Executive Summary

Despite a national mandate to improve outcomes, maternal mortality in the UK has not only failed to decline but has increased over the last decade. The data for the 2022–24 triennium reveals persistent systemic challenges, shifting clinical aetiologies, and entrenched socio-economic and ethnic inequalities.

Primary Clinical Aetiologies

The clinical drivers of maternal mortality remain concentrated in a few key areas during pregnancy and up to six weeks postpartum (Figure B):

  1. Thrombosis and Thromboembolism: Remains the leading cause of maternal death.
  2. Cardiac Disease: Represents the second most common aetiology.
  3. Psychiatric Causes: Ranks as the third most common driver in the immediate perinatal period.

Beyond the traditional six-week postpartum window (six weeks to one year postpartum), maternal suicides remain the leading singular cause of maternal death. Collectively, deaths from psychiatric causes accounted for an alarming 33% of all maternal deaths during this extended period, highlighting a critical gap in long-term maternal mental health provision.

Persistent Systemic Inequalities

Maternal mortality in the UK continues to disproportionately impact specific demographic groups. The data confirms that disparities across age, ethnicity, and socio-economic status are highly persistent (Figure F).

  • Age: Compared to women aged 25–29, women aged 35 or older were nearly twice as likely to die.
  • Ethnicity: Ethnic disparities remain starkly evident (Figure C). Black women face a nearly three-fold higher risk of maternal mortality compared to White women (Figure D). Asian women also demonstrate a slightly elevated risk of maternal death compared to the White reference group.
  • Deprivation: Socio-economic status heavily dictates maternal outcomes. Women living in the most deprived areas (IMD Quintile 5) continue to experience a maternal mortality rate twice as high as those residing in the least deprived areas (Figure E).

Visual Data Summaries

Figure A: Maternal Mortality Trend with Policy Target

This line graph visualises the long-term trajectory of maternal mortality across consecutive three-year rolling periods. It tracks two distinct series: the overall observed mortality rate and the underlying rate excluding COVID-19 deaths. A prominent dashed line anchors the chart, representing the ambition to halve maternal mortality from the 2009–11 baseline. The chart starkly communicates the primary policy failing: rather than trending downwards towards the 50% reduction target, recent mortality rates remain elevated above the historical baseline, an increase that persists even when the impact of the pandemic is stripped from the data.

Figure B: Ranked Cause-of-Death Lollipop Chart

This graphic details the leading causes of maternal mortality in the UK for the 2022–24 triennium. Eschewing traditional bar formatting, this lollipop chart utilises clean points and segments to rank causes in descending order based on the rate of deaths per 100,000 maternities. This immediately directs the reader’s eye to the most critical drivers of mortality (such as thrombosis, thromboembolism, and cardiac disease), making the hierarchy of clinical risk instantly comprehensible.

Figure C: Ethnicity Inequality Trend

Utilising a ‘small multiples’ layout, this visual presents a panel of individual trend lines for each major ethnic group. By giving each demographic its own facet whilst maintaining a common y-axis scale, it allows policymakers to clearly track the distinct historical trajectory and volatility of mortality rates within each specific community, without losing the ability to compare magnitudes across groups.

Figure D: Ethnicity Disparity Forest Plot

Arguably the most hard-hitting graphic in the suite, this forest plot directly addresses the stark inequalities in maternal outcomes. It maps the relative risk of maternal mortality for minority ethnic women against a baseline reference of 1.0 (representing White women, indicated by a vertical dashed line). By plotting the relative risks directly, most notably the prominently elevated risk for Black women. Translating raw rates into a direct, unavoidable statement regarding the scale of ethnic disparities.

Figure E: Deprivation Slope Chart

This line and scatter plot illustrates the profound impact of socioeconomic status on maternal outcomes, tracking mortality rates across the five Index of Multiple Deprivation (IMD) quintiles over time. As consistently reported, women living in the 20% most deprived areas of England continue to exhibit maternal mortality rates twice as high as those living in the 20% least deprived areas (RR 2.03, 95% CI 1.24-3.48, p=0.003).

While maternal mortality rates for women living in the most deprived areas non-significantly decreased in 2022–24 from 2021–23, rates for women living in other IMD quintiles continued to increase. The visual clearly emphasises the persistent deprivation gradient; an inequality gap that has stubbornly persisted across the reporting timeframe.

Figure F: Heatmap of Inequalities Over Time

This heatmap provides a powerful, high-level summary of systemic disparities by fusing the historical data for both ethnicity and socioeconomic deprivation into a single visual framework. Reading from left to right across the triennia, the intensity of the cell shading corresponds to the mortality rate. It underscores two critical narratives: firstly, the unbroken streak of severely elevated mortality risk assigned to Black women that has persisted for over a decade; and secondly, the clear vertical gradient within the deprivation panels, visually confirming that high mortality is consistently anchored to the most deprived quintiles.

