Complex needs, complex solutions: Reflections on the launch of the MBRRACE report 2025

AIMS Journal, 2025, Vol 37, No 4AIMS Journal, 2025, Vol 37, No 4

By Nadia Higson

Attending the launch of the latest MBRRACE¹ report Saving Lives, Improving Mothers' Care 2025 - Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2021-23 was always going to be a depressing experience. This year it was made even more so by the inclusion of a series of case studies of mothers with complex needs who died after failures to provide holistic care and support. This article is intended to offer a summary of the report and some of the presentations given on the day, as well as a brief AIMS commentary.

According to the report, for almost half (45%) of the women that died “better care might have improved the outcome” and for suicides it was as high as two-thirds (64%). Better care might also have made a difference to about a third (30%) of those who suffered serious health problems.

The issue of support for women with complex needs is thrown into sharp relief by the finding that out of the 643 women who died during or up to one year after pregnancy in the UK and Ireland, 583 (91%) faced multiple challenges.

Overall the maternal death rate in 2021-23 showed little change compared to the periods covering the pandemic ((2018-20, 2019-21, 2020-22) once deaths from Covid are excluded. However, the rate of late maternal deaths (those occurring between six weeks and one year after the end of pregnancy) continued to increase and were significantly higher in 2021-23 compared to 2018-20. Maternal suicide was the leading cause of late maternal deaths. This or ‘other psychiatric causes’ (such as drug and alcohol abuse) accounted for over a third (34%) of the total.

AIMS Comment: This highlights the importance of mental health and social support for mothers beyond the immediate post-natal period.

Inequalities persist: now closer to 2xmore Black mothers ²

Also concerning is the finding that inequalities in health outcomes persist many years after MBRRACE first identified them. The gap between ethnic groups appears to have narrowed, partly because of an increase in the mortality rate for white mothers. The rate for Black women has declined, but they are still over twice as likely as white women to die in pregnancy or up to a year after the birth.

Mothers who live in the most deprived areas are almost twice as likely to die as those from the least deprived areas.

AIMS Comment: Whilst it is appalling to see that inequalities remain, it is important to note that the outcome gap for Black mothers seems to have narrowed since the launch of the eye-catching and influential 5XMore campaign.

Needs of women with complex challenges

The MBRRACE team identified a number of important lessons from the cases they reviewed. They included the need for better pre-pregnancy counselling to enable appropriate support to be offered. The report notes that this should mean not only counselling on physical health issues, but the full range of ‘risk factors’ including social or mental health issues. Social risk factors, including financial need and housing, need to be assessed and documented in a standardised way. There should then be an urgent referral pathway so that women with high risk medical conditions or complex social circumstances can be seen by specialists early in their pregnancy.

Another important issue identified by the MBRRACE assessors was the lack of joined up care following discharge to primary care (GPs, health visitors etc). Recommendations include ensuring that discharge notes highlight any medical, mental health or social conditions that require ongoing support from primary care, and having “a clear postnatal plan for multidisciplinary care”. There also needs to be a system for information sharing across all the services involved in a woman’s care.

AIMS comment: While improved pre-pregnancy counselling (ideally for all women) is a laudable aim, such a system would depend on women seeking and receiving care both before they become pregnant and during early pregnancy. This may be challenging for those at most need from their social circumstances and/or with an unplanned pregnancy. We note that the National Maternity and Perinatal Audit (NMPA)’s recent State of the Nation report for 2023 reported that “In 2023, 1 in 4 (26.7%) women and birthing people attended their first (booking) appointment with a midwife after 10+0 weeks of gestation”. Potentially the Government's plan for Neighbourhood Health Services will help by making care more accessible.

Identifying more of those at risk will increase the demand for specialist support services. This will have implications for staffing and service organisation that need to be addressed if timely support is to be available.

AIMS questions whether the length of appointments with community midwives are sufficient for a full exploration of complex social issues. And will women feel sufficient trust in their midwives to reveal issues such as domestic abuse, childhood sexual abuse, sexual violence, drug and alcohol problems or mental health issues? We know from our Helpline that some women worry that disclosure of issues such as previous mental health problems will lead to unwanted involvement with children’s services. Offering Continuity of Carer, enabling the development of a trusting relationship, might help to overcome these problems.

Key points from the launch meeting

The launch meeting included short presentations highlighting a number of areas of concern. There are too many to cover in detail but we outline some of these here. Slide presentations for these and other topics are available on the MBRRACE website.

