By the AIMS Campaigns team
This note is intended to offer both a summary and AIMS commentary on the latest annual MBRRACE-UK report. MBRRACE stands for Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries, reporting on maternal deaths during pregnancy and up to a year after birth, for the UK and Ireland. This is the 11th annual MBRRACE-UK report1 into maternal deaths during 2020-2022, published in October 2024. The full version is available here2, with infographic3 , executive summary4 and lay summary5 versions also available.
The authors acknowledge how important it is to honour and remember the women who had died, and the purpose of their report is to learn from their stories and, where possible, prevent harm from happening to others. In 2020-22, 625 women died during or up to a year after pregnancy; 275 of these women died during pregnancy or within six weeks of giving birth. There were just over 2 million pregnancies during this period, giving a maternal mortality rate of 13.56 women per 100 000 pregnancies. Although the authors acknowledge that the UK remains a safe place to give birth, worryingly, this is a 9% increase in the maternal mortality rate compared with last year’s report, a statistically significant increase (even after adjustment for deaths due to Covid-19), which the authors acknowledge is a "concerning trend".
Overall, blood clots remain the leading cause of maternal death, responsible for the deaths of 43 women, followed by COVID-19 (38 women) and heart disease (36 women). These are the same three leading causes of maternal death as in last year’s report6, together accounting for nearly half of maternal deaths (43%).
The risk of dying from blood clots has increased in recent years, with a quarter of the women who died from blood clots being in early pregnancy. There is a new national recommendation for women at high risk of blood clots to be offered risk assessment in early pregnancy or before pregnancy where possible and a rapid access pathway so they can be offered preventative treatment more easily.
Between six weeks and a year after pregnancy mental health issues, including suicide and substance use, are the leading cause of death, responsible for 34% of maternal deaths. Very concerningly, the death rate for women in the postnatal period has risen yet again, a statistically significant increase compared with last year.
In disappointing echoes of last year’s report, disparities in the chances of dying remain along the lines of race and deprivation. Black women remain nearly three times (2.9) more likely to die, while Asian women also remain nearly twice (1.7) as likely to die, compared with white women, figures which are almost unchanged from last year’s report6. This report also shows the stark effects of social inequalities, with those in the most deprived areas still around twice (2.18) as likely to die as those in the least deprived areas. Older women are also around three times more likely to die as women in their early 20s (2.65 times for those 30-35 years, 4.82 times for women over 40 years).
This report also reviewed the care of 94 women who sadly died with or from cancer during or in the first year after pregnancy. Shockingly, the panel assessed that only a quarter of these women had received good care. Some women had a delay in the diagnosis because their cancer symptoms were similar to pregnancy symptoms (for example, a low iron level). Sadly, there was also often poor care offered, with issues accessing care and screening tests. Even at the end of life, sometimes deterioration in a woman's health wasn't recognised and it wasn't always clear whether women could bring their babies with them to hospital. In some cases, women were denied pain relief, or not given enough information or autonomy in making decisions. Recommendations include that healthcare professionals need to be aware that most imaging tests can be performed safely during pregnancy and that end-of-life guidelines need updating to ensure that women with young babies can always remain together in hospital. AIMS was glad to see the authors emphasising that women going through cancer treatment require personalised information and autonomy in making decisions, and should be fully supported in their choices, as recommended by the charity Mummy’s Star7.
An increase in the number of women dying from ectopic pregnancy (when a fertilised egg implants outside the womb) was reported to the MBRRACE committee, so this year’s report also has a review of women who died in early pregnancy. There are three main recommendations stemming from this: increase awareness about ectopic pregnancy and its symptoms, offer pregnancy tests when appropriate (which can speed up diagnosis) and – once again - listen to women. This is especially important as there are not always 'typical' symptoms of ectopic pregnancy, so healthcare professionals really need to think about what is being said to pick up on a possible ectopic pregnancy.
The proportion of women who died while known to social services has increased in recent years8, now making up 22% of the women who died. Women with recorded multiple disadvantages also make up 12% of those who died. This is also likely an underestimate, since factors such as domestic and substance abuse are often not disclosed or recorded: in over 30% of the women who died, for example, it hadn’t been recorded whether they had experienced domestic abuse.
As outlined above, suicide remains the leading direct cause of death between six weeks and one year after birth. A large proportion of the women who died from suicide or substance use were in contact with social care services, often having had their baby removed from their care or at risk of this, an issue highlighted previously by MBRRACE6. 59% of women whose deaths were linked to substance use had also had their baby already removed from them or were involved in care proceedings. The charity Birth Companions describes this as “Women …navigating one of the most traumatic experiences imaginable, alone.”8, because women often lose support if their baby is removed from their care after birth. The recent Maternal Mental Health services report, for example, found that only 27% of national maternal mental health services support women who have lost custody of their babies due to safeguarding concerns9,10.