Figure G: Full Triennial Maternal Mortality Trend Series

This longitudinal line chart provides a comprehensive historical overview of maternal mortality spanning two decades. Unlike the core executive summary figures, this chart disaggregates the overall mortality rate into its fundamental clinical classifications: direct deaths (resulting from obstetric complications) and indirect deaths (resulting from pre-existing or newly developed conditions aggravated by pregnancy). It affords policymakers a macro-level perspective, clearly illustrating that indirect causes consistently constitute the majority of maternal deaths.

However, the visual also highlights a critical epidemiological shift: the recent rise in UK maternal mortality is overwhelmingly driven by an acute breakdown in managing direct obstetric events. Since the 2009–11 baseline, the rate of direct maternal deaths (such as blood clots, severe bleeding, and pre-eclampsia) has surged by 52%. Conversely, indirect maternal deaths have remained largely unchanged, increasing by just 3% over the same 15-year span. This stark divergence suggests that systemic failures in acute delivery and immediate postpartum management are primary drivers of the current crisis.

Figure H: Detailed Cause Breakdown with 95% Confidence Intervals

Acting as a comprehensive statistical reference, this detailed forest plot expands upon the top-level summary provided in Figure B by delineating every categorised cause of maternal death for the 2022–24 triennium. It incorporates horizontal error bars representing the 95% confidence intervals, thereby explicitly communicating the statistical uncertainty inherent in these estimates across a wide spectrum of aetiologies.

Figure I: Focused Cause Breakdown (Log Scale)

Acting as a vital statistical and clinical companion to Figures B and H, this detailed forest plot delineates the specific causes of maternal death for the 2022–24 triennium, explicitly excluding the two most prevalent drivers. By employing a logarithmic scale, the visual space for lower-incidence data is expanded. This ensures that the horizontal error bars representing the 95% confidence intervals remain distinct and legible. This granular presentation enables clinical stakeholders to effectively evaluate the magnitude and statistical reliability of less common conditions that would otherwise be visually obscured on a standard linear axis.

Epidemiological Context: Intersectionality and Clinical Disparities

The persistence of the disparities visualised above strikes at the heart of current epidemiological research into maternal mortality. Addressing these gaps requires examining the concepts of intersectionality (how overlapping identities affect risk) and unmeasured confounding variables in clinical outcomes. Based on MBRRACE-UK enquiries and Office for National Statistics data, two critical issues emerge:

1. The Intersectional Data Gap: Ethnicity, Deprivation, and Geography

The Problem of Small Numbers and Deductive Disclosure Maternal death in the UK is a statistically rare event (approximately 250–300 deaths over a three-year period). If researchers divide this cohort into intersectional subsets, for example, “Black women, living in the most deprived quintile, in the West Midlands”. The resulting number of deaths in that specific demographic cell may be zero, one, or two. Because maternal deaths are investigated confidentially, publishing data at this level of granularity risks deductive disclosure (inadvertently identifying deceased individuals), heavily restricting how data can be publicly reported.

Deprivation Does Not Fully Explain Ethnic Risk Despite these reporting limitations, researchers have conducted multivariate analyses to determine if ethnic disparities are merely a proxy for socio-economic poverty. The findings are unequivocal: deprivation does not fully explain the ethnic gap. Even when controlling for socio-economic status and area of residence, Black and Asian women still face a significantly higher baseline risk of mortality than White women in equivalent income brackets.

Conclusion

The data for 2022–24 clearly defines the current frontier of maternal medicine. Traditional metrics, which track deaths by isolated demographic categories, are no longer sufficient to drive the necessary clinical improvements. To resolve the stark disparities visualised in this report, the UK healthcare system must transition towards highly individualised, intersectional risk assessments that account for specific genetic predispositions, nuanced socio-economic realities, and the systemic biases embedded within current diagnostic pathways.

National Policy Response: The Maternal Care Bundle

In direct response to the escalating mortality rates and persistent inequalities outlined in the triennial data, NHS England introduced the ‘Maternal Care Bundle’ (MCB) in 2026. This national policy mandates that all NHS trusts providing maternity services, along with Integrated Care Boards (ICBs), fully implement a targeted suite of interventions by March 2027.

The MCB is designed to establish a baseline of best practice across five critical clinical areas that directly map onto the leading causes of maternal mortality and morbidity identified in the data. Crucially, the interventions are designed with ‘proportionate universalism’ to actively reduce the stark health inequalities experienced by minority ethnic women and those from the most deprived areas.

