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Highlights • Antenatal testing and intrapartum antibiotic prophylaxis (IAP) with penicillin has reduced the incidence of invasive neonatal Group B streptococcus disease by up to 80%. • Countries persisting with a ‘risk based’ approach to IAP have not seen similar falls, and in some cases (e.g. the UK) have seen a rise in the incidence of disease. • Intrapartum antibiotic prophylaxis produces short-term alterations in the neonatal microbiome, but none so far are considered to be of clinical significance. • The cornerstone of neonatal care remains prompt recognition of signs of infection and administration of benzylpenicillin and gentamicin, pending culture results. •A vaccine against GBS infection would have many advantages but there are still many barriers to be overcome before one becomes available., Group B Streptococcus, a common commensal in the gut of humans and in the lower genital tract in women, remains an important cause of neonatal mortality and morbidity. The incidence of early onset disease has fallen markedly in countries that test women for carriage at 35–37 weeks of pregnancy and then offer intrapartum prophylaxis with penicillin during labour. Countries that do not test, but instead employ a risk factor approach, have not seen a similar fall. There are concerns about the effect on the neonatal microbiome of widespread use of antibiotic prophylaxis during labour, but so far the effects seem minor and temporary. Vaccination against GBS would be acceptable to most women and GBS vaccines are in the early stages of development. Tweetable abstract: Group B Strep is a key cause of infection, death and disability in young babies. Antibiotics given in labour remain the mainstay of prevention, until a vaccine is available.

Background: Ethnic disparities in maternal mortality were first documented in the UK in the early 2000s but are known to be widening. This project aimed to describe the women who died in the UK during or up to a year after the end of pregnancy, to compare the quality of care received by women from different aggregated ethnic groups, and to identify any structural or cultural biases or discrimination affecting their care. Methods: National surveillance data was used to identify all 1894 women who died during or up to a year after the end of pregnancy between 2009-18 in the UK. Their characteristics and causes of death were described. A Confidential Enquiry was undertaken to describe the quality of care women received, and describe any structural or cultural biases or discrimination identified. Findings: There were no major differences in assessed quality of care, nor in causes of death between women from different aggregated ethnic groups, with cardiovascular disease the leading cause of death in all groups. Multiple areas of bias were identified in the care women received, including lack of nuanced care (notable amongst women from Black aggregated ethnic groups who died), microaggressions (most prominent in the care of women from Asian aggregated ethnic groups who died) and clinical, social and cultural complexity (evident across all ethnic groups). Interpretation: This confidential enquiry suggests that multiple structural and other biases exist in UK maternity care. Further research on the role of microaggressions is warranted. Funding: NIHR Policy Research Programme Declaration of Interests: All authors have completed the ICMJE disclosure form and declare: Marian Knight, Sara Kenyon and Jennifer Kurinczuk received grants from the NIHR PRP in relation to the submitted work. Kathryn Bunch, Nicola Vousden, Anita Banerjee, Philippa Cox, Fiona Cross-Sudworth, Mandish K. Dhanjal, Jenny Douglas, Joanna Girling, Rohit Kotnis, Roshni R. Patel, Judy Shakespeare, Derek Tuffnell and Meg Wilkinson have no financial relationships with any organisations that might have an interest in the submitted work in the previous three years. No authors have other relationships or activities that could appear to have influenced the submitted work. Ethics Approval Statement: Identifiable MBRRACE-UK data were collected in England and Wales without consent with approval of the Secretary of State for Health and Social Care under Section 251 of the NHS Act 2006 (15/CAG/0119). Data were collected in Scotland without consent with approval from the Public Benefit and Privacy Panel for Health and Social Care (1920-0131). Identifiable information was not provided from Northern Ireland. The legal basis for this activity is Article 6 (1)(e) and Article 9 (2)(i) under the General Data Protection Regulation.

We of Group B Strep Support (GBSS) were disappointed that Margaret McCartney reiterated some myths about screening for group B streptococcus during pregnancy.1 We challenge four of her statements. (1) “The risks of antibiotic use include anaphylaxis, which is thought to be fatal in one in 10 000 women treated.” This is an unreferenced statement from the UK National Screening Committee’s 2008 review of antenatal screening for streptococcus B. Fatal anaphylaxis is extremely rare. Law et al reported that 1.8 million women in the US were given benzylpenicillin (or ampicillin) between 1997 and 2001 with no deaths from anaphylaxis reported.2 Their review of UK data showed no adverse drug reactions attributable to benzylpenicillin in a population of 630 000 over six months. They conclude that the risk of death is negligible. (2) “Broad spectrum antibiotics lead to resistant organisms . . . The potential for long-term persistence of early-colonising bacteria suggests that much more thought should …