Dr Vidya Shyam-Sundar1, Doctor Charlotte Frise2, Miss Louise Page3, Miss Chandrima Biswas3, Dr Kirsty MacLennan3, Mr Julian Sutton3, Miss Rachel Rees3
1Royal Free NHS Foundation Trust, London, U.K., 2Imperial College Healthcare NHS Trust, London, U.K., 3Maternity and Newborn Safety Investigation (MNSI) programme, Care Quality Commission, London, U.K.
Biography:
Biographies to come
Abstract:
Introduction: The 2015 national maternity ambition (1) in England aims to halve maternal deaths by 2025. Pregnant women in the first trimester pose a unique challenge to healthcare providers due to the unclear accountability of health services in the time between conception and registration with their maternity team. It is imperative to understand factors contributing to deaths in the first trimester so that services, maternal and neonatal outcomes can be improved. The Maternity and Newborn Safety Investigations (MNSI) (2) programme investigates patient safety events, working closely with staff, trusts and families, aiming to improve maternity safety in England.
Methods: 24 first trimester maternal deaths were identified from completed MNSI investigations between 2019 and 2023; these underwent detailed thematic review.
Results: The themes were:
• Significant inequalities in accessing services
• Limited communication between health records leading to medication errors and incomplete knowledge of women with medical problems
• The use of nationally advised scoring systems e.g. PUQE, MEWS, VTE risk assessment was limited and contributed to maternal deaths in 10 cases.
• Virtual consultations contributed to the late detection of medical problems (direct and indirect effects of the pandemic).
• No or incomplete safety-netting advice and unclear accountability when following-up women post-discharge.
Women did not have clear ownership of care prior to booking and this contributed to confusion about the required services to access. Whilst pre-conception counselling was offered to women with existing medical conditions, this often did not materialise, and in any event, there was a lack of timely specialty involvement when these women presented to secondary care.
Conclusions: National guidance is urgently needed to address the unclear accountability for women in their first trimester. Clinicians in primary and secondary care need clear direction about scoring systems and communication pathways. With these modifications women will receive safer, holistic, personalised care from the start of pregnancy.
Keywords
pregnancy, maternity, maternal medicine, health inequalities, first trimester, deaths in pregnancy, risk assessment
References
1. Maternity Safety Programme Team, Department of Health, Safer Maternity Care [Internet] 2016 [updated October 2016, cited May 25 2024] Available from: https://assets.publishing.service.gov.uk/media/5a80efa3ed915d74e33fd3d7/Safer_Maternity_Care_action_plan.pdf
2. Maternity and Newborn Safety Investigations [internet] 2024 [updated 2024, cited May 25 2024] Available from: https://www.mnsi.org.uk/