The Confidential Maternal Death Enquiry (CEMD) was initiated in England and Wales in 1952 and became UK - wide in the 1980's. Ireland became a participant in 2009. Although much has changed since its inception in 1952, the lessons to be learned from the Enquiry remain as valid now as in the past.
The aim of the Enquiry is to investigate why some women die during or shortly after pregnancy, and to learn how such tragedies can be avoided in the future. We can thus ensure that all pregnant and recently delivered women receive safe, high quality care delivered in settings appropriate to their individual needs.
Findings from previous UK maternal death enquiries have previously been published in a triennial report entitled Saving Mothers Lives (4,744kB), last published in 2011. The overwhelming strength of successive CEMD reports has been the impact their findings have had on improving standards of care and clinical governance in the UK maternity service and further afield.
In 2013, the UK CEMD (formally CEMACH, subsequently CMACE) was transferred to MBRRACE-UK, (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries). MBRRACE-UK is led from the National Perinatal Epidemiology Unit (NPEU) at the University of Oxford by Professors Jenny Kurinczuk and Marian Knight.
With the support of the HSE and the Institute of Obstetricians and Gynaecologists, MDE Ireland has reached agreement with MBRRACE-UK to continue Irish involvement with the UK Enquiry.
MBRRACE-UK has revised and updated the process for data collection and analysis for the CEMD. This will result in CEMD reports being published annually rather than triennially. As such, accurate and timely return of data is essential in order to adhere to a newly streamlined reporting timetable.
The next CEMD report, covering the years from 2009 to 2012, and including Irish data, will be published in December 2014. Future annual reports will feature rolling themed review topics on causes of maternal deaths. The themed review topics in the 2014 report will include sepsis, obstetric haemorrhage, anaesthetic related deaths, amniotic fluid embolism, neurological causes and deaths due to indirect causes.
Given the relatively small number of maternities annually in Ireland (70,000 - 75,000) and with due regard to confidentiality, it was imperative to join a larger cohort in order to maintain anonymity. Further, a larger cohort would allow more meaningful analysis and recommendations. The UK confidential MDE has a respected and validated research methodology. Recommendations from previous MDE UK reports have historically informed Irish health care professionals in ensuring continued improvement in Irish maternity services.
The establishment of MDE Ireland marked a significant step forward in promoting and supporting a culture of patient safety in Ireland and ensuring the continuous improvement of our maternity services.