New study uses HQIP-commissioned data to identify ‘recurring red flags’ in maternity

Published: 07 Mar 2025

A powerful new retrospective study on perinatal mortality has used reports from MBRRACE-UK, commissioned by HQIP on behalf of NHS England, to identify the maternity services that are most consistently reporting higher-than-average deaths in England.

Published in February 2025 in the Journal of Public Health, this paper compares MBRRACE-UK perinatal mortality surveillance reports from 2015–21 with EPM rates for births occurring in 124 hospital trusts in England between 2013 and 2019. It identifies 23 (18.5% of 124) ‘red flag’ trusts most consistently falling into MBRRACE-UK red and amber bands, finding that seven trusts reported higher-than-average deaths in all seven years. With further findings considered within the context of contemporary inquiries, inspections, investigations and other outcome measures, this study concludes by stating that further research is needed to examine the reasons for the geographic proximity of most ‘red flag’ trusts, including any potential conflict around measures of clinical performance.

“Understanding how to react to data is the most important thing,” Adam Sewell-Jones, Executive Director of Improvement, NHS Improvement  

Studies such as this highlight the critical importance of data from outcome reviews, clinical audits and registries, such as the National Clinical Audit and Patient Outcomes Programme (NCAPOP) commissioned by HQIP on behalf of NHS England, in improving healthcare and, in turn, saving and improving lives.

Read the study in full

P McDonagh Hull, T Boulton, B Lashewicz, Recurring red flags: a retrospective study of MBRRACE-UK Perinatal Mortality Surveillance (2015–21) to identify maternity services most consistently reporting higher-than-average deaths, Journal of Public Health, 2025, fdaf019: https://doi.org/10.1093/pubmed/fdaf019.
Copyright/access rights: Journal of Public Health, Oxford University Press.

Perinatal mortality surveillance report (MBRRACE-UK)

Published July 2024

Based on UK wide data for babies born in 2022, this report states that the most common causes of stillbirth and neonatal death were unchanged, finding that congenital anomalies contributed to 17% of deaths.

It also includes the following key findings:
• Stillbirth rates decreased across the UK in 2022, but neonatal mortality increased
• There was wide variation in neonatal mortality rates
• Stillbirth and neonatal mortality rates decreased in almost all gestational age groups
• Inequalities in mortality rates by deprivation and ethnicity remain.

Read in full

Further information

MBRRACE-UK is part of the Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP), established to identify avoidable deaths so that the lessons learned can be used to prevent similar cases in the future, leading to improvements in maternal and newborn care for all mothers and babies.

Almost one in 100 UK births leads to a stillbirth or newborn death and up to 100 women die each year during or just after pregnancy

Further MBRRACE data and reports:
• MBRRACE-UK reports on the HQIP website (scroll to the bottom of the page for all reports).

MBRRACE-UK/MNI-CORP is part of a wider programme of audits and outcome reviews, commissioned by HQIP (NCAPOP) on a range of clinical disciplines, from asthma to vascular care:
• All HQIP-commissioned reports.