Perinatal deaths of migrant mothers: Adverse outcomes from unrecognised risks and substandard care factors

Abstract

Migrant mothers have a high rate of perinatal mortality. We set out to investigate the reasons through a confidential enquiry of babies born to mothers who were themselves born outside of the UK. The cohort consisted of 36 perinatal deaths from three large hospitals in the West Midlands, including 30 stillbirths and six early neonatal deaths from 34 weeks' gestation, with 18 normally formed babies and 18 with congenital anomalies. The case notes were anonymised and reviewed by independent multi-professional panels to assess standard care factors and avoidability of outcome. Of the normally formed babies, nine (50%) deaths were considered potentially avoidable. The majority of cases had one or more medical (78%) or social (81%) risk factors, most of which were not identified by care providers during pregnancy. Key substandard care themes included poor translation services, inadequate information-sharing with mothers and within the multi-disciplinary team, inappropriate management planning as well as an ad hoc approach to social care and support. In addition, the majority of the perinatal deaths had not been reviewed in the Trust where they had occurred. We conclude that many migrant mothers have medical and social risks that are currently not recognised or acted on, which can result in perinatal deaths that are potentially avoidable. Good risk assessment and communication with the mother as well as within the multidisciplinary team underpins high-quality and safe delivery of maternity care.