🔗 Share this article

Recent research suggests that prevention recommendations issued by coroners following maternal deaths in the UK are being disregarded.

Key Findings from the Study

Academics from King's College London analyzed PFD reports issued by medical examiners concerning expectant mothers and new mothers who passed away between 2013 and 2023.

The study, released in BMJ Gynecology and Obstetrics Clinical Medicine, found 29 PFDs involving maternal deaths, but discovered that approximately 65% of these recommendations were not implemented.

Concerning Statistics and Trends

66% of these fatalities occurred in hospitals, with over 50% of the women dying post-delivery.

The most common causes of death included:

• Severe bleeding
• Problems during early pregnancy
• Self-harm

Medical Examiners' Primary Concerns

Problems highlighted by coroners commonly featured:

• Inability to deliver suitable treatment
• Absence of referral to specialists
• Insufficient medical training

Compliance Levels and Legal Obligations

Healthcare providers, similar to other regulatory organizations, are legally required to reply to the coroner within 56 days.

However, the study found that merely 38 percent of PFDs had published replies from the institutions they were sent to.

Worldwide and Local Context

Based on recent figures from the WHO, about two hundred sixty thousand women passed away during and after pregnancy and childbirth, despite the fact that the majority of these cases could have been prevented.

While the overwhelming majority of pregnancy-related fatalities happen in lower and middle-income countries, the risk of maternal death in wealthier countries is on average ten per hundred thousand live births.

In England, the maternal mortality rate for recent years was twelve point eight two per hundred thousand births.

Expert Commentary

"The concerns of mothers and pregnant people must be taken seriously," commented the principal researcher of the research.

The academic stressed that PFDs should be included as part of the upcoming official inquiry into NHS maternity and neonatal care to guarantee that the same failures and deaths do not happen repeatedly.

Personal Loss Highlights Widespread Issues

One relative described their story: "Postnatal mental health issues can be life-threatening if not dealt with quickly and properly."

They continued: "If lessons aren't being learned then it's probable other mothers are slipping through the net."

Formal Response

A representative from the official inquiry stated: "The objective of the independent investigation is to identify the underlying problems that have caused poor outcomes, including deaths, in maternity and neonatal care."

A Department of Health official described the failure of institutions to reply quickly to prevention reports as "unacceptable."

They stated: "Authorities are taking immediate action to enhance security across maternity and neonatal care, including through sophisticated tracking technology and programmes to avoid brain injuries during childbirth."