National maternity review says NHS system is failing women and babies
Interim report highlights repeated failures, racism and poor accountability across maternity services in England.
The NHS maternity system in England is “not working for women, babies and families, or for staff”, according to a major new interim report published today.
Baroness Valerie Amos, who is leading the Independent Investigation into Maternity and Neonatal Services, says she has heard consistent accounts of women being disregarded, not listened to and met with defensiveness when harm occurs.
The system is not working for women, babies and families, or for staff.
The national review, ordered by Health Secretary Wes Streeting last summer, has so far gathered evidence from more than 400 families and received over 8,000 responses to a public call for evidence.
Repeated failures and rising concern
The interim findings echo themes raised in previous maternity scandals, including poor leadership, a culture of fear and failure to learn from past mistakes.
Baroness Amos writes that families remain distressed that recommendations from earlier inquiries “do not seem to have been addressed or have only been partially addressed”, adding: “This cycle must stop.”
The report also highlights rising maternal mortality. The rate increased from 8.8 deaths per 100,000 maternities in 2017 to 2019, to 12.8 per 100,000 in 2022 to 2024.
Stark inequalities
Black women are almost three times as likely to die during pregnancy or within six weeks of birth compared with white women. Women living in the most deprived areas face double the maternal mortality rate of those in the least deprived areas.
One mother speaking to the investigation described feeling dismissed when raising concerns.
I was begging for help… I was made to feel like I was that aggressive, angry Black woman. But that isn’t me.
Families also reported difficulties accessing medical records and a lack of transparency when things went wrong.
Birth trauma and accountability
The findings land amid wider concerns about birth trauma care. Around 1 in 3 women in the UK experience some form of birth trauma, yet recent data shows more than half of GPs feel unequipped to support affected parents.
Campaigners have warned that trauma-informed care must become standard practice, not a postcode lottery.
The investigation will now continue gathering evidence before publishing final recommendations in Spring 2026. The Health Secretary will then chair a National Maternity and Neonatal Taskforce to deliver an action plan.
For families who have spoken out, the hope is that this time, change will follow.
Read more:
- Half of GPs feel unequipped to support parents with birth trauma – new report reveals worrying gaps
- ‘Incredibly concerned’: experts slam government’s 10-Year Health Plan for ignoring birth trauma and consent
- More than 500 new NHS mental health roles needed to support mums during pregnancy and after birth