MBRRACE-UK perinatal mortality surveillance

1. Introduction

1.1. Report overview

This is the tenth MBRRACE-UK Perinatal Mortality Surveillance Report. The report is divided into five sections: perinatal mortality rates in the UK; mortality rates for Trusts and Health Boards; mortality rates by gestational age; mortality rates by ethnicity and socio-economic deprivation; and a description of the causes of perinatal death.

This report focuses on births from 24 completed weeks’ gestational age, with the exception of the section on mortality rates by gestational age, which also includes information on births at 22 to 23 completed weeks’ gestational age. This avoids the influence of the wide disparity in the classification of babies born before 24 completed weeks’ gestational age as a neonatal death or a late fetal loss. Terminations of pregnancy have been excluded from the mortality rates reported.

Additional supporting materials to accompany this report include:

• a set of reference tables;
• a data viewer with interactive mapping, which presents mortality rates for individual organisations, including Trusts and Health Boards; and
• a technical manual containing full details of the MBRRACE-UK methodology, including definitions, case ascertainment and statistical methods.

A summary version of the report is also available to download as a PDF

1.2. Definitions and terminology

For definitions of the deaths reported to MBRRACE-UK and an explanation of the different types of mortality rates reported, see the MBRRACE-UK technical manual.

In this report we use the terms ‘women’ and ‘mothers’. However, we acknowledge that not all people who access perinatal services identify as women, and that our recommendations apply to all people who are pregnant or have given birth. Likewise, use of the word ‘parents’ includes anyone who has the main responsibility of caring for a baby.

2. Perinatal mortality rates in the UK: 2022

2.1. Introduction

Rates of stillbirth, neonatal mortality and extended perinatal mortality are presented by country of residence for the UK and for each devolved nation for the period 2013 to 2022. This is to show trends in mortality rates over time and to enable individual nations to monitor the progress of initiatives to reduce perinatal mortality,

2.2. Key messages

• Extended perinatal mortality rates decreased across the UK in 2022 (UK extended perinatal mortality rate: 5.04 per 1,000 total births) after a rise in 2021, although rates remain higher than both 2019 and 2020.
• Compared with rates in 2021, stillbirth rates per 1,000 total births in 2022 were lower across all the devolved nations except Scotland, where there was a small increase: 3.35 (UK); 3.33 (England); 3.31 (Scotland); 3.63 (Wales); and 3.49 (Northern Ireland).
• There were increases in the neonatal mortality rate per 1,000 live births in England and Wales compared with 2021: 1.69 (UK); 1.67 (England); 1.59 (Scotland); 1.91 (Wales); and 2.29 (Northern Ireland).

2.3. Perinatal mortality rates across the UK

Stillbirth and extended perinatal mortality rates decreased in the UK in 2022, following the increases seen in 2021. There was a small increase in neonatal mortality, however. The extended perinatal mortality rate for 2022 across the UK as a whole was 5.04 per 1,000 total births (5.19 in 2021); comprising 3.35 stillbirths per 1,000 total births (3.54 in 2021) and 1.69 neonatal deaths per 1,000 live births (1.65 in 2021).

Across the four UK nations, the lowest stillbirth and neonatal mortality rates were in Scotland (stillbirths: 3.31 per 1,000 total births; and neonatal deaths: 1.59 per 1,000 live births). The highest stillbirth rate was in Wales (3.63 per 1,000 total births), whilst the highest neonatal mortality rate was in Northern Ireland (2.29 per 1,000 live births). As in previous years, the number of babies born in the Crown Dependencies is too few to permit reliable comparison with the four countries of the UK.

2.4. Births and perinatal deaths

In 2022, there were 675,891 total births at 24 completed weeks or greater gestational age (excluding terminations of pregnancy) for the UK. This was a decrease of 23,018 births (3.3%) compared with 698,909 in 2021.

There were 2,266 stillbirths in 2022, compared with 2,473 stillbirths in 2021 and 2,292 in 2020. There were 1,141 neonatal deaths in 2021, compared with 1,151 neonatal deaths in 2021 and 1,051 in 2020. This is, in part, a result of the reduced births numbers in 2022 when compared with previous years.

