The current rates for maternal death in the UK are beginning to decline but remain higher than in reports from the early 2010s, according the latest MBRRACE-UK data. In this article Allison Felker, PhD: Senior Researcher and Marian Knight, DPhil: Professor of Maternal and Child Population Health, MBRRACE-UK, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, point to the reasons for the continued high rates and how these may be addressed going forward.
Introduction
By global standards, giving birth in the UK is a safe experience, but recent evidence highlights ongoing challenges in maternity services, increasing social complexities and persistent inequalities in maternal outcomes. Of the over 600 women who died during pregnancy or in the year after pregnancy from 2021 and 2023, 91% experienced multiple disadvantages.
Key findings
The findings of the most recent MBRRACE-UK surveillance report offer a sobering reminder that, while some progress has been made, maternal mortality remains a pressing concern in the UK. The rate of maternal death during pregnancy or in the six weeks after pregnancy fell slightly compared to the previous three-year period, but late maternal deaths, occurring between six weeks and one year after pregnancy, continued to rise.
The causes of maternal deaths also speak to ongoing challenges in maternity care. Blood clots were the leading cause of maternal deaths in the early perinatal period, and other direct, pregnancy-related deaths, which are largely thought to be preventable with timely intervention, remained high. In the late perinatal period, suicide and other psychiatric causes of death, including substance use, accounted for over a third of maternal deaths, highlighting the urgent need to prioritise women’s mental health care, particularly in the postnatal period.
Significant inequalities also persisted across age, ethnicity and socioeconomic status. Women over the age of 35 or who were living in the most deprived communities were twice as likely to die compared to women in their late 20s or those living in the least deprived areas, respectively. While inequalities in maternal outcomes for Black and Asian women improved slightly, Black women were still more than twice as likely to die compared to White women, particularly from blood clots or heart disease. Asian women, while no longer at a statistically significantly increased risk of overall maternal death, died from COVID-19 at rates more than four times higher than White women. Coupled with other recent reports about ethnic minority women’s experiences of maternity care, these findings highlight ongoing patterns of inequitable care and a need for personalised approaches.
Lessons for care
Beyond the numbers, the confidential enquiries in this year’s report review the care received by women who died from pre-eclampsia, heart disease and suicide and substance use, as well as those who were killed or had accidental deaths. The confidential enquiries also explored the care of women living in the most deprived areas of the UK who did not die, but who experienced multiple disadvantages. Several recurring themes were identified across these topics including the importance of pre-pregnancy counselling. For women with pre-existing medical conditions, the opportunity to discuss risks, review medications and make lifestyle changes, such as smoking cessation or weight loss, before becoming pregnant can improve outcomes. Yet, too often, this support is not consistently available or accessible. This is also true for women who have complex social circumstances such as financial difficulties, insecure housing or experiences of domestic abuse. These pressures can have profound effects on physical and mental health and wellbeing but are variably assessed and often overlooked in clinical care. It is important that any woman considered to be high-risk on the basis of her medical, mental health or social history has access to senior or specialist care early in pregnancy to create a plan for ongoing management.
A clear plan for management was also a focus of the report with respect to postnatal care, an area where women continue to fall through the gaps. Too often, the support provided to women during pregnancy ends abruptly after pregnancy loss or childbirth, with too little follow-up or clear communication to ensure continuity of care. The enquiries emphasise the importance of providing well-defined discharge summaries to primary care teams that clearly indicate any conditions, medical or social, that require ongoing support and management. Information sharing within maternity services or between other agencies, such as primary care and social services, was also inconsistent, particularly when safeguarding concerns were noted. In many instances, vital details about women’s circumstances were not known to all those caring for her, which may have placed them at greater risk.
This was especially true for women who died from mental-health related causes where information about women’s histories or escalating risks was not appropriately recognised or communicated between services. This was apparent when women were referred to perinatal mental health teams but were denied access to specialised services without consideration of the whole picture. The report emphasises the need for leadership from perinatal mental health teams, not just for women formally under their care but also in offering guidance and oversight for high-risk women who are not accepted for care. This includes women who may be grieving the loss of a child through early pregnancy loss, bereavement or custody loss, and those with substance use. The enquiries stress that mental health support should not be seen as separate or optional, but as an integral part of maternity care.
Conclusion
It is evident that the current maternity system in the UK does not provide adequate multi-agency support for women with complex care needs. To ensure safer maternity care and prevent future maternal deaths, an approach is needed that is personalised and holistic, focusing not only on physical health but with full consideration of women’s lives and histories. Pre-pregnancy counselling, specialist supports and continuity of care after birth are vital, but this must also incorporate the wider health and social care landscape to ensure interagency working and bridge the gaps in maternity care.
Bridging the gaps in maternity care requires individualised, multi-agency support that considers women’s physical, mental health and social complexities to ensure safer outcomes and prevent future maternal deaths.
Allison Felker, PhD: Senior Researcher – MBRRACE-UK, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
Marian Knight, DPhil: Professor of Maternal and Child Population Health, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, OX3 7LF, UK
