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

42
1 Which mothers died, and why
Table 1.27
Characteristics of the women who were poor or non attenders for antenatal care and whose pregnancy was 12 weeks
of gestation or more; Direct and Indirect deaths; United Kingdom: 2003-05.
Characteristic* Women who were poor
or non-attenders at
antenatal care
Overall number
of women
n (%) n (%)
Domestic abuse 13 (81) 16 (100)
Known to Child Protection Services
or social services
26 (81) 32 (100)
Substance misuse 21 (78) 27 (100)
Black Caribbean 4 (57) 7 (100)
Single unemployed 19 (56) 34 (100)
Both partners unemployed 14 (47) 30 (100)
Black African 12 (40) 30 (100)
No English 9 (35) 26 (100)
White 31 (17) 183 (100)
At least one partner in employment 9 (5) 165 (100)
* Some women had more than one characteristic recorded.
Characteristics of the women who were poor or non attenders for antenatal care and whose pregnancy
was 12 weeks of gestation or more; Direct and Indirect deaths; United Kingdom: 2003-05
What did you learn from this case and how has it changed your practice?
“I remember her lying in bed huddled up and crying and feeling frightened. In future I would like to
believe that if I see this again I would drop everything and sit, listen and offer support.”
It is easy to forget that, apart from the partners, families and the communities of the women who died,
every health care worker who knew or was involved in providing care for them was affected by their death.
These rare events have a huge and long lasting impact on the staff involved. As part of participating in this
Enquiry, every health care professional who was involved is asked “what did you learn from this case and
how has it changed your practice?”. Many had never come across a maternal death before and all hope
they would not do so again. A very few had to manage more than one, due entirely to the play of chance,
and the impact of several deaths in a short period of time was immensely distressing for them.
Many thoughtful answers were provided, in general revealing the huge depth of caring and respect the staff
had for the women who died, the babies and families who survived and the pain they themselves suffered
as a result:
“The midwifery report made me cry.” (Central assessor)
“We all attended the funeral, even though she died some months after she left our care.”
(A midwife who had cared for a terminally ill mother during her pregnancy).