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Saving Lives, Improving Mothers’ Care
Surveillance of maternal deaths in the UK

2011-13 and lessons learned to inform maternity
care from the UK and Ireland Confidential Enquiries

into Maternal Deaths and Morbidity 2009-13

December 2015

Maternal, Newborn and
Infant Clinical Outcome
Review Programme

Page 58

Saving Lives, Improving Mothers’ Care 201538

In a few further instances, family members were
given responsibilities for monitoring and caring for
the woman, which were likely to be overwhelming.
While families are important partners in care, and
have a greater knowledge of the patient than any
professional can ever have, they should not be
burdened with caring responsibilities beyond their

Family members have a crucial role to play in
recovery from illness. They know the woman
better than professionals do, and despite lack
of professional knowledge, may be more able to
recognise early changes in mental state. Their
views should always be heard and included in
the overall patient assessment and management
(Worthington, Rooney et al. 2013a, Worthington,
Rooney et al. 2013b).

Partners and other family members
may require explanation and education
regarding maternal mental illness and its
accompanying risks.

(Worthington, Rooney et al. 2013a,
Worthington, Rooney et al. 2013b)

In some circumstances, a partner or other family
member may not fully understand the seriousness
of the condition and resist professional
engagement. This needs to be handled sensitively
with time invested in explaining the nature and risks
associated with the particular patient presentation,
using written and internet resources where useful.
If admission is considered, offering the opportunity
to visit, or see a video of, the MBU may help to
destigmatise care. However, professionals should
always prioritise the safety and care of the patient,
even where, on rare occasions, this conflicts with
a family’s wishes.

Substance misuse
In addition to the 14 women who died by suicide
and also misused substances, there were a further
58 women who died in relation to drug or alcohol
misuse. The overwhelming majority misused
multiple substances, with alcohol use alone being
relatively unusual.

About 1% of all pregnant women are estimated
to have problem drug use and 1% have problem
alcohol use (Advisory Council on the Misuse
of Drugs 2011). All except one of the women
reviewed for the purposes of this chapter had
been identified in pregnancy. Two of them were
booked for midwifery-led care despite a clear

history of drug or alcohol misuse. The NICE
antenatal and postnatal mental health guideline
(National Institute for Health and Care Excellence
2014a) recommends that all women are screened
for alcohol and drug misuse at booking. Many
women at risk could be reluctant to admit to these
problems because of the fear that their child would
be removed. However in the group of women who
died failure to identify their substance use was not
a significant issue.

Pregnancy is a window of opportunity to engage
in treatment and women, including substance
misusers, want the best for their babies. Hence
women with a history of drug and alcohol misuse
may accept treatment at this time, especially if they
feel it may improve their chances of keeping their
babies. The NICE antenatal and postnatal mental
health guideline (National Institute for Health and
Care Excellence 2014a) recommends that women
with alcohol or drug misuse are offered brief
interventions and referred to a specialist substance
misuse service for advice and treatment.

Women who engage in methadone treatment
programmes during pregnancy improve the
outcomes for their baby (National Institute for
Health and Care Excellence 2010). However, there
is little evidence regarding the benefit of opiate
detoxification programmes during pregnancy and
there may be a number of risks, particularly in the
first trimester (Heberlein, Leggio et al. 2012). For
this reason, opiate maintenance therapies are seen
as standard management, with detoxification used
for those who refuse maintenance. Importantly,
it is recognised that there is a risk of accidental
overdose in women who stop or reduce drug
misuse in pregnancy but start misusing again after

It is unclear how many women received opiate
detoxification, but this was not without problems:

One woman was admitted for a three-week
inpatient accelerated detoxification from her
substance misuse treatment after discussion
with her substance misuse worker and social
worker. She died 5 days after discharge from
an overdose.

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Saving Lives, Improving Mothers’ Care 2015 39

Severe and multiple deprivation (SMD)
All the women who died primarily from drug misuse
were vulnerable in multiple ways, with substance
misuse being only one of their many problems, as
illustrated by the following vignette:

A single woman, who was using street drugs
in addition to a methadone programme,
became pregnant unintentionally and booked
late. She had a history of childhood and
domestic abuse, alcohol abuse, depression
and self-harm, had one child in care, was
homeless and had a criminal conviction.
During pregnancy her care was coordinated
by a specialist substance misuse midwife
with input from social care and a consultant
obstetrician; advice was given by telephone
by a nurse at an addictions service. She
repeatedly missed antenatal appointments
and each time the midwife made contact and
arranged to visit her at home. A pre-birth case
conference was held and a decision was
made to take the baby into care immediately
after birth. She delivered preterm and went
home after a few hours. After delivery she
was discharged by the midwife at 14 days
and it was hard for social services to maintain
contact with her; when they called at her home
she was usually out. The health visitor was
not involved because the child was in care.
Four weeks later she died after an apparent
overdose of methadone, heroin and cocaine.

The care given to this woman during pregnancy
was good; she had a specialist substance misuse
midwife who made great efforts to engage and
support her; followed her up after not attending
appointments; took advice about her substitution
therapy from addictions services and liaised
with social care to provide appropriate child
safeguarding. However, at 14 days the midwife who
had provided holistic care withdrew, just around
the time the child was taken into care. Thereafter
the woman did not want to engage with social care
who had removed her child. No-one was really
interested in her after the baby was considered
safe. This theme was also identified amongst the
women who died between six weeks and a year
after the end of pregnancy and is explored further
in chapter 7.

There were many other women who died that had
multiple individuals and agencies involved in their
care. For a number of women, as noted in other
chapters of this and previous reports, no-one took
overall responsibility for care.

Consider ways of ensuring that, for each
woman who misuses substances:

- progress is tracked through the
relevant agencies involved in her care

- notes from the different agencies
involved in her care are combined into
a single document

- there is a coordinated care plan.

Offer the woman a named midwife or
doctor who has specialised knowledge
of, and experience in, the care of women
who misuse substances, and provide
a direct-line telephone number for the
named midwife or doctor

NICE guideline CG110: Pregnancy and
complex social factors (National Institute
for Health and Care Excellence 2010)

The NICE pregnancy and complex social factors
guideline (National Institute for Health and Care
Excellence 2010) covers management for pregnant
women with substance misuse and recommends
ways of trying to keep women engaged in services,
but it does not cover the postnatal period (when
most women died), nor does it consider women
with both substance misuse and mental health

There is a need for evidence to inform the national
guideline covering pregnancy and postnatal care
for women with complex and multiple mental,
physical and social factors.

Child safeguarding
Substance misuse is a frequent cause of care
proceedings. Analysis of Serious Case Reviews
2009–2011 in England showed that parental
substance misuse was apparent in 42 per cent
of families (Brandon, Sidebotham et al. 2012). It
appears that the children of the women who died
were protected by child safeguarding processes.
However, the evidence here shows that the
safeguarding process does not take into account
the needs of the mother who has lost her child.

Page 116


National Perinatal Epidemiology Unit
Nuffield Department of Population Health
University of Oxford
Old Road Campus
Oxford OX3 7LF

Tel: +44-1865-289715

Email: [email protected]


ISBN 978-0-9931267-3-4

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