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

Foreword
Having a baby is a joyous and fulfi lling experience and, nowadays, a safe one for the great majority of women
in the United Kingdom. This safety has been hard won. It is the result of many years of painstaking work to
identify and reduce risks, and to defi ne the best treatment when complications do occur. Nevertheless some
mothers still die, and these deaths are all the more shocking because they are now so uncommon.
It is our duty to learn all we can from such tragedies. Confi dential enquiries into maternal deaths began in
England and Wales more than fi fty years ago and have covered the United Kingdom since 1985. The triennial
reports have become essential reading for health professionals, and a model for similar enquiries in many other
countries. The Enquiry, however, is continually evolving and the present report has a new title, Saving Mothers’
Lives. The previous name, Why Mothers Die, failed to emphasise that these reports not only describe the
reasons for maternal mortality but also make important recommendations to reduce the risk of death in the future.
We are concerned that the UK maternal mortality rate has not fallen in recent years. This is partly due
to the changing nature of our mothers’ overall health. In general, the women who died appeared to be in
poorer general health and smoked more, and over half were overweight or obese. Many also had chaotic
lifestyles and found it hard to engage with maternity services. The rate is almost certainly infl uenced by the
increasing number of deaths amongst migrant women, whose numbers have also risen.
For this triennium the Report not only identifi es areas of substandard care but also, even though the overall
percentage of such cases has not increased, includes for the fi rst time a list of ten overall recommendations
highlighting the key issues to be addressed as a matter of priority by commissioners, providers and
policymakers. We expect these, and the other recommendations in the Report, to lead to action.
Other innovations include contributions from a general practitioner and a consultant in emergency
medicine. These new chapters emphasise the need for wider awareness of risk factors and early signs
and symptoms of problems which may be crucial in pregnancy. The broad range of specialties represented
in the writing panel refl ects the teamwork required in modern maternity care. The team also includes the
woman herself. Women who are socially excluded, such as asylum seekers or homeless people, have a
disturbingly high risk of death.
Publication of this report has been achieved on schedule despite pressures from health service
reorganisation. This is due to the hard work and enthusiasm of many people but we are particularly grateful
to Dr Gwyneth Lewis, the National Clinical Lead for Maternal Health and Maternity Services in England. As
well as directing the UK Enquiry and making insightful innovations she has personally collated the data and
prepared the report. We thank her for her continuing commitment and dedication.
Saving Mothers’ Lives has important messages for everyone involved in maternity care. It is essential that
we do not become complacent. Although some maternal deaths are unavoidable, other women are still
dying needlessly in the UK. This can be prevented in future only if lessons are learned and acted upon,
and the process begins here.
Sir Liam Donaldson
Chief Medical Offi cer – England
Dr Michael McBride
Chief Medical Offi cer – Northern Ireland
Dr Tony Jewell
Chief Medical Offi cer – Wales
Harry Burns
Chief Medical Offi cer – Scotland
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