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rates have fallen among, for example, those with a history of thromboembolism. Recognition of risk factors early in pregnancy is essential.

       Age

      Since the 2006–2008 CEMD report, the maternal mortality rate (MMR) has remained fairly constant up to age 34, but it doubles after age 35 and quadruples after 40 years of age. The same pattern is seen in the latest 2016–2018 report. The average age of childbearing in the UK has risen ‐–in 2008 it was 29.3 years with 20% of births being to women aged 35 years or over, while in 2018 it was 30.6 years with 23% to women aged 35 years or over.

       Obesity

      This problem continues to grow. In the 2016–2018 report, 119 of 196 women who died whose body mass index (BMI) was known (i.e. 61%) were overweight compared with 49% in 2009–2012. Of these overweight women, 57 (29%) had a BMI of 25–29.9 and 62 (32%) were obese (with a BMI >30). This compares with 22% and 27%, respectively, in 2009–2012.

       Socioeconomic classification

      In 2016–2018, the MMR among women living in the most deprived areas was 15.3 compared with 5.7 for women living in the most affluent areas, a close to threefold difference. Attention should also be focused on women who book late or are poor attenders for antenatal care. In 2016–2018, 22% of women who died booked late, 61% did not receive the recommended level of antenatal care and 27% did not receive the minimum level of antenatal care as defined by National Institute for Health and Care Excellence (NICE) guidance.

       Ethnicity

Ethnic group (England only) Total maternities Deaths (n) Rate/100 000 (95%CI) Relative risk (95%CI)
White (inc. not known) 1 486 428 117 7.87 (6.51–9.43) 1 (Ref.)
Asian 191 145 28 14.65 (9.73–21.17) 1.86 (1.19–2.83)
Black 81 704 28 34.27 (22.77–49.53) 4.35 (2.77–6.62)
Chinese/others 75 270 6 7.97 (2.93–17.35) 1.01 (0.36–2.27)
Mixed 31 823 8 25.14 (10.85–49.53) 3.19 (1.35–6.50)

      Hypertensive disease

       Epigastric pain in the second half of pregnancy should be considered to be the result of pre‐eclampsia until proved otherwise

       Keep blood pressure (BP) below 150/100, and very high systolic BP is a medical emergency with urgent treatment needed

       Neuroimaging should be performed if a woman with hypertension or pre‐eclampsia has focal neurology, severe or atypical headache or incomplete recovery from a seizure

       Stabilising the mother including controlling her BP is vital prior to intubation

       New‐onset hypertension or proteinuria needs prompt referral with clear communication between health professionals

Cause 1952–1954 (England+Wales) 2006–2008 (UK) 2009–2011 (UK and Ireland) 2010–2012 2014–2016 2016–2018
Hypertensive disease 246 19 10 9 6 4
Obstetric injury 197 0 7 7 1 4
Haemorrhage 188 8 14 11 17 10
Early pregnancy/abortion 153 0 7 3 7
Thromboembolism 138 18 30 26 32 33
Anaesthesia 49 7 3 4 1 1
Genital tract sepsis 42 26 15

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