<scp>MBRRACE</scp>‐<scp>UK</scp> update: key messages from the <scp>UK</scp> and Ireland Confidential Enquiries into Maternal Death and Morbidity 2024

The eleventh annual MBRRACE-UK report from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity includes surveillance data on women who died during pregnancy or up to 1 year after pregnancy between 2020 and 2022 in the United Kingdom.1 Following the annual topic-specific format, the report also includes Confidential Enquiries into the care of women who died during this same period in the United Kingdom and Ireland from thrombosis and thromboembolism and malignancies as well as the care of women who died as a result of ectopic pregnancy from 2021 to 2022. The report also includes a Morbidity Confidential Enquiry into the care of migrant women who arrived in the United Kingdom less than 2 years prior to giving birth and who had a preferred language other than English. These women were identified from the MBRRACE-UK database of perinatal deaths or routine national birth records for 2022. The upward trend in the UK's maternal death rate observed in previous MBRRACE-UK reports continued in 2020–2022. The overall maternal death rate in 2020–2022 was 13.56 per 100,000 maternities (95% confidence interval [CI] 12.00–15.26), which is similar to rates reported nearly 20 years ago in 2003–2005 (risk ratio [RR] 0.97, 95% CI 0.82–1.15). Compared to 2017–2019, the last complete triennium, there was a statistically significant increase in the overall maternal death rate in the UK in 2020–2022 (RR 1.54, 95% CI 1.28–1.87). Thirty eight of the deaths that occurred between March 2020 and December 2022 were directly attributed to COVID-19 infection. If these 38 women's deaths are excluded, the maternal mortality rate for 2020–2022 would be 11.68 per 100,000 maternities (95% CI 10.24–13.27), which is also statistically significantly increased from the rate reported in 2017–2019 (RR 1.33, 95% CI 1.09–1.62) and suggests a concerning trend independent of COVID-19 specific deaths. For the first time since MBRRACE-UK reporting began, thrombosis and thromboembolism (VTE) was the leading cause of maternal death in the United Kingdom followed by COVID-19 and cardiac disease. Together these three causes accounted for almost half (43%) of women's deaths during pregnancy or up to 6 weeks after the end of pregnancy. The rate of VTE is more than twice that of any other direct cause of maternal death and is significantly increased from 2017 to 2019 (RR 2.30, 95% CI 1.33–4.14). Deaths from mental-health related causes continued to account for a large proportion (34%) of deaths occurring between 6 weeks and a year after pregnancy with deaths due to substance misuse and other psychiatric causes the leading cause of deaths in this period. Maternal suicide remained the leading cause of direct maternal deaths between 6 weeks and a year after the end of pregnancy. Women aged 35 or older had a three-fold higher rate of maternal death compared to women aged 20–24. Inequalities in maternal mortality rates also persisted in 2020–2022 with a nearly three-fold higher rate amongst women from Black ethnic backgrounds and an almost two-fold difference in rates amongst women from Asian ethnic backgrounds compared to White women. Women living in the most deprived areas also had maternal mortality rates more than twice that of women living in the least deprived areas. Nine percent of the women who died during or up to six weeks after the end of pregnancy in the United Kingdom in 2020–2022 were at severe and multiple disadvantage. As in previous reports, the main elements of multiple disadvantage were a mental health diagnosis, substance use and domestic abuse. These findings emphasise the need for a continued focus on action to address these disparities. During 2020–2022, 63 women died from thrombosis and thromboembolism during or up to a year after the end of pregnancy in the United Kingdom and Ireland. Importantly, COVID-19 vaccination and COVID-19 infection were not the cause of thrombosis or thromboembolism in any of the women who died. Of the women who died, most had at least one known risk factor for VTE; 40% were obese (BMI ≥30 kg/m2) and a further 42% were overweight (BMI ≥25 to <30 kg/m2), 33% of women were over 35 years of age, 24% were smokers and 21% had a history of VTE. Twenty-two women (35%) were still pregnant at the time of death and, of the women who gave birth, sixteen (44%) had a caesarean birth. Sixteen (25%) of the women who died were in their first trimester of pregnancy. There appeared to be a perception amongst clinicians that early pregnancy is safer than late pregnancy with regards to the risk of VTE; this misconception must be challenged. Many of the women who died in the first trimester had known risk factors, including a history of VTE, but there was very little evidence they received pre-pregnancy counselling, to discuss the risks of VTE and the need for, and timing of, thromboprophylaxis. For the women whose risk was recognised in early pregnancy, it was unclear who was responsible for prescribing thromboprophylaxis and what the referral pathway was for access or advice. It is imperative that the rapid access pathways for prescribing prophylaxis are clearly defined to ensure availability and access, particularly in the first trimester. It was evident in the care of many of the women who died from