Maternal deaths during the pandemic in England

This national learning report from the UK reviews the 20 maternal deaths (defined as death during pregnancy/childbirth or shortly after the end of a pregnancy) that occurred between 1st March and the 31st May, 2020 – the period of the first peak of the COVID-19 pandemic in England.

Seven themes emerged from the Health Safety Investigation Branch’s investigations:

  • 1) Unprecedented demand for telephone health advice caused delays for women or their family members in accessing health care;
  • 2) Public messaging and ‘safety netting’ advice (e.g. to stay at home) caused delays in seeking healthcare;
  • 3) Guidance changed rapidly and it was difficult for hospitals to keep staff up-to-date with the latest information from government;
  • 4) Use of early warning scores did not always detect deterioration;
  • 5) Personal protective equipment requirements changed due to Covid-19 and staff experienced communication difficulties associated with wearing PPE;
  • 6) Staff described stress and distress owing to communication difficulties, redeployment to unfamiliar work areas and reduced staffing levels;
  • 7) Difficulties were encountered in making a diagnosis and choosing treatment strategies owing to lack of face-to-face assessment, access to tests and concerns about infection prevention.

Read more: Healthcare Safety Investigation Branch (2021) Nationa Learning Report: Maternal death: learning from maternal death investigations during the first wave of the COVID-19 pandemic. Available at: <accessed 26 February, 2021>

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