MBRRACE-UK Saving Lives, Improving Mothers’ Care 2025 report

The latest report on the deaths of women during pregnancy or in the year after pregnancy has been published by MBRRACE-UK. This report examines the care of 643 women who died between 2021 and 2023 in the UK and Ireland.

The findings of this report are, more than ever, deeply challenging. The government inherited a target to halve maternal mortality rates in England by the end of this year. Rates of maternal mortality have, in fact, increased over the past 10 years. In particular, deaths in the later period – between six weeks and a year after the end of pregnancy – have risen significantly since 2018-2020, and the majority of these deaths were linked to mental health issues, including suicide and substance use.

This year’s MBRRACE-UK report presents a stark picture of unmet need, widening inequalities and rising inequity. The social determinants of women’s physical and mental health, including poverty, racism, abuse and social care involvement, are deeply implicated in these terrible outcomes and tragic losses.

We cannot read another MBRRACE report that tells the same story. The National Maternity Investigation, the NHS 10 Year Plan, and the Women’s Health Strategy must prioritise systemic change to address entrenched inequities, centring the needs of those experiencing acute disadvantage and deprivation. That includes women who have involvement from children’s social care, women experiencing abuse, women in contact with the criminal justice system, migrant women, and those who face racism and discrimination. This cannot be done without engaging with the complex reality of women’s lives, and the social determinants of their health, including financial need and housing issues.

We can’t pretend change is possible without a radical shift in funding and focus to provide better care, equity and justice to women and their families.  

Persistent inequalities, discrimination, and unmet needs

Women who live in poorer areas continue to be twice as likely to die during pregnancy, childbirth and the early postnatal period as those living in the least deprived areas.  

More than one in four - 28% - of all the women who died were known to social services.

Maternal suicides were the leading cause of deaths occurring between six weeks and one year after the end of pregnancy. As a whole, deaths from psychiatric causes (suicide and substance use) accounted for 34% of maternal deaths during this period.

Black and Asian women continue to face disproportionately higher risks, and reported discrimination remains widespread. Women from Black ethnic backgrounds are still more than twice as likely to die compared to White women.

Women who experience abuse, and those living in situations of severe and multiple disadvantage continue to be overrepresented amongst women who die in pregnancy and the year after pregnancy.

The trauma of having a baby taken into care

Over a third (35%) of women who died of suicide or substance use had experienced having their child taken into care or faced threatened child removal.

Of the 11 women who died by suicide while they were still pregnant, eight had older children in care or were known to social services.

Birth Companions recently worked with researchers at Kings College London and Oxford University to conduct a deep-dive review of the MBRRACE-UK data on maternal deaths during 2014-2022. That study highlighted the cumulative burden of disadvantage and inequity experienced by pregnant and postnatal women who have children’s social care involvement, and the extent of systemic and organisational barriers to the provision of good care, as well as individual bias and discrimination.

There is a mental health crisis among pregnant and postnatal women. Although specialist perinatal mental health (PMH) services were expanded in 2019, provision remains patchy and women often fall through the cracks. Many of the women who died did not have input from specialist PMH teams. Some women had referrals to these teams declined because they had lost custody of their baby. This cannot be our response to women facing acute trauma.

Domestic abuse

Rates of domestic abuse among the women who die have risen continually since reporting began, and in 2021-23 stood nearly four times higher than in 2012-2014.

All but one of the women who died as a result of homicide were murdered by their partner or former partner. Domestic abuse was documented for nearly half of these women, but disjointed services and limited communication between different healthcare providers and agencies meant that this information was not shared with all those caring for them.

Fragmented and failing care pathways  

This year’s report highlights the fact that women experiencing complex social factors, which include those living amidst disadvantage and those who have experienced abuse, need multi-agency support, yet often care is fragmented. Safeguarding is failing.

Assessors noted that maternity records are not designed to assess and record information about deprivation, including insecure housing or financial need.  For women in these situations, a focus on physical health on its own is insufficient and may mean other needs that require specialist input are overlooked. Guidance on supporting women with complex social factors is outdated and provision is patchy. While there were some examples of good care and high-quality support, this was not universal.

There was also variation in how information relating to social risk was recorded in women’s maternity notes. The current ‘tick box’ nature of electronic health records may obscure women’s circumstances and challenges.

Women facing high levels of social risk are being placed on standardised, low risk care pathways, with tragic results.  This has to change.

What needs to happen?

Shockingly, reviewers found that for 45% of women who died, improvements to care may have made a difference to their outcome. This figure is even higher for those who died by suicide, where it was felt that different care may have made a difference to the outcome for 53 women - 64%. Women’s lives could and should have been saved.

The importance and urgency of the government’s current national maternity investigation cannot be overstated. While maternity professionals and other healthcare providers are, in most cases, doing their very best for women and babies, clearly our systems are failing.

Comprehensive guidance, specialist pathways with urgent referral, and coordinated multi-agency approaches to care are essential to reduce inequalities and improve outcomes for women and babies across the country. This includes updating guidelines and improving the assessment and documentation of complex social needs or ‘risk factors’. Current NICE guidance on this is outdated and fails to address many of the needs highlighted in this report.  

Women who are at risk of having a child removed from their care, or who are dealing with the pain of child removal, are at particular risk of death by suicide or substance use, and yet their needs are among the most poorly met. That’s why we at Birth Companions are currently leading work to co-design a new National Care Pathway for women who have involvement from children’s social care in pregnancy and the first two years of a child’s life.

Racism persists and must be tackled. In the Black Maternity Experiences Report 2025 published by Five X More, 28% of Black women reported discrimination, with 25% of them saying this was based on their race. Birth Companions’ upcoming report on the experiences of refugee, asylum-seeking and undocumented women also highlights the impact of systemic and personal racism and discrimination faced by pregnant women and mothers seeking safety in this country.  

To find out more about Birth Companions’ work on these issues, and to keep in touch with upcoming projects, sign up to our newsletter.‍

‍To discuss this news story, or request interviews on this topic, please get in touch with Kirsty Kitchen: kirsty@birthcompanions.org.uk.

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