Mother died in childbirth, dear. In 1995

Maternal death rates are on the rise again. Celia Dodd hears a grandmother's agony and asks why

Diana Armitage's daughter Alison was 27 when she died two days after giving birth to her son Joseph, now 18 months old.

Like any grandmother-to-be, I was thrilled when I heard that Alison had gone into labour. There had been no problems whatsoever in the pregnancy and we were very happy about the whole event. Eventually, we got the news that she'd had a baby boy and he was fine. Alison had rung everybody herself, she was so excited.

I drove down the next morning to see her with my elder daughter, Trudy, and her two children. When I got there, the sister asked me to wait in a side room. I realised there was something wrong, but I expected there to be something wrong with the baby. But she said that my daughter's blood pressure had shot up during the night and she was having clotting problems and kidney failure.

I went in to see her, and the baby was sleeping in his cot. Alison tried to smile, poor thing, but couldn't. She was in agony and bright yellow. She started vomiting and just then the ambulance came to transfer her to a specialist centre. She was whisked off with blue lights flashing.

Even then we didn't think there was anything life-threatening about the situation. My elder daughter and I said: "Oh well, we can always donate a kidney."

The next time I saw her she was delirious, she didn't even know she'd had the baby. We were told that she was suffering from Hellp syndrome, a rare crisis of pre-eclampsia. Later that day she had a massive brain haemorrhage. They operated, and afterwards we were told that they would review the situation two hours later and let us know whether or not they were going to turn the life-support machine off.

Those two hours were the most obscene time of my life. It was horrific: she was in one hospital and her baby was completely alone in a different one. They switched the life-support machine off at noon on the Sunday, less than 48 hours after Joseph's birth.

The disease seemed to come out of the blue. Alison was very healthy and fit throughout her pregnancy and meticulous about antenatal checks. But looking back there were warning signs. She rang me a few weeks before the birth and said she had had a horrendous headache for a day. I told her to take paracetamol. Had I known it was a symptom of pre-eclampsia, I would have told her to go to the doctor.

I'm an ex-nurse, but I didn't know what pre-eclampsia was. Why does nobody warn you that women and babies can die? I don't think all the hospital staff where she had the baby realised the seriousness of the situation. She had been ill for at least 12 hours before she was moved to the specialist unit. All her organs had stopped functioning. Had she been transferred sooner, things might have been different.

My elder daughter looks after Joseph some of the time, as does his father and other members of the family. He's a little sweetheart, a very happy little boy. But it's been very, very hard to cope with.

Action on Pre-Eclampsia Helpline 0923 266778.

Last year Iris Fletcher, 34, narrowly escaped death when her womb ruptured during the birth of her second baby, Esther. Esther was severely brain-damaged and died four months later. Iris has subsequently been diagnosed as suffering from post-traumatic stress disorder; her womb is now so damaged that she is unable to have more children.

Iris is planning to sue the health authority for negligence. She says: "If there had been something wrong with Esther, like a heart condition, I could be getting on with my life now. But to think it should never have happened, that she should be running round the house at 18 months old, that's what makes me sick. Every time I see a baby in Tesco who is Esther's age it reminds me that she's not here."

It is widely assumed that women dying in childbirth is a thing of the past, the stuff of Victorian melodramas and Gone with the Wind. But today, after 40 years of steady decline, the number of such deaths is on the increase.

The latest Department of Health report on maternal deaths, published in January 1994, revealed that 238 women died between 1988 and 1990, 15 more than during the previous three-year period. Deaths caused by haemorrhaging and infection had doubled.

Even doctors who claim that the rise is accounted for by an overall increase in the number of births accept that the maternal death rate is a cause for concern. The UK now falls behind other European countries, with seven deaths per 100,000 compared with Greece's five per 100,000, Italy's four and Ireland's two. The question is, why?

The main causes of maternal death are pre-eclampsia and eclampsia. Pre- eclampsia, which affects one in five first pregnancies, can cause high blood pressure and other circulatory problems leading to convulsions (eclampsia) or organ damage. It can be mild or can lead to fatal complications.

The Department of Health report's most disturbing finding is that 49 per cent of all maternal deaths, and 88 per cent in cases of pre-eclampsia and eclampsia, were related to "substandard care": delays in taking clinical action, failure to appreciate the seriousness of symptoms of pre-eclampsia and eclampsia, and delay in consultant involvement. Like previous reports, it draws attention to the significant number of cases in which major problems were handled by junior doctors, and to a shortage of appropriate staff.

