MBRRACE-UK has published its latest report into maternal deaths – the deaths of mothers in pregnancy, during or after childbirth. Saving Lives, Improving Mothers’ Care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2017-2019 reports on the women who died during or in the first year after pregnancy in the UK between 2017 and 2019. MBRRACE point out that this will be the last of their annual and three-yearly reports which relate to maternal deaths before the COVID-19 pandemic.
Whilst reporting on medical causes of death, such as heart disease, stroke, blood clots or epilepsy, the report highlights additional risks mothers faced from other factors such as their age, level of social deprivation and ethnicity. These findings are increasingly common in national reports on maternity care. However, MBRRACE-UK’s finding that there has been no change in maternal mortality care in the last ten years, and that only 17% of women who died received good care, makes the findings of this report all the more shocking.
Key findings from MBRRACE-UK’s report on maternal deaths from 2017 to 2019
MBRRACE found that there was no statistically significant difference in maternal mortality (death rate among mothers) in 2017 to 2019, compared to 2010-2012. A total of 211 women died during or within six weeks after the end of pregnancy but 20 of those deaths were classified as coincidental. That means that:
- 191 women died from causes associated with their pregnancy from a total of 2,173,810 women giving birth in the UK, or 8.8 women per 100,000.
- 61 women (32%) were still pregnant at the time of their death, more than half at less than 20 weeks’ gestation.
- Of the remaining 116:
- 82% gave birth in hospital;
- 15% gave birth in A&E or in an ambulance;
- 3% gave birth at home.
What caused their deaths?
The largest single direct cause of maternal deaths was heart (cardiac) disease. Epilepsy and stroke were second, and sepsis and blood clots (thrombosis/thromboembolism) were the third and fourth most common causes of maternal death during or up to six weeks after the end of pregnancy
32 women died in the UK and Ireland from blood clot conditions during or up to a year after the end of pregnancy. Of these:
- 31 died from pulmonary embolism (where a blood clot blocks an artery in the lung);
- One died from a blood clot in the brain (CVST);
- A high proportion of those who died from blood clot conditions were young and obese.
- The assessors found that assessment and documentation of the risk of blood clots, was often done incorrectly and didn’t follow national guidance.
- For nearly two thirds of the women who died from blood clots, better care might have made a difference to their outcome.
Obstetric haemorrhage (bleeding) remained a common pregnancy-related cause of death. Cancer and maternal suicide were leading causes of maternal death occurring within a year of the end of the pregnancy.
Risks from pre-existing health problems (co-morbidity)
The report found that women are beginning pregnancy with more (and multiple) pre-existing physical and mental health problems. In 2017 to 2019, two thirds (65%) of the women who died were known to have pre-existing medical conditions, and one third (33%) were known to have pre-existing mental health problems.
What difference does the mother’s age make?
The report found that maternal mortality rates were higher for older women and those under 20. The proportion of women giving birth at an older age is still increasing, despite the increased risk of maternal death for older mothers. MBRRACE found that the women aged 40+ were at almost four times greater risk of maternal death, compared to 20 to 24-year-olds.
Despite the known risks to older mothers, the assessors found that fewer than one third of women received care which followed guidance. Very few women who were planning pregnancy as older mothers had documented discussions about the risks and potential impacts on their health and their unborn child. They recommended that all existing recommendations from various sources should be collated into a single, definitive source of guidance relating to the care of older women in pregnancy.
What impact did social deprivation have on the risk of maternal death?
MBRRACE found that the maternal death rate was different for women from deprived or affluent (wealthy) areas. Women living in the most deprived areas were twice as likely to die than those from the wealthiest areas. The notable exception was an increase in the death rate of women living in the least deprived sector, mainly due to deaths from cardiovascular disease.
8% of the women who died during or up to a year after pregnancy in 2017-19 were at known to be severely disadvantaged, and 17% were already known to social services. Those with multiple disadvantages often suffered from a mental health diagnosis, substance use and domestic abuse.
How does ethnic origin affect the risk of maternal death?
MBRRACE found that ethnicity still has a huge impact on a mother’s risk, with maternal death rates higher amongst women from some ethnic groups. Of greatest concern, the report found that compared to white women:
- Women from Black ethnic backgrounds had four times the risk of maternal death; and
- Women from Asian ethnic backgrounds had nearly double the risk.
MBRRACE called for further action to understand and address the increased risks faced by Black and Asian women.
Only 17% of the women who died during or after pregnancy received good care
In the assessors’ judgement:
- Only 17% of the women who died had received good care.
- Only 42% of those who received antenatal care, received the level of care recommended by NICE antenatal care guidelines.
- In 37% of those women, improvements in care might have made a difference to their outcome.
- The assessors identified opportunities to improve the care of 70% of the women who gave birth at the age of 45 or older, which might have improved the outcome in 29% of cases.
Most of the report’s recommendations were drawn directly from existing guidance or reports. The recurring theme was that risk changes, and can be reduced by multi-disciplinary teamwork and appropriate action before, during and after pregnancy. They emphasised that risk is increased by clinicians who focus solely on concerns arising from the woman’s pregnancy, rather than on the needs of the woman as a whole, as was often the case where the woman had cancer. Pregnant (or soon to be become, or recently pregnant) women should be treated in the same way as non-pregnant women unless there is a clear reason not to.
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