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Written on 26th January 2021 by Susan Brown

MBRRACE-UK have published their latest maternal deaths report: ‘Saving Lives, Improving Mothers' Care 2020: Lessons to inform maternity care from the UK and Ireland Confidential Enquiries in Maternal Death and Morbidity 2016-18’.

51% of the maternal deaths might have been avoided with better care

The latest report follows an audit and investigation of the causes of death of 566 women who died during or within a year of pregnancy in the UK and Ireland from 2016 to 2018. It concludes that just over half (51%) of all the women who died might have had a different outcome if they had received better care. 217 women died during or within six weeks of the end of pregnancy, from pregnancy-related causes. The fact that they leave behind a total of 356 motherless children, makes it all the more tragic to know that many of their deaths should have been avoided.

In many cases, the harm to these women would have been avoided if existing guidance had been followed. For example, amongst the women who were given antenatal care, only 29% received care which complied with NICE antenatal care guidelines. The maternity treatment of women with epilepsy, infection or sepsis, and obstetric haemorrhage were three of the areas in which MBRRACE-UK called for lessons to be learned.


The MBRRACE-UK 2020 report found that 29 women died from neurological causes. 22 out of those 29 women’s deaths were from causes related to epilepsy. The MBRRACE-UK reviewers found that for 68% of the women who died from epilepsy-related causes, different care may have led to a different outcome.

Epilepsy is the most common neurological disease. The care of pregnant and post-natal women with epilepsy has been a concern in previous MBRRACE-UK reports, but the latest report found a worrying increase in the number of women who died from Sudden Unexplained Death in Epilepsy (SUDEP). Most of the women who died had clear risk factors for SUDEP, such as uncontrolled seizures, tonic-clonic seizures, nocturnal (night-time) seizures and epilepsy which had started in childhood. Pregnancy is in itself a risk factor for SUDEP, but there was little evidence that their risk for SUDEP had been assessed, or that SUDEP had been discussed with them or their families, or that measures to reduce their risk, such as to avoid sleeping alone, had been put in place.

Common features in the care of women who died from epilepsy-related causes were:

  • lack of counselling before pregnancy;
  • lack of review or optimisation of medication before or during pregnancy;
  • fewer than half were reviewed by a specialist during their pregnancy, despite their history of uncontrolled epilepsy.

In many cases, simply because they were pregnant, women with epilepsy had either:

  • stopped taking their medicine on medical advice;
  • made their own decision (without medical advice) to stop taking their medicine;
  • were receiving inappropriate medication.

During the 2016-2018 period covered by this report, RCOG issued guidelines on epilepsy in pregnancy. MHRA also changed its guidance on prescribing valproate epilepsy medication in response to increased awareness of the risks of valproate exposure to unborn babies during pregnancy. MBRRACE-UK recommend that guidelines should also include SUDEP awareness, risk assessment and risk minimisation and quick access to specialist epilepsy neurology services as standard care for women with epilepsy before, during and after pregnancy.

Sepsis and infection

31 women in the UK and Ireland died from infection and sepsis. The MBRRACE-UK 2020 report identified that in 68% of the women who died from infective causes might have had a different outcome with better care. They re-stated the importance of the following in optimising the patient’s outcome:

  • prompt recognition of sepsis;
  • treatment with antibiotics;
  • controlling the source of the infection;
  • involving senior staff.

The report emphasised, however, that a correct response to sepsis depends on clinicians considering the diagnosis and severity of the illness in the first place. They found that in many cases, junior medical staff failed to escalate the critically ill woman’s care to a consultant, particularly around bank holidays and weekends. There was also a lack of confidence in decision-making when the woman presented with unusual or atypical symptoms or infections. The report reminded doctors that, even at consultant level, it is appropriate to seek advice from a colleague, in either the same or a different specialty.

Additional recommendations to improve the maternity care of women with infection or sepsis included:

  • “Think Sepsis” when presented with an unwell (recently) pregnant woman, and take appropriate action;
  • health professionals must perform and record all physiological vital signs, including pulse, blood pressure, temperature and respiratory rate, in any postnatal woman with symptoms or signs of ill health;
  • community midwives carrying out postnatal checks should have a thermometer to check the temperature of women who are unwell.

Obstetric haemorrhage (bleeding)

MBRRACE-UK pointed out that although major obstetric haemorrhage happens frequently on labour wards in the UK and Ireland, deaths from obstetric haemorrhage should be largely preventable. 20 women died from bleeding, 14 of whom died from obstetric haemorrhage during or up to six weeks after the end of pregnancy. For 79% of those women, different care might have made a difference to the outcome.

Failings included:

  • nobody took a ‘helicopter view’ of the woman’s condition;
  • failure to recognise deterioration, particularly the ‘lethal triad’ of acidosis, coagulopathy and hypothermia which are associated with risk of death in trauma;
  • continuing with controlled cord traction when the placenta had not separated, leading to uterine inversion;
  • failing to recognise signs of uterine inversion, including pain, loss of fundal height and rapid deterioration. 

Helping families claim compensation after maternal death

The unexpected death of any family member is traumatic and deeply upsetting, but the loss of a child’s mother leaves scars that, for many, never heal. Financial worries, arising from increased child-care costs, loss of parental earnings, and the practical day to day consequences of losing a mother increase the considerable stress faced by families at this time. Our compassionate medical negligence lawyers have helped countless bereaved families ease the financial hardship which follows a maternal death, allowing the family to focus on rebuilding their family lives with financial peace of mind.

If your family have suffered bereavement and loss caused by negligent medical care, contact us by email on