Suicide, mental health and addiction are among the factors associated with a “high” number of maternal deaths of women who attended the maternity service at University of Limerick Hospital Group (ULHG), its Chief Clinical Director has communicated to the HSE Chief Clinical Officer (CCO).
In correspondence dated 28 November 2022, Prof Brian Lenehan informed the CCO Dr Colm Henry that the response to these deaths – which included ‘late maternal deaths’ – would require the collaboration of a range of services across the community, voluntary and acute hospital sectors.
In his letter, Prof Lenehan outlined that the management team in ULHG’s maternal and child health directorate had escalated concerns to him relating to a “high number of maternal deaths of women attending maternity services” at the Hospital Group. Since August 2021, there had been a (redacted) number of maternal deaths notified to the directorate, some of which were late maternal deaths, according to the correspondence obtained from the HSE under Freedom of Information law.
A maternal death is defined by the World Health Organisation 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. A late maternal death is the death of a woman from direct or indirect obstetric causes, more than 42 days but less than one year after the end of pregnancy.
In his correspondence, Prof Lenehan referenced a national maternal mortality rate of 5.4 per 100,000 maternities, a figure that was published by Maternal Death Enquiry (MDE) Ireland for the triennium 2016-2018 (calculated excluding late maternal deaths). Prof Lenehan stated that “the number of recently reported maternal deaths in the mid-west are significantly higher than would be expected”.
“Systems analysis reviews” had highlighted suicide, mental health, addiction and social deprivation as factors in a number of maternal deaths. The ULHG Chief Clinical Director added: “Some of the women were known to perinatal or community mental health services. The mid-west has some of the most socio-economically deprived areas in the country, particularly in Limerick city.”
In the correspondence, Prof Lenehan advised Dr Henry he had recently discussed the matter at a meeting with Dr Peter McKenna, Clinical Lead of the HSE obstetric event support team (OEST), and Dr Cliona Murphy, Clinical Director of the HSE National Women and Infants Health Programme (NWIHP).
He added: “The service response required to prevent these tragic deaths is beyond the scope of the maternity services at [ULHG], and requires highlighting nationally with engagement and collaboration of a range of services across the community, voluntary and acute hospitals sector.”
In an email to the NWIHP about Prof Lenehan’s correspondence, Dr Henry stated that, after speaking with Dr McKenna, “we agreed that we would reply indicating how we propose to address (in so far as we can within the remit of healthcare services) the issues raised.”
Records show that NWIHP Director Mr Kilian McGrane responded that “this has been an area of concern for some time, and NWIHP colleagues requested the formal escalation. ULHG have a very good perinatal mental [health] service, and despite this the case numbers are concerning”. Mr McGrane referred to an ongoing recruitment process for a new national Clinical Lead for perinatal mental health and plans to hold a meeting with the ULHG when this person was in place.
When contacted for comment, ULHG did not provide information on the number and nature of the maternal deaths described in the correspondence, or whether it had been advised of further action towards a collaborative response.
A ULHG spokesperson said it “has long prioritised care for maternity service users with mental health needs”. In April 2018, University Maternity Hospital Limerick and HSE Mid West Community Healthcare opened the first specialist perinatal mental health service (SPMHS) outside of Dublin.
Since the commencement of the service to the end of 2022, the SPMHS had received 3,626 referrals. Last year it received an average of 68 new patient referrals each month, while there had been a 334 per cent increase in SPMHS attendances from 2019 to 2023. “The significant numbers of women accessing the service in part shows the growing awareness of the SPMHS and willingness of women to come forward to speak about their concerns.”
As many as one-in-five women have mental health problems in pregnancy or the year after birth, added the spokesperson. “Whilst the focus of this specialist service is on women with moderate-to-severe mental illness, it also ensures women with milder mental health problems are both identified and receive appropriate help from skilled staff within maternity services.”
Asked for statistics on the number of maternal suicides in the mid-west and other regions, the HSE stated: “Suicide is a verdict returned by the coroner and the purpose/role of a systems analysis review is not to determine the cause of death. As the numbers involved are very small and coroner confirmation may not be known, NWIHP is not in a position to release the numbers, in case any individual may be identified.”
Ireland and UK data
MDE Ireland statistics for the triennium 2018–2020 reported a national total of 11 maternal deaths (occurring during or within 42 days of the end of pregnancy) among 174,505 maternities. Of the four direct maternal deaths, one was due to “psychiatric causes” (suicide). One of the seven indirect maternal deaths was categorised as “psychiatric and alcohol related”. In addition, one of the eight reported late maternal deaths was attributed to suicide.
The Irish Maternity Indicator System National Report 2021 noted five maternal deaths in 2021 and two in 2020 (deaths of women while pregnant or within 42 days of the end of pregnancy) with the causes not included in the report.
According to UK maternal death data for 2018-2020, mental ill-health and heart disease are now on an equal footing as a cause of maternal deaths in the UK. Added together they represented 30 per cent of maternal deaths during or up to six weeks after pregnancy. Forty per cent of deaths within the year after pregnancy were from mental health causes, with maternal suicide remaining the leading cause of direct deaths in this period (MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, 2022).
The UK report also found that, in 2020, women were three times more likely to die by suicide during or up to six weeks after the end of pregnancy compared to data for 2017-2019 (1.48 per 100,000 compared with 0.46 per 100,000). A pattern of multiple adversity remained extremely common in women who died through suicide and substance misuse, it reported.
In Ireland, maternal mortality due to suicide was the subject of a learning notice issued by the NWIHP in October 2021 following notifications in the same geographical area, which was not named. The learning notice to Hospital Group CEOs and maternity units asked the services to review screening processes for perinatal mental health services with the relevant specialists in their hospitals. “The numbers are small and may be a statistically [sic] artefact, however, given the serious nature of the adverse outcome it is important that the wider maternity community should be informed,” according to the learning notice.
Prior to the reviews being completed, it was “difficult to speculate what other factors, like Covid or social exclusion, may have played in these unfortunate outcomes”, it added.
Asked about the ULHG correspondence in a wider interview on the OEST last month, Dr Murphy of NWIHP said the issues raised related to “the intersectionality between pregnancy and then homelessness and addiction” – issues which she said were not necessarily well captured by maternity services.
The need to better support women with additional needs and vulnerability had also been highlighted in UK maternal death data, noted Dr Murphy, who said the NWIHP was following up on these matters.
Mr McGrane of NWIHP said that a new national Clinical Lead for perinatal mental health had recently been appointed, had visited the sites to identify challenges, and would bring his findings to the Clinical Lead for mental health services in the first instance. He said the system, which is based on a hub-and-spoke model, was “good” but “busier than we anticipated”.
Mr McGrane also stated that the programme had not yet received reports on the cases referenced in the ULHG correspondence to identify the specific factors involved.