Since before the discovery of penicillin, anaesthesia, epidemiology or even basic sanitation, women have been giving birth. Across centuries, this practice has evolved from taking place in the home, typically surrounded by other women with no medical training, to occurring in a hospital surrounded by doctors (male and female) with years of experience.
The world of modern medicine has come so far, particularly in the last two hundred years, and it begs the question, why – with all these new, life-changing developments – are women still dying from the oldest procedure in the book: pregnancy and childbirth?
Published in November 2022, the Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) report is the ninth annual enquiry commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP).
The report is entitled Saving Lives, Improving Mothers’ Care: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2018-20 and serves to highlight areas that need the most work in order to reduce the maternal mortality rate.
“Despite improvements in maternity care, the overall rate of maternal deaths in the UK has remained unchanged over the past 30 years,” says consultant anaesthetist and MBRRACE-UK enquiry assessor, Dr James Bamber of Cambridge University Hospitals NHS Foundation Trust. “This is against a backdrop of rising maternal social inequalities, increasing maternal obesity, increasing maternal age and rising caesarean section rates, all risk factors for maternal death and morbidity.
“The UK Government has set a challenging ambition to reduce maternal mortality by 50 per cent by 2030. This challenge means the enquiry process will be as important now as at any time since 1952.”
So, what are the leading issues when it comes to maternal mortality and what can be done to help the Government reach their goal?
Summing it up
Some 229 women died during or up to six weeks after the end of pregnancy in 2018-20, equating to 10.9 women per 100,000 giving birth; a figure that is 24 per cent higher than the 2017-19 period, according to the MBRRACE-UK report.
Of course, 2020 included the beginning of the Covid-19 pandemic and sadly nine of these women died due to contracting the virus. Excluding their deaths, however, 10.5 women died per 100,000 which is still 19 per cent higher than in previous years.
Alongside this, a further 289 women died between six weeks and a year after the end of pregnancy in 2018-20, equating to 13.8 women per 100,000 giving birth. The majority (86 per cent) died in the postnatal period and one in nine of the women who died had severe and multiple “disadvantages”. Disadvantages were listed as substance use, mental health diagnoses and domestic abuse. Indeed, in 2020, women were three times more likely to die by suicide during or up to six weeks after the end of pregnancy compared to 2017-19.
“The progress towards the Government ambition to reduce maternal morality by 50 per cent between 2010 and 2030 can be assessed by comparing maternal death rates between the 2010-12 and 2018-20 triennia,” said the report. “Over this time, maternal mortality has increased by eight per cent. Excluding 2020 maternal deaths from Covid-19, maternal mortality over this period has increased by three per cent.”
Furthermore, when considering the data from a diversity point of view, black and Asian women were 3.7 and 1.8 times more likely to die during the postnatal period than white women respectively – a figure that has decreased slightly in the past few years. The maternal mortality rate amongst women who live in the most deprived areas, however, is increasing, and “addressing these disparities must remain an important focus”.
Various direct and indirect causes are cited as being responsible for the UK's maternal mortality rate.
When it comes to direct causes, the report finds that thrombosis and thromboembolism (VTE) is the leading cause of death occurring within 42 days of the end of pregnancy, followed by deaths due to suicide, sepsis and obstetric haemorrhage. Indeed, the mortality rate for pregnancy related sepsis has continued to increase steadily, something the report’s authors say “highlighted the importance of thinking sepsis and not just Covid-19”.
Pre-eclampsia and eclampsia mortality rates continue to be low but are still four times higher than their lowest observed rate in 2012-14.
Deaths due to indirect causes made up 52 per cent of maternal deaths in the UK. Cardiac disease was the leading indirect cause with 34 of the 229 women who died during or up to six weeks after the end of pregnancy affected. In almost one third of these instances, according to the assessors, different care may have prevented these women's deaths. They highlighted raising awareness of the importance of ‘red flag’ cardiac symptoms and considering cardiac causes as a diagnosis for women presenting with pain, wheezing and breathlessness as “the most important actions” to be taken by healthcare professionals.
A particularly worrying discovery is that maternal suicides continue to be the leading cause of direct deaths occurring between six weeks and one year after the end of pregnancy, with deaths from psychiatric causes as a whole accounting for 38 per cent.
Indeed, there was a statistically significant increase in the rate of suicide during pregnancy and up to six weeks after, from 0.46 in every 100,000 women giving birth in 2017-19 to 1.48 in 2018-20. In contrast to previous years – and perhaps as a consequence of reduced healthcare access due to the Covid-19 pandemic – the report finds that very few women who died by suicide had formal, clearly diagnosed mental health conditions.
In fact, the report found that “on occasion specialist Perinatal Mental Health Teams declined to become involved with women who had a complex history with previous secondary mental health involvement, despite evidence suggesting that the woman might struggle with the adjustment to parenthood, with potential for an associated deterioration in mental state and increase in risk of self-harm or other risky behaviour.”
It concluded that “there were several instances where services did not become involved soon enough during pregnancy. There seemed to be a general lack of consideration of the potential interaction between mental and physical symptoms such as the influence of mental state on chronic pain and seizure-like activity.”
A lack of sleep, an existing mental health condition and issues with substance abuse were all cited as risk factors for maternal mental health. Furthermore, as in previous reports, it was advised that “loss of child, either by miscarriage, stillbirth and neonatal death or by the child being taken into care increases vulnerability to mental illness for the mother and she should receive additional monitoring and support”.
