Every other day in the UK a pregnant or recently pregnant woman dies.
According to a report launched today by MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) 564 women died over a three year period between 2012 and 2014, either during or within a year of the end of their pregnancy; 200 of those mothers died either during or within six weeks of the end of their pregnancy.
Behind every early maternal death is the unimaginable tragedy experienced by her remaining family: 358 motherless children (105 of them newborns), not to mention partners, parents and siblings. When a mother dies, there is often the double tragedy of her baby’s death too. The death of women in pregnancy from 2012 to 2014 resulted in the stillbirths and neonatal deaths of 36 babies as well.
Heart disease is the leading cause of mothers dying during or up to six weeks after the end of pregnancy and is responsible for one in four deaths during that period. Today’s report includes heart-breaking stories which highlight safety issues: the case of pregnant woman, for instance, who reported concerns on multiple occasions during her pregnancy but whose heart disease risks were not recognised, whose care, therefore, was not referred on and who eventually died.
The report’s study into women who died of heart disease found that in some cases diagnosis of heart disease in young women was overlooked and for others who knew they had heart disease, care was fragmented. One in three deaths due to heart disease might have been prevented if care had been better.
Clea Harmer, Chief Executive of Sands (Stillbirth & neonatal death charity), said: “Today’s report echoes much of what we know at Sands from families whose baby dies either before or shortly after birth: that care for women can be dangerously fragmented, that women need more information about their health and mental wellbeing in pregnancy and beyond, but also that they are not sufficiently listened to when they raise concerns about their own or their baby’s health, resulting in desperately sad and avoidable tragedies. The vital messages in this report, if taken up by health services, have the potential to have a profound impact on the lives of families across the UK.”
MBRRACE-UK’s latest report on maternal deaths contains direct messages on improving care for all those designing and delivering maternity and post-natal services. It also encourages women to find out if there is a history of heart disease in their family before they become pregnant, and to be aware that chest pain spreading to the left arm and back and persistent breathlessness while sitting or lying down could be signs of heart disease.
The report encourages women and their partners to ‘speak up for safety’ if they are worried about any aspect of their care, or if they feel unsafe; and to ask for different care or a referral to a different service if they feel they are not being taken seriously or listened to.
While maternal deaths are relatively rare in the UK (at around 8 per 100,000), MBRRACE-UK’s latest report shows that there was no significant fall in the maternal death rate in the three years between 2009 and 2011 compared to the period between 2012 and 2014.
Meeting the Secretary of State’s ambition to reduce maternal deaths (along with stillbirths, neonatal deaths and brain injury during childbirth) by 20% by 2020 and to halve that rate by 2030, will therefore be “a major challenge for UK health services”, states the report, “requiring coordinated action across multiple specialties”.
Saving Lives, Improving Mothers’ Care, Surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14.
MBRRACE-UK runs the Maternal, Newborn and Infant Clinical Outcome Review Programme which is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as one of the Clinical Outcome Review Programmes. HQIP’s aim is to promote quality improvement and is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. The Clinical Outcome Review Programmes, which encompass confidential enquiries, are designed to help assess the quality of healthcare, and stimulate improvement in safety and effectiveness by systematically enabling clinicians, managers and policy makers to learn from adverse events and other relevant data.
The Maternal, Newborn and Infant Clinical Outcome Review Programme is funded by NHS England, the Welsh Government, the Health Department of the Scottish Government, Northern Ireland Department of Health, the States of Jersey, Guernsey, and the Isle of Man.
Notes to editors
For further information or to be put in touch with families affected by stillbirth or neonatal death, please contact the Sands press office on 0203 598 1959 or firstname.lastname@example.org
The embargoed report, executive summary, lay summary and an infographic can be found here: https://oxfile.ox.ac.uk/oxfile/work/extBox?id=39697355DEB78EBFB3
The report, executive summary, lay summary and infographic can be found here: www.npeu.ox.ac.uk/mbrrace-uk/reports