While all untimely deaths are tragic, the death of a new mother in pregnancy or the post-natal period carries a particular poignancy. The tragedy is frequently compounded as when a mother dies often her baby dies too. A maternal death can also rob a loved one of their life partner and other surviving children of their mother.
According to the HSE's National Guideline for Bereavement Care Following Maternal Death within a Hospital Setting (2017), "A maternal death has far-reaching consequences. It may occur in many settings, eg maternity/general/psychiatric hospital, in the home, hospice or clinic. It frequently involves a second death, the death of a baby. Most maternal deaths occur suddenly. Without warning spouses/partners, children and other relatives face a new reality for which there can be no preparation."
In an ideal world, guidelines like these would not be needed. New mothers are not supposed to die, but, sadly, they do.
The report was published by the Health Service Executive in conjunction with the Institute of Obstetrics and Gynaecology at the Royal College of Physicians of Ireland earlier this year, and was developed "to improve and standardise bereavement care provided to families in the aftermath of a maternal death".
The report outlines "the bereavement care process" that should take place when a mother dies. It was developed by a group composed of multi-disciplinary staff from the HSE clinical and administrative services, the Irish Hospice Foundation, and academic specialists. Families affected by a maternal death also informed the group.
All maternal deaths in Ireland are recorded by the confidential Maternal Death Enquiry (MDE) Ireland. Launched in April 2009, MDE Ireland is a standalone office, based in the National Perinatal Epidemiology Centre in Cork University Maternity Hospital and is funded by the HSE.
MDE Ireland conducts confidential enquiries into maternal deaths from all causes that occur during, or within one year of, pregnancy. It produces maternal mortality reports on a regular basis and also participates in the UK confidential enquiry into maternal deaths. The British study is a national programme investigating maternal deaths in the UK and Ireland. Since June 2012, the programme has been carried out by the MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries) collaboration.
Learning opportunity
Edel Manning is the co-ordinator for MDE Ireland and a research midwife in the National Perinatal Epidemiology Centre.
Manning has worked with MDE Ireland since its inception in 2009 and says that, while the number of maternal deaths in Ireland is relatively low particularly in comparison with developing countries, “we really can’t afford to become complacent”.
According to Manning, the confidential data recorded by MDE Ireland provides a valuable learning opportunity for Irish maternity services. For example, she says one issue that has come through from both the Republic’s and the UK enquiries was the impact of mental health on maternal deaths. “It is only through reviewing these cases that we can learn from them,” she says.
“It gives us an awareness of why women die and the MDE reviews deaths to see if there are any lessons to be learned and whether there are recommendations for the maternity services,” Manning adds.
“Historically, Irish healthcare professionals have learnt from recommendations within previous UK enquiry reports. Ireland joined the UK-based enquiry because participating in a larger cohort protects confidentiality and allows for meaningful recommendations for care,” she says.
Over the past eight years of working with MDE Ireland, Manning says that the enquiry has raised awareness of maternal death and the maternity units throughout the country have been very supportive of its work.
She also says the data has highlighted the higher proportion of maternal deaths due to indirect causes and the importance of counselling and multidisciplinary care prior to conception for women with pre-existing medical and mental health disorders.
The World Health Organisation defines a maternal death as "the death of a woman while pregnant or within 42 days of the end of the pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes."
‘Chain of events’
Maternal deaths are classified as direct or indirect. Direct maternal deaths are those that result from “obstetric complications of the pregnant state (pregnancy, labour and the puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above.”
Indirect deaths are those “resulting from previous existing disease, or one that developed during pregnancy and which was not the result of direct obstetric causes, but which was aggravated by the physiological effects of pregnancy.”
Late maternal deaths are those that occur between 42 days and one year after the end of the pregnancy as a result of direct or indirect causes.
The latest report from MDE Ireland, which covers maternal mortality in Ireland between 2012 and 2014, revealed that 22 mothers died during or within 42 days of the end of their pregnancy. Of these, 20 were classified as direct or indirect and two were attributed to coincidental causes.
The direct maternal deaths were due to issues such as thromboembolism (blood clot), pre-eclampsia and eclampsia (seizures related to high blood pressure), amniotic fluid embolism (a condition where material enters the mother’s blood stream via the placenta) and genital tract sepsis.
The indirect causes included cardiac disease and other issues such as infectious disease.
Seven late-maternal deaths were reported to MDE Ireland in the period 2012-2014. The causes of death were: psychiatric causes (four cases), thromboembolism (one case) and two cases of malignant disease which were classified as coincidental to the pregnancy.
Overall the report found that between 2012 and 2014, the State’s maternal mortality rate was 9.8 per 100,000 maternities this was similar to the UK rate of 8.54 per 100,000.
Dr Michael O’Hare is a consultant obstetrician in Newry and chairman of MDE Ireland. He agrees that the maternal death rate in Ireland was very similar to that in the UK and on an international basis, certainly in comparison with eastern Europe, our rates compare favourably.
O'Hare points out that, prior to MDE Ireland, there had been no systematic audit of maternal mortality conducted in the State for about 25 years. By comparison, maternal death enquiries in England and Scotland were first initiated in 1952.
A popular phrase that regularly turns up in debates on maternity services here is that “Ireland is one of the safest places in the world to have a baby.” Indeed, in June 2014, Taoiseach Enda Kenny referred to Ireland as one of the “safest places on the planet in which to give birth”.