The report describes women who were afraid to ask for help or disclose information, and there was also a lack of early intervention, with situations often left to develop until a crisis occurred. The MBRRACE team advise healthcare professionals and policy makers to “consider barriers in access to care” and “facilitate alternative ways of engagement”. This highlights a real need for personalised, woman-centred care, and a Continuity of Carer model of care. We know that this model of care - which AIMS wants to see implemented11 - can make a real difference to the most vulnerable women, including those with complex social circumstances12,13. AIMS also calls for improvements in maternity care for women who have had a baby removed from them, or are at risk of this, including improved access to mental health services and a new national pathway for their care, as recommended by Birth Companions8,14,15.
This MBRRACE report has also reviewed the care of 38 migrant women who had been in the UK16 for less than two years and whose first language was not English. There were many structural barriers preventing migrant women accessing maternity care, including that they had not been made aware about what services were available and were not registered with a GP. While there are some examples of good care in the report, there are also many examples of poor or inappropriate care, especially regarding problems with translation and interpretation services. The authors suggest that improvements in care could have made a difference to the outcome for nearly two thirds (66%) of migrant women. Most women “did not receive adequate support for their language needs”, including not being offered professional interpreters or with their preferred language (where they were not fluent in English) not assessed or recorded. 61% of the women who needed interpretation services for safe care were not offered a professional interpreter and were using family members or apps to translate what was often “important or difficult” information. Women were also routinely given written information in English, even when it was clear that this was not helpful. There were examples where interpreters were used for some but not all appointments, giving disjointed care. MBRRACE recommends that language needs are “assessed, documented and considered at all stages of maternity care”, including recording when formal interpreters are offered or used and that interpreters should always be offered, including in emergency situations. As the authors themselves note, it is essential for healthcare professionals to share information in a way that it can be understood, checking if women are confident reading or writing in their preferred language (where they are not fluent in English) and checking understanding as needed. This resonates, of course, with wider issues of literacy, with some estimates suggesting that up to 16% (1 in 6) of people in the UK struggle to understand written information17. It is vital that services can also support individualised care when implementing these recommendations. For example, a woman may prefer a female interpreter, or a telephone interpretation service which uses staff from outside the local community, rather than a face-to-face interpreter who may live locally to her.
AIMS supports the report’s recommendation to urgently review interpretation services and ensure that care is safe and culturally appropriate, including that women are given clear information, in a format they can understand, especially about how to access maternity services or raise any concerns. For over 20 years, AIMS has argued that antenatal services need to be more flexible, to meet the needs of all women. The National Institute of Clinical Excellence (NICE) antenatal care guidelines also state that there should be flexibility in the number and length of antenatal appointments where interpreting services are used18.
Here at AIMS, we are shocked and saddened yet again by these latest figures from MBRRACE. Shockingly, nearly half of the women who died (45%) were found to have poor care, with the authors arguing that improvements in care could have made a difference to their outcomes. Stark racial inequalities in maternal mortality unfortunately still persist, with Black and Asian mothers remaining significantly more likely to die during or soon after pregnancy, with Black women in particular still nearly three times more likely to die, and women in the most deprived areas twice as likely to die during or after pregnancy, compared with those in the least deprived areas. AIMS has long campaigned for equitable maternity services, to mitigate, as far as possible, the kinds of disparities seen in this report, yet these figures show we still have a long way to go..
At the virtual conference17 presenting this report, Dr Roshni Patel (Consultant in Maternal Medicine and Obstetrics) outlined five main areas where maternity care urgently needs to improve - listening to women, improving systems, staffing levels, training and knowledge. The publication of yet another sobering MBRRACE report highlights yet again how urgently large-scale reform of the maternity services is needed. AIMS calls on the government to urgently invest in safe, personal and equitable maternity care, as recommended by Better Births19, where staff work in well-supported teams providing compassionate care and have the skills to care for all women and birthing people, including those with complex physical, mental and social needs. The urgency of this is underlined for women with increased medical or social complexity. It is clear that improvement is also desperately needed in mental health support in the perinatal period, given that suicide remains the main cause of death in this period.
We see in this report vulnerable women not being listened to, unable to access care, and maternity services failing to meet many of their needs. As the authors of the report point out:
“Inequalities will continue if women’s individual circumstances are not recognised and considered during her maternity journey.”
