Dr Jenny Hall summarises the latest MBRRACE Confidential Enquiry, highlighting important aspects for midwives to take on board to prevent further maternal deaths in the future.
During November MBRRACE released the next confidential enquiry on maternal deaths and morbidities across the UK for the years 2017-2019. This follows a previous report for 2016-18. Within this time period 191 women died due to direct and indirect causes. As always, the report is harrowing reading, highlighting the stories of the women who have died, not just statistical numbers.
Positively, there is a decrease in the numbers of deaths when compared with the previous report of 2014-16, though not statistically significant, and an overall decrease of rates of 44% when compared with figures from 2003-5. However, it has not reached the lowest rate over time, which was for the years of 2013-15. Of concern is that of these deaths only 17% were deemed to have received good care with improvements that may have made a difference to the outcome of 37%. 49% of the deaths occurred in the postnatal period from 1-49 days postbirth.
For the cases highlighted thrombosis is still the top cause of direct maternal death during or up to six weeks after the end of pregnancy, with maternal suicide as the main cause of direct deaths within a year after the end of pregnancy. Further concern is that the number of teenage pregnancy suicides is increased.
The key findings of the report clearly address the continued inequality for women related to ethnicity, age, and socio-economic backgrounds. Asian women are twice as likely to die, and Black women are four times likely to die than white women; those who are living in the highest areas of deprivation are also twice as likely to die. Though there has been a start on addressing some of the structural racism toward pregnant women there is evidence in this report that there is a lot more still to do.
A chapter is included that provides an in depth morbidity inquiry into the care of women aged over 45 as the numbers of these pregnancies are increasing. The chapter highlights the potential for complexities for these women, particularly following the use of assisted reproduction at this later age. Underlying health conditions, such as diabetes, heart disease and cancer are pointed out as well as the risks of thromboembolic conditions related to obesity.
A further chapter addresses cancer in particular, highlighting how symptoms were assumed to be related to pregnancy conditions in a number of cases. Diagnosis of cancer was missed or late and the message is clear to ‘treat a pregnant woman as you would a non-pregnant woman unless there is a clear reason not to.’
There are a number of key points that leap out to me:
- Remember things change over pregnancy- be alert to change and refer sooner than later.
- Be more aware of those who are older, had assisted pregnancy, are of higher weight; watch for thromboembolism, particularly in the postnatal period
- In caring for a diverse population individual health carers and services are not getting this right at all. The message is to sort out your cultural biases individually and as a team. Get training. Decolonise your practice.
- Recognise some women have multiple and complex social needs which put them at major risk. Take previous mental health conditions seriously- sort out the pathways to mental health services to be clear and coordinated for everyone and don’t expect family to provide care. Recognise and act quickly.
It is to be noted this report stops at 2019. We know the COVID-19 pandemic has increased mental health needs for everyone. Loss of employment, increasing rental, utility, petrol, etc are increasing stress, and that is without a new baby. Midwives MUST have a focus on postnatal care and prevention of mental health crisis. The public health role of the midwife should be paramount to refer women to support services as soon as possible and be aware of those with multicomplex needs.
Personally, I may be old school, but the past compulsory visits for ten days plus postnatally meant we could notice better when women and families were not coping so well and provide support. It rings alarm bells that nearly half of the deaths took place after the first postnatal day. Continuity of care should include the postnatal period to ensure the midwife can recognise better those at risk and when further health support is needed. However, as the authors of the paper Better Births – But why not better postnatal care? point out, the current aim of UK maternity policy is focussed on birth rather than on the continuum of postnatal care.
The report is essential reading for all those who work in maternity services, with many aspects to consider individually and corporately. It is to be remembered that each woman lost in this report is representative of a family who are left behind. The message is maternity services need to do better. Steps to stop structural racism should be accelerated as well as improving access to mental health support services. The wider issues of multiple deprivation is a societal concern where inequality of services and health remain. Midwives are key in shouting out through their public health role to get the help women need. However, with the current low staffing levels, more women maybe slipping through the net. It is to be hoped that government and policy makers will take the messages from the report, and others, on board and provide the funding needed in order to save more women’s lives. The next triennial report will show what this impact will be.
Dr Jenny Hall
Dec 2021
1 comment
An interesting article. As a representative of the charity Positive about Down syndrome, it worries me enormously that many expectant and new parents are not only left unsupported when given news baby has/may have Down syndrome, but are sadly subjected to shocking discrimination and blatant prejudice around their baby.
I was yesterday reading the experiences of women who have had a baby with Down syndrome and was horrified at how many are being failed and subjected to awful attitudes. One mother shared, ‘We were told we could walk away from the hospital without our new born daughter and nobody would think any less of us. Also told our other 2 children didn’t deserve to be burdened with a sibling like A. I found the whole experience horrible, what should have been a special happy time was replaced with outdated negativity, I was made to feel like an awful mum to my older 2 children for bringing A home to them. Within a few months of A’s birth I was being treated for post natal depression and required counselling because the neo natal doctor told me Down syndrome tends to come from the mother!’
Another wrote, ‘Our sonographer asked us why we hadn’t terminated the pregnancy in the 20 week scan, and then after the scan had a stern conversation about how serious Downs Syndrome was, encouraging us to consider a termination.’
There were dozens more who felt woefully unsupported, left with no accurate information and feeling pressured to terminate.
I am concerned that these women are vulnerable and unsupported, many struggle with the news baby has Down syndrome and some may be high risk for suicide. We have to challenge attitudes and ensure women are better supported. I hope this report ensures all women are better supported – including those whose baby may have a disability as they are all too often overlooked.
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