Children’s social care involvement common to nearly third of UK mothers who died during perinatal period: Study

The involvement of children’s social care services was a common factor in nearly a third of UK maternal deaths occurring during, or within a year of, pregnancy between 2014 and 2022, finds research published in BMJ Medicine.

These women were at heightened risk of dying from psychiatric causes and being murdered, the findings indicate.

But uncoordinated appointment schedules across a wide number of services added to the many disadvantages these women already faced. Changes to maternity care practice and policy are now urgently required, say the researchers.

In the UK, children’s social care services might become involved during pregnancy or after birth when concerns are raised that the infant might be at significant risk of harm. And the number of such cases has steadily risen over the past decade, note the researchers.

Although maternal deaths in the UK are relatively rare, recent evidence indicates a substantial increase in deaths from all causes compared with previous years, even allowing for the effects of the COVID-19 pandemic, they add.

To explore this further, in the context of children’s social care services involvement, and analyze the quality of maternity care women received, the researchers drew on national surveillance data—MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK)—-for all mothers who died between 2014 and 2022 either during, or up to a year after, pregnancy.

During this period, 1695 women died, but involvement with children’s social care services wasn’t known for 244, so 1451 women were included in the final analysis.

Children’s social care services had been involved in the care of nearly a third (420; 29%) of the women who died, an involvement that has steadily increased since 2014, reaching 34% in 2019–21, the data show.

Three out of four (75%) of these women died between six weeks and 12 months after the end of pregnancy.

Women with children’s social care involvement were more likely than those with no known involvement with these services to die by suicide (20% vs. 10%), other mental health-related causes, including drug overdose (30% vs. 3%), and murder (5% vs. 2%).

And they were nearly twice as likely to be young (aged 20 or below), twice as likely to be living in the most deprived areas, and significantly less likely to be of Black or Asian ethnicity.

A higher proportion of them were unemployed, living alone, and reported to have been subjected to domestic abuse before or during their pregnancy than women with no known involvement with children’s social services: 65% (205) vs. 3% (23).

And a higher proportion of them had pre-existing medical problems (75% vs. 59%), mental health issues (75% vs. 27%), smoked during pregnancy (73% vs. 21%), and were known to have substance misuse issues (55% vs. 5%).

But they also received antenatal care less often during pregnancy (89% vs. 94%). And of those who did, a higher proportion started this after 13 weeks of pregnancy (32% vs. 19%).

A review (confidential inquiry) of the care of a random sample of 47 women with children’s social care services involvement showed that these women tended to have complex social risk factors, with almost half having five or more (45%; 21).

Multiple personal barriers hindered their access to, and engagement with, health care. These included previous trauma and poor experiences of children’s services involvement (including previous removal of older children); domestic abuse; financial hardship; insecure housing; and challenges related to mental health, neurodiversity, learning disabilities, and language needs.

They also faced barriers in service provision. For example, health care professionals often didn’t explore the interplay between medical and social complexity and didn’t consistently consider the wider social circumstances that affected engagement and treatment compliance. And they didn’t always understand the impact of trauma.

Access to appropriate and timely advice about drug treatments was challenging for many women, both before conception and during the perinatal period, with evidence of judgment and stigma in some women’s records.

For most women, the coexistence of complex social adversity and medical or obstetric problems triggered a range of health and social care referrals, resulting in a high volume of appointments—more than 30 for some women—across different services and agencies.

These appointments were often uncoordinated and lacked a collective approach to safeguard both women and their babies.

“The complexity of a multi-agency system with various professionals was compounded by communication gaps, uncertainty about professional roles, and disjointed processes, resulting in a rigid system unable to tailor care to the needs of women,” point out the researchers.

They identified risk assessment and recognition, medication management, coordination of care, and staff competencies as essential components of personalized, holistic, and responsive (to trauma) care when dealing with medical and social complexity.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. The researchers acknowledge that data for some important demographic variables were missing. The study also only considered women who died: the findings might therefore not be applicable to women with children’s social care services involvement during and after their pregnancy who didn’t die.

But the researchers nevertheless conclude, “While some women received excellent, coordinated care, we identified that urgent changes to practice, clinical guidance, and policy are required to prioritize this group of marginalized women.

“A critical review of current maternity care pathways is needed to adjust and customize care to the needs of women with complex social adversity, and to look at the existing health inequalities that disproportionately affect [them].”