We are pleased to announce the publication of the new Severe Maternal Morbidity Report. This site is based on the findings of the Severe Maternal Morbidity in Ireland audit for the year 2022.
At the NPEC, we acknowledge that the statistics presented in our reports represent our patients, and we use this data to learn from past experiences and produce recommendations for improved care.
Please be aware that the data discussed in this report might be distressing or emotionally challenging to read. Please remember to prioritize self-care and seek support if needed while engaging with this material.
"The findings of the SMM audits over the last nine years continues to lend itself to educating our obstetric and midwifery staff; greater education results in earlier identification and treatment of SMM and more positive outcomes for women; our partners, daughters, sisters, mothers and friends."
Claire Jones, Patient Representative on the NPEC SMM Group.
Maternal morbidity is a term that refers to any health problem that occurs during or as a result of pregnancy and childbirth, which negatively affects a woman's well-being. Each number reported in this report represents a woman’s experience during pregnancy.
The purpose of the National Severe Maternal Morbidity Audit is to understand and examine how Severe Maternal Morbidities are affecting women in Ireland, and what can we learn from them in order to improve care for women.
In this Audit, we focus on collecting data on the most Severe Maternal Morbidities, the SMMs included in this audit are:
- Major obstetric haemorrhage
- Uterine rupture
- Eclampsia
- Renal or liver dysfunction
- Pulmonary oedema
- Acute respiratory dysfunction
- Pulmonary embolism
- Cardiac arrest
- Coma
- Cerebrovascular event
- Status epilepticus
- Septicaemic shock
- Anaesthetic complications
- Peripartum hysterectomy
We also collect data on the cases of women that are admitted to ICU/CCU or that require interventional radiology.
The high quality of the maternity care services in Ireland ensures that the number of women experiencing a maternal morbidity is low.
Experiencing a Severe Maternal Morbidity can have long term physical and psychological consequences. The information provided in this report is crucial to ensure that we continue to improve care and reduce the rates of adverse outcomes for all women and their babies.
Table 1 details the national number of cases, total maternities and SMM rates derived from the participating units since the first year of the audit, 2011. Based on this national clinical audit, the SMM rate of 6.27 per 1,000 maternities in 2022 was 63% higher than the rate of 3.85 per 1,000 maternities in 2011. Thus, the incidence has changed from one case of SMM for every 260 maternities in 2011 to one case in 159 maternities in 2022. The increase was largely confined to the first years of the audit, which could reflect enhancement of case ascertainment as the SMM audit matured. The SMM rate has been relatively stable at approximately six cases per 1,000 maternities since 2015.
Specific severe maternal morbidities
Nearly three quarters of the women who experienced SMM in 2022 were diagnosed with one morbidity (n=232, 70%); 24% (n=81) were diagnosed with two morbidities; 6% (n=19) with three SMMs and 0.6% (n=2%) experienced four morbidities.
Although rare, our findings showed that the most common Severe Maternal Morbidity was Major Obstetric Haemorrhage. Affecting 3 of every 1000 women. Major Obstetric Haemorrhage refers to severe bleeding during pregnancy, childbirth or the postpartum period that can be life-threatening. It means losing a lot of blood, requiring multiple blood transfusions, or needing special treatment for blood clotting issues.
The second most common SMM was ICU/CCU admission, which was experienced by 145 women (43.4%). Peripartum hysterectomy was the next most frequently reported SMM with 10% of women (n=32) experiencing this. Further frequently reported SMMs included renal or liver dysfunction (5%), uterine rupture (5%) and septicaemic shock (4%). Pulmonary embolism was diagnosed in 12 women (4%) and eclampsia in 11 individuals (3%). The remaining seven specific SMMs were relatively rare, being experienced by 18 women with each accounting for no more than 2% of the reported SMM cases (Table 2).
In comparison to findings in 2021, there was a notable decrease in the frequency of women experiencing acute respiratory dysfunction requiring invasive ventilation, from 7.5% (n=28) in 2021 to 0.9% (n=3) in 2022. The higher incidence of this morbidity in 2021 was primarily associated with COVID-19, when virulent variants of concern at the time were found to impact negatively on maternal wellbeing.
Read the full report for more information on the specific Severe Maternal Morbidities
Trends in Severe Maternal Morbidities
Major obstetric haemorrhage (MOH)
There were 180 MOH cases in 2022 giving a rate of 3.38 per 1,000 maternities, which is very similar to the incidence in recent years.
