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New academic investigation indicates that prevention guidance issued by medical examiners following maternal deaths in England and Wales are being disregarded.

Key Findings from the Research

Academics from a leading London university analyzed prevention of future deaths documents issued by coroners involving pregnant women and new mothers who passed away between 2013 and 2023.

The study, released in a prominent medical journal, identified 29 prevention of future death reports involving maternal deaths, but revealed that nearly two-thirds of these recommendations were not implemented.

Alarming Data and Trends

Two-thirds of these deaths took place in hospitals, with more than half of the women dying after giving birth.

The most common causes of death were:

• Haemorrhage
• Problems during the first trimester
• Suicide

Coroners' Main Worries

Issues highlighted by coroners most frequently featured:

• Failure to provide appropriate care
• Lack of referral to specialists
• Insufficient staff training

Response Rates and Regulatory Requirements

Healthcare providers, like other regulatory organizations, are legally required to respond to the medical examiner within eight weeks.

However, the research found that only 38% of PFDs had published replies from the institutions they were sent to.

Global and Local Perspective

According to latest data from the WHO, about 260,000 women passed away throughout and following pregnancy and childbirth, even though most of these cases could have been prevented.

While the overwhelming majority of maternal deaths occur in lower and middle-income countries, the risk of maternal mortality in wealthier countries is typically 10 per 100,000 live births.

In England, the maternal mortality rate for recent years was 12.82 per 100,000 births.

Professional Commentary

"The voices of mothers and expectant individuals must be given proper attention," commented the lead author of the study.

The academic emphasized that PFDs should be incorporated as part of the forthcoming official inquiry into maternity services to ensure that the same failures and fatalities do not occur again.

Individual Loss Highlights Systemic Problems

One family member shared their experience: "Postpartum psychosis can be fatal if not handled quickly and appropriately."

They added: "Unless insights aren't being learned then it's probable other women are being missed by the system."

Formal Reaction

A spokesperson from the national maternity investigation said: "The aim of the independent investigation is to pinpoint the underlying problems that have caused poor outcomes, including deaths, in maternity and neonatal care."

A Department of Health official characterized the failure of institutions to respond promptly to PFDs as "unacceptable."

They stated: "Authorities are implementing urgent measures to improve safety across maternity and neonatal care, including through advanced monitoring systems and programmes to prevent neurological damage during delivery."