On Thursday, a damning interim report published after a national investigation into England’s maternity services found deep-rooted issues affecting women and their babies, including insensitivity from maternity staff, racism and discrimination, and chronic staff shortages. Below is an exploration of what led to the report and what happens next.
What is the national maternity and neonatal investigation?
Last June, the health secretary, Wes Streeting, announced a national investigation into NHS maternity services across England. The investigation, led by Lady Amos, was called to examine what the health secretary described as the “systemic causes of unacceptable care affecting women, babies and families”.
Consisting of a call for evidence from the public and panels of experts, among other metrics, the investigation’s aim is to establish national recommendations to improve maternity and neonatal care and safety across the country. The investigation will also address persistent inequalities in maternity care faced by women from ethnic minority and deprived backgrounds.
It will also include local investigations into maternity and neonatal services at 12 NHS trusts. The full report is due to be published in the spring of this year, after initial impressions published in December and an interim report published on Thursday.
Why has it been launched?
The investigation follows a series of high-profile maternity failings across several NHS trusts.
These include the results of a five-year investigation into 1,862 maternity cases led by expert midwife Donna Ockenden, which concluded that hundreds of babies died or were left brain damaged due to inadequate care provided by Shrewsbury and Telford NHS trust.
In February of last year, Nottingham university hospitals NHS trust was fined £1.6m after admitting it failed to provide safe care and treatment to three babies who died within months of one another.
In 2024, the UK’s first inquiry into birth trauma found that women had been ignored and left with permanent damage by midwives and doctors, while many were left with post-traumatic stress disorder.
What is the current state of maternity care across England?
The rate of maternal death in the UK, at 12.8 deaths per 100,000 maternities, is 20% higher than it was in 2009-11, when the then-government set an ambition to halve the rate of maternal mortality in England.
Many maternity wards have also fallen short of the required standards, with inspections by the Care Quality Commission finding more than a third (36%) of NHS maternity services required improvement while just over one in 10 (12%) were inadequate.
Ethnic and socioeconomic inequalities are also evident throughout maternity care. Black women are three times more likely to die during childbirth compared with their white counterparts, and women from the most deprived areas are twice as likely to die during childbirth compared with their more affluent counterparts.
How have the bereaved and those affected responded to the investigation?
Although some families have welcomed the investigation, others have said that it does not go far enough and have called for a statutory inquiry.
The Maternity Safety Alliance, led by bereaved women, is calling for a judge-led statutory inquiry into England’s maternity units, having described the government’s current approach as “performative”. The organisation described the initial reflections as using language that “minimised the severity of the avoidable harm taking place in NHS services”.
What are the new findings and what happens next?
The interim findings of the investigation have reinforced allegations of inadequate staffing.
The new findings, however, also detailed that many families have experienced “cover-ups” and a lack of transparency from NHS trusts while attempting to get to the bottom of the birth trauma and baby loss they had experienced.
The investigation is set to conclude in the spring, with two final reports due to be published with a full set of recommendations and reflections.
