Maternity care – confidential enquiries 2021-23 (MBRRACE-UK)

Reports | Published: 11 Sep 2025

This report from MBRRACE-UK (Maternal, Newborn and Infant Clinical Outcome Review Programme) is based on UK and Ireland Confidential Enquiries into Maternal Deaths from hypertensive disorders, cardiac disease, mental health-related causes, homicide and accidents, as well as morbidity findings for women living in the most deprived areas. It includes a focus on deprivation.

There was a statistically non-significant decrease in the overall maternal death rate in the UK between 2020-22 and 2021-23

This report found that thrombosis and thromboembolism was the leading cause of maternal death during or up to six weeks after the end of pregnancy. 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. Suicide was the leading cause, with deaths from psychiatric causes accounting for 34%.

While inequalities in maternal mortality remained in 2021-23, the rate for women from Black ethnic backgrounds continued to decrease (double the risk, compared to White women – down from 5 times greater in 2014-16.

The report contains a number of recommendations to support improvement relating to, but not limited to: care before conception; future health risks after pregnancy complications; unexplained symptoms or declining physical or mental health; mental health; and training for maternity staff. Specific recommendations include calls at a national level to:

  • Set up an urgent referral pathway in early pregnancy for women with high-risk medical conditions or complex social circumstances, to ensure they receive early triage for senior or specialist consultation
  • Develop guidance for information-sharing within maternity services, and across health services and other agencies, in the event of safeguarding concerns.

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Maternity care – confidential enquiries 2021-23 (MBRRACE-UK)