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

Abstract Background This study aimed to identify maternity services in England that most consistently reported both higher-than-average and lower-than-average rates of extended perinatal mortality (EPM), including stillbirths and neonatal deaths, throughout the government’s decade-long National Maternity Safety Ambition to halve the rate of stillbirths and neonatal deaths. Methods We conducted a retrospective study of MBRRACE-UK Perinatal Mortality Surveillance Reports (2015–2024) to compare EPM rates for births occurring in 121 organizations providing maternity services in England between 2013 and 2022. Utilizing MBRRACE-UK definitions and designations, we devised a scoring method to determine which organizations most consistently reported higher-than-average and lower-than-average deaths. Results We identified 10 organisations providing maternity services (8.3%) with the five highest scores and 15 (12.4%) with the five lowest scores. A total of 20 organisations (16.5%) reported higher-than-average deaths in ≥80% of MBRRACE-UK reports and/or each of the past five years, and 22 (18.2%) reported lower-than-average deaths. Strong indications of a North-South divide for EPM were evident. Conclusions We provide evidence of regional EPM variation over the past decade, building on previous study findings of a North–South mortality divide in England. We propose that shared learning between outlier maternity services has the potential to ameliorate avoidable harm.