‘Support, not blame’: Study explores links between children’s social care involvement and maternal deaths

Published on Friday, 11 July 2025 Post

A new study using data collected by the MBRRACE-UK collaboration has found that one third of women who died during or in the year after pregnancy were known to children's social care, which is higher than previously reported. The study is published in BMJ Medicine and was led by researchers from King's College London, Oxford Population Health's National Perinatal Epidemiology Unit, and the charity Birth Companions.

This study is the first to detail the situations of the 1,695 women who died within a year of pregnancy between 2014 and 2022. 420 of the women who died were in contact with children's social care. Researchers used national surveillance data published by MBRRACE-UK to analyse how the women died and the quality of the care they received.

The number of newborn babies in care proceedings in England is a growing problem with 2,914 babies in care in 2019/20, an increase of 20% in seven years. Children under the age of one make-up over a quarter of all children in care proceedings.

Key findings:

• Three quarters of the mothers known to social services died between six weeks and the year after pregnancy;
• Most of the deaths were due to suicide (20%), other psychiatric causes including drug related deaths (30%), and homicide (5%);
• Women with social care involvement more frequently died from homicide and mental health related causes than women without involvement;
• Two thirds (65%) of women with children's social care involvement reported domestic abuse before or during pregnancy, compared to 3% of women without social care involvement;
• One in three of the women who died disclosed abuse during childhood compared to 2% of women without social care involvement;
• A higher proportion of women known to social care had pre-existing medical problems (75%, versus 59%), mental health issues (75% versus 27%), smoking during pregnancy (73% versus 21%) and known substance use (55% versus 5%) than women with no social care involvement.

The researchers also conducted a confidential care review, which looked at anonymised care records for 47 of the women who died.

The study found uncoordinated involvement of services and agencies, such as maternity and mental health services, children's social care, and other medical specialists, resulted in overwhelming appointment schedules and compounded the adversity the women were facing rather than helping them. In several case reviews women had more than 30 different appointments during pregnancy. In many instances, risk management solely focused on safeguarding the infant, disregarding the mother's own safeguarding needs.

First author Kaat De Backer from King's College London said 'This report details for the first time the high proportion of women with children's social care involvement who die in the UK and the care they receive during pregnancy and the postnatal period. What the analysis tells us is that these women come from backgrounds of trauma and abuse, and yet despite their efforts to keep up with demanding appointment schedules, they often face scrutiny and judgment rather than receiving support for the issues they are facing. Too often, the professionals the women are in touch with don't work together to provide holistic care, which increases the pressure on a mother.

'When women have access to designated multi-disciplinary teams, with specialist knowledge and capacity to provide integrated and holistic care, these barriers can be overcome. It makes it easier to understand who is doing what and when, for women and professionals.'

The researchers highlighted the complex care journeys that women navigate during pregnancy and the postnatal period. They say urgent changes to practice, clinical guidance and policy are required to prioritise mothers with social care involvement in pregnancy and early motherhood.

Kirsty Kitchen, Head of Policy at the charity Birth Companions, said 'This study highlights the acute need for personalised, holistic and trauma-informed care for women with children's social care involvement, and the multiple individual and systemic barriers to providing that care.

'To help improve things, we need coordinated national policy and clear expectations across the health and social care systems. In response to this study, Birth Companions is launching work to co-design a national care pathway, to help deliver consistent, compassionate support for all women who have children's social care involvement in pregnancy and early motherhood.

'We are excited about developing this pathway in close partnership with mothers with lived experience, national policymakers, commissioners, and practitioners across health, social care, the family justice system, academia and the voluntary sector. This work holds the potential to transform care, break cycles of harm, and contribute to less mothers losing their lives in such tragic circumstances.'

Nicola Vousden, Clinical Lecturer in Maternal and Child Population Health at the National Perinatal Epidemiology Unit, said 'This study adds to findings from MBRRACE-UK that women with multiple disadvantages prior to, and during pregnancy, are at increased risk of worse outcomes. We've identified practical changes that are required within maternity care.

'We also need joined up pathways of care across maternity, social care and community health partners to support the needs of women with children's social involvement, including domestic abuse, substance misuse and mental health. This will require local and national action.'