Maternal death rates are widely considered to reflect a country’s overall wellbeing and the quality of the healthcare system.
In most high-income countries, giving birth is a relatively safe experience. Nevertheless, maternal deaths still happen and are increasing in many countries around the world.
Recent data from the UK show that death rates during pregnancy and the period shortly after are reaching levels not seen in the country for almost 20 years. It is important to understand why this is happening and what needs to be done to stop this worrying trend.
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COVID-19 not the only factor
As the world continues to recover from the effects of a pandemic, it would be easy to blame the increase in maternal deaths directly on COVID-19 infection. Coronavirus may be part of the reason, but it is not the full picture. When the women who died directly from COVID-19 are not included in statistics, the UK maternal mortality rates are still higher than they were before the pandemic. This suggests there are larger issues with maternity care and the wider health system.
During pregnancy the immune system changes to protect the growing baby. This means that pregnant women are at higher risk from some infections than those who are not pregnant. Large multi-country studies have shown that women who get COVID-19 are more likely to need intensive care if they are pregnant or recently pregnant.
In the UK from 2020 to 2022, COVID-19 was responsible for 14% of maternal deaths. This did not have to be the case. Studies clearly show that the COVID-19 vaccine is safe in pregnancy – but many pregnant women are still hesitant to get vaccinated.
Pregnancy and inequality
Being pregnant or recently pregnant leads to inequitable care. Pregnant women are often excluded from medical research. This means that they do not have the evidence necessary to make informed choices about their health and the health of their baby. It also means that the people caring for pregnant women do not feel prepared to offer advice or treatment. Enquires into the care of pregnant women with COVID-19 showed that many were denied treatments known to be effective just because they were pregnant.
Inequalities are even greater when a pregnant woman belongs to an ethnic minority or socio-economically disadvantaged group. Black women and women living in the 20% most deprived areas of the UK have unjustly high maternal mortality rates. This is not a problem unique to the UK. Nor is this a new problem. The problems faced by minority groups when accessing healthcare are well known and widespread. They were also made worse by the COVID-19 pandemic.
The pandemic placed unprecedented stress on health care systems all over the world. It created new strains due to increased demand for services, staff shortages and burnout. It also revealed cracks in established services and changed the way that care was provided.
Maternity care was not immune to pressures of the pandemic. Most women who die in high-income countries are not dying from pregnancy complications such as bleeding. However, rates for these direct deaths are rising in the UK. Pregnancy complications can be managed if women have timely access to quality care and skilled health professionals. It is becoming increasingly clear that this may not always be the case in current under-pressure health systems.
Overstretched health system
In the era of COVID-19, services that should be easily available to women are becoming increasingly difficult to access. The current maternity population is more complex than it once was. Women giving birth are often older and many are overweight or obese. Many women also have other medical or mental health conditions that require additional care in pregnancy. From 2019 to 2021 12% of the women who died in the UK had severe and multiple disadvantages including a mental health diagnoses, substance use or domestic abuse.
The changing maternal population needs enhanced services that can adjust to fit their individual needs. But access to specialised care was irregular or lost during the pandemic. This is especially true for care before or after pregnancy. Many women do not get the care they need before conceiving and many more are falling through the cracks after they have their baby. Mental health conditions are an important example of this. Almost half of maternal deaths in the year after pregnancy are due to suicide or substance use. Access to maternal mental health services is improving but more capacity is still needed.
The pandemic exposed and accelerated the cracks in health systems, and, as these latest figures show, this has set back progress towards safer pregnancy in the UK by decades. As a barometer of a nation’s health, this is a statistic we cannot ignore. Novel approaches and investment are needed to ensure every woman gets the individualised and equitable care they need before, during and after pregnancy.
Marian Knight receives funding from the Healthcare Quality Improvement Partnership and the National Institute for Health and Care Research.
Allison Felker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