Of the 180 MOH cases reported in 2022, 65.6% (n=118) involved an estimated blood loss ≥2,500ml without a transfusion of ≥5 units of blood, 3.9% (n=7) involved a transfusion of ≥5 units of blood without an estimated blood loss of ≥2,500ml and 30.6% of MOH cases (n=55) met both criteria.
The primary cause of MOH by mode of delivery can be seen on Table 3. Please click to enlarge.
The increasing rates of MOH warrant further investigation (See table 4). As discussed earlier, recommendations from previous SMM reports have been progressed as follows:
1. A detailed national audit of MOH events, identified in this SMM audit, has been conducted for the reporting years 2021 and 2022 by the NPEC. Findings from this audit will be published in Q1 2025. It is anticipated that this will enhance learning and identify any possible change in practice, risk factors or in the profile of the pregnant population compared to findings of the NPEC MOH audit 2011-2013.
2. The Postpartum Haemorrhage Quality Improvement Initiative (PPHQII), a collaboration between the NWIHP and the NPEC, has been implemented nationally and is addressing standardised approaches through unit led toolkits in the evaluation of blood loss and in the management and review of PPH/MOH events.
Intensive care unit/coronary care unit (ICU/CCU) admission
Table 5 details the specific SMMs involved in the 145 cases admitted into an ICU/CCU in 2022. Approximately 35% of these involved MOH, 7% (n=10) were associated with peripartum hysterectomy and six cases related to eclampsia (4%). Additionally, about 3% ICU admissions (n=5) related to septicaemic shock and 3% (n=4) involved pulmonary oedema.
COVID-19 and Severe Maternal Morbidity
In comparison to findings in 2021, there was a notable decrease in the frequency of women experiencing acute respiratory dysfunction requiring invasive ventilation, from 7.5% (n=28) in 2021 to 0.9% (n=3) in 2022. The higher incidence of this morbidity in 2021 was primarily associated with COVID-19, when virulent variants of concern at the time were found to impact negatively on maternal wellbeing.
Trends in less frequent SMMs
Trends in renal or liver dysfunction
The infrequency of some specific SMMs, such as renal or liver dysfunction, compared to MOH and ICU/CCU admission makes it difficult to assess time trends based on the annual rate. The time period of the SMM audit is long enough to allow their time trend to be examined by triennium. The 69 cases of renal or liver dysfunction reported in 2011-2013 gave a rate of 0.35 per 1,000 maternities. The rate of reported cases increased steadily, doubling to 0.70 per 1,000 by 2015-2017. Since then, the rate decreased steadily and at 0.45 per 1,000 maternities in 2020-2022, the rate is no longer statistically significantly higher than in 2011-2013 (Table 7).
Trends in peripartum hysterectomy
In the early years of this national audit, there was a consistent rate of peripartum hysterectomy of approximately 0.33 per 1,000 maternities. This is equivalent to one in every 3,000 women experiencing a peripartum hysterectomy. The rate has increased in the last 10 years and in 2020-2022 it was 59% higher than in 2011-2013, at 0.53 per 1,000. This indicates that approximately one in every 1,900 women giving birth in Ireland experience a peripartum hysterectomy.
This Irish rate is marginally higher than the rate reported in earlier studies in the United Kingdom (0.41 per 1,000 births) but it is lower than the rate reported in the USA and Australia (0.82 per 1,000 and 0.85 per 1,000 respectively).
Trends in pulmonary embolism
The incidence of reported cases of pulmonary embolism (PE) has increased over the years of the SMM audit but there was a drop in 2022 when 12 cases were reported, which is the lowest number since 2011.The rate of 0.24 per 1,000 maternities in 2011-2013 indicates that one woman in approximately 4,000 experienced PE. The rate of 0.33 per 1,000 indicates that in 2020-2022 one woman in approximately 3,000 experienced PE.
Recent reports on maternal mortality in Ireland and the UK have identified thrombosis/ thromboembolism as a leading direct obstetric cause of maternal death. , At 0.33 per 1,000 maternities, the incidence of PE in Ireland was more than twice the reported rate in the UK (0.14 per 1,000 maternities).
