Saving Mothers' Lives: - Public Health Agency for Northern Ireland

10
1 Which mothers died, and why
The women who did not come for care
Fifty women, 17% of those who died from Direct or Indirect causes, fi rst booked for maternity care after
22 weeks of gestational age, missed over four routine antenatal visits, did not seek care at all or actively
concealed their pregnancies. This compares to 20% in the last Report. The 83% of the women who died and
who had sought maternity care at an appropriate time in early pregnancy contrasts with the 98% of women
overall who reported having “booked” with NHS maternity services by 18 weeks of gestation in a recent study
undertaken by the National Perinatal Epidemiology Unit (NPEU) 2 . The possible reasons for this difference are
varied and complex and are explored in depth throughout this Report. Identifying and overcoming the barriers
to care these women faced in reaching maternity services will help improve the accessibility of local maternity
services as well as the outcomes for maternal and newborn health. However, even when mothers seek care
early the system can let them down. There were several instances of women not receiving appointments
once referred for maternity care until several months into their pregnancy.
Maternity team and consultant led care
For the majority of women who died antenatal care was shared between their GP, midwife and obstetrician;
so-called traditional “shared care” or, as described in the recent maternity services implementation strategy
for England, “Maternity Matters”, “team-based care” 3 . Many of these women saw a member of the obstetric
staff once or twice, just to check all was well, and in the main their care was managed by a midwife. 18%
of the mothers who died were already known or perceived to have been at higher risk of complications
and their care was provided by the consultant-led maternity team, including midwives, obstetricians and
anaesthetists. As a refl ection of the changing nature of maternity service provision, only 3% of women had
their care shared between midwives and their GPs.
Midwifery care
A renewed emphasis is being placed on midwives being the experts in the management of normal
pregnancy and birth, as envisaged both in the National Services Framework for Maternity Care in England
(NSF) 4 and “Maternity Matters3 . In future it is likely that the majority of women with no known risk factors
will have midwifery led care throughout pregnancy, delivery and after birth. This change is already
happening. The recent NPEU study2 demonstrated that around 50% of women surveyed reported having
midwifery only antenatal care. For this Report, 27 (9%) of the mothers who died received midwifery care
only throughout their antenatal period compared to 16 women who died from either Direct or Indirect
causes in the previous triennium. Another six women who died of Coincidental causes, including murder in
cases of known domestic abuse, had midwifery led care. For most of the women who died, their midwifery
led care was both appropriate for their circumstances and of high quality, and they died of unforeseen
catastrophic events during delivery or after childbirth. However, in a few cases discussed in the midwifery
Chapter, this type of care was inappropriate.
The women who died before delivery
As shown in Table 1.5, 100 women died before delivery, 18 from Coincidental causes. For women dying of
Direct causes, the largest numbers were from ectopic pregnancy and pulmonary thromboembolism. There
were a wide variety of causes of Indirect deaths amongst undelivered women, with deaths from cardiac
disease amongst the largest group.