Tackling persistent inequities underlying maternal mortality

The MBRRACE-UK collaboration , co-led by Oxford Population Health’s National Perinatal Epidemiology Unit , has published the full Saving Lives, Improving Mothers’ Care report on women who died during, or up to a year after, pregnancy between 2019 and 2021.

The data from this report were published by the collaboration in May 2023. The full report, which is considered a gold standard for identifying improvements needed for maternity services, examines in detail the care received by the women who died and suggests strategies and interventions to prevent future deaths. This is the first full report to cover the period when the Delta variant of COVID-19 was most prevalent and its impact on maternal deaths.

Data published by the MBRRACE-UK collaboration in May 2023 showed that persistent disparities in maternal health remained. In 2019 - 2021, women from Black ethnic backgrounds were four times more likely to die during or up to six weeks after pregnancy when compared to White women. There was an almost two-fold difference in the rate of deaths amongst women from Asian ethnic backgrounds compared to White women.

The data also showed that 12% of the women who died during or up to a year after pregnancy were at severe and multiple disadvantage, and women living in the most deprived areas of the UK were more than twice as likely to die when compared to women living in the least deprived areas. Deaths from mental health-related causes as a whole account for nearly 40% of deaths occurring between six weeks and a year after the end of pregnancy with maternal suicide remaining the leading cause of direct deaths in this period.

The full report found evidence that staff in maternal healthcare settings were expected to care for women with vulnerabilities or complex and multiple conditions without proper training or skills; in the postnatal period in particular many women who were at severe or multiple disadvantage did not have their specific care needs met.

The leading cause of death in this period was COVID-19 infection. In this period, maternal deaths attributable to COVID-19 were at a rate well in excess of any other single cause. The report has shown that confused messaging and vaccine hesitancy from both clinicians and pregnant women are likely to have contributed to the deaths of 27 women who were eligible for vaccination against COVID-19 and could have received two doses before they died. Only one of the women who died had received a single dose of COVID-19 vaccination.

In addition, pregnant women were often denied basic care such as access to treatments for COVID-19 that were proven to reduce the risk of death, including tocilizumab and steroids, and heart-lung bypass support (extracorporeal membrane oxygenation or ECMO), simply because they were pregnant. This was as a result of uncertainty among medical teams regarding how to appropriately diagnose and treat pregnant women.

The report also found evidence that clinical staff were not always equipped to have discussions with women regarding the benefits and risks of taking medications during pregnancy. Women were thus not able to make an informed choice about which medications to take.

The key recommendations from the report were:

  • Pregnant women must be included in medicines and vaccine research;
  • A route for the rapid delivery of advice and data on new vaccines and treatments to pregnant women and their clinicians must be established;
  • Pregnant, recently pregnant, and breastfeeding women should be treated the same as a non-pregnant person unless there is a very clear reason not to;
  • Guidance for administering ECMO support to pregnant women must be established;
  • Care after pregnancy must be tailored to women’s individual needs, and staff in maternal care must have the skills to care for complex physical, mental, and social care needs;
  • Training resources must be developed to promote shared decision making and counselling on medication use during and after pregnancy.

Marian Knight MBE , Professor of Maternal and Child Population Health at Oxford Population Health and maternal reporting lead, said ’This report shows persistent inequities impacting the care of pregnant, recently pregnant and breastfeeding women. Improvements in care may have been able to change the outcome for 52% of the women who died during or up to a year after pregnancy. This demonstrates an even greater need to focus on the implementation of the recommendations within this report to achieve a reduction in maternal deaths.’

The full set of reports, including a plain language summary, can be downloaded from the MBRRACE-UK webpages.