3. Perinatal mortality rates for Trusts and Health Boards

3.1. Introduction

To account for the wide variation in case-mix, Trusts and Health Boards were classified hierarchically into five mutually exclusive comparator groups, based on their level of service provision. In order to compare Trusts and Health Boards more fairly, stabilised & adjusted mortality rates were calculated and colour-coded according to the variation from their respective comparator group average. A complete explanation of the MBRRACE-UK methodology, including statistical methods, can be found in the technical manual.

Where there is only a small number of births in an organisation it is difficult in any one year to be sure that any extreme value seen for the crude mortality rate is real and not just a chance finding. A stabilised rate allows for the effects of chance variation due to small numbers. The mortality rates are also adjusted to account for key factors which are known to increase the risk of perinatal mortality. The extent of the adjustment is limited to those factors that are collected for all births across the whole of the UK: mother’s age; socio-economic deprivation based on the mother’s residence; baby’s ethnicity; baby’s sex; whether they are from a multiple birth; and gestational age at birth (neonatal deaths only). A complete explanation of the MBRRACE-UK methodology, including statistical methods, can be found in the technical manual.

3.2. Key messages

• Stabilised & adjusted stillbirth rates in 2022 showed much more limited variation than in the years 2020 and 2021, with all Trusts and Health Boards having a stabilised & adjusted stillbirth rate within 5% of their comparator group average.
• Stabilised & adjusted neonatal mortality rates continued to show wide variation, with just 21.5% of Trusts and Health Boards falling within 5% of their comparator group average.
• After the exclusion of deaths due to congenital anomalies, 26.8% of Trusts and Health Boards had a stabilised & adjusted neonatal mortality rate within 5% of their comparator group average.

3.3. Variation in perinatal mortality rates within Trust and Health Board comparator groups

Stabilised & adjusted stillbirth rates in 2022 showed much more limited variation than in the years 2020 and 2021, with all Trusts and Health Boards having a stabilised & adjusted stillbirth rate within 5% of their comparator group average. This is similar to the lack of variation seen in the years 2012 to 2019.

Stabilised & adjusted neonatal mortality rates continued to show wide variation, with only 21.5% of Trusts and Health Boards falling within 5% of their comparator group average. 38.3% of Trusts and Health Boards had neonatal mortality rates which were more than 5% higher than their comparator group average. Significantly, 15.4% of Trusts and Health Boards had neonatal mortality rates more than 15% lower than their comparator group average. This is in contrast to the preceding two years, where the proportion of Trusts and Health Boards with neonatal mortality rates in the “Green” band was small (7.1% in 2020 and 3.9% in 2021).

3.4. The effect of congenital anomalies on perinatal mortality rates

Deaths due to congenital anomalies continue to account for a large proportion of perinatal deaths (see Section 6). Exclusion of deaths due to congenital anomalies removes almost all variation in stabilised & adjusted stillbirth rates compared to the comparator group average, with all Trusts and Health Boards falling within 5% of the group average.

Exclusion of deaths due to congenital anomalies has a limited impact on the variation in stabilised & adjusted neonatal mortality rates, with 26.9% of Trusts and Health Boards having a rate within 5% of their comparator group average. Within the comparator group most likely to care for these babies (Level 3 NICU and neonatal surgery), only 30.8% of Trusts and Health Boards fall within 5% of the group average.

3.5 Mortality rates for Trusts and Health Boards

Mortality rates for individual Trusts and Health Boards, including comparison to their respective comparator group average, can be found in the data viewer. The viewer also contains details of mortality rates for other organisations responsible for providing or commissioning perinatal services.

4. Mortality rates by gestational age

4.1. Introduction

Mortality rates by gestational age group are presented to monitor the progress of national initiatives to reduce preterm births.

