What is the purpose of the MBRRACE - UK report
The report reviews deaths and severe complications during and after pregnancy to understand why they happened and what can be done to prevent them in the future. Its findings provide essential guidance for improving maternity care, highlighting areas where care is working well and where women are still falling through gaps.
While the overall maternal mortality rate has not changed significantly from the previous period, the report makes it clear that many women are still falling through the gaps before, during, and after pregnancy. It emphasises that care must be holistic, personalised, and coordinated, considering not just physical health, but mental wellbeing and social circumstances.
Key Messages to Improve Care
MBRRACE-UK’s assessors have drawn recommendations directly from existing guidance and highlighted areas where implementation needs strengthening. Several new national recommendations are particularly important for early pregnancy care and mental health:
- Urgent referral pathways in early pregnancy for women with high-risk medical conditions or complex social circumstances to ensure timely access to senior or specialist consultation. This is especially crucial for conditions like ectopic pregnancy, where delays can be life-threatening.
- Clearer discharge summaries for primary care that indicate key conditions requiring ongoing support, with detailed information about medical, mental health, and social complexities. This ensures women don’t get lost in the system after hospital care ends.
- Standardised assessment of social risk factors, including domestic abuse, at booking and at least once more later in pregnancy. The report stresses that codes for safeguarding concerns should be clear and known to all involved in a woman’s care.
- Perinatal mental health teams should take a leadership role for all pregnant or recently pregnant women with mental health conditions – even if women aren’t formally accepted onto their services. This includes risk assessment, joint care planning, and rapid referral to appropriate mental health support.
The report concludes:
“Many women are still falling through the gaps before, during and after pregnancy. Any care provided must be holistic and personalised to consider this complexity.”
Early pregnancy and ectopic pregnancy
The recommendation for urgent referral pathways is particularly significant for women experiencing ectopic pregnancies or other early pregnancy complications. Previous MBRRACE-UK reports have shown that ectopic pregnancy remains the leading cause of maternal death in early pregnancy, and in many cases, improvements in care could have made a difference. Rapid access to specialist care, timely diagnostics, and effective triage can save lives.
Ectopic pregnancy was not highlighted in this 2025 report because it was addressed separately in last year’s MBRRACE-UK 2024 report, which focused specifically on early pregnancy-related deaths. The MBRRACE team brought forward the review into early pregnancy-related deaths and reported last year due to the concerning increase in deaths and serious harm associated with ectopic pregnancies.
The 2024 report revealed that 12 women died from ectopic pregnancies between 2021 and 2022, marking a significant rise from 5 deaths in 2019. Alarmingly, all 12 deaths could have been prevented with better care, and improvements might have made a difference for 9 of these women (75%).
Key recommendations from the 2024 report include:
- Revising ambulance service protocols to ensure that 999 calls involving women who are pregnant, recently pregnant, or may be pregnant are appropriately assessed and managed.
- Raising awareness among women and clinicians about the symptoms of ectopic pregnancy and the need to “Think Ectopic”
You can read more about the 2024 report here: https://ectopic.org.uk/blog/the-epts-statement-on-the-mbrrace-uk-report-2024
Supporting Awareness and Action
While MBRRACE-UK highlights where care needs to improve, we all have a role to play in raising awareness and supporting women. Campaigns like Think Ectopic help women and clinicians recognise the early warning signs of ectopic pregnancy, which can save lives by encouraging timely assessment and treatment.
Equally, initiatives that focus on perinatal and post-pregnancy mental health are essential. They help ensure that women receive the emotional and psychological support they need after pregnancy loss or complications.
By sharing information, supporting these campaigns, and advocating for joined-up care, we can help ensure that every woman receives the care, attention, and compassion they need – before, during, and after pregnancy.
Support for you
If you’ve experienced an ectopic pregnancy and are struggling, please know you’re not alone.
We offer a range of support, including:
- Our support services, such as our helpline, online forum, and email support
- Information on the workplace and talking to your employer
- A compassionate community who understands what you’re going through
You can explore our support options here.
