Understanding the relationship between social determinants of health and maternal mortality

This paper aims to inform those involved in the care of pregnant women in the UK about the relationship between social determinants of health and the risk of maternal death. Social determinants are the social conditions in which people are born, grow, live, work and age. These conditions can shape a person's health, their exposure to illness and access to care. The worse social and economic positions people are in, the worse their health outcomes are likely to be. Exploring these issues in relation to maternal outcomes is timely because the profile of mothers giving birth in the UK is changing. Increasingly, babies are being born to older or obese mothers, or to women born outside of the UK. The evidence suggests a strong relationship between social determinants and poor maternal outcomes, including an increased risk of maternal death. Despite the provision of free reproductive and maternity services, current models of care are still failing those pregnant women living in adverse social circumstances prior to, during and after pregnancy. The reasons are complex but maternal outcomes are particularly poor for socially disadvantaged women affected by pre- existing physical or mental health problems, those who misuse substances, have a low level of education, are overweight, undernourished or poorly sheltered, and those who are at increased risk because of abusive and unsupportive partners, families and peers. Some traditional, cultural and social norms, and reproductive laws and policies, also appear to influence a pregnant woman's relationships, behaviour and access to healthcare services. These factors can reinforce a web of social disadvantage and poor outcomes for some pregnant women, which can persist for future generations. Public awareness of these issues has increased as a result of the COVID- 19 pandemic which has highlighted the ways in which health inequalities can adversely affect health outcomes beyond an individual's control. However, addressing the relationship between COVID- 19 and social determinants of health is outside the scope of this paper. While social determinants of maternal health also have an impact on offspring health, this is also outside the remit of this paper. Healthcare professionals have limited power on their own to modify social determinants of health, but this paper concludes with recommendations to improve the maternal outcomes of vulnerable pregnant women residing in the UK and proposes improvements to the collection and reporting of maternal outcome data, with further investment in prevention and intervention measures to better support these women.

Within this document we use the terms pregnant woman and women's health. However, it is important to acknowledge that it is not only people who identify as women for whom it is necessary to access care. Obstetric and gynaecology services and delivery of care must therefore be appropriate, inclusive and sensitive to the needs of those individuals whose gender identity does not align with the sex they were assigned at birth.