4.2. Key messages

• Late fetal loss and stillbirth rates decreased in 2022 compared with 2021 for all gestational age groups, except for babies born between 24 and 27 completed weeks where there was an increase from 212.1 per 1,000 total births in 2021 to 216.0 in 2022.
• Neonatal mortality decreased in 2022 across all gestational age groups, except for babies born between 32 and 36 completed weeks, where there was an increase from 5.35 per 1,000 live births in 2021 to 6.58 per 1,000 live births in 2022.
• Late neonatal mortality for babies born between 22 and 23 completed weeks was 126.1 per 1,000 live births in 2022, the highest rate since 2014 when MBRRACE-UK began reporting rates for these babies. This should be viewed in the context of increased provision of survival-focused care following the implementation of recent national guidance.
• 75% of stillbirths and late fetal losses and 74% of neonatal deaths were born preterm (before 37 completed weeks).

4.3. Late fetal loss, stillbirth and neonatal mortality rates by gestational age

A decrease in the stillbirth rate was seen in all gestational age groups, except for babies born at 24 to 27 completed weeks’ gestational age, where there was an increase from 212.1 per 1,000 total births in 2021 to 216.0 per 1,000 total births in 2022.

The greatest decrease in stillbirth rates was for babies born at 32 to 36 completed weeks’ gestational age, from 16.36 per 1,000 total births in 2021 to 12.68 in 2022. This fall in stillbirths is accompanied by a rise in neonatal mortality in the same gestational age group over the same period, from 5.35 per 1,000 live births in 2021 to 6.58 in 2022.

Late neonatal mortality for babies born between 22 and 23 completed weeks was 126.1 per 1,000 live births in 2022, the highest rate since 2014 when MBRRACE-UK began reporting rates for these babies. For babies born at 22 to 23 completed weeks in 2022, there were 579 live births out of 974 total births (59%). For the period 2014 to 2019, live births at this gestation made up around 50% of total births. The number and proportion of babies born at 22 to 23 weeks who subsequently died during the late neonatal period almost doubled between 2014 and 2022: from 41 babies (11% of all neonatal deaths) in 2014 to 73 babies (20% of all neonatal deaths) in 2022. This should be viewed in the context of increased provision of survival-focused care following the implementation of recent national guidance.

4.4. The impact of preterm birth

The effect of preterm birth in relation to both stillbirth and neonatal death rates in the UK remains unchanged. Despite only 8% of babies being born before 37 weeks’ gestational age, they continue to make up three-quarters of stillbirths, including late fetal losses (75%), and neonatal deaths (74%). Including babies born at 22 to 23 weeks’ gestational age, 38% of stillbirths and 45% of neonatal deaths in 2022 were extremely preterm (less than 28 weeks’ gestational age).

4.5. Babies born at 42 weeks' gestational age or later

The small number of babies born at 42 weeks’ gestational age or later means that rates are subject to higher levels of yearly variation.

5. Mortality rates by socio-economic deprivation and ethnicity

5.1. Introduction

To explore inequalities in perinatal outcomes, rates of stillbirth and neonatal death are compared for area level socio-economic deprivation based on the mother’s postcode of residence at the time of the birth, and the baby’s ethnic group.

5.2. Key messages

• Stillbirth rates for babies born to mothers from the most deprived areas decreased (from 4.69 per 1,000 total births in 2021 to 4.60 per 1,000 total births in 2022), but remain much higher than those for babies born to mothers from the least deprived areas (2.61 per 1,000 total births).
• There was an increase in the neonatal mortality rate for babies born to mothers from the most deprived areas (from 2.15 per 1,000 live births in 2021 to 2.38 per 1,000 live births in 2022), a rate which is now twice that of babies born to mothers living in the least deprived areas (1.18 per 1,000 live births).
• Stillbirth rates by ethnicity decreased in all groups after a rise in 2021, but wide ethnic inequalities remain; babies of Black ethnicity are still more than twice as likely to be stillborn than babies of White ethnicity (Black: 6.19 per 1,000 total births; White: 2.99 per 1,000 total births).
• Neonatal mortality rates decreased for babies of Black and White ethnicity, with rates for babies of Black ethnicity decreasing after a two-year period of increase. However, neonatal mortality for babies of Asian ethnicity increased for the second year. Babies of both Asian and Black ethnicity continue to have much higher rates of neonatal mortality than babies of White ethnicity (Asian: 2.50 per 1,000 live births; Black: 2.41 per 1,000 live births; White: 1.56 per 1,000 live births).

