The MBRRACE-UK collaboration, co-led by Oxford Population Health’s National Perinatal Epidemiology Unit, has today published the full Saving Lives, Improving Mothers’ Care report on women who died during or up to a year after pregnancy between 2021 and 2023.

The report presents key recommendations for maternal medicine networks in England, health boards and integrated care boards, NICE, and the NIHR for improving the care of women with complex medical, mental health and social needs.

This report follows the data brief that was published in January 2025 that showed a slight improvement in the UK maternal death rate in 2021–2023. It examines the care received by the women who died in more detail and suggests strategies and interventions to prevent future deaths. 

The data published by the MBRRACE-UK collaboration in January 2025 also showed that persistent disparities in maternal care remained. In 2021–2023, Black women were more than twice as likely to die during or up to six weeks after pregnancy when compared with White women. Asian women and women from mixed ethnic backgrounds also had a slightly, statistically non-significant increased risk of death when compared with White women.* Women living in the most deprived areas of the UK were more than twice as likely to die when compared to women living in the least deprived areas.

The data also showed that 91% of the women who died during or up to a year after pregnancy faced multiple or interrelated challenges including multiple and severe disadvantages, physical health problems, and mental health challenges.

The leading cause of death in this period for women who died during pregnancy or within six weeks after pregnancy was blood clots (thromboembolism), followed by COVID-19 and heart disease. The most common causes of death in women who died between six weeks and a year after the end of pregnancy were mental health related, including suicide and drug and alcohol use.

Key recommendations for the care of women with medical, mental health and social challenges:

  • Urgent referral pathways must be set up to assess high-risk women for senior or specialist review in early pregnancy;
  • Discharge summaries provided by hospitals for primary care (including local GP surgeries) should include a summary box of actions concerning conditions that require postnatal management;
  • Care guidelines for women with complex social needs should be updated to include clear steps for asking about and recording social risk factors early in pregnancy and again later;
  • Ensure codes for domestic abuse in women’s records are used and information is shared appropriately in the event of safeguarding concerns;
  • Ensure 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.

Professor Marian Knight, Director of the National Perinatal Epidemiology Unit and MBRRACE-UK programme lead, said ‘This latest national enquiry has identified several key actions which are needed to ensure women with medical, mental health and social challenges receive appropriate care. It is imperative that care guidelines for women with complex social needs are updated to ensure equitable outcomes for all women. Research to better understand the needs of vulnerable women must be commissioned and prioritised to fill gaps in the evidence needed to update current guidance.’

The full report is available on the MBRRACE-UK website.

*Caution should be used when interpreting the figures for women from mixed ethnic backgrounds as low numbers mean the rate may be affected by random variation.