The five mandated clinical elements are as follows:

1. Venous Thromboembolism (VTE)

To combat the leading direct cause of maternal death, the MCB requires screening for VTE risk at the earliest possible opportunity. Specifically at the first NHS care contact with a positive pregnancy test, even prior to formal antenatal booking.

  • Women are to be offered a national self-assessment questionnaire.
  • Those identified as high risk must be offered low molecular weight heparin (LMWH) and receive it within 72 hours.

2. Pre-Hospital and Acute Care

Recognising that unwell pregnant women often present across various emergency and community settings, this element focuses on the timely detection and management of maternal deterioration.

  • Trusts must implement the national Maternity Early Warning Score (MEWS) tool across all settings for women who are pregnant or have been pregnant in the past four weeks.
  • Ambulance services and labour wards must implement a standardised pre-alert communication system and ensure adequate signage to facilitate the rapid conveyance of obstetric emergencies.

3. Epilepsy in Pregnancy

With neurological conditions representing a leading indirect cause of death, the NHS now mandates rapid optimisation of epilepsy care.

  • Every pregnant woman with epilepsy must have access to a local epilepsy in pregnancy team, consisting at minimum of an epilepsy nurse specialist or neurologist, and a maternal medicine obstetrician.
  • Complex cases must be seamlessly referred to a Maternal Medicine Network (MMN) multidisciplinary team.

4. Maternal Mental Health

Addressing the reality that suicide remains the leading cause of death between six weeks and one year postpartum, this element standardises emotional wellbeing assessments.

  • Women must be invited to self-administer the Whooley questions ahead of specific antenatal and postnatal appointments.
  • Positive screens must trigger further assessment using the Edinburgh Postnatal Depression Scale (EPDS).
  • Clinicians are required to facilitate compassionate conversations and timely referrals to specialist perinatal mental health services where clinical concern exists.

5. Obstetric Haemorrhage

To reduce severe morbidity and mortality from significant bleeding, the MCB standardises identification and escalation protocols.

  • Visual estimation of blood loss is to be replaced by cumulative measured blood loss for all births, utilising scales and under-buttock collection drapes.
  • Clinical escalation is rigidly defined by cumulative volume thresholds (alerting the multidisciplinary team at 500mL, treating as an obstetric emergency with senior presence at 1,000mL, and requiring consultant attendance at 1,500mL).
  • Multidisciplinary team case reviews are mandated for all significant bleeds exceeding two litres.

Conclusion

The NHS Maternal Care Bundle represents a vital systemic shift. By standardising the clinical response to thrombosis, haemorrhage, neurological risks, and psychiatric vulnerabilities, and by embedding early warning scores across the entire acute care footprint, the policy provides a direct, actionable framework to begin reversing the alarming mortality trends and entrenched demographic disparities visualised in this review.

Patient Empowerment and Self-Advocacy

While reversing maternal mortality trends relies heavily on systemic healthcare reforms, the tragic realities behind the statistics highlight the vital role of patient empowerment. Women must be supported not merely as passive recipients of care, but as educated, active partners in their own health journeys.

The NHS Maternal Care Bundle explicitly states that care must be tailored around the informed decision of each service user. To achieve this, pregnant women and their families must be equipped to recognise clinical red flags and feel empowered to ask direct, challenging questions of their healthcare providers.

1. Recognising the Red Flags of Venous Thromboembolism (VTE)

Blood clots remain the leading direct cause of maternal death. Pregnancy naturally increases clotting risks, but certain complications drastically multiply this danger.

Hyperemesis Gravidarum (HG): Extreme pregnancy sickness is not simply ‘morning sickness’. The NHS classifies HG that causes dehydration or immobility as a primary, high-risk factor for developing a VTE. Dehydration thickens the blood, whilst immobility allows it to pool, creating a highly dangerous environment for clot formation.

Asymmetrical Leg Swelling: While general, symmetrical swelling in the legs and ankles is a normal physiological symptom of late pregnancy, a noticeable difference in size between the two legs is a critical warning sign. Recent clinical research confirms that asymmetric lower limb oedema (where one calf measures significantly larger than the other) is a highly predictive symptom of Deep Vein Thrombosis (DVT) in the postpartum period. Women should immediately report uneven swelling, redness, or localised heat in one leg.

