Underlining the same key themes found in our investigation into 19 maternal deaths that happened between March and May last year, it also reinforces the increased risk of COVID-19 to women from Black, Asian and minority ethnic backgrounds.
Out of the 19 maternal deaths included in the review, six women died from complications due to COVID-19 and it was the leading indirect cause of death. All of the six women were from Black, Asian or minority ethnic backgrounds.
Blood clots in the lung caused the death of three women and was the leading direct cause of death. Other causes which led to the deaths of 10 women included disorders related to the heart, brain, nervous system, high blood pressure and excessive bleeding.
Seven key themes
The report sets out seven themes identified by the review and charts the safety risks for pregnant women that emerged as the NHS adapted to respond to COVID-19.
It describes the circumstances and pathways of care for the 19 women where some of the risks identified in the theme areas may have contributed to the outcome for those women.
The review also highlighted that the ‘system factors’ identified in the maternal reviews were seen across the NHS and have been or are being addressed in other HSIB investigations. The seven themes are:
- Unprecedented demand for telephone health advice caused delays in accessing healthcare.
- Public messaging and safety netting advice caused delays in presentation.
- Guidance changed rapidly.
- Use of early warning scores did not always detect deterioration.
- Personal protective equipment requirements changed due to COVID-19.
- Staff described feelings of stress and distress which can affect performance.
- Difficulties in making a diagnosis and choosing treatment strategies – the difficulties were in the context of clinicians tackling an unknown virus that they had to learn about as it progressed.
Racial disparity a factor in maternal deaths
Our review also supported current evidence from MBRRACE-UK on the existing racial disparity in maternal deaths and also that pregnant women from Black, Asian and minority ethnic backgrounds are at higher risk in relation to the virus.
A study carried out by the UK Obstetric Surveillance System in May 2020 found that 55% of pregnant women admitted to hospital with COVID-19 were from Black, Asian and minority ethnic backgrounds.
Our report acknowledges specific guidance and toolkits were developed to improve outcomes but concludes that it would be beneficial for further work to be done to understand the increased risk of maternal death for women of Black, Asian and minority ethnic backgrounds and with higher socio-economic deprivation.
Dr Lesley Kay, Deputy Medical Director at HSIB says: “Our report doesn’t focus on individual causes or statistical comparisons, rather it provides a compelling narrative of the care that pregnant women received in the early stages of the pandemic.
“The themes we identified during the review were found in two or more of the 19 cases. This highlighted where the changes to tackle COVID-19 had the most impact – from accessing telephone advice to the challenges in making a definitive diagnosis.
"The review also emphasised that the themes we identified were seen across all areas of healthcare. We cannot underestimate the impact that the pandemic has had on every level of interaction between the patient and healthcare system. Our aim is to share learning to support the system to provide the safest level of care possible and also explore the issues through further investigations.”
Dr Louise Page, Clinical Advisor in the Maternity Team at HSIB says: “We recognise that in a time of extraordinary pressure on NHS maternity services, thousands of mothers received excellent care and their babies were delivered safely. We also recognise the changes made to reduce risk to pregnant women since our investigations took place.
However, the impact of a maternal death on the family is profound and devastating. We heard their perspectives during this review and how the pandemic had made circumstances even more difficult when experiencing such a loss.”
Other key points
- This report includes maternal deaths that occurred in England between 1 March 2020 and 31 May 2020 and met the following HSIB maternity referral criteria: direct or indirect maternal deaths of women while pregnant or within 42 days of the end of pregnancy.
- Twenty maternal death investigations met HSIB criteria between March and May 2020 and proceeded to investigation; 19 families gave permission to include their investigations in this review.
- The experience of the families of the 19 women were included in the investigation. Four themes were identified relating to their concerns; impact of maternal collapse at home, visiting restrictions, families’ ability to advocate or support, families want to know more about how their relative died.
- The HSIB cohort of maternal deaths differs from that covered by the MBRRACE-UK COVID-19 rapid review and we refer to MBRRACE-UK as the best source of information for the epidemiology and quantitative analysis of maternal deaths in the UK.
- Maternal deaths are rare in the UK. occurring in fewer than 10 per 100,000 pregnancies.
- HSIB has initiated national investigations in two areas identified from this report, namely the response capacity of the NHS 111 service to an unprecedented increase in demand and the detection of venous thromboembolic disease in pregnancy.