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

Most staff reported learning clinical lessons which, in many cases, led to a change in personal or Trust
based practice. Other staff were more refl ective and philosophical:
Even though she was a mother she was still a child herself.” (In relation to a young schoolgirl).
“How inspiring the human spirit can be in the face of insuperable odds.”
(For a woman dying of cancer).
On the other hand a few professionals seemed oblivious to the poor quality of care they had provided, or to
have had any understanding of the wider circumstances that may have affected a mother’s life and death.
The assessors were also concerned by the apparently culturally dismissive or insensitive remarks made by
a few professionals during the course of the reviews.
In some cases staff appeared to take the blame upon themselves despite providing the best possible care.
In these cases the Enquiry assessors were saddened as they considered the care these professionals
had provided was exemplary and that the failings in the system were totally outside the control of these
workers. Some staff who cared for women who declined help, or who had to watch a woman bleed to
death while refusing blood products, reported signifi cant personal distress. It is important that all staff
affected by a maternal death should be offered support and counselling to help them come to terms with
their own reactions.
Discussion and conclusions
Although it is disappointing that the UK maternal mortality rate identifi ed by this Enquiry has failed to
decline there are a number of changing demographic and public health factors which may explain this lack
of progress. The Annex to this Chapter demonstrates the rapidly changing nature of motherhood in the UK,
with more than 20% of women having babies in the UK themselves having being been born elsewhere.
In addition, women who have just recently arrived in the UK from every part of the world present new, but
often differing, challenges for maternity services.
Maternal deaths are extremely rare, and the proportion of the very small number of mothers whose care
was less than optimal has not increased for many years. In fact there were many instances of exemplary
care provided for extremely sick women. However there is always room for improvement and high quality
clinical care cannot, and should not, be taken for granted. When reviewing the cases for this triennium,
the apparent lack of basic clinical knowledge and skills amongst some doctors, midwives and other health
professionals, senior or junior, was one of the leading causes of potentially avoidable mortality. The
Enquiry assessors were also struck by the number of health care professionals who failed to identify and
manage common medical conditions or potential emergencies outside their immediate area of expertise.
Resuscitation skills were also considered poor in an unacceptably high number of cases. As a result,
several of the top ten recommendations of this Report address these critical areas.
This Chapter and its Annex has shown that women are starting motherhood later in life which may have
consequences for their pregnancy. Mothers also tend to be less healthy than in the past and embark on
pregnancy in poorer overall general health. Over half of the women who died were overweight or obese,
and the fact that cardiac disease is now the leading cause of maternal death demonstrates the growing
impact of less than healthy lifestyle choices. What has been noticeable over the past few Reports is the
steady increase in deaths in young mothers in what should be the prime of their lives from diseases such
as lung cancer and myocardial infarction, conditions never seen in earlier triennia.
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