5.3. Socio-economic deprivation

Stillbirth rates of babies born to mothers living in the least deprived quintile increased from 2.37 per 1,000 total births in 2021 to 2.61 per 1,000 total births in 2022. This, alongside a slight decrease in stillbirth rates of babies born to mothers living in the most deprived quintile, from 4.69 in 2021 to 4.60 in 2022, has resulted in a small narrowing in inequalities over this period.

The neonatal mortality rate for babies born to mothers living in the most deprived quintile has continued the increase first seen in 2021, and is now 2.38 per 1,000 live births, the highest since 2017. A corresponding decrease in neonatal mortality rates for babies born to mothers living in the least deprived quntile, following an increase in 2021, has led to a widening of inequalities in 2022. The difference in neonatal mortality rates between the least deprived and most deprived quintiles is now the highest it has been since 2017.

Socio-economic deprivation is measured using the Children in Low-Income Families Local Measure based on the mother’s postcode of residence at the time of birth.

5.4. Ethnicity

Stillbirth rates by ethnicity decreased in all groups after a rise in 2021, but wide ethnic inequalities remain; babies of Black ethnicity are still more than twice as likely to be stillborn than babies of White ethnicity (Black: 6.19 per 1,000 total births; White: 2.99 per 1,000 total births).

Neonatal mortality rates decreased for babies of Black and White ethnicity, with rates for babies of Black ethnicity decreasing after a two-year period of increase. However, neonatal mortality for babies of Asian ethnicity increased for the second year. Babies of both Asian and Black ethnicity continue to have much higher rates of neonatal mortality than babies of White ethnicity (Asian: 2.50 per 1,000 live births; Black: 2.41 per 1,000 live births; White: 1.56 per 1,000 live births).

Mortality rates using more refined ethnic categories can be found in the accompanying reference tables. As the mortality rates for some groups are based on small numbers they are not presented here, and may be suppressed in the reference tables.

5.5. The combined effect of deprivation and ethnicity

A detailed examination of the relationship between these ethnicity and socioeconomic deprivation was included in the MBRRACE-UK Perinatal Mortality Surveillance Report for Births in 2020. This demonstrated that babies of Asian Bangladeshi, Asian Pakistani, Black African, and Black Caribbean ethnicity were disproportionately affected by the higher rates of stillbirth and neonatal death associated with socioeconomic deprivation. More recent data from 2020 to 2022 shows that these inequalities remain. The highest stillbirth and neonatal mortality rates continue to be for babies of Asian Bangladeshi, Asian Pakistani and Black ethnicity born to mothers living in the most deprived areas. The lowest stillbirth and neonatal mortality rates continue to be for babies of White ethnicity born to mothers living in the least deprived areas.

6. Causes of perinatal death

6.1. Introduction

Causes of death are reported to MBRRACE-UK using the Cause of Death & Associated Conditions (CODAC) classification system. The CODAC system has a three level hierarchical tree for the coding of both the primary cause of death and any associated conditions. The CODAC level 1 and level 2 classification for all stillbirths and neonatal deaths is available in the accompanying reference tables.

6.2. Key messages

• The most common causes of stillbirth were in the placenta, congenital anomaly, cord and fetal categories. There remains a high proportion of stillbirths with an unknown cause of death (33.9%).
• The most common causes of neonatal death were in the congenital anomaly, extreme prematurity, neurological, cardio-respiratory and infection categories.
• Congenital anomalies continue to contribute significantly to mortality rates, comprising 8.3% of stillbirths and 33.7% of neonatal deaths.

