‘We are failing women who have their newborn babies removed: that needs to change’

By Kirsty Kitchen

For several years I’ve been part of the team that develops the ‘lay summary’ of MBRRACE-UK’s* annual report on maternal deaths. During this time, my colleagues from across the voluntary sector and I have reflected on this powerful inquiry into the care of the women who die in pregnancy or in the year after birth.

I remember, in the first meeting I took part in, digesting the detailed chapters on deaths relating to cardiac disease, epilepsy, blood clots and ectopic pregnancy, and the high numbers linked to mental health issues. These findings were distressing, as was the degree to which improvements in care could, in many cases, have changed the outcomes for these women.

But the statistic I was most struck by was the proportion of women who died while known to social services.

Rising rate of social care involvement

In the 2016 report, covering 2012-14, that figure stood at 12% of all deaths occurring in pregnancy or up to six weeks after birth; 24 women. In 2017, covering 2013-15, it was 14% (28 women).

By 2021, in the report covering 2016-18, it stood at 20% (43 women in total). In the latest report, published in October 2024 and covering 2020-22, the proportion of women who died while having some involvement from social services had risen to 22%; 61 women.

It’s worth bearing in mind that the percentages reported are the proportion of those women who die in pregnancy or in the following six weeks. Most of the maternal deaths related to mental health occur between six weeks and a year after pregnancy; the period in which maternal suicide is the leading direct cause of death.

Link to mental health-related deaths

And there is evidence of a link between social services involvement and deaths relating to mental health.

Analysis of the deaths that occurred in 2020 found more than one in ten (11%) of those who died by suicide, and 59% of those who died through substance misuse, had had an infant removed into care and/or were involved in ongoing care proceedings. The MBRRACE report authors noted that in several instances, this removal led to an escalating pattern of mental health issues, substance misuse and domestic abuse.

Also, in an increasing proportion of cases, the data on whether women have social services involvement is missing, rising from 3% of cases in 2016 to 15% in 2024.

Rising number of infant care proceedings

We don’t fully understand what’s driving this marked and sustained increase in the number of women dying while known to social services, but the rise in the number of infants subject to care proceedings, and the increase in the number of hearings held with little or no notice in the days immediately following birth, are likely to be significant factors.

At Birth Companions we have always had a focus on supporting women who are at risk of, or experiencing separation from their baby, but the MBRRACE research was one of the reasons we increased our focus on policy and research in this area. Their needs are largely absent from health and social care policy, and they struggle to access mental health support.

Women are navigating one of the most traumatic experiences imaginable, alone.”

That has to change, and we are encouraged that this government, with its mission to give children the very best start in life, and its commitment to keeping families safely together wherever possible, can bring about that change.

Supporting mothers to navigate ‘complex systems’

Our own services have been developed with these needs in mind. This includes our newest service, in Hackney, East London. The Izzy Project was co-designed with women with lived experience of social services assessment and removal during pregnancy and early motherhood, along with over 40 local stakeholders.

Through this service, our specialist staff work closely with, but independently of, maternity and children’s social care teams in the borough, supporting mothers to navigate these complex systems by delivering practical and emotional help and advocacy.

Already, just seven months in, maternity and social care teams describe themselves as working better together than ever before, as a result of the service. Our ambition is that this work, along with the expertise of others in the maternity, social care and voluntary sectors, will shape a different approach across the country for those mothers who have been ignored and abandoned.

Services ‘failing women and perpetuating cycles of harm

Systems and services are failing women and their families and perpetuating intergenerational cycles of harm. Our Birth Charter, published in 2023, calls for the creation of a joint national health and social care pathway for women at risk of, or experiencing separation from their baby.

The National Bereavement Care Pathway, developed by the charity Sands, has helped embed better and more consistent care for parents who experience loss through miscarriage, stillbirth and neonatal death throughout our maternity services. Women who experience loss through separation deserve something akin to this, embedded across the health, social care and justice systems.

By creating such a pathway, and by ensuring that a focus on pregnancy and early motherhood is built into every relevant policy and every piece of guidance – from government departments and the NHS – we can break these cycles and truly deliver the best start for all.

Kirsty Kitchen is head of policy at Birth Companions, a charity set up to tackle inequalities and disadvantage during pregnancy, birth and early motherhood

*MBRRACE-UK stands for Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries Across the UK