Valerie Amos has released a review into maternity and neonatal services in England, identifying systemic failures that have contributed to avoidable deaths and injuries. The report calls for an urgent transformation of care standards and the appointment of a maternity commissioner to address persistent safety concerns and institutional failings across NHS trusts.
Why was this maternity review commissioned?
Last June, the then health secretary, Wes Streeting, announced a national investigation into NHS maternity services to address what he described as "systemic causes of unacceptable care." The move followed a series of high-profile inquiries into clinical negligence. Notably, a 2022 review by Donna Ockenden into the Shrewsbury and Telford Hospital NHS Trust found that 300 babies suffered avoidable brain damage or death. A report last week regarding Nottingham University Hospitals NHS Trust identified over 500 cases of mothers and babies who died or were injured due to inadequate care. Amos was tasked with examining maternity and neonatal care across the country while also specifically examining maternity services at 12 NHS trusts, with the aim of developing one set of national recommendations.
What is the current state of maternal safety in the UK?
Official data indicates that maternal mortality in the UK is high compared to international peers. According to the most recent statistics, the maternal mortality rate stands at approximately 12.8 deaths per 100,000 maternities—a 20% increase since the government’s 2009-11 ambition to halve the rate. Research published in 2022 highlighted that the UK recorded the second-highest maternal death rate among eight European nations, with UK mothers being three times more likely to die around the time of pregnancy than those in Norway.
Beyond mortality, morbidity rates have risen. The incidence of postpartum haemorrhage—severe bleeding—increased from 27 per 1,000 births in 2020 to 32 per 1,000 in 2025. Similarly, third- or fourth-degree perineal tears rose from 25 per 1,000 in June 2020 to 29 per 1,000 in June this year.
What factors are driving these clinical failures?
The Care Quality Commission reports that 36% of NHS maternity services require improvement, while 12% are inadequate. Multiple factors contribute to these outcomes:
- Workforce Shortages: The Royal College of Midwives reports a shortfall of 2,500 midwives across the NHS, while one in three graduate midwives report difficulty securing employment.
- C-sections carry higher inherent risks of complications than vaginal deliveries, with approximately 25% of all births across England delivered via emergency C-section.
- Health Inequalities: Disparities remain stark. Data shows Black women are almost three times more likely to die during childbirth than white women, and women from the most deprived areas are twice as likely to die during childbirth than more affluent counterparts.
- Systemic Issues: The investigation identified deep-seated issues, including institutional racism and a culture within some trusts that prioritized the protection of institutional reputation over transparency with bereaved families.
What happens next for NHS maternity care?
The government has committed to a "watershed moment" for maternity services, pledging to dismantle the "toxic dynamics" currently affecting hospital staff relationships. The primary mechanism for this reform is the appointment of a powerful maternity commissioner. This role will be tasked with pushing through an urgent transformation of childbirth care in England. Additional independent reviews, such as those commissioned for Leeds Teaching Hospitals and University Hospitals Sussex, are due to be published over the next few years.