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

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1 Which mothers died, and why
Critical incident reports and internal reviews
The above vignette highlights another area of poor practice, that of not providing a critical incident report
or undertaking an internal review after any serious untoward incident, or death. This was not the only case.
Without such reviews lessons cannot be learnt and practice cannot improve.
Even when the reviews were carried out their quality was extremely variable. Although there were many
examples of very good internal reviews following a maternal death, this was not always the case. It was also
not always evident who was involved in such reviews. In some cases it was clear the review only involved
those directly associated with the woman’s care and lessons may not have been widely disseminated to
others in the maternity service. If lessons are to be learnt it is important that all clinical staff are aware of
the fi ndings of such reviews, particularly those who may not have ready access e.g. GPs and community
midwives. The Supervisor of Midwives network is an opportunity to disseminate fi ndings to midwives.
Underlying health status
Age
Maternal mortality is closely associated with mothers’ ages, as shown in Table 1.13. The highest rates are
among the oldest women, although differentials have changed over time and Indirect deaths have made
an increasing contribution. The linear trend by age was statistically signifi cant in 2003-2005. As discussed
in the Annex to this Chapter the average age at childbirth has risen, with increases in the proportions of
women who have babies in their thirties and forties. In the 2003-05 triennium, the youngest mother who
died was a girl of 14 and the oldest was 46 years of age.