The evidence for this declaration is unclear, however. According to O’Hare, it certainly predates the establishment of MDE Ireland and relies on data taken from Central Statistics Office figures which significantly underestimate maternal deaths.
“What we can say is that, from a maternal point of view, we are as safe as other countries in western Europe and including the UK,” O’Hare says.
Devastating impact
Coupled with the devastating impact a maternal death has on the mother’s family, the loss of a mother also has a traumatic effect on all those involved in her care.
“Any maternal death in any maternity unit has a profound effect on the whole department, all of the unit and the morale in the unit . . . it is a major tragedy,” O’Hare adds.
Historically, maternal deaths by suicide were classified as indirect maternal deaths. However, according to the MDE Ireland report, “in recognition of the importance of maternal suicide and its direct link to pregnancy, the most recent WHO guidance on classification of maternal mortality has recommended that maternal deaths due to suicide are classified as direct rather than indirect maternal deaths”.
There were three maternal deaths by suicide in Ireland within 42 days of the end of the pregnancy and a further four late-maternal deaths between 2012 and 2014. This means that suicide is now the leading cause of both direct- and late-maternal deaths in Ireland.
Perinatal psychiatrists are specialist mental health professionals who care for women in the antenatal and post-natal period. Consultant perinatal psychiatrist with the National Maternity Hospital in Holles Street Dr Anthony McCarthy is one of just three consultant perinatal psychiatrists in the State, all of whom are part-time and based in Dublin – there are no perinatal psychiatrists outside the capital.
About 20 per cent of maternal suicides occur in pregnancy. Understanding the reasons mothers take their own lives during pregnancy or the post-natal period is a major issue, says McCarthy.
“A woman is 19 times more likely to be admitted to a psychiatric hospital in the first six weeks after the birth of her baby than in any other six week period in her whole life. So there is something about having a baby that produces this acute window of challenge for any mother,” he explains.
There is a myriad of complex physical and psychological issues that face women in pregnancy and after the birth of a new baby. These may include the physical demands of both pregnancy and birth – the birth itself may be hugely traumatic, the impact of hormones, sleep disturbances that come with a new baby, and perhaps exhaustion from breastfeeding.
‘Challenging’ time
While having a new baby is a wonderful period for many women, McCarthy points out that for some it is “a challenging and questioning time.”
“Obviously, if there were any complications in one’s sense of being mothered, being fathered, that can come up. Equally any other challenges around the baby. Is it a baby that sleeps? Is it a baby that is healthy? Is it a baby that you wanted? Is it a baby that has colic and you don’t sleep at all? Who does the baby look like? Does it look like the man who raped you? Does it look like your father who sexually abused you? Does it look like your mother who died six weeks ago? Does it look like yourself and you hate yourself?” says McCarthy.
“For a woman, her whole body is being challenged, her whole psychological history, her whole life story, her whole self, her relationships, everything is at play and particularly if she has underlying mental health problems that are not being addressed,” he adds.
It is estimated that 11 per cent of women will suffer from post-natal depression, 2-3 per cent will develop a very serious depression and one in 500 new mothers will develop post-partum psychosis.
So does all this lead to suicide? “Suicide is a very particular act because although suicide is the most common direct cause of maternal death in that most recent [MDE Ireland report], it is still very rare,” McCarthy says.
“I can give you all the background factors, but what makes any one individual person at that particular moment decide to kill themselves, that is a very personal individual question and I wouldn’t want to generalise at all about that . . . sometimes reading these confidential enquiries into maternal deaths, reading 850 pages of notes written by all sorts of people who might have seen the woman during the pregnancy and after it. And I am still at the end of it all saying but why did she do it? What was that last straw? I don’t know but it is a vulnerable time certainly,” McCarthy says.
Mental health services
The lack of perinatal mental health services for women in this country has long been highlighted. However, the State's first national perinatal mental health strategy entitled Specialist Perinatal Mental health Services: Model of Care for Ireland is due to be published shortly.
This much-needed strategy calls for a major expansion of services for maternal mental health throughout the country and McCarthy says that, if delivered, it would be “an extremely positive development for mothers in pregnancy throughout the country”.
When the tragedy of a maternal death visits a family, all members of the multi-disciplinary team have a role to play in supporting the bereaved.
One such professional is Rev Dr Daniel Nuzum, a healthcare chaplain, adjunct lecturer in the Department of Obstetrics and Gynaecology in UCC and member of the maternal death bereavement care guideline development group.
Describing it as a “lifelong bereavement” Nuzum says that the most important way to support a family is simply by being present. “From a chaplaincy perspective, it is not actually the words we use at all but it is the presence and support because literally somebody’s world has fallen apart.”
From a chaplaincy perspective Nuzum suggests that one thing that can help is to record the story of how the mother died. This can be particularly beneficial if the surviving newborn wishes to know more about his or her birth story in the years to come. He explains that this can sometimes take the form of a letter to the baby in which the family can write the narrative of their birth. This can include who was there, what happened, where they were and that they cared for his or her mother.
Nuzum says that another important aspect of his work is caring for healthcare professionals in the wake of a maternal death.
“It is a devastating experience when a mum dies . . . and it’s important that people have time to process and reflect on what has happened and also to be aware of the personal impact and personal sense of loss that professionals can feel when somebody they have been caring for like this dies. They are always tragic deaths.”
If you have been affected by anything in this article, help and support is available. Please call Samaritans’ 24-hour helpline: 116 123 for immediate support.
