NHS Maternity Deaths Hit 20-Year High Amid Ignored Warnings

New data and investigative reports indicate a significant decline in the safety of maternity and neonatal care in England, characterized by a rising maternal death rate and a systemic failure to implement safety recommendations.

Figures from MBRRACE-UK, a research project led by the University of Oxford, show that the rate of women dying during or shortly after pregnancy in the UK increased by 20% between 2009-11 and 2022-24.

This increase occurred despite a 2015 pledge by then health secretary Jeremy Hunt to reduce maternal deaths by 50% by 2030 and make the NHS one of the safest places in the world to have a baby. Hunt later moved the target date for this reduction forward to 2025.

Analysis of Maternal Mortality Trends

The MBRRACE-UK data reveals a distinction between direct and indirect causes of maternal death. The rate of indirect maternal deaths, which are caused by pre-existing conditions exacerbated by pregnancy, remained largely stable with a 3% increase over the last 15 years.

In contrast, deaths linked directly to pregnancy—including those resulting from pre-eclampsia, blood clots, and bleeding—rose by 52%.

Blood clots were identified as the leading cause of death during pregnancy or up to six weeks following delivery. Health experts note that these cases can generally be resolved if they are identified and treated early.

Systemic Failures and Ignored Warnings

A study from King’s College London, published in BMJ Gynecology and Obstetrics Clinical Medicine, found that healthcare organizations in England and Wales are systematically ignoring critical safety advice from coroners.

The research examined Prevention of Future Deaths (PFD) reports issued between 2013 and 2023. It discovered that nearly two-thirds of these safety recommendations were not acted upon by the relevant healthcare organizations.

The study identified 29 PFDs specifically related to maternal deaths, noting that two-thirds of these deaths occurred in hospitals and more than half happened after giving birth. Common causes identified by coroners included:

• Haemorrhage
• Complications during early pregnancy
• Suicide

Coroners cited inadequate escalation of cases, insufficient staff training, and failures to provide appropriate treatment as contributing factors to these deaths.

The research also highlighted a failure in administrative accountability. While NHS organizations are legally required to respond to PFD reports within 56 days, the study found that only 38% of the organizations had published responses.

National Maternity and Neonatal Investigation

Valerie Amos, leading the national maternity and neonatal investigation (NMNI), has described the scale of care failings as unacceptable. In a report based on visits to seven trusts and meetings with staff and families, she stated that the care provided led to tragic consequences.

The NMNI report highlighted that the NHS recorded 748 recommendations regarding maternity and neonatal care over the past decade, a figure Baroness Amos described as staggering.

I expected to hear experiences from families about where they had been let down by the care they had received in maternity and neonatal units across the country, but nothing prepared me for the scale of unacceptable care that women and families have received, and continue to receive, the tragic consequences for their babies, and the impact on their mental, physical and emotional wellbeing.

Valerie Amos

The investigation found that reforms within maternity services have been too slow despite the urgent necessity for change. Baroness Amos suggested that the continued occurrence of harm and baby deaths across the country indicates a need to standardize the level of care across different trusts.

The Department of Health and Social Care has described the failure of NHS organizations to respond promptly to coroners’ reports as unacceptable.