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Patient safety and adverse maternal health outcomes: the missing social inequalities ‘lens’

There is a small, but growing, national and international literature that specifically describes itself as being concerned with ‘patient safety’ issues in maternity services. This has included studies on reduction in clinical errors and on improvements in the management of obstetric emergencies. Recent work conducted in an English hospital, funded by the National Patient Safety Agency (NPSA), has also highlighted the relationship between shortfalls in midwifery staff levels and adverse events and near misses. The Confidential Enquiries into Maternal Deaths (CEMD) has been the single most important mechanism for learning from adverse maternal health events in the UK since the 1950s. The most recent CEMD Report concluded that some form of suboptimal care had occurred in 67% of the 261 cases reviewed. Forty-seven percent of the Direct Deaths were in women who had ‘major substandard care in which different treatment may have affected outcome’. The new and wider public health focus taken in the two most recent CEMD has also highlighted social inequalities in maternal health and healthcare in the UK. The latest report estimated the risk of maternal death in women rom the most socially disadvantaged groups as up to 20 times greater than in women from the more advantaged groups. The risk of a woman in the UK dying today of a pregnancy-related cause is extremely small, but it is of concern that a very high proportion of the women who died during 2000–2002 were classifiable as ‘vulnerable’ or ‘socially excluded’. Such findings raise questions about how well our maternity services are able to meet the needs of women from all groups in society. A structured review of research and evaluation literature since 1990, commissioned by the UK National Patient Safety Agency, attempted to identify the existing evidence on the factors contributing to patient safety incidents in maternity care and adverse maternal health outcomes in the UK. The review considered literature for three population subgroups that had been identified through the CEMD as being at increased risk of maternal death when compared with the general population: ‘teenagers’, ‘women who experience domestic violence’ and ‘women from minority ethnic groups’. ‘Women with physical and sensory disabilities’, and ‘women classified as ‘‘asylum seekers’’’ were also selected for review by the NPSA commissioners because of accumulating evidence that women might be disadvantaged within the current system. These five groups are not the only subpopulations for which there are concerns about disadvantage or possible vulnerability, but they serve to highlight some general issues. The subsequent search of 13 bibliographical databases, websites and other sources of ‘relevant grey’ literature revealed substantial gaps in information and in knowledge for all the groups.