral vein thrombosis.9 Both cases involved inadequate
follow-up and delayed investigation. Persistent headache
should not be assumed to always be caused by CSF leakage. In
response to these deaths, evidence-based guidance on treat-
ment of obstetric post-dural puncture headache has been
developed by the OAA.27,28 Although there have been no
150 BJA Education - Volume 22, Number 4, 2022
recent reports of deaths caused by high or total spinal blocks,
a 2017 study of cardiac arrest in pregnancy revealed that a
quarter of all arrests were related to anaesthesia, and more
than half of anaesthesia-related cardiac arrests were caused
by total spinal anaesthesia and the cardiovascular complica-
tions of this.29 Since then, international guidelines on the
management of hypotension for Caesarean section under
spinal anaesthesia have been published.30
Lessons for monitoring
In several cases deterioration after surgery was missed
because of poor monitoring and lack of equipment in obstetric
settings. Pregnant and postpartum women require the same
standard of monitoring (and documentation) as patients
receiving anaesthesia in settings other than the labour ward.9
Lessons for maternal resuscitation
All those involved in resuscitation of pregnant and post-
partum women, including anaesthetists, should be aware of
the adaptations required in pregnancy, which have been
recently reviewed in this journal.31 In particular lateral uterine
displacement to offset aortocaval compression in supine
women is essential to maximise the efficacy of chest com-
pressions and has repeatedly been highlighted in reviews of
maternal deaths where it has been absent. The full left lateral
position should be used in refractory severe hypotension.25
During cardiac arrest, a woman in the supine position
should undergo manual displacement of the uterus.31
In both the UK and the USA, the importance of perimortem
Caesarean section (also known as ‘resuscitative hysterotomy’)
in women over 20 weeks’ gestation has been emphasised.
Emptying the uterus improves the chance of survival after
cardiac arrest for both the woman and the fetus, if performed
swiftly.31 It should be performed as soon as possible after
cardiac arrest is confirmed and completed within 5 min
whenever possible. Delaying perimortem Caesarean section
can be lethal, although it should be attempted even if the 5
min deadline is missed, as survivors have been reported.29
Factors causing delay, such as unnecessary fetal assessment
before delivery, transfer to an operating theatre and objection
to the procedure by relatives, have adversely affected out-
comes and been highlighted by CEMD reports.21
When profound hypotension occurs as in anaphylaxis,
cardiopulmonary resuscitation should be commenced when
systolic arterial pressure is <50 mmHg or unrecordable
despite a palpable pulse.25 Delivering chest compressions to a
beating heart is unlikely to cause harm. The 2020 CEMD report
suggests that chest compressions may be of use in venous air
embolism, where it may contribute to the breakup of intra-
ventricular air.4
Lessons for management of haemorrhage
Failure to recognise the severity of a woman’s condition dur-
ing obstetric haemorrhage is a common cause of suboptimal
care identified by CEMD reports. False reassurance from point-
of-care haemoglobin values obtained during ongoing hae-
morrhage has led to inadequate fluid resuscitation and
transfusion. Clinicians must be aware that a patient can be
hypovolaemic but have a normal haemoglobin concentration
if haemodilution from fluid resuscitation has not yet occurred,
particularly when early in the course of a haemorrhage

situation.9 Trends in vital signs and values such as pH, lactate
and base deficit should help guide fluid resuscitation and
blood transfusion with repeated point-of-care and laboratory
tests to assess efficacy of treatment. A woman’s body habitus,
in addition to the actual (or estimated) volume of blood lost,
should be taken into account when estimating the severity of
haemorrhage. In several cases the severity of the situation
was overlooked in smaller women.9 Obesity causes problems
because of inaccurate monitoring and difficulty with i.v. ac-
cess. Consideration should be given to using intraosseous
access in emergencies when i.v. cannulation is difficult.9
Some of the deaths associated with haemorrhage occurred
after tracheal extubation with suboptimal resuscitation be-
forehand. Haemodynamic instability, ongoing bleeding, sig-
nificant anaemia, metabolic acidosis and hypothermia should
all be corrected before extubation. Residual neuromuscular
block and the effect of opioids on respiratory function have
been implicated in fatal deterioration after surgery.25
Cardiac disease
Cardiac disease remains the leading cause of maternal death
in both the USA and UK. Most of the women who died were
not known to have cardiac disease upon entering pregnancy.
