Women who decline blood during labour: Review of findings and lessons learnt from 52 years of Confidential Enquiries into maternal mortality in the United Kingdom (1962-2019).

Objective: Patients who decline blood products because of their religious beliefs pose a unique challenge in the context of obstetric haemorrhage. Four large series assessing maternal outcomes in Jehovah's Witnesses from USA, UK, Netherlands and Japan estimate that maternal mortality is increased by between 44 and 160-fold. A review of maternal deaths from obstetric haemorrhage was undertaken in mothers who decline blood transfusion, using UK Confidential Enquiries into Maternal Deaths reports (1967-2019) in order to identify common trends and lessons learnt.

Design: Retrospective review using 18 triennial Confidential Enquiries in Maternal Deaths reports between 1967 and 2019.

Results: Fifteen maternal deaths from haemorrhage were reported in patients who declined blood products for religious beliefs in the 52 years reviewed. Common themes noted included delay in senior escalation, hesitation to perform life-saving hysterectomy and loss of situational awareness. Placental abruptions (3/15) and curettage for secondary postpartum haemorrhage (2/15) especially warrant senior input and cooperation with Jehovah's Witness Hospital Liaison Committees is recommended.

Conclusions: Guidelines from the UK's Royal College of Obstetricians and Gynaecologists and Royal College of Surgeons highlight the need for collaborative, Montgomery-competent discussions during the antenatal period, as well as the engagement of local Jehovah's Witness Hospital Liaison committees. Consultant-led care, antenatal optimisation of haemoglobin and techniques to mitigate blood loss at delivery are paramount. We advocate using a lower threshold for hysterectomy than was used in the cases analysed, for example when the haemoglobin level drops below 8-9 g/l in the context of ongoing bleeding. As patients increasingly begin to decline blood products for non-religious reasons, the lessons learnt in the management of Jehovah's Witnesses are becoming ever more relevant.