Symptoms of a Pulmonary Embolism (PE): If a clot travels to the lungs, it becomes a life-threatening emergency. Women should seek immediate emergency care if they experience:

  • Sudden shortness of breath or difficulty breathing.
  • Unexplained chest pain, often worse when breathing in.
  • A sudden, unexplained spike in resting heart rate (tachycardia).
  • Note on Wearable Technology: While consumer smartwatches cannot diagnose a blood clot, they can alert women to sudden spikes in resting heart rate or drops in blood oxygen. This objective data can be a powerful tool to validate a woman’s symptoms when presenting at triage or an emergency department.

2. Crucial Questions to Ask Healthcare Providers

Patients should be actively encouraged to advocate for their safety. If a woman is diagnosed with severe pregnancy sickness, or possesses other risk factors (such as a high BMI or a family history of clots), she should ask her clinical team:

  1. “Have I been formally assessed for my VTE risk?” The NHS mandates that women must be offered a national self-assessment questionnaire on VTE risk at their very first care contact with a positive pregnancy test.
  2. “Given my severe sickness and dehydration, am I at high risk for blood clots?”
  3. “Should I be prescribed blood thinners?” National guidelines dictate that women identified as high risk for VTE must be offered low molecular weight heparin (LMWH) within 72 hours.
  4. “Who do I escalate to if my symptoms worsen?”

3. Advocating for Mental Health

With psychiatric causes accounting for a third of maternal deaths between six weeks and one year postpartum, mental health requires the same level of rigorous advocacy as physical health.

  • Demand Routine Screening: Women should expect to be asked the ‘Whooley questions’ (screening for low mood and loss of interest) at routine antenatal and postnatal appointments.
  • Requesting Further Support: If a woman feels her mental health is deteriorating, she can advocate for a formal assessment using the Edinburgh Postnatal Depression Scale (EPDS) and request a direct referral to specialist perinatal mental health services.

Conclusion: A Shared Responsibility

No amount of personal vigilance can replace a timely, accurate medical diagnosis. However, by equipping women with the knowledge of clinical red flags and the confidence to question their care plans, we can build a critical safety net. Healthcare providers have a duty to ensure women are supported to understand their options and the potential risks, fostering an environment where a patient stating, “I am worried about my risk of a blood clot,” is met with immediate clinical validation rather than dismissal.

References

National Reports and Policy Documents

  • NHS England (2026). The Maternal Care Bundle.
  • MBRRACE-UK (2025). Saving Lives, Improving Mothers’ Care 2025: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2021-2023.
  • MBRRACE-UK (2024). Maternal Mortality 2021-2023 Data Brief.
  • Care Quality Commission (2024). Maternity services 2022-2024 safety report.
  • NHS England (2025). Staying safe from suicide guidance.
  • NHS England (2024). Equity and equality: guidance for local maternity systems.

Clinical Guidelines

  • NICE Guideline 217: Epilepsies in children, young people and adults.
  • NICE Clinical Guideline 110: Pregnancy and complex social factors.
  • NICE Clinical Guideline 192: Antenatal and postnatal mental health: clinical management and service guidance.
  • NICE Guideline 121: Intrapartum care for women with existing medical conditions or obstetric complications.
  • RCOG Green-top Guideline 37a: Reducing the Risk of Thrombosis and Embolism during Pregnancy and the Puerperium.
  • RCOG Green-top Guideline 52: Prevention and management of postpartum haemorrhage.
  • RCOG Green-top Guideline 68: Epilepsy in pregnancy.

Selected Academic Literature

  • Bistervels, I. M., et al. (2022). Standardised dosing of LMWH. The Lancet.
  • Buist, A., et al. (2006). Acceptability of routine screening for perinatal depression. Journal of Affective Disorders.
  • Crampton, J., et al. (2016). Disclosure of maternal mental health. Midwifery.
  • El-Den, S., et al. (2015). Screening for perinatal depression. Journal of Affective Disorders.
  • Fairbrother, N., et al. (2025). Perinatal anxiety and depression emergence.
  • Filip, C., et al. (2025). Predictive Value of Centered Clinical Asymmetric Lower Limb Edema in Diagnosing Deep Vein Thrombosis in Puerperium. Journal of Clinical Medicine, 14(10), 3320.
  • Geddes-Barton, A., et al. (2024). Disparities in severe maternal morbidity.
  • Jardine, J., & NMPA Project Team (2019). NMPA Intensive Care sprint report.
  • Johnson, A., et al. (2021). Digital versus paper formats of the EPDS.
  • Liu, X., et al. (2018). VTE risk during and after pregnancy.
  • Oquendo, M. A., et al. (2024). Suicide risk and undiagnosed mental health conditions. JAMA Psychiatry.
  • Sher, L. (2024). Suicide in the perinatal period. QJM: An International Journal of Medicine.