Once again, the latest MBRRACE-UK reports on maternal mortality rates, stillbirths and neonatal deaths during 2016-2018 have highlighted significant and growing inequalities stemming from deprivation and disadvantage. The deeply concerning evidence about these deaths should not be a surprise; these inequalities have been known and written about for many years.
The statistics are stark. Babies born in the most deprived areas are at an 80% higher risk of stillbirth and neonatal death compared to those living in the least deprived. Women living in these areas are almost three times more likely to die themselves in pregnancy, childbirth or in the year after. ‘Saving lives, improving mother's care’ shows that as the level of deprivation increases, so does the risk of dying. Of the women who died, 37% lived in areas ranked at the very highest index of multiple deprivation, compared to 7% in the least (MBRRACE-UK, 2020).
The number of women who are known to have been experiencing multiple disadvantages when they died increased by a third since the last report, from 6%–8% (MBRRACE-UK, 2020). The sharpness of this increase in just 12 months shows these inequalities were widening even before COVID-19 hit.
While deprivation and multiple disadvantage have been featured in previous MBRRACE (2020) summaries and infographics, this is the first time connections to social services have been spotlighted. This year's report shows a fifth (20%) of the women who died were known to social services, a figure that has risen from 12% in 2012–2014.
We all know these sad deaths are the tip of the iceberg. Behind them lie untold numbers of near misses and serious incidents that risk the lives and long-term physical and mental wellbeing of women and their babies.
The wider determinants of health
Work is underway to address the inequalities experienced by black, Asian and other minority ethnic women and their babies; work that's greatly needed. However, inequalities arising from structural, institutional and interpersonal racism don't exist in a vacuum. To address these, and the other disparities outlined above that act on the health of women across all ethnicities, we need to focus on the impact of deprivation and complex social factors that intersect with, and intensify, each other.
Evidence shows our health and social care systems are not as informed as they should be by evidence on the social determinants of health (Health Foundation, 2010). Our own research at Birth Companions, in partnership with Birthrights (2019) and Revolving Doors (2018), has demonstrated these systems are often ill-equipped to respond to the complexity of many women's needs during pregnancy and the year after birth.
That so many of the women who died were known to social services is a crucial clue. ‘Saving lives, improving mother's care’ tells us ‘involvement with social services is an indicator of the otherwise largely invisible levels of need and adversity experienced by many of the women who die’.
Working together to address complex needs across systems is difficult. Prejudice may also play a part: we should interrogate the assumptions and biases that inform the care of people in the most disadvantaged parts of our society, and the way these feed into structural inequality.
What needs to happen now
Now is the time to improve data collection, particularly on the social factors that have a bearing on outcomes for women and their babies. Local Maternity Systems, hospital trusts, child and adult social services and voluntary sector organisations will need to work together more closely and creatively than ever to build personalised, trauma-informed care pathways for women experiencing inequalities. At the heart of these efforts must be a recognition of the fact that women's needs often span several complex systems beyond maternity including social services, immigration, housing and others.
Birth Companions will be engaging with stakeholders across all these systems in the coming months to discuss the best ways to move forward and offering our support in this crucial work. Together, we can narrow these gaps, and improve the outcomes of women and babies who have been forgotten for too long.