Recommendations for maternal medicine in England call for improvements in the care of women with complex medical, mental health and social needs, aimed at saving mothers’ lives during and after pregnancy through the improvement of maternity services.
‘Saving Lives, Improving Mothers’ Care’, points to a need for multi-disciplinary care plans that start before pregnancy, identifying individual risk factors which consider the whole person, not just their pregnancy, and continue after the mother has given birth.
The report includes guidance for integrated care boards, health boards, NICE, and the NIHR, focusing on how services can be strengthened to better support women with multiple interrelated pregnancy challenges. Health challenges include problems with previous pregnancies, smoking habits, heart disease, whilst mental health issues may include a mental health diagnosis or substance abuse, and social complexities could involve issues such as domestic abuse, being known to social services and living in a deprived area.
The work is from the Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK), commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme.
It follows a briefing published in January 2025, which showed a slight improvement in the UK maternal death rate between 2021- 2023 and 2020- 2022, but rates of death are still higher than before the Covid-19 pandemic.
In the new report, co-led by the University of Oxford, the researchers examined women who died in the most recent cohort during or up to a year after pregnancy in more detail. Between 2021 and 2023, the maternal death rate of women who died in pregnancy or in the first six weeks of their baby’s life was 12.82 women per 100,000 women giving birth, representing 257 women out of a total of 2,004,184 women giving birth at this time.
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Women ‘still falling through gaps’
The leading cause of maternal death was blood clots, followed by heart disease, Covid-19, mental health conditions, epilepsy, and stroke. The most common causes of death in women who died between six weeks and a year after the end of pregnancy were mental health-related, including death by suicide and drug and alcohol use.
The data also showed that 91 per cent of the women who died faced multiple or interrelated challenges, including multiple and severe disadvantages, physical health problems, and mental health challenges.
Women from ethnic minority backgrounds and deprived areas are ‘still falling through the gaps before, during and after pregnancy’, according to the report. Black women were more than twice as likely to die during or up to six weeks after pregnancy when compared with White women. In addition, women living in the most deprived areas of the UK were more than twice as likely to die when compared to women living in the most affluent areas.
Urgent referral pathway needed
The report calls for the set-up of an urgent referral pathway to triage high-risk women for specialist review in early pregnancy.
It recommends clearer hospital discharge summaries for general practice that cover issues requiring postnatal management, and updated guidelines to ensure social risk factors are identified and recorded throughout pregnancy.
Stronger safeguarding measures are also advised, including the sharing of evidence of domestic abuse.
In addition, specialist perinatal mental health teams are recommended to take a leadership role in the care of pregnant women with mental health conditions, including coordinating joint care, carrying out risk assessments and ensuring rapid referral into appropriate services.
Professor Marian Knight, from the University of Oxford, said, ‘This latest national enquiry has identified several key actions which are needed to ensure women with medical, mental health and social challenges receive appropriate care.
‘It is imperative that care guidelines for women with complex social needs are updated to ensure equitable outcomes for all women.
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‘Research to better understand the needs of vulnerable women must be commissioned and prioritised to fill gaps in the evidence needed to update current guidance.’
Bridging the gaps in maternity care
National recommendations for the care of women with medical and social challenges
Urgent referral pathways
Set up an urgent referral pathway to triage high-risk women for senior or specialist review in early pregnancy
Information sharing
Ensure codes for domestic abuse in women’s records are used and information is shared appropriately in the event of safeguarding concerns
Discharge summaries
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Discharge summaries for primary care should include a summary box of actions concerning conditions that require postnatal management
Source: MBRRACE-UK – Saving Lives, Improving Mothers’ Care 2025
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