The latest MBRRACE-UK report, Saving Lives, Improving Mothers’ Care, published on Thursday 11th September 2025, examines the care of 643 women who died during or up to one year after pregnancy between 2021 and 2023 in the UK and Ireland. The report presents the findings and shares recommendations for improving care for these women and birthing people.
As always, our thoughts go out to the families whose loved ones’ deaths are represented in this report.
Key findings from the report include:
- Between 2021-2023, 257 women died during pregnancy, or up to six weeks after pregnancy. This figure is lower than in the previous report, which examined deaths between 2020-2022 (though the decrease is not statistically significant).
- When late maternal deaths are included, 643 women died during pregnancy, or up to one year after pregnancy. Concerningly, this is an increase when compared with 2020-2022.
- Rates for late maternal deaths continued to increase and were significantly higher in 2021-23 compared to 2018-20. This increase is statistically significant (see graph below).
- Nearly 8 out of 10 women who died could have received better care and, tragically, improvements to care may have made a different to the outcome in nearly half (45%) of maternal deaths reviewed.
- Blood clots were the leading cause of maternal death during or up to six weeks after the end of pregnancy, followed by heart disease and COVID-19. These main causes remained the same as the causes identified in last year’s report.
- Mental health issues, including suicide and substance abuse, were the leading causes of late maternal death in 2021-2023.
- The rate of maternal deaths due to pre-eclampsia was similar to previous years, and reviewers felt that care could have been improved for all of the women that died from high blood pressure disorders.
The graph below, taken from the report, shows that the rates for late maternal deaths (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.
Biases and inequalities contribute to maternal deaths
The report emphasises the biases and inequalities that contribute to deaths before and after pregnancy, and advocates for ‘individualised, holistic care’ for those with medical and social complexities.
Of the 643 women that died, 91% faced multiple challenges such as domestic abuse, deprivation or mental health problems. The report writers advocate for ‘the need for improved systems, guidelines and policies to support robust responses and individualised care.’
The report also identifies inequalities in outcomes relating to ethnicity and deprivation:
- Women from Black ethnic backgrounds were more than twice as likely to die, and Asian women were 1.3x more likely to die when compared with White women. While this might seem like an improvement when compared with previous reports, the MBRRACE-UK team point out that Black and Asian women still face disproportionately higher risks during and after pregnancy, as well as well-documented discrimination.
- Women living in the most deprived areas were nearly twice as likely to die than those living in the least deprived areas.
How can we improve outcomes?
Key messages for healthcare professionals
The MBBRACE-UK team have included national recommendations and specific clinical messages for healthcare professionals. These include:
- Information sharing within maternity systems and across health services and multidisciplinary teams, making every contact count, and being curious, asking questions and offering support to women that may face multiple disadvantages.
- Perinatal mental health team referrals should be offered to women with mental health issues who are pregnant, postnatal, or who have experienced the loss of a baby (including custody loss), and ‘red flag’ symptoms such as significant changes in mental state should not be underestimated.
- Women and birthing people with complex, high-risk conditions should be referred early in pregnancy for specialist review, and discharged to primary care with appropriate postnatal management plans. Healthcare professionals should remain inquisitive when women present with unexplained symptoms or declining physical or mental health.
Key messages for families
The team have also published key messages for women, birthing people and their families, including:
- Being aware of the signs and symptoms of mental health issues, and speaking out if you or a loved one experience the symptoms of mental health problems such as unwanted thoughts or suicidal thoughts.
- Getting ready for pregnancy by discussing any physical or mental health conditions with your GP.
What we’re doing at Baby Lifeline to improve outcomes for women, birthing people and their families
Our Mind the Gap research – which surveyed training for maternity services professionals during part of the time period covered in the MBRRACE-UK report (2020-2021) – shows that there are huge gaps in training in areas relating to the leading causes of death for mothers:
- Training in how to manage blood clots – the leading cause of death in this year’s MBRRACE-UK report – was offered by fewer than 40% of maternity services to their staff in 2020-2021
- Training in management of stroke was offered in 1 in 10 services
- Training related to heart disease was offered by fewer than a third of maternity services
- Around half of organisations offered training in both perinatal mental health and substance misuse
- Nearly 9 in 10 organisations offered training related to domestic violence in 2020-2021.
Baby Lifeline’s training courses such as Improving Outcomes for Those with Comorbidities in Pregnancy, Enhanced Maternal Care, and Delivering Excellence in Perinatal Mental Health Care discuss these important topics to build skill, knowledge and confidence for maternity healthcare professionals. We also offer training to improve cultural curiosity and safety. This training is available to health professionals across the UK, and you can find out more here.
Judy Ledger, Chief Executive and Founder of Baby Lifeline said:
“Today’s MBRRACE-UK report is a stark reminder that urgent action is still needed to improve care for mothers before, during, and after pregnancy. We urge decision-makers to take its recommendations seriously and treat this report as a call to prioritise maternal safety and equity. This must include sustained investment in the maternity sector and comprehensive training for all staff to ensure culturally competent, trauma-informed, and safe care for every family.”
Read the full report and its important recommendations here.
Baby Lifeline’s Research & Development Manager, Dr Abaigh McKee, was part of the lay writing group for this report.