Maternal, Newborn and Infant Clinical Outcome Review (MBRRACE-UK)

Clinical Outcome Review

Delivered by:

MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK)

Website:

MBRACE-UK

The UK is one of only a few countries with a national review system for maternal and perinatal deaths. The system of Confidential Enquiries into Maternal Deaths has been in place since the 1950s and was expanded in the 1990s to include perinatal mortality. Since 2012, MBRRACE-UK has been the collaboration responsible for delivering this longstanding programme, which is globally respected as an example of best practice for maternity review. The overarching aim of MBRRACE-UK is to support the delivery of safe, equitable, high-quality and patient-centred maternal, newborn and infant health services.

The main purpose of MBRRACE-UK is to conduct robust national surveillance and investigate the deaths of women and babies who die during pregnancy or shortly after pregnancy in the UK. The surveillance of maternal and perinatal deaths, including specific findings around socioeconomic and ethnic inequalities, are essential to monitor trends that underpin many current and future government ambitions, including new national ambitions and targets. The confidential enquiries, conducted annually for maternal deaths and morbidity, and biannually for perinatal events, are vital to identify areas where care can be improved to prevent future deaths or serious complications.

The findings and recommendations emerging from MBRRACE-UK have played a pivotal role in strengthening patient safety across maternity services. By systematically reviewing maternal and perinatal deaths and identifying areas for improvement in clinical practice, communication, and systems of care, MBRRACE-UK has provided clear, evidence-based guidance to healthcare professionals and policymakers.” Siobhean, Service User Voice Representative, MBRRACE-UK

Supporting improvement

The overarching healthcare improvement aim of MBRRACE-UK is to conduct maternal and perinatal mortality surveillance and confidential enquiries to quantify and assess the quality of maternity, neonatal and other services relevant to pregnant and postpartum women and newborn babies. This is in order to stimulate healthcare improvements in clinical quality and safety by enabling clinicians, managers, commissioners and policy makers to learn systematically from adverse events, reduce inequalities and attain parity of esteem. The objectives of this programme of work are to:

Assess the quality and safety of maternity and infant services
Support improvements in service quality through national learning
Produce evidence-based recommendations and good practice points
Influence clinical practice, service provision, health policy and clinical education.

It is the aim of MBRRACE-UK that, through these objectives, the UK will see reductions in maternal and perinatal mortality and fewer disparities in mortality based on ethnicity, deprivation and other characteristics.

MBRRACE-UK data and recommendations have been cited in, or prompted the development of, numerous guidelines, toolkits and policy documents, that aim to improve patient care and outcomes. Examples include:

The NHS England Maternal Care Bundle, which sets best practice standards for implementation by NHS providers and commissioners in England with an aim to reduce maternal mortality and morbidity
A preconception care toolkit with resources for healthcare professionals
A postnatal care toolkit for ICBs, partners and providers
The Joint Royal Colleges Ambulance Liaison Committee’s (JRCALC) Prehospital Maternity Decision Tool
A report on Black maternal health from the Woman and Equalities Committee presented to the House of Commons in September 2025.
A ‘Share the care’ awareness campaign developed by the charity Mummy’s Star, which advocated for holistic end-of-life care for pregnant women with cancer.

British Association of Perinatal Medicine (BAPM) guidance on extreme preterm birth and neonatal mortality.

Additional data and resources

In addition to HQIP-published reports below, you can access an array of resources – including data, lay summaries, infographics and more – on the MBRRACE-UK website.