RCM comments on MBRRACE-UK Saving Lives, Improving Mother’s Care report

on 01 November 2018 MBRRACE Maternal Death Obesity Antenatal / Prenatal Prenatal Depression Perinatal Mental Health Specialist Midwives Specialist Mental Health Midwives

Today (Thursday 1st November) MBRRACE – UK have published the Saving Lives, Improving Mothers’ Care report.

The MBRRACE-UK report, led by the National Perinatal Epidemiology Unit at the University of Oxford, includes data on women who died during or up to one year after pregnancy between 2014 and 2016 in the UK.

Responding to the report and its recommendations, Mandy Forrester Head of Quality and Standards at the Royal College of Midwives (RCM) said; “Every maternal death is a heart-breaking tragedy which leaves families devastated and is particularly difficult for children left without a mother.   

“Cardiac remains the single biggest cause of maternal death and we need to ensure that these women have increased  support from the very early stages of their pregnancy. In most cases, the women who died also had pre-existing medical conditions, such as obesity, diabetes and mental health conditions. This is why we urgently need to see improvements in support for women who have pre-existing medical conditions in forward planning for pregnancy and throughout their antenatal and post natal care journey.

“Obesity remains a factor in maternal deaths and we know there is strong evidence of the risks of obesity and excess weight gain in pregnancy. This is especially pressing because of the potentially serious complications that can arise in pregnancy as a result of women being overweight or obese.

“Disappointingly there has been no real change in the rates of haemorrhaging, so we need to ensure that we have the right maternity teams in the right places at the right time to save women’s lives.

“One quarter of those who died where born outside of the UK and many had pre-existing medical conditions. The RCM believes much more research is urgently needed to understand why black women are five times more likely and Asian women twice as likely to die compared to white women.

“Shockingly 10 women where murdered during pregnancy or up to six months after birth, some of whom where victims of domestic violence prior and during their pregnancy. This is why it is vital we ensure midwives have enough time to spend with women to identify those who are vulnerable or may be at risk.

“71 women died by suicide and of those that died by suicide many of their history was not know to maternity services. That is why we need see an improved sharing of records between all healthcare professionals and take a multi agency approach to sharing vital records.

“We know that large gaps in quality remain in perinatal mental health care services for women and support often is wrongly a postcode lottery. Action has to be taken to now to prevent more women from dying or suffering unnecessarily.

“The RCM has said time and time again that there is an urgent need for the government to invest more into funding support services for women suffering with mental health problems. Every trust with maternity services should have a specialist  midwife in post to enable women who are unwell to get the very best care and support they need.

“The RCM believes continuity of carer is vital to improving the care women receive while pregnant and it crucially could save lives. Continuity of carer enables a woman to see the same midwife, or small group of midwives throughout and after her pregnancy. This is even more so important particularly for women with  pre-existing health and mental health conditions who are being cared for by multidisciplinary team maternity professionals.

“Paramount is the need for improved communication between maternity professionals and those in other disciplines, so that if a midwife or doctor spots something is not right for a woman they can share the problem with the right colleagues so that the right actions can be taken in good time.

“The RCM is urging policy makers, service planners, commissioners and all healthcare professionals who work in our maternity services to work on the recommendations contained within this report to achieve a greater reduction in the number of maternal deaths and to ensure all women receive safe high quality  maternity care.”


*Read RCM’s report ‘Every mother must get the help they need’*

The report is inspired by Lucie Holland’s 2015 Change.org petition. Lucie Holland’s sister died in tragic circumstances as a result of a devastating mental illness.  Lucie subsequently set up a Change.org petition in 2015 about the urgent need for better awareness and care for those affected by perinatal mental illness. This petition went viral with thousands of signatures, and many people left heartfelt comments about their own experiences.

The RCM and its partners have analysed and collated all the comments to form the report - Every mother must get the help they need


Notes to editors

The RCM is the only trade union and professional association dedicated to serving midwifery and the whole midwifery team. We provide workplace advice and support, professional and clinical guidance and information, and learning opportunities with our broad range of events, conferences and online resources. For more information visit the RCM website at https://www.rcm.org.uk/