In respect of national confidential enquiry work CMACE carries out ongoing mortality surveillance alongside national projects on issues of importance arising from the surveillance work. The amalgam of ongoing surveillance and national projects is distinctive to the CMACE approach to national confidential enquiry. Our firm belief is that this integration of surveillance and project work is an ideal model for a national confidential enquiry into maternal and child health, where both clinical practice and wider demographic factors are important in improving outcomes.
The maternal and perinatal mortality surveillance work has a long pedigree and has been inherited from CMACE’s predecessor bodies i.e. CEMACH, CESDI and CEMD. Our goal is to collect a standard dataset of all maternal and perinatal deaths and to report annually on mortality trends. This would compliment the triennial report on maternal deaths giving results of our case studies into those deaths. Changes in rates, causes of death and risk factors are monitored. Local health services, including individual health providers, receive information to support the monitoring of their mortality rates compared to other providers. A further key purpose of the surveillance work is to identify topics that require more in-depth enquiry through carrying out a time-limited project. There is no funding to provide a similar mortality surveillance system for children, though CEMACH has undertook a one year study (2006) of child mortality in 5 areas of the UK, the results of which were reported in May 2008.
Our national projects cover children as well as mothers and babies. We use a modified national clinical audit methodology to help us to identify avoidable factors associated with adverse outcomes. This requires there to be clear, authoritative, evidence-based standards against which the actual clinical care provided in individual cases can be assessed using a case note review approach. Topics where there are existing clinical guidelines published by NICE or other authoritative sources are particularly appropriate, although in areas where there are no existing guidelines, CMACE will use consensus standards developed by a multidisciplinary group of experts which it will itself bring together if necessary.
These standards form the basis of an audit questionnaire for the topic. This is used to assess the care provided in the individual case and as the basis for the subsequent aggregation of findings to develop recommendations for national application. When linked with a case control approach, this can be used to identify those standards where adherence or non-adherence makes a difference to the clinical outcome. Case control studies tend to be larger, more complex and more resource-intensive than more straightforward clinical audits, and it is not always possible as a result for us to use a case control approach.
The methodology also requires the clinical case notes to provide sufficient information on which to base the assessment. CMACE’s most distinctive contribution is in areas where other larger scale review mechanisms might encounter medico-legal inhibitions on the release of documentation.
Thank you to clinicians
CMACE depends on the voluntary support of the many clinicians across the UK who help us in different ways to deliver our programmes. Every unit has a unit coordinator who provides us with perinatal mortality data and there are many people who take the trouble to ensure that we are notified of maternal deaths. Every project depends on a network of clinicians who provide notification data.
One of the distinctive features of CMACE is its confidential enquiry work where multidisciplinary groups of clinicians participate in enquiry panels so that lessons can be learned and shared from individual adverse outcomes. The work of CMACE would not be possible without the sustained support of large numbers of practising clinicians with a wide variety of experience.
CMACE is grateful for the support it receives from obstetricians, midwives, paediatricians and other clinical professionals which makes the work possible. |