Care of women with social care involvement

Kirsty Kitchen (Birth Companions) and Kaat De Backer (King’s College London)

Over the period 2014-22 one third of the women who died were known to social services. Their suicide rate was 20% compared with 9% for those without social services involvement. They had commonly suffered baby loss, often due to the baby being taken into care. Although there were examples of good care, too often care fell short. In particular, these women need a one-stop shop for appointments and better support postnatally, especially after a baby has been taken into care.

The charity Birth Companions is helping to co-design a national pathway for health and social care in the first 1000 days. (They will tell us more about this in the March 2026 issue of the AIMS Journal.)

AIMS Comment: We recall that the recent report published by the Maternal Mental Health Alliance revealed that only 27% (11/41) of Maternal Mental Health Services are supporting women who have lost custody of their babies due to safeguarding concerns (see the Birth Activists Briefing: Maternal Mental Health Service Progress Report). There is clearly a pressing need for improvement in the support offered to mothers in this situation.

We hope the involvement of Birth Companions, a well-informed charity, will help to deliver an improved pathway, and that this will be implemented effectively across the UK.

Social complexities and safeguarding

Anita Banerjee and Sophie Russell (MBRRACE Assessors)

In the period 2021-23, 14 women died as the result of homicide in the UK. All but one of these were murdered by their partner or former partner. Six of them had reported domestic abuse.

The concern is that even when a woman discloses issues such as domestic abuse to one agency the information is often not shared with others involved in her care. There needs to be a UK-wide process for identifying, recording and urgent referral of women who are at higher risk due to these factors. Risks should be assessed at every appointment.

AIMS comment: Again, this is a laudable aim, but requires both a relationship of trust between a woman and her carers, sufficient time for risks to be “assessed at every appointment” and also for an updated action plan to be discussed and agreed where necessary.

Mental Health

Andrew Cairns (MBRRACE Assessor)

Key issues in the deaths of mothers with mental health issues, we were told, were lack of information on discharge to primary care and lack of multi-disciplinary involvement after birth. It was argued that GPs need to know about conditions that need ongoing care, including mental health, and safeguarding concerns.

The MBRRACE report recommends that “specialist perinatal mental health teams undertake a leadership role for the care of pregnant or recently pregnant women with mental health conditions even if women are not accepted for care under their services. This should include a risk assessment, provision of advice and guidance, oversight for joint care planning and support to ensure rapid onward referral into other appropriate mental health services.”

AIMS comment: Although Maternal Mental Health Services have been put in place across most of England many are struggling to cope with the demand. This results in a postcode lottery in whether a woman is assessed as qualifying for support. The waiting time just for assessment can be up to six months in some areas (See Birth Activists Briefing: Maternal Mental Health Service Progress Report).

Whilst giving specialist perinatal mental health teams a leadership role for all mothers with mental health needs could be helpful, will already over-stretched services have the capacity to take on this additional role?

Birth Trauma

Steve Cantellow, (MBRRACE Assessor)

As AIMS knows all too well, perceived loss of control and unmet expectations during labour and birth can contribute to postnatal depression. Physical consequences such as pelvic floor damage can also have an impact on psychological wellbeing. We were glad to see the emphasis in this presentation on the need to support women’s decision-making.

It was also good to hear the recognition that physical recovery after birth is not necessarily accompanied by psychological recovery. Mothers who have suffered severe health problems need follow-up and a structured assessment of their mental health.

AIMS comment: This will also require proper handover to primary care and the resources to follow up mothers’ mental wellbeing beyond the six-week check-up.

Conclusion

The annual MBRRACE report continues to play an invaluable role in identifying the causes of maternal deaths and the care failings that too often contribute to these. AIMS is mindful that the mothers who die from suicide or other psychiatric issues are only the tip of the iceberg. How many more are struggling with lack of support for their mental health, addiction or domestic abuse in the year after giving birth?

Much of the recent focus on the maternity services, such as the recently announced National Maternity review, has rightly emphasised failings in hospital care. The MBRRACE report makes it clear that there are also serious short-comings in antenatal care, immediate post-natal care, and longer-term support for new mothers. We hope that in time the development of Neighbourhood Health Services providing community-based care, and greater investment in perinatal mental health services will start to address these problems.

AIMS has long campaigned for Continuity of Carer to be the standard for all mothers, so we were pleased to learn at this meeting that Scotland is making progress towards having Continuity of Carer for all by the end of March 2026. We believe that Continuity of Carer is essential to address the needs of mothers affected by multiple disadvantages. It would be helpful for MBRRACE to include an analysis in future reports of how many of the mothers who died had continuity of midwifery care.