Women and babies are being failed by NHS maternity services

A Government-ordered investigation has found that NHS maternity services are failing women and babies by not admitting mistakes and showing a lack of kindness and compassion alongside widespread discrimination.

The interim report, led by Baroness Amos as part of her National Maternity and Neonatal Investigation, found deep-rooted issues across the NHS and a system that “is not working for women, babies and families, or for staff”.

The investigation involved discussions with over 400 family members and gathered insights from more than 8,000 individuals, including NHS staff, through a public call for evidence.

This call for evidence is set to close next month, while Baroness Amos’s final recommendations to the NHS in England are anticipated in the spring.

The report highlights pressures on the maternity system but says the failings need to stop

In her interim report, Baroness Amos said “time and time again” families and staff see the same issues repeated and numerous reviews making recommendations. “This cycle must stop,” she said.

She pointed to six factors contributing to pressures on the maternity system, including shortages of staff, capacity issues, culture and leadership, racism and discrimination, lack of accountability when things go wrong and the poor condition of NHS hospitals and buildings.

She said: “We have heard about families being disregarded and not listened to during pregnancy and labour, a lack of kindness and compassion, and reluctance on the part of trusts and professionals to admit mistakes and say sorry when things have gone wrong…

“We have seen maternity and neonatal services trying to respond in difficult circumstances and dealing with competing pressures but too often failing to deliver the safe care that women, families and babies expect and deserve, at times with devastating consequences.”

The investigation found women pointing to a “postcode lottery” of care, with Baroness Amos agreeing “this looks like a fragmented service”.

The interim report from the National Maternity and Neonatal Investigation also found:

– Capacity pressures mean women, midwives and obstetricians say antenatal appointments are often not long enough to discuss a woman’s pregnancy meaningfully, particularly for women with complex health needs.

– Women and families report waiting hours for medical assessment, review or clinical opinion in day assessment units and triage areas.

– Women and staff report delays to admissions, progression for induction, and planned Caesarean sections.

– Community midwives say they can be moved to work in delivery units in hospitals to cover staffing gaps, creating possible issues for patient safety as they are not always familiar with working practices.

– Staff from postnatal wards are frequently redeployed to delivery units to maintain staffing levels.

– There can be delays “in providing early senior clinical review, particularly in relation to decisions about care and treatment”.

– IT issues include incomplete patient records, with patient information and notes frequently stored on multiple systems, creating a patient safety risk.

– In some trusts, “we heard troubling accounts from staff of poor relationships between team members… the effect on care of differing approaches can be disastrous”.

– Staff described instances where other staff conduct fell markedly short of social and workplace norms, “including verbal aggression, refusal to carry out designated functions such as attending handover rounds or call-outs at night, and sometimes bullying and racist behaviour”.

– Investigators heard repeatedly “from women and families about a lack of transparency, clear communication and learning when things went wrong… We heard from many families about feeling that there had been a ‘cover up’ and defensiveness from NHS trusts, the resistance they faced from trusts when requesting their notes, and instances of medical notes being amended or redacted”.

– Investigators heard evidence “from a number of families where there was ambiguity regarding whether their baby had been born alive. This ambiguity created distress and long-lasting trauma for families as they struggled to deal with the fact they were given no clear explanation for the death of their baby, precisely because their baby was deemed to be stillborn.”

– There remain “persistent inequalities within the maternity and neonatal system”, with women from black and Asian backgrounds and those in more deprived areas experiencing worse outcomes.

– Racism and discrimination occurs throughout the system. The report added: “We have heard about stereotypes being used in maternity and neonatal services… This includes accounts of Asian women being stereotyped as ‘princesses’, with the implication that they are overly demanding or unable to cope with pain.”

– Black women “reported being deemed as having ‘tough skin’ and able to tolerate pain”.

– Muslim families described feeling discriminated against on the basis of their religion and “feeling unable to raise concerns due to fear that discriminatory attitudes may result in poor treatment for their baby”.

– There are buildings with leaking roofs and inadequate facilities. “In one visit, we were informed that when an instrumental vaginal delivery was required in the delivery room, the door had to be left open to provide enough space – with a screen placed outside of the room to protect families’ privacy. It is inconceivable that anyone would choose to give birth in such a manner. We have to ask ourselves how this can be regarded as acceptable in 2026?”

– Poor bereavement care in some trusts, with patients describing how they were taken through a delivery suite with their dead baby, hearing other mothers in labour.

Baroness Amos said of her interim report: “It is clear from the meetings and conversations I have had with hundreds of women, families and staff members across the country, that maternity and neonatal services in England are failing too many women, babies, families and staff.”

The public call for evidence remains open until March 17.

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