Beverley Beech, chairwoman of Aims (Association for Improvements in the Maternity Services), is particularly concerned that emergency operations are too often carried out by registrars rather than consultants, about the high levels of infection in many hospitals, and that midwives and doctors do not always listen or respond to the symptoms women report.

At the same time, Ms Beech maintains that maternal deaths are caused by unnecessary interference in the birthing process, and is therefore campaigning for more home births. "It's an irony that some women are getting intervention which they don't need," she says, "but others aren't getting enough. One reason we've been campaigning to get women out of hospital is because many maternal deaths are obstetrically induced - by the inappropriate use of technology to accelerate labour or the failure of the hospital to respond to clear indications of the problem."

Iris Fletcher (not her real name) feels her baby's brain damage and her own near death were entirely due to the fact that warning signs were not picked up. Having had her first baby by Caesarean, Iris was advised by her consultant to try a natural labour for a few hours without intervention, and if that didn't progress well, she would have a Caesarean.

However, the junior doctor attending her in labour appeared to ignore the plan and administered drugs to accelerate labour, which Iris believes increased the stress on her womb. When, after several hours, Iris asked for a Caesarean, she was refused. She believes the staff were not sufficiently alert to the risk of rupture when a natural birth follows a Caesarean. "Their attitude seemed to be that I was a typical neurotic mother," she says.

Despite an epidural, which should completely block pain, Iris was in agony, but her complaints were ignored. She also later discovered that crucial signs on the monitor that her womb was in difficulty were not picked up.

When Esther was finally delivered by forceps, attention focused on the baby's poor state. The registrar failed to recognise that Iris's womb had ruptured, although she was vomiting, haemorrhaging and writhing in agony. She was finally taken into theatre nearly four hours after delivery, and needed a massive blood transfusion.

"It was only when my husband brought me a photograph of Esther from special care that I realised she was alive. But I couldn't bring myself to look at the photograph. It was so devastating. Eventually they took me in a wheelchair to see her. I couldn't cry, I was in such shock.

"We were desperate for a girl. She was beautiful, but she was spastic in all her limbs, with no sight or hearing, and couldn't suck or swallow. As far as I'm concerned, that is entirely due to the fact that warning signs hadn't been picked up. I think if the consultant had been there, it would not have happened. And if I'd gone for a Caesarean, I'd have a child now. I had never been told about the risk of rupture. It all could have been avoided had the doctors listened, and had they taken the right action, and had the right doctor been there."

Although it is difficult to draw links between maternal deaths and the small rise in home births from less than 1 per cent in 1987 to 1.6 per cent in 1993, many obstetricians believe the maternal death rate provides a powerful argument for keeping all births on the labour ward. They point out that the dramatic fall in maternal deaths, from five per 1,000 in the Thirties when only a third of babies were born in hospital, coincided with a huge increase in hospital births until they peaked in the Eighties at 99 per cent.

Chris Redman, professor of obstetrics medicine at Oxford University, says: "If home births were to become very widespread, there is no question that there would be situations where women would die as a result of having chosen to deliver at home. The great advantage of having a baby in hospital is that if you start bleeding, the rescue team is there. I have seen women who developed Hellp syndrome [a crisis arising from pre-eclampsia] over 12 hours - if they were at home, they would be dead before they got to the hospital."

But some researchers conclude that the place of delivery is not the main issue. They point to the higher maternal death rates, both here and elsewhere in Europe, among women who have immigrated from less developed countries. They believe there is a need to investigate the extent to which this reflects the health of the women and the problems they may have in communicating with the health services.

Since the early Eighties, Department of Health reports on maternal deaths have made recommendations to reduce the number of deaths: hospitals should establish set procedures to deal with life-threatening emergencies; regional specialist centres should be set up to deal with crises; obstetric units should be attached to general hospitals with intensive care facilities and blood banks. But in many areas the recommendations have been ignored.

Equally worrying is the trend towards cutting the costs of antenatal screening through less thorough and less frequent checkups. Regular routine tests on blood pressure and urine have proved to be the most effective way of preventing deaths through pre-eclampsia.

Professor Redman adds: "The distress and tragedy of maternal death for the children, husbands and mothers of the women who died is profound. But that's the tip of the iceberg - there are also women who become dangerously ill and recover, but remain disabled in some way, and others whose whole experience of childbirth has been traumatised."

Beverley Beech of Aims wants to see a system of near-miss reporting where births that go badly wrong but do not end in death are also recorded. She also believes women themselves need to know more about the danger signs to look out for and about the risks, however small, to themselves and their babies when they are making decisions about birth and care in pregnancy. As Diana Armitage says (see left), had she known more about pre-eclampsia, her daughter might be alive today.