MBRRACE-UK Reports: Improvements to care may have made a difference to over half of babies and mothers who died.

Whilst tragedies in maternity care are thankfully rare, far too many are preventable. At Baby Lifeline, it is our mission to make sure NHS professionals have the tools they need to improve care and save lives. We do this by providing relevant training and required equipment, and carrying out research.

The recent MBRRACE-UK reports looked at babies who died in twin pregnancies in 2017 and mothers who died from 2016 – 2018. Both reports highlighted that in half of cases, the mother or baby may have had lived if they had had better care. In fact, in less than 1 in 3 mothers’ deaths and around 1 in 5 babies’ deaths, the care was considered good.

The hopeful message which stems from this is: if we can get this right, we could improve care for everyone and save a lot of lives. It’s just clear that we have some way to go.

Making sure recommendations reach the frontline

Many reports say the same thing and repeat the same recommendations. It begs the question: is enough being done to inform the frontline of new recommendations and guidelines?

Source: MBRRACE-UK Perinatal Confidential Enquiry Stillbirths and neonatal deaths in twin pregnancies (2021)


Twin Pregnancies

Examples of where care could have been better

  • Aspirin is recommended for women with twin pregnancies due to an increased risk of preeclampsia, but this was not documented as being prescribed for half of those women eligible.
  • Almost half of the women did not have scans to check the growth of their babies as regularly as recommended.
  • National guidance that antenatal steroids and magnesium sulphate should be considered and/or initiated prior to preterm birth to improve neonatal outcomes, was only followed in a third of applicable pregnancies. 



We looked at the level of training in each area shown to relate to causes of deaths in mothers. The training numbers are from Baby Lifeline’s Mind the Gap report, gathered from 2017/18 – the last two years in the MBRRACE-UK data.

Despite the prevalence of some of these causes, training for the frontline in these areas seems to be lacking. Multi-professional attendance also seems to be rare.

Sources: Maternity mortality (2016-2018) as reported by MBRRACE-UK (2020)
Training (2017/18) as reported by Baby Lifeline’s Mind the Gap report (2018)


Although rare, there are far too many preventable deaths of babies and mothers. Areas of national guidance seem to be all-too-often missed in women’s care, and training in main areas shown to relate to avoidable deaths are often not provided to the frontline.

As a priority, professionals need to have access to high-quality, effective training to ensure that national best practice guidance is followed, and that care improves.