AIMS continues to advocate for services which are designed around the needs of all women, including migrant women, women from the global majority and those with social complexity. AIMS continues to campaign for a universal relational model of midwifery care (Continuity of Carer) to be fully implemented for all, as a key plank to reducing these disparities.9,20 Especially with an ongoing cost of living crisis, it is essential that policymakers really understand and act on the barriers to all service users accessing safe, supportive and equitable care.
For further information about MBRRACE-UK please see https://www.npeu.ox.ac.uk/mbrrace-uk/maternal-programme
MBRRACE-UK (2024) Saving Lives, Improving Mothers’ Care Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2020-22
https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2024/MBRRACE-UK%20Maternal%20MAIN%20Report%202024%20V2.0%20ONLINE.pdf
MBRRACE-UK (2024) Key Messages from the report 2024
https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2024/MBRRACE-UK_Maternal_Report_2024%20_Infographics_V1.0.pdf
MBRRACE-UK (2024) Executive Summary
https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2024/MBRRACE-UK%20Maternal%20MAIN%20Report%202024%20V1.0%20-%20Ex%20Sum.pdf
MBRRACE-UK (2024) Saving Lives Improving Mothers’ Care 2024: Lay Summary
https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2024/MBRRACE-UK_Maternal_Report_2024%20_Lay_Summary_V1.0.pdf
Hart, C. (2024) MBRRACE-UK Reports – Shocking Racial and Socioeconomic Inequalities Continue and Even Widen
AIMS Journal, 36 (1) https://www.aims.org.uk/journal/item/maternal-deaths-mbrrace-updates
Mummy’s Star (2025)
www.mummysstar.org
Birth Companions (2024) Saving Lives, Improving Mothers’ Care 2024: Birth Companions' response to MBRRACE-UK report
https://www.birthcompanions.org.uk/articles/birth-companions-response-to-mbrrace-maternal-deaths-report-2024
Maternal Mental Health Alliance (2024) Maternal Mental Health Services Progress Report
https://maternalmentalhealthalliance.org/media/filer_public/8c/f5/8cf5b1f4-c19b-4554-bbf5-caf6ebf4a6d4/mmha_progress_report_on_mmhs_final.pdf
AIMS (2024) Birth Activists Briefing: Maternal Mental Health Service Progress Report
https://www.aims.org.uk/journal/item/perinatal-mental-health
AIMS Position Paper: Continuity of Carer
www.aims.org.uk/assets/media/726/aims-position-paper-continuity-of-carer.pdf
Rayment-Jones, H., Silverio, S. A., Harris, J., Harden, A., & Sandall, J. (2020). Project 20: Midwives’ insight into continuity of care models for women with social risk factors: what works, for whom, in what circumstances, and how. Midwifery, 84, 102654
https://www.sciencedirect.com/science/article/pii/S0266613820300279
Sandall, J., Coxon, K., Mackintosh, N., Rayment-Jones, H., Locock, L. and Page, L. (writing on behalf of the Sheila Kitzinger symposium) (2016) Relationships: the pathway to safe, high-quality maternity care
https://pre.rcm.org.uk/media/2962/skp_report.pdf
Birthrights and Birth Companions (2019) Holding it all Together
https://hubble-live-assets.s3.amazonaws.com/birth-companions/attachment/file/276/Holding_it_all_together_-_Exec_Summary_FINAL_%2B_Action_Plan.pdf
Birth Companions (2023) The Birth Charter for women with involvement from children’s social care
https://hubble-live-assets.s3.eu-west-1.amazonaws.com/birth-companions/file_asset/file/838/BC_BIRTH_CHARTER.pdf
MBRRACE-UK (2024) The care of recent migrant women with language barriers who have experienced a stillbirth or neonatal
https://timms.le.ac.uk/mbrrace-uk-perinatal-mortality/confidential-enquiries/confidential-enquiry-migrant-women.html
MBRRACE-UK (2024) Virtual Conference Presenting the MBRRACE-UK ‘Saving Lives, Improving Mothers’ Care’ Report 2024
https://mbrrace.brightvisionevents.live/login (unfortunately this virtual conference is no longer available online)
National Institute for Health and Care Excellence (2021) Antenatal Care
https://www.nice.org.uk/guidance/ng201/resources/antenatal-care-pdf-66143709695941
National Maternity Review (2016) Better Births Improving outcomes of maternity services in England A Five Year Forward View for maternity care
https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf
NHS England (2023) Core20PLUS5 (adults) – an approach to reducing healthcare inequalities
www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5
We hope that this page is of interest, especially to our colleagues in the maternity services improvement community.
The AIMS Campaigns Team relies on Volunteers to carry out its work. If you would like to collaborate with us, are looking for further information about our work, or would like to join our team, please email campaigns@aims.org.uk.
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AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.