A major national review has concluded that England’s NHS maternity services require significant reform, warning that the current system is failing to provide consistently safe, high-quality and compassionate care for women and babies.
The independent inquiry, led by Baroness Valerie Amos and commissioned by the government, identified widespread problems across maternity services, including racism, discrimination and inconsistent standards of care. Baroness Amos said the findings showed that the country could no longer accept the current situation and called for urgent action.
Inquiry Recommends Eight Key Reforms
The report outlines eight recommendations aimed at improving maternity services across England. One of the main proposals is the creation of an independent Maternity and Neonatal Commissioner who would focus on improving safety, increasing accountability and driving long-term improvements throughout the NHS.
The inquiry released its findings only days after a separate review into maternity services in Nottingham revealed that poor care had harmed hundreds of mothers and babies.
Disagreement Over Final Report
The inquiry has also attracted attention because Dr Bill Kirkup, one of the UK’s leading maternity investigators, resigned from the review team before the review team published the final report.
Dr Kirkup reportedly disagreed with Baroness Amos’s conclusion that pressure to achieve “normal births” at the expense of offering caesarean sections was not a widespread national problem.
Review Followed Years of Maternity Scandals
Last year, then Health Secretary Wes Streeting launched the National Maternity and Neonatal Investigation in response to a series of serious maternity failures that had damaged public confidence in NHS maternity services.
As part of the review, Baroness Amos and her team spoke with more than 450 families and visited 12 NHS trusts to understand the challenges facing maternity services. read more
The inquiry found that one of the biggest problems was the failure to properly listen to women and their families. It also identified major differences in the quality of care provided between NHS trusts.
According to the report, the maternity system has become fragmented, overly complicated and slow to learn from previous mistakes.
Faster Maternity Triage Recommended
The inquiry highlights maternity triage as an area requiring immediate improvement, describing it as increasingly performing a role similar to accident and emergency departments.
The report recommends assigning dedicated midwives to answer telephone calls and provide timely advice. Women who remain concerned after speaking with staff should be offered face-to-face appointments without unnecessary delays.
The inquiry believes these changes could prevent avoidable harm and save lives.
Racism and Discrimination Must Be Treated as Safety Risks
The review also found that racism and discrimination continue to affect maternity care and called on the NHS to treat them as major patient safety concerns.
It recommends collecting more detailed data on unequal health outcomes and urges NHS leaders to monitor the information closely so they can identify problems early and take action more quickly.
Baroness Amos Rejects Calls for Public Inquiry
Although some campaign groups have demanded a statutory public inquiry with legal powers to compel witnesses to give evidence, Baroness Amos does not believe such an investigation is currently necessary.
She said statutory inquiries often take many years to complete and argued that immediate improvements to maternity care should remain the priority.
Families Give Mixed Reactions
Campaigners welcomed several of the recommendations but also expressed disappointment with parts of the report.
Rhiannon Davies, whose daughter Kate died in 2009 following failures at Shrewsbury and Telford Hospital NHS Trust, praised the report for recognising that listening to women is essential for patient safety. She also supported the recommendations to strengthen maternity triage services.
However, Dr Kim Thomas from the Birth Trauma Association described the report as a missed opportunity. She said many women’s experiences were not fully reflected, including birth injuries caused by forceps deliveries and the long-term psychological effects of traumatic births on parents.
She also argued that the report focused too heavily on the views of healthcare staff rather than those of affected families.
East Kent Campaigner Raises Concerns
Helen Gittos, whose daughter Harriet died after suffering a brain injury while receiving care at East Kent NHS Trust in 2014, welcomed many of the recommendations but questioned the report’s assessment of improvements made at East Kent.
She argued that if intensive national support has not produced lasting improvements at individual trusts, then wider reforms are still needed across the system.
Campaign Group Questions Commissioner Proposal
The Maternity Safety Alliance, which represents families calling for a statutory public inquiry, criticised the recommendation to appoint a maternity commissioner.
The group argued that concentrating responsibility in a single position without sufficient independence would not address the underlying problems affecting NHS maternity services. know more
Government Promises Action
The Department of Health and Social Care said it would respond quickly to the inquiry’s findings.
The government confirmed plans to establish a Maternity and Neonatal Commissioner with powers to independently monitor the system, encourage improvements and help rebuild public confidence.
Officials also announced that the government will publish a national action plan to reform maternity services in December. The government has also committed £41 million to improve safety across maternity and neonatal care in England.