Trends in septicaemic shock
The reported incidence of septicaemic shock was low at the start of the SMM audit. Eight cases were reported in the first two years but sixteen were reported in 2013. Even then, the rate for 2011-2013 was just 0.12 per 1,000 maternities. This increased rapidly and the 80 cases reported in 2014-2016 gave a rate of 0.44 per 1,000, more than three times the rate reported for 2011-2013. The apparent increase in reported cases at that time may have reflected an increased awareness of sepsis following the introduction of guidelines on sepsis and the implementation of the Irish Maternity Early Warning System. Since then, the rate has decreased to 0.25 per 1,000 in 2020-2022 though this is still twice the rate reported for 2011-2013
Maternal Characteristics
Age
Maternal age was recorded for all the 334 cases of severe maternal morbidity (SMM) in 2022 and ranged from 16 to 48 years (mean=33.5 years, SD=5.7 years). The age distribution of women who experienced SMM in 2019-2022 is detailed in Table 12. In 2022, the women’s age profile was broadly similar to the population of women who gave birth. However, women in the younger age groups were under-represented among those who experienced SMM (53.9% of SMM cases were aged <35 years vs. 59.8% of all maternities) so women aged at least 35 years were over-represented (46.1% vs. 40.2%).
Previous pregnancy
Previous early pregnancy loss was reported for over one-third of the women who experienced SMM in 2022 (39.3%, 131 of 333, unknown for one woman). Seventeen women (5.1%) had previously experienced three or more pregnancies that ended before 24 weeks’ gestation.
Approximtely 40% (n=133) of the women who experienced an SMM in 2022 were nulliparous which is similar to previous years and to the percentage of nulliparous women among all maternities in 2022 (Table 13). Women with one previous completed pregnancy were under-represented among SMM cases relative to the population of women who gave birth in 2022 (30% vs. 34%) whereas women with at least three previous completed pregnancies were over-represented among those who experienced SMM (13% vs. 9%).
Body mass index
Body mass index (BMI) for the women who experienced SMM in 2022 ranged from 18.3 to 56.4 kg/m2. BMI was not known for 11 (3.3%) of the women.
Approximately 40% of the women who experienced SMM in 2022 had a BMI in the healthy range, 29% were overweight and 31% had obesity (Table 14). This is within the range observed in recent years, with 35-41% women with a healthy BMI in 2019-2021, 27-33% overweight and 25-36% in the obese category. The proportion of women experiencing SMM who were overweight has remained generally similar in past years (from 30% in 2020, 27% in 2021 and 29% in 2022).
It was also observed that of the total number of women experiencing two or more SMMs in 2022, a higher proportion (54%) were overweight or had obesity.
As shown in Table 14, women with a BMI less than 25 kg/m2 were underrepresented among SMM cases (41% vs. 50% in the population) whereas women with a BMI in the obese category were overrepresented relative to the population of women who gave birth in hospital in 2022 (31% with SMM vs 23%).
Ethnicity
There are no national data available on ethnicity for the pregnant population in Ireland which impedes the calculation of SMM risk per ethnic group. The distribution by ethnic group of the women who experienced SMM in 2022 broadly reflected that of the general population of women aged 15-49 years as reported from the most proximal national census with available data (Table 17). In those who experienced SMM, there was an over-representation of women whose ethnicity was described as Asian as they made up 6.6% of SMM cases compared to 4.6% of the population aged 15-49 years in this ethnic group. Similarly, women of Black ethnicity (4.2%) and Irish traveller (3%) were over-represented in experiencing SMM when compared to the percentage of women aged 15-49 years of that ethnic group in the Irish population.
Recommendations being progressed
A quantitative approach involving volume and weight assessment to estimate blood loss should be considered for use in all maternity units. Development of a national tool-kit would assist standardisation of such an approach.
The National Women and Infants Health Programme (NWIHP), in collaboration with the NPEC, have developed a national quality improvement initiative to evaluate postpartum haemorrhage (PPH) rates. This includes the development of a standardised national approach in estimating blood loss and a focus on identifying better management of PPH. For more information, please email pphqii@ucc.ie.
Implementation of a case assessment audit of major obstetric haemorrhage (MOH)
From January 2021 to December 2022, the NPEC conducted a national case assessment audit of women experiencing an MOH using a validated quality-assessed tool. Cases of MOH were identified in this SMM audit. Findings from the MOH audit will be published in the Q1 2025. This will enhance learning and identify any possible change in practice or risk factors in the profile of the pregnant population compared to findings of the NPEC MOH audit 2011-2013.
