Objective Migrant mothers have an increased risk for adverse perinatal outcome. We wanted to investigate the maternity care which women received where there had been a stillbirth or neonatal death.

Method All stillbirths from 24 weeks and neonatal deaths from 34 weeks during 2008 were investigated, which occurred in three PCTs. Confidential case note review was undertaken by independent multi-professional panels.

Results 36 deaths fitted the selection criteria over a 12 month period, including 30 stillbirths and 6 neonatal deaths. 18 cases had a congenital anomaly. The review panels identified significant sub-optimal care factors in 32 of the 36 cases (89%). These included (1) inadequate or absent management plans in early pregnancy (18/36, 50%); (2) lack of identification of social or psychological risk factors requiring referral (17.36, 47%); (3) poor continuity and antenatal follow-up; (4) substandard postnatal care (26/36, 72%) for example, premature discharge despite complications; (5) substandard communication (23/36, 64%), with lack of interpreters and inadequate information sharing between professionals. Half of the 18 cases without congenital anomalies were considered by panels to have been potentially avoidable deaths.

Conclusion Maternity care for migrant women poses substantial challenges for the health service. Independent case reviews of pregnancies ending with adverse outcome highlight many instances of substandard risk assessment and social care, poor communication and a frequent lack of support services being engaged for vulnerable women. Care providers require appropriate training and workforce to be able to provide equitable care for migrant mothers.