A decade-long analysis of England’s maternity services uncovers stark regional disparities in perinatal deaths. However, improvements are possible when struggling trusts learn from those that perform better.
Study: Lessons to be learned: a retrospective study of MBRRACE-UK perinatal mortality surveillance (2015–2024) to identify maternity services most consistently reporting higher- and lower-than-average deaths. Image credit: Lopolo/Shutterstock.com
A recent study in the Journal of Public Health analyzed maternity services in England to determine organizations with higher-than-average and lower-than-average rates of extended perinatal mortality (EPM). The study highlights a significant North-South divide in perinatal mortality performance across England's maternity services over ten years.
A decade of progress in reducing perinatal mortality
National Maternity Safety Ambition is a decade-long UK government initiative launched in 2015 to reduce stillbirths, neonatal and maternal deaths, and brain injuries occurring during or soon after birth by half. Originally targeting 2030, the deadline was revised to 2025. While a House of Commons Research Briefing predicted the goal would fall short, significant progress has been made; perinatal mortality has dropped 36 % to 4.84 per 1000 total births, with the largest annual reduction occurring in 2025 among term births (37–41 weeks’ gestation).
When the initiative launched, the UK began publishing annual perinatal mortality data that compared outcomes across individual hospital trusts and health boards. These Perinatal Mortality Surveillance Reports are produced by Mothers and Babies, Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), a collaboration led by the University of Oxford. The reports build on work begun in 1992 to reduce mortality by identifying problems in practice and service provision.
Nearly three decades later, the Health and Social Care Committee’s independent inquiry into England’s maternity services echoed this mission, recommending better use of data to understand causes of variation in clinical performance across locations.
Analyzing MBRRACE-UK reports
Analysis of the first seven MBRRACE-UK reports (2015–2021) identified 23 maternity services in England with consistently higher-than-average perinatal mortality rates. Approximately 70 % of these events occurred in the North or Midlands, including at Shrewsbury and Telford Hospital NHS Trust, which is now under police investigation.
The current study analyzed ten years of MBRRACE-UK Perinatal Mortality Surveillance Reports (2015–2024), covering births occurring between 2013 and 2022. It aims to identify both high-performing and struggling maternity services to encourage learning between them. To improve stability, MBRRACE-UK adjusts data for factors that affect perinatal mortality, including maternal age, socio-economic deprivation, baby’s sex and ethnicity, multiplicity, and gestational age.
In this study, organizations were grouped into five categories based on service level and annual birth volume, enabling fair comparisons. Within each group, organizations received traffic-light-colored bands indicating their deviation from average EPM rates. Red bands indicated mortality rates more than 10 % above average (2015–2018) or more than 5 % above average (2019–2024). Amber bands indicated up to 10 % higher (2015–2018) or up to 5 % higher or lower (2019–2024). Yellow and green bands indicated lower-than-average rates.
Each colored band was assigned a numeric value (0–5) to calculate 10-year scores, with higher scores indicating worse performance. From 2019 onward, comparator tables excluded deaths due to congenital anomalies, limiting direct comparability with earlier reports.
Ten-year perinatal mortality patterns and regional disparities
Across the 2015–2024 surveillance reports, England recorded 33,943 extended perinatal deaths, comprising 23,465 stillbirths and 10,478 neonatal deaths. The 121 maternity organizations reporting data received 10-year scores ranging from 22 to 47 out of 50.
Ten maternity services (8.3 %) with the highest scores (41–47) were identified, including Shrewsbury and Telford Hospital NHS Trust (score 42), and three organizations with consistently higher-than-average deaths across all ten years were Royal Devon University Healthcare NHS Foundation Trust, Sandwell and West Birmingham Hospitals NHS Trust, and Leeds Teaching Hospitals NHS Trust.
Approximately 12.4 % of maternity services had the lowest scores (22–27), including three organizations with consistently lower-than-average deaths across all ten years: Norfolk and Norwich University Hospitals NHS Foundation Trust, Royal Free London NHS Foundation Trust, and University College London Hospitals NHS Foundation Trust. Twenty maternity services (16.5 %) reported higher-than-average deaths in at least 80 % of reports, while 18.2 % reported lower-than-average deaths in these periods.
Seven maternity services reported higher-than-average death rates in all five recent surveillance reports (2020–2024). Leicester was the only organization in the red band for all five years. Nottingham University Hospitals, currently under police investigation, reported higher-than-average deaths in the past four years. The authors note that Leicester represents a marked deterioration in performance, having reported lower-than-average mortality in several earlier years.
Thirteen maternity services reported lower-than-average death rates in all five recent surveillance reports (2020–2024). Plymouth achieved the yellow band in three of those years. Plymouth demonstrated sustained improvement over time after earlier periods of higher mortality. Maternity services in England rarely achieved the green band during the decade. However, during 2015–2018, 22 organizations achieved it once, 5 twice, and 1 three times. No maternity services achieved green-band performance after 2018, when the definition of green became more stringent.
The current study identified a robust regional pattern, where all ten organizations with the highest scores were located in the Midlands and North of England, while all fifteen with the lowest scores were in the South. This North-South divide persisted for organizations reporting consistently higher-than-average or lower-than-average death rates over the past five years and across most surveillance reports.
The authors emphasize that these patterns reflect statistical outliers rather than definitive assessments of care quality, may mask variation within individual organizations, and should not be interpreted as evidence of causality, particularly given underlying socio-economic differences between regions.
Conclusions
The current study revealed a significant and persistent variation in EPM across England’s maternity services as reported between 2015 and 2024. A pronounced North-South divide characterizes performance patterns; organizations reporting consistently higher mortality are concentrated in the Midlands and North, while those with consistently lower mortality are predominantly in the South.
Future research must focus on identifying the drivers of these disparities. Meanwhile, facilitating structured knowledge exchange between high-performing and underperforming services offers an immediate opportunity to reduce preventable perinatal deaths and address regional health inequalities, particularly by identifying practices associated with sustained improvement over time.
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