Cardiovascular risk assessment is recommended for all
pregnant women and various toolkits for identifying cardio-
vascular disease are available.32 In recent CEMD reports, car-
diac causes for a patient’s symptoms were often overlooked
by clinicians who attributed them instead to anxiety,
dyspepsia or pneumonia. Pulmonary embolism was
frequently considered to be the cause of chest pain or
breathlessness even when evidence for it was lacking. A
positive diagnosis should be made for significant symptoms
and signs such as chest pain, tachypnoea, tachycardia and
orthopnoea and women should receive the same in-
vestigations as non-pregnant women. Chest pain requiring
parenteral opioids should be considered a ‘red flag’ requiring
urgent investigation.33 Anaesthetists have experience in
managing critically unwell patients and should be able to alert
the wider maternity team to potential cardiac concerns.
Lessons for prescribing
The use of NSAIDs in a woman with pre-existing renal
impairment has been highlighted. Creatinine concentration
decreases in pregnancy, so an apparently normal level may
indicate renal dysfunction.9
Women receiving anticoagulants during pregnancy need a
plan to guide dosing during the antenatal, intrapartum and
postpartum periods. In the UK, anaesthetists are often
responsible for prescribing thromboprophylactic drugs after
operative delivery. This differs from the USA where this is
managed by the obstetric or surgical team. The 2015 CEMD
report documented four maternal deaths from venous
thromboembolism where postpartum thromboprophylaxis
had been inappropriately delayed.34 UK guidance suggests
postnatal thromboprophylaxis with low molecular weight
heparin (LMWH) should be given 6e8 h after delivery regard-
less of whether this coincides with drug rounds, with at least 4
h since spinal injection or removal of epidural catheter.34 The
2018 guidelines from the American Society of Regional Anes-
thesia and Pain Medicine suggest a delay to starting prophy-
lactic LMWH 6e12 h after delivery, with at least 4 h having
elapsed since catheter removal.35
Maternal care
Organisational considerations
Review of maternal deaths repeatedly highlights delays in
assembling the correct personnel to care for sick women.
Senior clinicians are often involved too late in the manage-
ment of complex or high-risk patients. Having a senior
clinician take a ‘helicopter view’ of a crisis situation was
recommended in the 2020 CEMD report.4 Lack of antenatal
coordination of the care of women with complex medical
problems is also a recurring theme. Management should be
led by a consultant obstetrician. In the USA, this would be
the equivalent to the attending obstetrician who would co-
ordinate the input of other subspecialties.
Lessons for critical care
Critical care should be undertaken as soon as it is warranted,
regardless of location. It should not depend on a physical
intensive care bed being available. Obstetric anaesthetists,
critical care doctors and outreach staff should work collabora-
tively to enable this.33 In the UK, there is a national recom-
mendation that admission to a critical care unit should occur
within 4 h of a decision for admission.36 Women admitted to
critical care should continue to receive input from obstetri-
cians, obstetric anaesthetists and midwives who are best
placed to guide treatment of obstetric conditions.
In the USA, there is guidance on the transfer of pregnant
patients for both maternal and neonatal indications, with
facilities and staff capabilities described for each level of care.
Regional collaboration amongst institutions to ensure women
receive the most appropriate level of care is recommended.37
Guidance based on recent CEMD reports suggests transfer of
critically unwell pregnant women should be avoided unless
appropriate care or intervention cannot be provided locally.
Whenever possible, expert opinion or review should come to
the woman, not necessitate her transfer. If transfer cannot be
avoided, it should be to a location that can provide all required
input, including obstetric services.33
The increased susceptibility to respiratory infection in
pregnancy and the current ongoing COVID-19 pandemic
highlights the importance of a low threshold for escalation of
care in expectant mothers. The MBRRACE-UK rapid review of
COVID-19 maternal deaths conducted during the first wave of
the pandemic revealed previously reported issues with
delayed escalation of care for critically unwell women,
absence of multidisciplinary working and lack of senior input,
albeit in a healthcare system under much strain.8
Conclusions
Maternal mortality remains a global problem that unevenly
affects different countries and ethnic groups. Efforts to sus-
tain the worldwide reduction in maternal death will require
societies and governments to allocate sufficient resources to
women’s health and to value and empower women. In the
USA, increasing maternal mortality rates are not attributable
to a single cause and may partly reflect recent advances in
reporting. The UK’s CEMD highlights the range of clinical
scenarios where the involvement of anaesthetists in multi-
disciplinary care could help reduce morbidity and mortality
experienced by pregnant and postpartum women, beyond the
provision of anaesthesia.
Declaration of interests
The authors declare that they have no conflicts of interest.
BJA Education - Volume 22, Number 4, 2022 151
Maternal care
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
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