Research on the incidence of morbidly adherent placenta in Ireland is warranted.
Research on morbidly adherent placenta, more recently described as Placental Accreta Spectrum (PAS) is underway. Further, under the auspices of the NWIHP and the Institute of Obstetrics and Gynaecology (IOG), a national clinical practice guideline on ‘Diagnosis and Management of Placenta Accreta Spectrum (PAS)’ was published in December 2022.
Antenatal education
- Antenatal education/information should be provided by the multidisciplinary team to women to ensure an understanding of maternal morbidity and complication awareness.
- When a pregnant woman is identified as high risk for significant morbidity, specific education should be available during her antenatal care and at birth preparation.
- The national standards on antenatal education should provide guidance on specific education for maternal morbidity awareness.
Progress: In line with the National Standards for Antenatal Education in Ireland 2020 1 the National Women and Infants Health Programme (NWIHP) has developed national standardised, evidence-based programmes for antenatal education providers and a parent education programme for women and their chosen birth partners.
Recommendations made from this report
Protected time for clinical staff
Robust clinical audit on adverse maternal outcomes requires the protected time of clinical staff. Funding should be provided by the Health Service Executive (HSE) to facilitate the same. Administration staff, trained in data collection and management, working with clinicians should be considered in the context of staffing difficulties in clinical disciplines. Owner: Quality and Patient Safety Directorate (NQPSD)
Social inequalities
Internationally, social inequalities have been shown to impact on risk of SMM. There is a need to establish the evidence in this regard in Ireland. This requires improved maternity data at national level and more research. There is an opportunity with the Maternal Newborn Clinical Management System data from Irish maternity units to mine data at national level. These data could be collated to identify the influence of risk factors for SMM in Ireland including ethnicity, maternal age, BMI, smoking, maternal age, body mass index, smoking, employment status and other socio-economic factors. This should overcome the current deficit in the pregnant population data at national level. Owner; the NPEC to progress this
Public health education programme
A public health education programme on maternal morbidity and modifiable risk factors should be developed. Owner: in discussion with the National Women and Infants Health Programme (NWIHP).
In Summary
The rate of severe maternal morbidity (SMM) in Ireland in 2022 was 6.27 per 1,000 maternities, 7% lower than in 2021 but 63% higher than in 2011, the first year of this national clinical audit.
Although increasing SMM rates may reflect complexity of the pregnant population, it also acts as a surrogate measure of quality of care in the maternity services. Further, increasing numbers of women, during or shortly after pregnancy, require higher Levels of Care. This highlights increasing demands on the maternity services.
Multiple pregnancy was over three times more common in cases of SMM than in all maternities.
Increasing national rates of MOH, and variations in rates of MOH between units, continues to be identified in this SMM audit. These issues have underscored recommendations in previous NPEC SMM reports. The development of a national quality improvement initiative to evaluate postpartum haemorrhage, in a joint NWIHP NPEC collaboration, highlights the value of on-going SMM audit in order to identify quality improvement initiatives to improve care for women in the Irish maternity services.
The rate of peripartum hysterectomy (PH) has increased in recent years (2020-2022). Similar to national and international studies, this audit has identified the strong association between PH and Placental Accreta Spectrum (PAS).
Women with a BMI in the obese category had a 62% higher risk of experiencing SMMs. Similarly, women with high BMI showed a significantly higher risk of experiencing specific conditions such as MOH, ICU admission, PH and PE.
Watch this video to learn more about the 2022 Severe Maternal Morbidity Audit and use it to help us spread our findings.
Help us disseminate our findings
Citation for this report: Leitao S, Manning E, Corcoran P, Keane J, McKernan J, Greene RA, on behalf of the Severe Maternal Morbidity Group. Severe Maternal Morbidity in Ireland Annual Report 2022. Cork: National Perinatal Epidemiology Centre, 2024
Credits:
Creado con imágenes de kjekol - "Close-up of pregnant woman sitting in sofa with her hands at belly" • Cavan for Adobe - "Cropped image of boyfriend holding girlfriend's hands sitting at home" • danutelu - "Iintensive care unit with monitors" • nataliaderiabina - "Close-up newborn baby feet." • Daenin - "Doctor talking to patient and filling patient history, examination, treatment, medical and health concept."