Maternity deaths in the UK have hit a 20-year high, a damning analysis has found, despite years of warnings to the NHS about potentially fatal ‘red flag’ symptoms in pregnant women and new mothers.
The findings show deaths during pregnancy, childbirth or in the six weeks afterwards have risen sharply – with more than 12 women per 100,000 now dying, the highest level since 2005.
Over the past decade, the NHS has been issued with 67 separate warnings urging staff to take serious complications more seriously.
Yet in that same period, maternal death rates have risen by around half.
The biggest killer remains blood clots – which are often treatable if caught early – while suicide is now the leading cause of death in the postnatal period.
Analysis shows 257 women died in the two years to 2023, with clinicians failing to act on warning signs such as heart problems, severe bleeding and sepsis.
In total, nearly 60 official reports by MBRRACE-UK – the body that audits maternal deaths – have produced 748 recommendations aimed at improving maternity care. Despite this, outcomes have continued to worsen.
Hospitals have been told at least 23 times to urgently triage women with symptoms of blood clots or stroke, and to take reports of severe pain and bleeding seriously.
Investigators heard repeatedly from women and families about a lack of transparency, clear communication and learning when things went wrong
Staff have also repeatedly been warned not to dismiss symptoms simply because a woman is pregnant, and to better recognise signs of cardiac disease and sepsis.
More than 30 recommendations have focused on improving access to mental health services, amid rising concern over deaths by suicide.
The audit also highlights stark inequalities, with Black women still three times more likely to die than white women during pregnancy or shortly after birth.
Campaigners say the findings expose a system overwhelmed by recommendations but unable to deliver meaningful change.
Former Conservative MP Theo Clarke, who led a parliamentary inquiry into birth trauma, described the situation as a ‘national scandal’.
‘NHS maternity services are swamped with recommendations from scores of reports, and still women and their babies are being harmed by a lack of focus and leadership necessary to implement them,’ she told The Times.
But like other campaigners, she is sceptical that another Government review – due this summer – will bring real improvement.
Jo Cruse, founder of Delivering Better, said trusts had effectively been set up to fail, with successive governments ‘failing to appropriately resource trusts to act on recommendations’.
‘For over a decade, politicians have failed to recognise what is happening in maternity care for what it is – a public health crisis unfolding in plain sight,’ she added.
Senior NHS clinicians have echoed those concerns, warning that the sheer volume of recommendations has made it difficult for trusts to prioritise action, particularly without additional funding.
Dr Clare Tower, a consultant obstetrician at Manchester University NHS Foundation Trust, said: ‘While they are always well-intentioned, a lot of recommendations are poorly thought-through and made without any evidence base of cost-effectiveness analysis.
‘Trusts are poorly resourced to deliver changes and often they result in frontline staff having so many forms to fill and boxes to tick that they don’t have time to focus on the individual needs of the woman in front of them.’
Alongside Wes Streeting’s national maternity inquiry, the Department of Health and Social Care has pledged new standards to tackle the leading causes of maternal death, including recruiting more midwives, addressing inequalities and improving early warning systems.
A spokesperson said: ‘The secretary of state has ordered an independent national investigation to drive rapid improvements in maternity and neonatal services.
‘It will bring together the findings of past reviews into one clear set of national actions to ensure every woman and baby receives safe, high-quality and compassionate care.
‘A new taskforce, chaired by the secretary of state, has also been set up to act immediately on the recommendations due in June.’
The death of Jennifer Cahill, 34, and her baby Agnes in 2024 – after what were described as ‘horrors that should be consigned to a Victorian-age nightmare’ – is the latest in a series of high-profile maternity scandals in which women and babies have died or suffered avoidable harm.
