Systematic exploration of local reviews of the care of maternal deaths in the UK and Ireland between 2012 and 2014: a case note review study

BMJ Open. 2019 Jun 29;9(6):e029552. doi: 10.1136/bmjopen-2019-029552.


Objectives: Local reviews of the care of women who die in pregnancy and post-birth should be undertaken. We investigated the quantity and quality of hospital reviews.

Design: Anonymised case notes review.

Participants: All 233 women in the UK and Ireland who died during or up to 6 weeks after pregnancy from any cause related to or aggravated by pregnancy or its management in 2012-2014.

Main outcome measures: The number of local reviews undertaken. Quality was assessed by the composition of the review panel, whether root causes were systematically assessed and actions detailed.

Results: The care of 177/233 (76%) women who died was reviewed locally. The care of women who died in early pregnancy and after 28 days post-birth was less likely to be reviewed as was the care of women who died outside maternity services and who died from mental health-related causes. 140 local reviews were available for assessment. Multidisciplinary review was undertaken for 65% (91/140). External involvement in review occurred in 12% (17/140) and of the family in 14% (19/140). The root causes of deaths were systematically assessed according to national guidance in 13% (18/140). In 88% (123/140) actions were recommended to improve future care, with a timeline and person responsible identified in 55% (77/140). Audit to monitor implementation of changes was recommended in 14% (19/140).

Conclusions: This systematic assessment of local reviews of care demonstrated that not all hospitals undertake a review of care of women who die during or after pregnancy and in the majority quality is lacking. The care of these women should be reviewed using a standardised robust process including root cause analysis to maximise learning and undertaken by an appropriate multidisciplinary team who are given training, support and adequate time.

Keywords: clinical governance; obstetrics; quality in health care; risk management.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Cause of Death
  • Female
  • Humans
  • Ireland / epidemiology
  • Maternal Death / statistics & numerical data*
  • Medical Audit* / methods
  • Pregnancy
  • Pregnancy Complications / mortality
  • United Kingdom / epidemiology