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Recent research suggests that prevention guidance issued by coroners after maternal deaths in England and Wales are not being acted upon.

Key Findings from the Research

Academics from a leading London university examined prevention of future deaths reports released by medical examiners involving pregnant women and new mothers who passed away between 2013 and 2023.

The research, released in BMJ Gynecology and Obstetrics Clinical Medicine, identified 29 prevention of future death reports related to maternal deaths, but discovered that nearly two-thirds of these recommendations were not implemented.

Concerning Statistics and Patterns

Two-thirds of these deaths occurred in hospitals, with over 50% of the women dying after giving birth.

The primary causes of death included:

• Severe bleeding
• Problems during early pregnancy
• Self-harm

Medical Examiners' Main Worries

Problems highlighted by coroners commonly included:

• Inability to deliver appropriate care
• Absence of referral to specialists
• Inadequate medical training

Response Levels and Regulatory Requirements

Healthcare providers, like other regulatory organizations, are mandated by law to reply to the medical examiner within eight weeks.

However, the study discovered that only 38% of PFDs had publicly available replies from the institutions they were addressed to.

Worldwide and National Context

According to recent figures from the World Health Organization, approximately 260,000 women died during and after pregnancy and childbirth, despite the fact that the majority of these instances could have been prevented.

While the overwhelming majority of maternal deaths happen in lower and middle-income countries, the risk of maternal mortality in wealthier countries is typically 10 per 100,000 births.

In the UK, the maternal mortality rate for recent years was 12.82 per 100,000 births.

Professional Perspective

"The voices of parents and expectant individuals must be taken seriously," commented the lead author of the research.

The researcher stressed that prevention reports should be included as part of the upcoming independent investigation into NHS maternity and neonatal care to ensure that the same failures and deaths do not happen repeatedly.

Personal Loss Highlights Widespread Problems

One family member described their story: "Postnatal mental health issues can be fatal if not handled quickly and appropriately."

They added: "If lessons aren't being learned then it's probable other mothers are slipping through the net."

Formal Response

A representative from the official inquiry stated: "The aim of the official review is to pinpoint the systemic issues that have caused negative results, including deaths, in maternity and neonatal care."

A Department of Health spokesperson described the inability of institutions to respond quickly to PFDs as "unacceptable."

They confirmed: "Authorities are taking immediate action to improve safety across maternity and neonatal care, including through sophisticated tracking technology and initiatives to avoid neurological damage during delivery."