OAA response to the HSCC Expert Panel
Written evidence submitted by The Obstetric Anaesthetists’ Association (EPE0008)
Introduction
The Obstetric Anaesthetists’ Association (OAA) is a subspeciality organisation of over 2000 members whose aim is to provide education and training for anaesthetists, midwives and other practitioners involved in caring for pregnant women in the UK. A key objective is promoting safety in maternity care. In 2019 the organisation celebrated its 50th anniversary.
The anaesthetist is a crucial member of the maternity unit team. Approximately 1 in 4 women deliver by caesarean section, and many more require anaesthetic care for the provision of labour analgesia, operative/assisted deliveries and other procedures during pregnancy or around the time of delivery. Anaesthetists are also involved in planning and delivering medical care to high-risk women during pregnancy and delivery. During the COVID-19 pandemic, anaesthetists had a pivotal role in delivering critical care in a variety of settings, including in maternity services. It is estimated that anaesthetists provide anaesthesia and analgesia to 315,000 women annually.1 The obstetric population is changing with a higher prevalence of risk factors for poor outcomes. These include higher fertility rates in women aged 40 and over (an age group who have been specifically identified as at increased risk of mortality by MBRRACE in its reports of the UK Confidential Maternal Death Enquiries), higher levels of obesity and more women with significant pre-existing conditions, e.g., congenital cardiac disease.2 These groups require specialised services to support them during pregnancy and delivery. With their broad training, obstetric anaesthetists have historically bridged multiple disciplines, including obstetrics, medicine and general surgery, to be vital members of the multidisciplinary maternity team.
The OAA welcomes the opportunity to submit written evidence to the Health and Social Care Committee’s inquiry into the progress the Government has made against its commitments in maternity services in England. In this written evidence, we comment only on those areas relevant to obstetric anaesthesia or on which we have a particular view.
A Summary of the views of the OAA
Since the Confidential Enquiry into Maternal Deaths reported on maternal deaths for the UK in 1985, there has been no sustained reduction in either the number of maternal deaths or maternal mortality rate in the intervening 30 years of the Enquiry. In the 1985-87 triennial report, the maternal mortality rate per 100,000 maternities was 9.83 involving 223 maternal deaths from Direct and Indirect causes, whilst in the 2015-17 triennial report, the maternal mortality rate was 9.16 involving 209 maternal deaths. Intervening reports from 1987 to 2015, identified both increased maternal mortality rates and number of maternal deaths.
What has changed significantly since 1985 are the proportions of maternal deaths attributed to Direct causes (deaths resulting from obstetric complications of pregnancy) and Indirect causes (deaths resulting from existing disease, or disease that developed during pregnancy and which is not due to direct obstetric causes). In the 1985-87 triennium the number of Direct deaths represented 62% of all maternal deaths (Direct and Indirect); this proportion has decreased continually so that in the 2015-17 triennium, Direct deaths represented 35% of all maternal deaths.
The increasing proportion of maternal deaths due to Indirect causes has occurred in the context of increasing maternal age and obesity, and other wider socioeconomic changes. The delivery of good and safe maternity care increasingly requires effective multidisciplinary management of co-existing disease and planning of care. Obstetric anaesthetists, with their clinical skills and experience, have a vital role to play in the delivery of multidisciplinary care, which may include the provision and delivery of antenatal clinics by obstetric anaesthetists.3
Our view is based on evidence from a survey of obstetric anaesthesia workload undertaken by the OAA in January 2021 following a request by NHS England for assistance to identify what national resource needs were required to meet the recommendations of the Ockenden Report. The OAA invited all consultants in the UK who are service leads for obstetric anaesthesia in their individual hospitals to participate in an online survey. The survey requested information on several topics, which included: the number of anaesthetists working in individual maternity units, the number of contracted sessions provided by consultant anaesthetists and information about the provision of multidisciplinary ward rounds and elective caesarean section lists. The recommendations in the Ockenden report, alongside national standards, were used for benchmarking.4,5
There were 117 responses to the survey. From its own research, the OAA estimates that the total number of consultant-led maternity units in the UK is 184, which gives a survey response rate of 64%.
The results of the survey relevant to an assessment of appropriate staffing in maternity units include:
For 24% of maternity units, there are no designated elective operating lists for planned caesarean sections with allocated personnel and theatre capacity in addition to the personnel and theatre capacity that is available for emergency work.
There is no provision of antenatal anaesthetic clinics in 10% of ‘very large’ maternity units and 30% of ‘small’ maternity units.
In 40% of maternity units, there is insufficient anaesthesia sessional to support anaesthetic attendance during evening multidisciplinary ward rounds.
Less than 10% of maternity units had provision for contracted anaesthetic consultant sessional work at the weekends.
Only 21% of maternity units had a consultant anaesthetist on-call rota that covered exclusively obstetrics.
Conclusions
To achieve significant improvement in maternal mortality, there is a need to address mortality due to causes arising from existing disease aggravated by pregnancy. This will require increased emphasis on multidisciplinary planning and provision of care for women who have existing disease and will require the necessary resources to meet this need.
Obstetric anaesthetists have an essential role in the delivery of safe, effective multidisciplinary care, but obstetric anaesthesia is often under-represented and under-resourced in the planning of maternity care.
References
standards-quality/guidance-resources/guidelines-provision-anaesthetic-services (accessed 28 April 2021).
May 2021
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