King's College London

The study is published today in BMJ Medicine and led by researchers in the Faculty of Life Sciences & Medicine, Oxford University and the charity Birth Companions, and funded by the National Institute for Health and Care Research. It is the first to detail the situations of the 1695 women who died within a year of pregnancy; of whom 420 were in contact with children’s social care. Researchers analysed national surveillance data from 2014 to 2022 to understand how the women died and the quality of the care they received.

The number of newborn babies in care proceedings in England is a growing problem. 2914 were in care in 2019/20; up 20% in seven years. Children under one make-up over a quarter of all children in care proceedings.

Women who died

The study finds three quarters of the mothers known to social services died between six weeks and the year after pregnancy and most deaths were due to suicide (20%), other psychiatric causes including drug related deaths (30%), and homicide (5%). Women with social care involvement more frequently died from homicide and mental health related causes than women without involvement.

Many of the women who died had significant experiences of abuse and mental ill-health. Two thirds (65%) of women with Children’s Social Care involvement reported domestic abuse before or during pregnancy, compared to 3% of women without social care involvement. One in three disclosed abuse during childhood compared to 2% of women without social care involvement.

A higher proportion of women known to social care had pre-existing medical problems (75%, versus 59%), mental health issues (75% versus 27%), smoking during pregnancy (73% versus 21%) and known substance use (55% versus 5%) than women with no social care involvement.

The researchers also conducted a confidential care review, which looked at anonymised care records for 47 of these women. The study found uncoordinated involvement of services and agencies, such as maternity and mental health services, children’s social care, and other medical specialists. This resulted in overwhelming appointment schedules, and compounded the adversity the women were facing rather than helping them. In several case reviews, women had more than thirty different appointments during pregnancy. In many instances, risk management solely focused on safeguarding the infant, disregarding the mother’s own safeguarding needs.

Kaat de Backer added: “What the analysis tells us is that these women come from backgrounds of trauma and abuse, and yet despite their efforts to keep up with demanding appointment schedules, they often face scrutiny and judgment rather than receiving support for the issues they are facing. Too often, the professionals the women are in touch with don’t work together to provide holistic care, which increases the pressure on a mother. When women have access to designated multi-disciplinary teams, with specialist knowledge and capacity to provide integrated and holistic care, these barriers can be overcome. It makes it easier to understand who is doing what and when, for women and professionals.”

Changes to social care 

The researchers highlighted the complex care women have to navigate during pregnancy and the postnatal period. They say urgent changes to practice, clinical guidance and policy are required to prioritise mothers with social care involvement in pregnancy and early motherhood.

Naomi Delap, Director at the charity Birth Companions, said: “This study highlights the acute need for better care for women with Children’s Social Care involvement, and the significant barriers that get in the way of providing that care.

“To help improve things, we need coordinated national policy and clear expectations across the health and social care systems. In response to this study, Birth Companions is launching work to co-design a national care pathway, in order to deliver consistent, compassionate support for all women who have Children’s Social Care involvement in pregnancy and early motherhood. This work holds the potential to transform care, break cycles of harm, and help ensure fewer mothers lose their lives in such tragic circumstances.”

Senior author Dr Nicola Vousden, from Oxford Population Health’s National Perinatal Epidemiology Unit, said “This study adds to findings from MBRRACE-UK that women with multiple disadvantages prior to, and during pregnancy, are at increased risk of worse outcomes. We’ve identified practical changes that are required within maternity care. We also need joined up pathways of care across maternity, social care and community health partners to support the needs of women with children’s social involvement, including domestic abuse, substance misuse and mental health. This will require local and national action.”