191 Assessing the care received amongst recently arrived pregnant or postnatal migrant women who died in the UK 2012-2021: a co-produced national review of medical records

Abstract OP 26: Exclusion and Discrimination 4, B207 (FCSH), September 4, 2025, 16:00 - 17:00 Background In 2023, one in three women giving birth in England and Wales was not born in the UK. Within high-income countries, some migrant women are at higher risk of maternal mortality. To our knowledge, this is the first study to describe the demographics and perinatal outcomes of recently arrived migrant women who died in the perinatal period over the past decade in the UK, and to conduct a confidential national enquiry to identify areas for improvement in care. Methods This study used surveillance data from the UK Confidential Enquiry into Maternal Deaths to identify maternal deaths amongst recently arrived migrant women (less than two years before their death) between 2012-2021. Maternal characteristics were summarised, followed by a systematic review of medical records using a bespoke ‘gold standard care’ checklist for recently arrived migrant women which was created with migrant women with lived experience and health and policy professionals. Findings 39 recently arrived migrant women died in the UK between 2012-2021. Amongst those eligible for antenatal care, most (70%, n = 19/27) were booked late. Over half of women did not have an interpreter for consent for intrapartum interventions (56%, n = 5/9). Many women’s records contained indications of potential discrimination in care (64%, n = 25/39). Three women (8%, 3/39) were recorded as being eligible for NHS charging. The review identified a series of potential areas for improvement in care including the delivery of respectful care; follow-up after non-attendance; access to formal interpreting services; and early access to booking appointments. Interpretation The review highlights the areas to improve maternity care for migrant women in the UK, and highlights the value of involving service users in similar reviews. The findings may also have relevance to maternity care for migrant women in similar countries.