A new scientific paper, Understanding the Relationship Between Social Determinants of Health and Maternal Mortality, has highlighted the link between social factors affecting health and the risk of maternal death.
The research, which was commissioned by the Royal College of Obstetricians and Gynaecologists (RCOG), and carried out by researchers at three universities, confirms that the care of ‘vulnerable, minoritized and disadvantaged women’ is affected by complex inequalities that are often beyond their control. It says that despite the provision of free maternity services, the women who need the most care, because they are at highest risk, often have the poorest access to care. They have been let down by the way that maternity services are delivered. If further maternal deaths are to be prevented, this needs to change.
What is maternal death?
Maternal death is defined by the World Health Organisation (WHO) and MBRRACE-UK as the death of a woman while pregnant or within six weeks of the end of the pregnancy. Maternal death may be directly caused by complications related to pregnancy and birth, such as incorrect treatment or interventions, or indirectly from a pre-existing condition or disease which develops or is made worse by the effects of pregnancy. Late maternal deaths occur after six weeks but within a year of the end of the pregnancy.
What are social determinants?
Social determinants describe people and the conditions in which they live. On a personal level, these include age, gender, health conditions, family and other relationships. They can also include cultural, political, and economic factors, such as income, occupation and employment status, as well as housing and environment. As highlighted by recent reports, these factors can make a difference to the outcomes that people from different backgrounds and social living conditions experience relating to their health.
Is there a link between these social factors and the risk of maternal death?
The research confirmed that there is a strong relationship between social factors and poor maternal health outcomes, including an increased risk of maternal death. The poorer a person’s social and economic position, the worse their health outcome is likely to be.
Risk factors for maternal death which were related to social factors included:
- Maternal age:
- older mothers may be better off financially, but are at increased risk from smoking, medical conditions, previous pregnancy problems and less use of antenatal care;
- teenage pregnancies are more likely in women from the poorest backgrounds;
- teenage mothers were more likely to have left education, be unemployed, live in poor areas and be single parents, and had a higher rate of abortions.
- Parity (the number of previous pregnancies of more than 24 weeks):
- high parity increases the risk of maternal death (although high parity is rare in the UK);
- Black, Asian and ethnic minority (BAME) mothers were more likely to be multiparous (with many past pregnancies) and more prone to obstetric haemorrhage, one of the causes of maternal death.
- Pre-existing health conditions – the ability to access specialist care in pregnancy is influenced by social factors.
- Non-infectious diseases – obesity, smoking and age all influence the risk of maternal death related to cardiac conditions, high blood pressure, diabetes, thrombosis and epilepsy.
- Communicable diseases – BAME and social deprivation are known risk factors for some diseases, such as TB or more severe infections.
- obesity is a key risk factor for poor maternal outcome;
- obesity and undernutrition are strongly linked to deprivation;
- obesity increases the risk of conditions in pregnancy, such as high blood pressure, pre-eclampsia, gestational diabetes and wound infections or thrombosis from caesarean section;
- BAME mothers are more often obese and have gestational or type 2 diabetes than white British women.
- Mental health conditions, including maternal suicide, are often associated with severe and multiple social disadvantage, but mental health conditions ranging from anxiety and depression to PTSD have recently become more prevalent in women who are Black, unemployed or living in large households.
- Smoking during pregnancy:
- strongly linked to social deprivation and poor access to maternity services;
- associated with fetal growth restriction, stillbirth, maternal high blood pressure and thrombosis.
- Alcohol and drug misuse are associated with domestic abuse, lack of support severe and multiple disadvantage.
- Poor social or economic status – poverty, unemployment (including unemployed partner), deprivation, and lack of education are all associated with increased risk of maternal poor outcomes.
- women from BAME backgrounds have a higher risk of maternal death;
- the risk of maternal death for Black women is four times higher than for white women;
- migrant and asylum-seeking women (who were born outside the UK) are also at greater risk of maternal death.
How does health care affect the risk of maternal death?
The research highlighted that delayed access to healthcare during pregnancy or ‘late booking’ for antenatal care is linked to worse maternal outcomes. A pregnant woman who is not seen early in pregnancy misses out on routine antenatal checks and tests of both the mother and baby’s wellbeing, but also preventative interventions, such as vaccines, and important, timely screening tests and lifestyle advice.
The research paper highlights that 61% of the women who died (maternal death) between 2016 and 2018 did not receive the recommended level of care. Social factors were strongly linked to delayed access to antenatal care. Other factors included lack of knowledge, concerns about experiences of racism, discrimination and bias in their care. Another key factor was medical mistakes and NHS system errors.
The research concluded that despite the provision of free reproductive and maternity services, the care system is failing women living in poorer social conditions, before, during and after pregnancy. Recommendations included supporting and training midwives and doctors to gather better information from women about the social factors which affect them to better understand their risk, and developing new ways to reach, include and engage pregnant women and more holistically improve their care.
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