VTE that the current UK VTE risk assessment tool was not being used or interpreted appropriately. In some instances, local risk assessment tools were used in place of the national tool leading to inaccurate categorisation of women's risks, and in other instances confusion with the national risk assessment tool resulted in scoring inaccuracies. This was particularly apparent when women were re-assessed after birth as it was unclear how to account for changes in risk factors that occurred as a result of pregnancy. This included uncertainty in whether to consider the woman's most recent pregnancy in the parity calculation and which weight should be used, especially if women's booking BMI was on the borderline between risk categories. While it is apparent that the current national VTE risk assessment tool would benefit from a restructure to make it easier to use and clearer, this must be evidence-based and underpinned by appropriate research to ensure accuracy and useability. It was also apparent that many women were not risk assessed when they should have been. For instance, several women were admitted to the hospital with severe hyperemesis, but their VTE risk was not re-assessed. Many women were also not assessed after birth, which resulted in some instances where thromboprophylaxis was provided for too short a period of time. It is important to remember that risk is dynamic and there may be periods of increased risk that develop throughout pregnancy and postnatally that necessitate re-assessment of VTE risk. Amongst women who were prescribed thromboprophylaxis, several received subtherapeutic doses and many developed thromboses while on thromboprophylaxis or soon after cessation. There were also gaps in the provision of thromboprophylaxis around labour and immediately after birth. Some did not pick up their prescriptions at discharge, but this was not followed-up. Other women struggled to obtain prescriptions after pregnancy due to confusions around who was responsible for prescribing. Women should be made aware of the importance of thromboprophylaxis and asked about adherence at each assessment. The deaths of women from cancer are often thought to be coincidental to pregnancy, but as MBRRACE-UK reports have highlighted, being pregnant or recently pregnant can greatly impact the care of women with medical conditions, including cancer. Additionally, the global incidence of breast and gynaecological cancers is increasing amongst women of childbearing age2 and rates of cancer in pregnant women are expected to increase with the rising age of the maternity population. In 2020–2022, 94 women died from malignancy during or up to 1 year after pregnancy in the United Kingdom and Ireland. Twenty-five women had breast cancer; 18 (72%) had a triple negative tumour. It is important to keep in mind that women who have breast cancer in pregnancy have similar prognoses to non-pregnant women with the same stage and disease subtype, provided their cancer is appropriately managed.3 The majority of the remaining women died from gastrointestinal or haematological cancers. As has previously been emphasised by MBRRACE-UK reports, the ongoing exclusion of pregnant and breastfeeding women from research, including new treatment trials, means that there is often little evidence to guide management, which can result in inappropriate delays or denial of treatment and imaging. The use of imaging modalities, including mammography, to investigate, diagnose and stage malignancies was frequently inappropriate and women continued to be denied imaging because they were pregnant. For many, this meant that their diagnosis was delayed or the extent of their disease was not recognised. Most imaging and interventions are safe in pregnancy and should not be inappropriately denied to women because they are pregnant. Guidance for cancer diagnosis and management in pregnant women should be revised and implemented to include clear recommendations on the use and safety of diagnosis imaging modalities. A common theme in the malignancy confidential enquiry, as well as the enquiries into deaths from VTE and ectopic pregnancy, was around the recognition of symptoms. For many of the women who died from cancer, symptoms such as persistent nausea and vomiting, anaemia that did not resolve with iron supplementation, ‘red flag’ headaches, rectal bleeding or changes in bowel movements, and pain not responding to analgesia were dismissed or incorrectly attributed to pregnancy. It is important to remember the essentials and properly investigate and escalate any new, persistent or unusual symptoms to avoid delays in diagnosis and treatment. There was also evidence in the reviews that abnormal findings, such as ovarian masses or vaginal bleeding with a suspicious appearance of the cervix, were not followed-up appropriately, which should include urgent referral and senior review. Twenty (21%) of the women who died entered pregnancy with a known history of past or current cancer. It is essential that women with known cancer receive pre-pregnancy counselling including advice on delaying pregnancy and contraceptive advice. Many of the women whose care was reviewed did not seem to be aware that they could get pregnant naturally during or after completing treatment. Women with a history of malignancy also require a high index of clinical suspicion and recurrence should always be considered