Overall, the assessors felt that “improvements to care may have made a difference to the outcome in more than two thirds of women who died by suicide and more than a third of those who died from substance misuse.”
Suffering in silence
It’s not just ante and postnatal problems which appear to be frequently overlooked across the UK, but fertility struggles too. Indeed, the 2023 Workplace Infertility Stigma Survey conducted by Fertility Family, found that one in five healthcare employees would call in sick before sharing fertility struggles with their employers.
The study also found that just 15 per cent of workplaces in the healthcare sector have a supportive policy for employees struggling with their fertility, despite the fact it affects one in six people worldwide, according to the World Health Organization (WHO).
Key points from the survey also included the fact that less than two per cent of healthcare sector workers felt supported by their company during their fertility journey and over a third stated that they didn’t receive any support from their employer whilst experiencing fertility issues.
Furthermore, two in three employees believed that paid compassionate leave should be provided to those struggling with their fertility and the form of support desired most was flexible working to leave for fertility-related appointments.
“It can be daunting for an employee to share details of their health, particularly with sensitive conditions like fertility,” says Kate Palmer, director of HR Advice and Consultancy at HR support company, Peninsula. “It’s important to create a culture of open communication and support. Doing so allows employees to ask for the help they need, which in turn contributes towards increased productivity, satisfaction and retention.”
“The mortality rate for pregnancy related sepsis has continued to increase steadily”
Comparing the UK and Europe
Maternal mortality rates in the UK were even more shocking when compared with those across Europe. In fact, women in the UK are three times more likely to die around the time of pregnancy compared to those in Norway and Denmark, according to a new study entitled Maternal mortality in eight European countries with enhanced surveillance systems: descriptive population based study.
The international team of researchers, including academics from the University of Oxford, examined data on millions of live births across Denmark, Finland, France, Italy, the Netherlands, Norway, Slovakia and the UK, finding that, after Slovakia, the UK had the second highest mortality rate. Across all nations, maternal deaths were highest in the youngest and oldest mothers.
“Despite its rarity in high-income countries, maternal mortality remains an important health indicator of the quality of the care provided and health system performance,” the authors wrote in their new study, published in the BMJ.
“Maternal mortality ratios up to 42 days after the end of pregnancy varied by a factor of four from 2.7 and 3.4 per 100,000 live births in Denmark and Norway to 9.6 in the UK and 10.9 in Slovakia.”
Authors said that cardiovascular diseases and mental health of new mothers need to be “prioritised in all countries” and they called on nations to learn best practises from each other to reduce deaths.
What can healthcare professionals do?
The MBRRACE-UK report splits its key messages to improve care between professional organisations, policy makers, service planners/commissioners, service managers, health professionals (ranging from hospital to pharmacy) and those designing professional education programmes.
For health professionals, they recommend the following:
- Assess women with persistent and severe insomnia carefully for signs of underlying mental illness
- Be alert to factors, such as cultural stigma or fear of child removal, which may influence the willingness of a woman or her family to disclose symptoms of mental illness, thoughts of self-harm or substance misuse
- Be aware of the common risk factors for heart disease and venous thromboembolism, such as extreme obesity, and consider on an individual basis whether women should be made aware of the symptoms and signs of heart disease as well as those of venous thromboembolism
- Be aware of the added risk of foetal compromise when a woman’s pregnancy is complicated by both hypertension and diabetes. It is not only babies predicted to be small for gestational age who may be at risk.
Emphasis on ectopic
When it came to early gestational deaths, the most recent Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) report found that 109 women died whilst less than 24 weeks gestation or after a pregnancy that ended at less than 24 weeks in the United Kingdom and Ireland.
Eight of these women died due to an ectopic pregnancy, a number that has increased since the 2017-19 report. In fact, the report stated that “assessors concluded that almost all women who died from an ectopic pregnancy could have had better care, which might have altered the outcome for a third”. Furthermore, the report found that “vulnerable and young women remain disproportionately represented amongst those who have died from ectopic pregnancy”.
In a statement released in response to the MBRRACE-UK 2022 report, the Ectopic Pregnancy Trust called for “crucial” action to stop deaths from ectopic pregnancies. “It is shocking that women are still dying from ectopic pregnancy,” said a charity spokesperson. “The Government has a commitment to reducing maternal deaths, but these statistics show that compared with the last report, the UK death rate from ectopic pregnancy has increased from five women dying to eight. This is devastating and unacceptable.”
The charity, alongside the authors of the MBRRACE-UK report called for a greater awareness of the symptoms of ectopic pregnancy, both amongst healthcare professionals and patients themselves.
“Every opportunity should be taken to ensure women of reproductive age who seek gynaecological or early pregnancy care are aware of the symptoms associated with ectopic pregnancy,” said the report. “It is important that all women know where to seek advice if they are concerned, that early pregnancy services are visible and welcoming to young and vulnerable women.”
This need for awareness extends to the pharmacy team, who are often first port of call for mothers in the early stages of pregnancy. Staff should be aware of the following symptoms and refer any customers who are experiencing:
- Pain low down and on one side of the abdomen
- Bleeding from the vagina
- Pain in the tip of the shoulder
- Discomfort when going to the toilet
- A brown watery discharge from the vagina.