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Authors' reply re: Factors associated with maternal death from direct pregnancy complications: a UK national case‐control study

Sir, We refer to the article ‘Factors associated with maternal death from direct pregnancy complications: aUKnational casecontrol study’ published in BJOG. This study highlights the significant contribution of medical co-morbidities to deaths arising from obstetric causes (direct deaths). Surprisingly, no mention is made of preconception care and its possible value. The importance of preconception care has been stated and re-iterated in the two most recent confidential enquiries into maternal deaths and we are concerned that there appears to be a lack of implementation of this key aspect of women’s health. Of the six risk factors associated with maternal death from direct pregnancy complications identified in the study, we believe preconception counselling could have affected at least four of these— inadequate use of antenatal care, substance misuse, medical co-morbididties and previous pregnancy problems. Did any of these women receive advice before becoming pregnant? In a recent survey of 100 pregnant and newly delivered women in our unit, 26 had received some form of preconception advice from a health care professional. More concerning was that only one-third of women with medical disorders received advice before getting pregnant. Women were asked what would help to raise awareness and they suggested social media, advertising with posters, and introduction of such awareness as part of secondary school education. As a result we have developed a local initiative (babySAFER) to raise awareness of smoking, alcohol, folic acid, exercise and eating, and rubella vaccination. The information presented as a smart card also refers to the importance of existing medical conditions and medications. This has been widely circulated, for example in pharmacies and GP surgeries, and is under evaluation. Although limited evidence exists in the form of randomised controlled trials to confirm the impact of preconception awareness on maternal and child health, it seems obvious that all women should be encouraged to seek advice before they conceive. Messages from previous maternal mortality reports do not seem to have been taken up by health services. We feel a collective approach from health care professionals involved in the care of women of reproductive age is essential to promote preconception awareness. There is unlikely to be a change in the profile of maternal mortalities before this happens.&