as part of the differential diagnosis if they present with unexplained symptoms. As was highlighted by the confidential enquiry into deaths from VTE, many women who died from cancer did not have accurate VTE risk assessment. Twenty-five (27%) women with malignancies experienced a thrombosis or thromboembolism and many were not provided with appropriate prophylaxis during pregnancy or postpartum. The odds of a VTE in pregnant women with an active malignancy are almost seven times greater than those in a pregnant women without4 and assessors felt that, given the increased risk, consideration should be given to extending the provision of thromboprophylaxis throughout pregnancy and for a longer period after pregnancy for all women with cancer. For many women who died from malignancies, there appeared to be significant challenges balancing medical care with compassionate end-of-life care. For several women, their deterioration due to disease progression was recognised late as the focus was on their ongoing pregnancy. In other instances, there was little evidence of psychological support and discussion of the terminal nature of women's disease. There appeared to be limited planning for emergencies that resulted in prolonged futile resuscitation or unnecessary hospital admissions, which reduced opportunities for the woman to spend time with her baby. Maternity and palliative care teams must work together to support women in their decision-making, allow them to exercise autonomy and die as a new mother rather than a cancer patient. End-of-life guidance should be updated to include recommendations for the appropriate service delivery to pregnant or recently pregnant women to offer the same quality of care as any non-pregnant person. Around a third of women with ectopic pregnancies have no discernible risk factors. Recognising the possibility of ectopic pregnancy in women of reproductive age is imperative for prompt intervention to prevent severe complications such as tubal rupture and death from hypovolemic shock. This review of deaths due to early pregnancy causes was expedited due to concerns over the number of deaths due to ectopic pregnancy, hence this confidential enquiry reviewed care only for women who died in 2021–2022. During this 2-year period, 12 women died from early pregnancy-related causes, all due to ectopic pregnancy. This is almost twice the mortality rate reported in 2018–2020 (RR 1.91, 95% CI 0.74–5.14). As was the case for women who died from cancer, there appeared to be limited recognition or appreciation of symptoms in women with ectopic pregnancy. Symptoms of ectopic pregnancy may be atypical, subtle or resemble other common conditions and a number of women will be unaware that they are pregnant when they experience symptoms. Many women whose care was reviewed presented with typical symptoms of ectopic pregnancy including a lighter than normal period, abdominal pain, diarrhoea or gastrointestinal upset and shoulder tip pain. Others presented with less common, but still worrying symptoms such as dizziness and repeated syncope. In women with abnormal symptoms, a full detailed history should be taken including the date of the woman's last menstrual period and any changes in bleeding different from a normal period. A pregnancy test should also be offered to rule out the possibility of pregnancy. Until pregnancy can be excluded, ectopic pregnancy should be considered in the differential diagnosis of women of reproductive age with atypical symptoms. Vulnerable women remained disproportionately represented amongst the women who died from ectopic pregnancy. Five (42%) of the women who died in 2021–2022 had disadvantages including a mental health diagnosis, substance use or domestic abuse. Another two had language difficulties. Assessors felt that some of these vulnerabilities, particularly mental health problems or language difficulties, may have impacted their care and prevented their concerns about symptoms being heard or acted upon. Of the women who sought medical attention prior to their death, 80% were falsely reassured or had their symptoms or concerns dismissed. Ten (83%) of the women who died from ectopic pregnancy contacted emergency services, and nine of these women (90%) faced significant delays in the arrival of ambulance services and/or transfer to hospital. Assessors felt that part of the reason for these delays was inappropriate triaging of women when they called 999 as it was felt that many were wrongly categorised as low priority. There also seemed to be no escalation in categorisation when repeat calls were made or when calls were made by minors. In many instances, ectopic pregnancy and concealed intra-abdominal bleeding did not seem to be considered by pre-hospital teams. As such, several women did not receive adequate fluid replacement during resuscitation. Bleeding from a ruptured ectopic pregnancy can be catastrophic and requires urgent transfer to hospital where appropriate imaging, including point-of-care ultrasound and surgical intervention can occur. Ambulance service algorithms for risk categorisation should be reviewed so that calls regarding women who are pregnant, recently pregnant or have the potential to be pregnant are appropriately managed, which may include early navigation and assessment. As with pre-hospital care, women also faced challenges accessing services in Early Pregnancy