6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

Oates, CantwellAll women who are substance users should have integratedspecialist care. Women should not be managedsolely by their GP or midwife. Integrated care shouldinclude addictions professionals, child safeguarding, andspecialist midwifery and obstetrics.Other deaths from medical conditions associatedwith psychiatric disorderIn addition to the 13 women who died from medical conditionsassociated with their substance abuse, a further 12women died who had an underlying psychiatric disorder thatmay have contributed to their terminal condition or influencedthe care received. Two of these occurred during pregnancy,seven after delivery and there were three Late cases.The deaths of three women from venous thromboembolismare counted and discussed in Chapter 2. One motherhad a needle phobia which led to her refusing blood testsand thrombo-prophylaxis and another, who had an emotionallyunstable personality disorder, was unable to selfadministerthrombo-prophylaxis and avoided postnatal careafter her child was removed by social services. A womanwith a diagnosis of schizophrenia died while receiving inpatientpsychiatric care: her antipsychotic medication wasassociated with weight gain and she was a heavy smoker.In a fourth case, the developing symptoms of physical diseasewere misattributed to psychiatric causes. In somecases, these women also failed to attend for regular antenatalcare.Four deaths were from neurological causes and arecounted in Chapter 10. The first was from sudden unexplaineddeath in epilepsy in a woman who had an emotionallyunstable personality disorder and poor compliancewith care and anti-epileptic medication. The second died inlate pregnancy following an epileptic fit. She had paranoidschizophrenia. Both her epilepsy and schizophrenia haddeteriorated during pregnancy. Her epilepsy was managedby her psychiatrist. The third death involved a subarachnoidhaemorrhage in a distressed asylum seeker with posttraumaticstress disorder whose developing symptoms weremisattributed to psychiatric causes. In the fourth, a womandied from encephalopathy whose symptoms were misattributedto psychiatric causes over a prolonged period of time.Also counted in the Other Indirect deaths chapter is adeath in pregnancy of a woman who died from miliarytuberculosis but whose anorexia and weight loss was misattributedto psychiatric causes. A further death from pneumoniasecondary to autoimmune disorder occurred. Formany weeks this woman’s symptoms were misattributed todepression.There were two Direct deaths. The first, counted inChapter 3, was in a woman with mild learning disabilityand epilepsy whose early symptoms were misattributed toanxiety and agitation, and another woman died from postpartumhaemorrhage and is counted in Chapter 4. Thisdeath, which received media coverage, was associated withneonaticide in a woman without any previous psychiatrichistory:An older, religious, single professional woman with noapparent social problems or previous psychiatric history diedfrom exsanguination as the result of postpartum haemorrhage.She had concealed her pregnancy and deliveredunassisted at home. She died of haemorrhage and a deadinfant was found at home.This woman demonstrates the classical features of neonaticide:previously good character, no psychiatric history, nosocial services involvement and a stable occupation. Shehad a concealed pregnancy and unassisted delivery, andthere was a lack of awareness of close family members,work colleagues and health professionals that she was pregnant.In these cases, the infant is either abandoned or diesshortly after delivery. The lack of a psychiatric diagnosis isalso typical, but it is likely that at the time she was sufferingfrom an acute dissociative state. If she had survived,she would have been charged with infanticide (neonaticide).This is the only record of infanticide in this Enquiry.Misattribution of causeIn six of these 12 examples of physical disease there was adelay in diagnosis and appropriate treatment being given,sometimes over prolonged periods of time. This wasbecause of misattribution of the signs and symptoms of amedical condition to a psychiatric disorder. In two women,an acute confusional state, a symptom of the underlyingmedical condition, was misattributed to a functional psychiatricdisorder leading to repeated requests for psychiatricassessment and a delay in diagnosis and appropriate treatment.In four others there was no significant psychiatricdisorder, but initial difficulties in making a substantivephysical diagnosis had led to an assumption that the symptomsmust be of psychological origin. Difficulties in eatingwere described as ‘food avoidance’ and ‘refusing to eat’ andwere thought to be an eating disorder. Difficulties in holdinga conversation were described as ‘refusing to speak’and thought to be depression. Distress and agitation weredescribed as ‘behavioural’. As an example of this:A woman died of an autoimmune disorder that had beendiagnosed before pregnancy. Her medical diagnosis initiallypresented with lethargy and malaise. Despite this, and herlack of a psychiatric history, her complaints of feelingincreasingly unwell were attributed by the GP to depressionin mid-pregnancy, and she was referred to a psychiatrist.She deteriorated and, when admitted to a maternity140 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203