6.3. Stillbirth and neonatal mortality rates by cause of death

Stillbirths

The most common causes of stillbirth were in the placenta, congenital anomaly, cord and fetal categories, with 53.7% of stillbirths having a cause of death in one of these groups. As in previous years, there remains a substantial proportion of stillbirths where the cause of death is classified as Unknown. Unknown causes accounted for 33.9% of stillbirths, a rate of 1.14 per 1,000 total births

Placental causes made up 36.3% of stillbirths, a rate of 1.22 per 1,000 total births. The stillbirth rate for placental causes has been slowly rising since 2018, and 2022 continued this trend. The proportion of stillbirths due to congenital anomalies has remained fairly constant since 2016, but there was a small decrease in 2022: from 9.3% in 2021 to 8.3% in 2022, a rate of 0.28 per 1,000 total births. Cord-related causes are relatively stable and comprised 5.3% of stillbirths in 2022, a rate of 0.18 per 1,000 total births. Stillbirths caused by fetal problems accounted for 3.8% of deaths, a rate of 0.13 per 1,000 total births.

Neonatal deaths

The most common causes of neonatal death were in the congenital anomaly, extreme prematurity, neurological, cardio-respiratory and infection categories, with 74.1% of all neonatal deaths having a primary cause of death within one of these five groups.

Congenital anomalies continue to account for a significant proportion of neonatal deaths: 33.7% in 2022. The neonatal mortality rate due to congenital anomalies was 0.57 per 1,000 live births, which is the second consecutive year of increase.

Extreme prematurity accounted for 11.8% of neonatal deaths in 2022 compared to 14.2% in 2021 and 10.8% in 2020. This is similar to previous years and suggests the 2020 to 2021 period was something of an outlier. The neonatal mortality rate within this group was 0.20 per 1,000 live births, also a return to 2017 to 2019 levels.

12.4% of neonatal deaths were due to neurological causes, a rate of 0.21 per 1,000 total births. Cardio-respiratory causes are relatively stable at around 9% of neonatal deaths, with a mortality rate of 0.16 per 1,000 live births. Infection was the primary cause of death in 6.6% of neonatal deaths, a rate of 0.11 per 1,000 live births.

6.5. Post-mortem examination

Post-mortem examination (PM) was offered to parents for 98.1% of stillbirths and 85.8% of neonatal deaths. Where a PM was offered, full or limited consent was given for 49.9% of stillbirths and 26.9% of neonatal deaths. Examination by the coroner or procurator fiscal accounted for an additional 2.4% of neonatal deaths.

6.6. Placental histology

The proportion of stillbirths with a placental examination was slightly lower in 2022, falling from 95.0% in 2021 to 93.7% in 2022, although this remains relatively stable over the last three years. For neonatal deaths on day 1 of life or where the cause of death was reported as intrapartum-related, the proportion with a placental examination also fell slightly, from 84.1% in 2021 to 82.5% in 2022.

7. Recommendations and supporting data

Given the short period of time elapsed between this report and the previous “State of the nation” report (published in September 2023), where recommendations from the previous report are supported by the most recent data, these are included below. For definitions see the MBRRACE-UK technical manual.

8. Further information

8.1. Supporting materials

Additional supporting materials to accompany this report include reference tables, a data viewer for viewing and and comparing perinatal mortality rates for the organisations responsible for the commissioning and provision of care, and a technical manual.

8.2. Deaths reported to MBRRACE-UK

Deaths reported to MBRRACE-UK since 1 January 2013 are:

• late fetal losses: a baby born between 22 and 23 completed weeks’ gestational age showing no signs of life, irrespective of when the death occurred;
• stillbirths: a baby born at or after 24 completed weeks’ gestational age showing no signs of life, irrespective of when the death occurred;
• neonatal deaths: a liveborn baby (born at 20 completed weeks’ gestational age or later) who died before 28 completed days after birth.

These definitions also include any late fetal loss, stillbirth, or neonatal death resulting from a termination of pregnancy.