Assessment Units (EPAUs). Often appointments were made more than 24 h after initial presentation due to limited availability and weekend closures. As highlighted in previous MBRRACE-UK reports and national guidance, EPAUs, should be available 7 days a week and provide a full range of services including ultrasound and pregnancy testing. It situations where these services are not available or women cannot be seen within 24 h, they should be referred to other facilities that offer specialist assessment, which, in some cases, may be the emergency department. In 2022, almost one in three live births in England and Wales were to women born outside of the United Kingdom.5 It is known that migrant women interact with and experience maternity services differently to women born in the United Kingdom and in 2020–2022 approximately 30% of the women who died during pregnancy or in the 6 weeks after pregnancy were born outside the United Kingdom. Additionally, 4% of the women who died in 2020–2022 in the United Kingdom were not able to speak and/or understand English, and this rate is likely to be higher in the general maternity population. This year's morbidity enquiry reviewed the care of 38 women who had arrived in the United Kingdom less than 2 years prior to giving birth and who were identified as having a preferred language other than English. Due to the nature of the sampling strategy, which drew partly from the MBRRACE-UK perinatal mortality database, 63% of women experienced a perinatal death from 24 weeks' gestation; a further two experienced a pregnancy loss at ≤20 weeks' gestation. The majority of the women were from Pakistan (26%) and Romania (18%) and were multiparous. Thirteen women (34%) were pregnant when they arrived in the United Kingdom. Most women whose care was reviewed did not have their language needs properly assessed or documented in their maternity records. As such, most did not receive adequate or consistent support for their language needs throughout their care. Professional interpreter services were not provided for many interactions including scheduled visits, in emergency situations or during sensitive discussions including provision of surgical consent, ultrasound results or the importance of fetal movements. The digital maternity record should include details of language needs including the use of formal interpreter services so that they can be considered at all interactions. In the absence of professional interpreter services, many women (61%) relied on family members or friends to interpret, which is not recommended. In many instances, written information, including consent forms and discharge materials, was also provided in English with no apparent consideration for the woman's level of English or overall literacy. For several women, it was felt that their inability to understand written materials may have affected their decision-making and outcomes. It is important that all information provided is understood so that women are able to make informed decisions about their health and the health of their babies. This may require the development and use of for written information and when information is given It was evident from the care of these women, that most did not understand the or how to access maternity As a many women late in pregnancy. were not with a and for many they did not to be aware of their to of address or that maternity care is at the of than a third of women presented for the first time in pregnancy to urgent or emergency rather than maternity While most women had into maternity services after to the emergency there were several opportunities for and of women. Many of the women whose care was reviewed were women were or and more still had to and These and other in access to care may have to late booking and For instance, digital exclusion when and changes are by or to can how women with maternity women not the must be in to and of There was evidence of or in the care of many of the women to their language or migrant In some instances or was not or was with Assessors also felt that some women's backgrounds may have impacted their quality of care or challenges with may have impacted women's autonomy in Guidance and is to ensure a greater amongst clinicians in maternity year on year the maternal mortality rate for this period is significantly higher than that reported that for 2017–2019, the last complete triennium, when deaths due to COVID-19 are While changes by the COVID-19 impacted women's care as by significant delays in the pre-hospital care or limited availability of specialist such as interpreter services, there were many factors independent of the that may be to the increased maternal death The current maternity is more Many of the women who died were older than 35 years of age and the majority were overweight or of these are known risk factors for thrombosis and which is the leading cause of maternal Many also had multiple or had multiple including mental health conditions and which assessors felt may have impacted the care that they This was particularly apparent in the care of recent migrant women who faced due to language or limited of UK maternity Inequalities also continued to amongst women from Black and Asian ethnic backgrounds and in women living in the most deprived areas. these and the increasing and of the maternity must an important focus in to and prevent maternal deaths.