MBRRACE-UK 2026: recurring maternity themes remain

Covering maternal deaths during 2022–24, the report identifies recurring themes including workforce and service capacity, fragmented care, communication, recognising and responding to deterioration, and ethnic and socioeconomic inequalities. It also notes that many of its recommendations have been made previously, with some dating back more than a decade.

This echoes the conclusions of Fletchers Solicitors recent white paper, ‘Why learning in maternity safety is not translating into change.’ Drawing on more than 4,600 maternity investigations alongside national reviews, NHS data and cross-sector discussion, the paper found a striking consistency in the issues identified over time.

The white paper describes this as an “Implementation Gap”, the disconnect between identifying risk and creating this change in practice. The latest MBRRACE report provides another opportunity to consider that gap.

One of the areas highlighted by MBRRACE is the changing landscape around caesarean birth. In England, 45% of births were by caesarean in 2025, compared with 33% in 2020. The report notes that increasing caesarean rates place additional demands on theatre and workforce capacity.

One case discussed in the report involved a woman at high risk of uterine rupture whose planned caesarean was postponed twice because of theatre availability and workload pressures. She subsequently went into spontaneous labour, suffered uterine rupture and massive haemorrhage, and died several days later. Her baby was stillborn. Assessors considered that both the mother and baby would have survived had the caesarean taken place on either of the rescheduled dates.

The report recommends senior input and documented reassessment where planned caesareans for high-risk women are postponed, alongside a review of theatre and workforce capacity.

 “I often speak with families where in their experience, hospitals have competing demands when it comes to caesarean sections and having to prioritise women.  I regularly see cases where the records say that the theatre is busy with another emergency, that there weren’t enough staff to open the back up theatre or that the back up theatre did not have all the equipment it needed to be up and ready quickly.  This then results in a delay in delivery. Babies and mother’s injuries or their lives could have been saved if the hospitals were better equipped to deal with the increases they are seeing in rates of caesarean sections.” –  Sahida Patel, Partner & Birth Injury Specialist.

Professor Andrew Weeks, Consultant Obstetrician & Professor of International Maternal Healthcare at The University of Liverpool also discusses the relationship between caesarean rates and safety in our ‘For every birth. For every baby. For every family.’ podcast series. He highlights the importance of individualised risk assessment, informed choice and considering the implications of repeated caesareans for future pregnancies, rather than assuming that more caesarean births necessarily mean safter maternity care.

You can watch this full conversation here on YouTube

Racial inequalities remain another important feature of the report. Black women in England were almost three times as likely to die as White women during 2022–24, while women living in the most deprived areas had around twice the maternal mortality rate of those in the least deprived areas.

The report also provides examples of how individual circumstances can interact with wider system pressures.

One Black woman who required interpreter support developed sepsis following a scheduled caesarean. There were incomplete observations at her first presentation, followed by delays in administering antibiotics and, later, a three-hour delay during transfer to high-dependency care, including difficulties prescribing within new electronic systems. She died the following day.

The case reflects several of the themes identified in our white paper, particularly communication, escalation, fragmentation and the challenges of translating established learning into reliable processes.

These issues sit at the heart of our ‘For every birth. For every baby. For every family.’ Campaign. The principle that every family should receive safe, responsive and equal maternity care, and that learning from harm should lead to meaningful improvement.

“Sadly, we often see mothers and families complain about how they were not listened to, that they knew something was wrong, but no one had the time to listen.  Mothers we speak to, often say they complain of being in pain or something not being right but have then been dismissed and left wondering whether their ethnicity played a part in the adverse outcome.  Delays in care can result from a range of pressures, including limited resources, staffing shortages, competing demands and the time of day. Staff shortages during evenings, weekends and bank holidays are recurring themes in reports of adverse outcomes for mothers and babies.

The MBRRACE report is yet another report that highlights the themes that we are all too familiar with. The report includes the need to recognise women who are not well or signs of deterioration and to respond promptly and escalate where appropriate. Recognising and responding to haemorrhage post birth doesn’t always happen as observations on the mother are not carried out or there are competing demands making this difficult. We are acting for a number of families where there was a failure to take heed of mothers post birth not being monitored properly, or at all, leading to serious neurological issues and death.

Martha’s Rule which will be implemented in all maternity settings in England has the potential to reduce poor maternal outcomes and deaths by improving the recognition and deterioration and escalation of care.  Only time will tell whether this is going to have a positive impact.” – Sahida Patel, Partner and Birth Injury Specialist.

The latest MBRRACE recommendations include reviewing theatre and workforce capacity, appropriately prioritising time-critical planned caesareans and ensuring rapid access to antibiotics across hospital-based care settings.

These are important recommendations, but their publication also brings the wider question of implementation into focus.

Fletchers Solicitors white paper found that the maternity safety system has generated substantial learning, but that the same themes continue to emerge across investigations and reviews. We identified factors including competing priorities, limited capacity, fragmented organisations, unclear ownership and limited visibility of whether recommendations have resulted in measurable change.

This does not suggest that progress is absent. The white paper also identified examples where change has been achieved, particularly where there is clear ownership, multidisciplinary collaboration and a focus on embedding learning within systems rather than relying solely on individual behaviour.

The latest MBRRACE report therefore sits within a much wider body of maternity safety learning. Its findings reinforce the importance of continuing to identify risk, while also asking how recommendations can be prioritised, implemented and sustained in practice.

For maternity services, policymakers and those working with families affected by birth injury, the recurring nature of these themes makes implementation an important part of the ongoing conversation around maternity safety.

The coming months will be an important point in the maternity safety landscape. The Government is due to publish its national maternity and neonatal action plan in December 2026, setting out priority actions and longer-term reforms in response to the National Maternity and Neonatal Investigation and wider maternity reviews. The National Maternity and Neonatal Taskforce will then have responsibility for monitoring implementation and assessing whether the actions are delivering improvements for women, babies and families.

These key updates will allow us to see whether the lessons identified across successive reports can translate into sustained change in practice. We look forward to seeing the contribution of Michelle Welsh, the Government’s first Maternity Adviser, and the wider Taskforce in driving implementation, accountability and meaningful improvements for families.