Characteristics, outcomes, and maternity care experiences of women with children's social care involvement who subsequently died: national cohort study and confidential enquiry

Abstract

Objectives: To investigate maternal mortality in the context of children's social care (CSC) involvement, and to explore the quality of maternity care that women with CSC involvement received.

Design: National cohort study and confidential enquiry.

Setting: MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) national surveillance dataset for deaths that occurred during pregnancy or up to a year after pregnancy, UK, 2014-22.

Participants: 1451 women who died during or in the year after pregnancy in the UK; 420 women (28.9%) had CSC involvement. 47 women's healthcare records were included in the confidential enquiry to describe the care of a random sample of women who died during the perinatal period who had CSC involvement.

Main outcome measures: Rates and causes of maternal deaths by CSC involvement and quality of care.

Results: A third (420/1451, 28.9%) of the women who died during or in the year after pregnancy had CSC involvement for their (unborn) baby. Women with CSC involvement were more likely to be aged ≤20 years (rate ratio 1.85, 95% confidence interval 1.27 to 2.63, compared with those aged 21-29 years), living in the most deprived areas (rate ratio 2.19, 1.42 to 3.50, compared with those least deprived), and less likely to be from black (rate ratio 0.56, 0.35 to 0.84) or Asian ethnic backgrounds (rate ratio 0.26, 0.14 to 0.44, compared with white women) than women who died with no known CSC involvement. Deaths occurred predominantly between six weeks and the year after pregnancy (75%), and higher proportions of deaths were caused by suicide, other psychiatric causes, including substance overdose, and homicide. A confidential enquiry identified that risk assessment and recognition, medication management, coordination of care, and staff competencies were essential components in providing personalised, holistic, and trauma-informed care when dealing with medical and social complexity. Multiple individual and systemic barriers hindered access and engagement with healthcare.

Conclusions: Women with CSC involvement who died during or in the year after pregnancy encountered multiple inequalities and were at an increased risk of maternal mortality from psychiatric causes and homicide. A critical review of current care pathways and policy changes is urgently needed to tailor care to the needs of this group of women and to look at the inequalities that disproportionately affect them.

Keywords: Child protective services; Health services; Obstetrics; Prenatal care; Quality of health care.

Figure 1. Sampling for confidential enquiry into maternal deaths with children’s social services involvement

Figure 2. Proportion of women who died with children's social care (CSC) involvement. Proportions of women who died with CSC involvement in each overlapping triennia do not include women who had missing data. Observed increase in proportion is independent of missing values

Figure 3. Flowchart of women who died in 2014-22 with children's social care involvement and whose medical notes were reviewed. *All cases available in this group. CSC=children's social care; MBRRACE-UK=Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK

Figure 4. Visual display of confidential enquiry findings. Four essential requirements are required to provide personalised, holistic, and trauma informed care, in a complex multi-agency system. System complexity and complex adversity on an individual level create barriers to outreach, access, and engagement with care. The influence of perpetrators of domestic abuse (by a partner or ex-partner) extends across the individual barriers faced by women, even when the perpetrator is absent from clinical view