MBRRACE-UK: Actions to Save Mothers’ Lives

A Blog by Head of Research and Development, Sara Ledger


The day the MBRRACE-UK reports come out is always a mixed day – an opportunity to learn and improve maternity care, but also the reality that these statistics relate to families that will never be the same again. There was a statistically non-significant increase in deaths from the last report, which shows the increased need to implement the report’s new recommendations, and a renewed focus on implementing guidelines and previous recommendations.

“Assessors judged that 29% of women who died had good care. However, improvements in care which may have made a difference to the outcome were identified for 51% of women who died.” – MBRRACE-UK, 2021

Given that over half of the 217 women who died may have had a different outcome with better care, we can hope that implementing changes will make a difference.


Baby Lifeline’s Mind the Gap report looked at training provision in later years of the MBRRACE-UK data and analysis, and so I have compiled both sets later in this blog to demonstrate a lack of training for the frontline in areas shown to relate to avoidable harm in maternity.


New Recommendations

MBRRACE-UK does an amazing job of giving clear guidance and practical advice on what now needs to happen to change outcomes. For the purposes of spreading awareness, I will list the new recommendations for health professionals here:

  • Regard nocturnal seizures as a ‘red flag’ indicating women with epilepsy need urgent referral to an epilepsy service or obstetric physician
  • Ensure that women on prophylactic and treatment dose anticoagulation have a structured management plan to guide practitioners during the antenatal, intrapartum and postpartum period
  • Ensure at least one senior clinician takes a ‘helicopter view’ of the management of a woman with major obstetric haemorrhage to coordinate all aspects of care
  • Ensure that the response to obstetric haemorrhage is tailored to the proportionate blood loss as a percentage of circulating blood volume based on a woman’s body weight
  • Do not perform controlled cord traction if there are no signs of placental separation (blood loss and lengthening of the cord) and take steps to manage the placenta as retained.
  • Be aware that signs of uterine inversion include pain when attempting to deliver the placenta, a rapid deterioration of maternal condition and a loss of fundal height without delivery of the placenta.


MBRRACE-UK also reiterates guidance from green top guidelines and previous recommendations within the report, to improve awareness around implementation.



One key finding identified by the report is a concerning rise in the number of women dying from Sudden Unexplained Death in Epilepsy (SUDEP). The enquiry found that a low proportion of women’s medications were optimised either before or during pregnancy, and a recommendation for improvements to care is a rapid pathway to expert teams in epilepsy and/or neurology to support the management of care.



Women from Black ethnic backgrounds have a 4 x higher risk of dying when compared to white women, mixed ethnicity women have a 3 x increased risk, and Asian women have a 2 x increased risk.

There has been a recent, and overdue, widespread awareness and consequent action around the disparity of maternity mortality based on ethnicity. Whilst maternal mortality does remain rare, the gap between outcomes for women from Black and white ethnic groups is widening, and this is unacceptable.


What’s being done about inequalities?

‘The NHS Long Term Plan’ (NHS England 2019)

The NHS Long Term Plan has set out that ‘by 2024, 75% of women from Black and minority ethnic communities and a similar percentage of women from the most deprived groups will receive continuity of care from their midwife throughout pregnancy, labour and the postnatal period’.


COVID-19 Immediate Actions

Following the MBRRACE-UK Rapid Report into care during the pandemic, it was determined that disparity existed for women affected by the virus. To minimise this, actions were set out, including:

  • increased support
  • tailored communications
  • discussion of nutrition
  • ensuring all providers record on maternity information systems the ethnicity of every woman, as well as other risk factors; such as, living in a deprived area (postcode), co-morbidities, BMI and aged 35 years or over, to identify those most at risk of poor outcomes.


Increasing Understanding

The Royal Colleges have started work to address racism and disparity. The RCOG “taskforce”, will seek to better understand where disparities exist and improve understanding on causality.


Training being delivered at the time to the frontline (2017/18)


2016-2018: Maternity mortality as reported by MBRRACE-UK (2021)

2017/18: Training as reported by Baby Lifeline’s Mind the Gap report (2018)

Whilst “training our way out of it” is increasingly being seen as an over-simplification of a more complex issue in maternity safety, it should not be assumed that training in areas shown to cause avoidable deaths is sufficient.

Baby Lifeline’s Mind the Gap report audited training in 2017/18 – the topics chosen were ones repeatedly cited in report recommendations relating to improving safety in maternity. The fact that heart disease remains the single cause of indirect maternal deaths and training in how to manage this is only provided in less 1 in 3 trusts demonstrates a drastic disconnect. Maternity leaders should be supported to know what to prioritise in team training.

Further, this is also to assume that the quality of this training makes it meaningful and impactful, and that professional time is protected to attend it. We found that less than 10% of trusts evaluated all training they provided to professionals. In addition, the biggest barriers to attending training related to lack of funding and staff shortages – something which has not yet been rectified.

One way to ensure that the frontline – those directly caring for mothers – are up-to-date with recommendations to improve care and updated guidelines is through training, and this needs to be considered.


In Conclusion

Over half of mothers who died potentially could have had a different outcome with improved care and less than a third of mothers received “good care” – there is both a long way to go and a real opportunity to save a lot of lives. New recommendations should be rapidly implemented, and an audit on existing recommendations and guidelines needs to be prioritised locally.

Whilst training frontline professionals isn’t the only fix to make maternity safer, the numbers of professionals accessing training in areas relating to avoidable harm are not sufficient.




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