MBRRACE-UK 2025 annual report – the key highlights

Overall, the report concluded that there had been a decrease in the overall maternal death rate compared to 2020-2022, however, noted that this was not a significant reduction in figures.

The leading cause of mothers dying during or up to six weeks after the end of pregnancy was thrombosis and thromboembolism, followed by cardiac disease and COVID-19.

However, where a mother died between six weeks and one year after the end of pregnancy, the leading cause of death was suicide. In fact, 35% of the maternal deaths between six weeks and one year after the end of pregnancy were due to psychiatric causes.

The following trends were furthermore uncovered:

• asian women had a maternal mortality rate 1.3 times higher than white women, for black women, it was 2.3 times higher than white women.
• women aged 35 or older were 1.6 times more likely to die than women aged between 25 and 29.
• women living in the most deprived areas had a maternal mortality rate that was 1.9 times higher than that of women in the least deprived areas.

Following the above statistics, the report has identified that some of the common themes were related to the importance of pre-pregnancy counselling and getting women ready for pregnancy, recognition of risk factors, including social and/or mental health complexities and risk assessments during the postnatal period.

As a result, it has set new national recommendations to improve care which comprises:

1. setting up an urgent referral pathway in early pregnancy for women with high-risk medication or complex social circumstances. This is aimed at ensuring that women can access care with senior or specialist consultations quicker;
2. discharge summaries for primary care should clearly indicate in an initial summary box the key conditions that require ongoing support or management and a clear plan for postnatal care. It is recommended that detailed information about medical, mental health and social complexities and ongoing medications, monitoring requirements or safeguarding concerns must be included to facilitate a clear plan for postnatal care;
3. updated guidelines on the care of women with complex social factors to include clear guidance for a standardised assessment and documentation of social risk factors at booking appointments and at least once more later in pregnancy. In the absence of sufficient evidence to update guidance, commission research to explore the unique care needs of vulnerable populations;
4. developing guidance for information sharing within maternity services and across health services and other agencies in the event of safeguarding concerns. Ensure that codes for flagging domestic abuse are applied in women’s records and are known to all those caring for her.
5. Ensure specialist perinatal 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.

Those of us who work for families affected by failures in maternity care welcome these recommendations and are hopeful that this will lead to a decrease in maternal deaths and morbidity.