8.3. The birth cohort

In this report rates of stillbirth, neonatal death and extended perinatal death (stillbirths and neonatal deaths combined) are presented for babies born in England, Wales, Scotland, Northern Ireland, and the Crown Dependencies, for the period 1 January 2022 to 31 December 2022 inclusive; thus, neonatal deaths of babies born in December 2022 which occurred in January 2023 are included. The reporting of mortality for a birth cohort is in contrast to statutory publications, which are based on deaths occurring or registered in a calendar year. This method of reporting allows more accurate estimates of mortality rates to be produced as appropriate denominators are available. Deaths for Guernsey are not included in 2022, but appear in trend data for previous years.

8.4. Data sources

The data presented in this report is derived from a number of sources in addition to the information submitted via the MBRRACE-UK web-based reporting system: ONS, PDS, NRS, PHS, NISRA, Health and Social Services Department (Bailiwick of Guernsey), and the Health Intelligence Unit (Bailiwick of Jersey). Full details of all data sources and the case ascertainment procedure can be found in the accompanying technical manual.

8.5. Why do MBRRACE-UK statistics on stillbirths and neonatal deaths for England and Wales differ from those published by ONS?

MBRRACE-UK report on perinatal mortality for the whole of the UK and Crown Dependencies, as well as for each individual nation. The Office for National Statistics (ONS) also publishes annual data on perinatal mortality in England and Wales. ONS figures on perinatal mortality are based on all births and deaths registered via the General Register Office. This includes all stillbirths registered at 24 weeks or more gestation, in line with the Stillbirth (Definition) Act 1992, and neonatal deaths of babies born at any gestational age. Our goal is to publish data on perinatal deaths that are clinically comparable across different organisations, such as healthcare providers or the devolved nations within the UK. Since registered stillbirths and neonatal deaths are affected by some inconsistencies in reporting between organisations, we apply a rigorous definition of deaths to ensure comparability.

There are five key differences in the way MBRRACE-UK and ONS report stillbirths and neonatal deaths:

1. We report stillbirths where the birth occurred from 24 completed weeks’, irrespective of when the baby died in utero (including some unregistered deaths), while ONS statistics are based only on registered stillbirths.
2. We report neonatal deaths from 24 completed weeks’ gestational age. ONS has no gestational age limit.
3. We don’t include deaths following termination of pregnancy, which are included in ONS figures.
4. We report deaths by the year of the baby’s birth, while ONS report deaths by the year of the baby’s death.
5. We report some rates by place of baby’s birth, and others by place of residence. ONS report deaths by place of residence.

Alongside this summary, we also provide a more detailed explanation of the reasons behind these differences, and their effect on the statistics we publish.

8.6. Funding

The Maternal, Newborn and Infant Clinical Outcome Review Programme, delivered by MBRRACE-UK, is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). HQIP is led by a consortium of the Academy of Medical Royal Colleges and the Royal College of Nursing. Its aim is to promote quality improvement in patient outcomes. The Clinical Outcome Review Programmes, which encompass confidential enquiries, are designed to help assess the quality of healthcare, and stimulate improvement in safety and effectiveness by systematically enabling clinicians, managers, and policy makers to learn from adverse events and other relevant data. HQIP holds the contract to commission, manage, and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual projects, other devolved administrations and Crown Dependencies.

More details can be found on the HQIP website.

8.7. Stakeholder involvement

Organisations representing parents and families are involved in the MBRRACE-UK programme as part of the ‘Third Sector’ stakeholder group, identifying possible areas for future research and helping to communicate key findings and messages from the programme to parents, families, the public and policy makers, including through the development of lay summary reports. A full list of organisations can be found in the acknowledgements.

8.8. Attribution

This report should be cited as:

Gallimore ID, Matthews RJ, Page GL, Smith LK, Fenton AC, Knight M, Smith PW, Redpath S, Manktelow BN, on behalf of the MBRRACE-UK Collaboration. MBRRACE-UK Perinatal Mortality Surveillance, UK Perinatal Deaths of Babies Born in 2022: State of the Nation Report. Leicester: The Infant Mortality and Morbidity Studies, Department of Population Health Sciences, University of Leicester. 2024.

Published by:

The Infant Mortality and Morbidity Studies
Department of Population Health Sciences
University of Leicester
George Davies Centre
University Road
Leicester LE1 7RH

9. Version history