England’s maternity system is “not working for women, babies and families, or for staff”, the interim report of the government’s independent national investigation into maternity and neonatal services has concluded. “We have seen and heard about problems at every stage of the maternity and neonatal journey,” its chair, Baroness Amos, writes.
Reflecting on conversations with hundreds of harmed and bereaved families, visits to 12 NHS Trusts and evidence gathered from staff, the report paints a bleak picture. Families, Amos says, have been “disregarded and not listened to”, treated with a “lack of kindness and compassion,” and faced “reluctance on the part of trusts and professionals to admit mistakes and say sorry when things have gone wrong.” England’s maternity system is rife with structural racism and discrimination and a demoralised overstretched workforce, who “want to improve services and provide safe care” but too often face an uphill battle.
The maternity system was – quite literally – crumbling in places, too. Amos found examples of corridors not wide enough to “navigate a hospital bed” and staff handover notes containing the weather forecast “because they have to be ready for heavy rain because of the numerous leaks.” In one of the hospitals she visited, she was informed that “when an instrumental vaginal delivery was required in the delivery room, the door had to be left open to provide enough space”. A screen was placed outside to protect women’s privacy.
Outcomes for women and their babies are not improving fast enough and, in some cases, getting worse. The rate of maternal death was 20 per cent higher in 2022-2024 (the latest data available) than it was in 2009-11 when the government set a target to halve the rate of maternal mortality in England. Attempts to halve 2010 rates of stillbirths and neonatal deaths by 2030 are unlikely to succeed.
Amos identifies six factors that could be responsible for the current state of affairs: capacity pressures, culture and leadership, racism and discrimination, poor responses and lack of accountability when things go wrong, the quality of estates, and the workforce. Most of these, and more besides, were identified in the two major maternity investigations completed by the New Statesman into services provided by Oxford University Hospitals NHS Foundation Trust and University Hospitals Sussex NHS Foundation Trust. Both trusts are part of the group of 12 visited by Amos and her team.
As I have found with my own reporting of England’s maternity scandal, the hardest reading of this interim report comes from the stories of individual families. Black and Asian mothers reported their care being impacted by racist stereotypes. “I was begging for help,” one woman told Amos. “I was made to feel like I was that aggressive, angry black woman. But that isn’t me.” One hospital staff member who trained students was reported to have said, “the bloody Asian ones just go on and on and on.” Black women are almost three times as likely to die during pregnancy or shortly after birth compared with white women. Asian women are 1.3 times more likely to die. Inequalities “extend to babies’ outcomes”, too.
Just as I have heard from countless families, Amos was told repeatedly that there was “a lack of transparency, clear communication and learning when things went wrong.” Internal investigations were of poor quality and did not accurately reflect the events which took place. Many families felt “there had been a ‘cover up’ and defensiveness from NHS trusts”, with trusts resisting releasing medical notes or families finding they had been “amended or redacted.” One family told Amos their solicitor was handed “magical notes that reappeared out of nowhere after three years.”
Most upsetting to read is how bereaved parents have been treated. Amos describes how families whose babies were stillborn felt the current system, which denied them an independent investigation, was “deeply unfair”. Many received no clear explanation as to why their babies had died. “They felt the system incentivised the recording of deaths as stillbirths as this prevents the case from being investigated by a coroner” (something the New Statesman has highlighted). Others had to endure “listening to nearby babies crying whilst they are mourning their own baby” or receiving care in the same ward as women in active labour. Some have even been transported through delivery units holding their dead children. One of the 12 hospitals visited by Amos has no bereavement facilities at all.
Across its 35 pages, Baroness Valerie Amos describes an English maternity system that has not managed to keep pace with the needs of the women it serves. There is a “markedly different environment today compared with even a decade ago”, the Labour peer explains. Women are giving birth at older ages and more pregnant women have pre-existing health conditions. There is increasing clinical complexity, yet the facilities and workforce of the NHS have not managed to meet it.
Amos will meet with more families over the coming weeks, and a public call for evidence remains open until 17 March. More than 8,000 responses have been submitted already. The Labour peer will deliver a final set of national recommendations in spring 2026. In her concluding remarks, Amos tries to assuage the fears of women who are pregnant or hoping to start a family. “I would like to reassure you that whilst there are many instances of unacceptable levels of care, there is also good practice across the NHS,” she writes. If they have read the 9,000 words preceding these remarks, they might be doubtful.
[Further reading: It’s better for a church to become a mosque than a shell]
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