Maternal deaths at highest level in two decades

Maternal deaths in the UK have reached their highest level in two decades, despite repeated warnings about life-threatening symptoms and multiple national recommendations aimed at improving maternity safety. An investigation by The Times reports that between 2013 and 2023, the NHS received 67 separate warnings to take red flag symptoms in pregnancy and the postnatal period seriously. Over the same period, the UK’s maternal death rate increased by around 50 per cent, rising from 8.54 deaths per 100,000 pregnancies in 2013 to 12.80 in 2023.

The most recent data shows that 257 women died during pregnancy or within six weeks after birth between 2021 and 2023. The leading causes included blood clots, cardiac conditions, suicide, stroke, sepsis and severe bleeding.

These findings highlight a deeply concerning pattern: repeated identification of risks, but insufficient and inconsistent implementation of change.

Over the past ten years, 748 recommendations for improving maternity care have been issued across 59 official reports. Many focus on the same core issues, repeated again and again. Hospitals were advised 23 times to rapidly assess and treat symptoms of blood clots and stroke, with specific warnings not to dismiss symptoms because a woman is pregnant. Severe pain should be taken seriously, highlighted in 13 separate recommendations. Signs of severe bleeding were emphasised 12 times, heart conditions 10 times, and recognition of sepsis nine times. These are not rare or obscure complications. They are well recognised causes of maternal death, and many are treatable when identified early. The repetition of these recommendations suggests the problem is not a lack of knowledge, but a gap between guidance and consistent implementation in practice.

The investigation also found that 31 recommendations focused on improving mental health and support services. Despite this, suicide is now the leading cause of death in the postnatal period, with maternal deaths from suicide reported to be 74 per cent higher than in 2019. This reinforces longstanding concerns about gaps in perinatal mental health care, continuity of support, and early identification of risk.

Repeated recommendations have also called for action on racial disparities in maternity care. Despite this, Black women in the UK remain three times more likely to die during pregnancy or shortly after birth than white women. This reflects broader evidence showing that inequalities in maternity outcomes are systemic and require sustained, coordinated action across services.

One woman died following a postpartum haemorrhage after concerns about bleeding were not treated as an emergency.

Another mother and baby died after delays transferring to hospital during a haemorrhage.

In another case, a woman at high risk of blood clots did not receive preventative medication and died shortly after giving birth.

Clinicians and campaigners have raised concerns that maternity services are overwhelmed by the volume of recommendations, often without additional resources to implement them. There are also concerns that repeated recommendations, without prioritisation or clear accountability, can lead to frontline staff facing increasing administrative burden rather than meaningful system change.This highlights the need for coordinated national leadership, prioritisation of key safety actions, and investment in workforce, training, and infrastructure.

The national maternity investigation led by Baroness Valerie Amos is expected to publish recommendations later this year. The aim is to bring together findings from multiple reviews into a single, coherent set of national actions. For families and professionals alike, the key question remains whether this will lead to meaningful implementation, rather than further recommendations alone.

At MAMA Academy, we know that early recognition and timely escalation can save lives. Many of the red flag symptoms highlighted in this investigation are the same concerns we encourage families and professionals to act on, including severe pain, bleeding, sudden swelling, breathlessness, and changes in wellbeing. We also recognise that midwives and clinicians are working under immense pressure. Improving maternity safety requires system-level change, not individual blame. Maternal deaths are not inevitable. Many are preventable with timely recognition, escalation, and coordinated care.

This moment must serve as another call to move beyond identifying risks and towards sustained, measurable change that protects both mothers and babies.