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

Table 1.24
Characteristics of the antenatal care sought by pregnant or recently delivered women who were murdered or known
to be suffering domestic abuse; United Kingdom: 2003-05.
Type of death Death
in early
pregnancy
Late or non attenders for antenatal care (ANC) Total number
of deaths of
women*
Booked after
22 weeks or
missed more
than four visits
No
ANC
Subtotal
n n n n (%) n (%)
Direct 3 0 0 3 (75) 4 (100)
Indirect 1 6 3 10 (83) 12 (100)
All 4 6 3 13 (81) 16 (100)
Coincidental 2 4 3 9 (69) 13 (100)
Late deaths 0 15 2 17 (41) 41 (100)
Total 6 25 8 39 (56) 70 (100)
* Total number of deaths of women who were murdered or known to be suffering domestic abuse same as Table 13.1
Child protection issues
Sixty-nine of the women whose deaths were reviewed this triennium were known to social services and /or
child protection services (CPS), the vast majority of whom had previous children in care. Thirty women died
from complications related to their pregnancy, i.e. from Direct or Indirect conditions, and half of the women
who were murdered were also known by the CPS and/or social services.
As shown in Table 1.25, more than 80% of the women who died from Direct or Indirect did not seek care at
all, booked late or failed to maintain regular contact with the maternity services, in the main because of fear
that their unborn child might be removed at birth.
In forty-one cases a child protection case conference was held, 23 after the removal of the infant into care.
Five women committed suicide shortly before or after their child’s case conference and another 18 women
died from an apparent accidental overdose of a drug of abuse. Many of these women were late in booking
and often defaulted from maternity care because of fear of social services involvement. In most cases,
it appears that upon removal of the child the level of support and care from both maternity and social
services fell or ceased. For example, in two such cases where an overdose of street drugs may have
masked a suicide and a murder by a known abusive partner, the assessors said:
“Despite intensive support during pregnancy her care stopped in the post natal period. As soon
as the baby was removed her care plans stopped, 24 hours after delivery.
“Once again it appears the care for the mother stops at the point at which the safety of the child
is secured.”
Of all of the women who died and whose cases were assessed, 112 of their previous living children had
already been adopted or placed in care. Several mothers had more than six previous children in care, the
highest number being eight.
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