This year’s report examines the care of 643 women who died during, or up to one year, after pregnancy between 2021 and 2023 in the UK and Ireland.

  • Between 2021 and 2023, 257 women died during or up to six weeks after pregnancy in the UK. This equates to 12.82 women per 100,000 giving birth, which is lower than reported in last year’s report.
  • Blood clots (thrombosis and thromboembolism) remained the leading cause of maternal death followed by heart disease and COVID-19, which happened at equal rates.
  • Late maternal deaths, occurring between six weeks and one year after the end of pregnancy, continued to increase and were significantly higher in 2021-2023 compared to 2018-2020.
  • Deaths linked to mental health issues, including suicide and substance use, were the leading causes of late maternal death (deaths between six weeks and one year after the end of pregnancy).

Of the 643 women who died during or up to one year after pregnancy in the UK and Ireland in 2021-2023, 583 (91%) faced multiple interrelated challenges

Women from Black ethnic backgrounds were still more than twice as likely to die compared to White women.

  • Twenty-two percent of women who died were subject to domestic abuse either prior to their pregnancy or their during their pregnancy. This was nearly four times higher than it was in 2012-2014
  • Seven percent had a history of abuse as a child
  • Twenty-one percent were known to social services
  • Seventeen percent were known to use substances
  • Forty-six percent had mental health problems

Of the 155 women who died from mental health (psychiatric) causes during or after pregnancy in the UK and Ireland, 88 died by suicide and 67 died in relation to substance use

For all of the women who died from high blood pressure disorders, better care may have made a difference to their outcomes.

The report also highlighted that no woman who had high blood pressure during pregnancy had placental growth factor (PLGF) testing, even when pre-eclampsia was suspected.

Only 11% of the 79 women who died from heart disease in 2021-2023 had pre-existing heart problems,

For 45% of women who died, improvements to care may have made a difference to their outcome.

MBRRACE 2025 – Key Points, pre-eclampsia

New guideline recommendations

  • For women with high-risk medical conditions or complex social circumstances, there should be a separate, parallel, urgent referral pathway to ensure they receive senior or specialist consultation as soon as possible in pregnancy.
  • Discharge summaries for primary care should clearly indicate in an initial summary box the key conditions that require ongoing support or management and a clear plan for postnatal care. Detailed information about medical, mental health and social complexities and ongoing medications, monitoring requirements or safeguarding concerns must be included to facilitate a clear plan for postnatal care.

The women who died

  • In 2021-23, six women died from hypertensive disorders of pregnancy in the UK and Ireland. This is down from 8 BUT still higher than the 2 recorded in 2012-14.
  • Five women died during pregnancy or up to six weeks after pregnancy.
  • One died between six weeks and one year after the end of pregnancy.
  • Half of the women who died from hypertensive disorders in 2021-23 had pre-existing hypertension and were on antihypertensive medications prior to becoming pregnant.
  • Every woman who died from hypertensive disorders of pregnancy had at least two known risk factors for pre-eclampsia.
  • Frequently discharge summaries also did not include clear instructions or a detailed plan for postnatal care, including a time frame and whose responsibility it was to monitor the woman’s hypertension.
  • Three women presented with pre-eclampsia at term, which was not recognised until they developed symptoms and signs of intracranial haemorrhage.
  • No women who died from hypertensive disorders of pregnancy had placental growth factor (PLGF) testing.
  • Different care may have made a difference to the outcome for five of the women who died (83%).

“The MBRRACE report once again makes disappointing and depressing reading with stubborn figures showing far too many women are dying and that the women who are dying aren’t getting the care they deserve.

87% of women who died with pre-eclampsia could have had better care and not one had a PlGF test. Every trust across the United Kingdom who does not have these tests must implement them as a matter of priority.

It’s now clear this is a matter of life and death.”

Marcus Green; CEO, APEC