Major review calls for urgent reform of England's maternity services
National investigation highlights the need for changes to ensure safety and compassion
A major review, led by Baroness Amos, has found that urgent reforms are needed for maternity services in England to deliver safe and compassionate care consistently.
The final report from the Independent National Maternity and Neonatal Investigation was released today, identifying systemic issues within the current system and the need for prioritising safety and equity.
Critical issues identified
The report outlines several critical concerns, including a lack of focus on women's voices, systemic racism, slow adaptation to safety demands, and fragmented care services.
The investigation, which began in September 2025, involved consultations with more than 450 families and input from over 9,000 staff and 38 national leaders.
Baroness Amos outlines several themes repeatedly heard from women, families and staff:
- Women are not being listened to, heard or believed, with serious consequences for safety and quality of care, resulting in avoidable harm, trauma and loss of confidence in themselves and in the system.
- Racism and discrimination are embedded throughout the maternity and neonatal system, with unacceptable impact on safety, equity and quality of care, and staff wellbeing.
- Service design and planning is slow to respond to safety and demand and is not equipped to meet the changing needs of women, babies and families - including the changing profile of women giving birth and the increase in medical interventions during births.
- The system is fragmented and care is inconsistent – antenatal, birth and labour, neonatal and postnatal services are not joined up.
Eight key recommendations for England's maternity systems
The report proposes eight transformative recommendations, including establishing a statutory Maternity and Neonatal Commissioner, enhancing governance, and revising service frameworks to meet modern standards.
The full list of changes:
- The creation of a statutory national Maternity and Neonatal Commissioner to drive the urgent, systemwide change identified by the Investigation and provide leadership for a redesigned maternity and neonatal system, through the Health Bill currently before Parliament
- Systematically listening to the voices of women and families
- Improving how the system responds when something goes wrong, including providing a sincere apology and learning lessons
- Creating a modern service framework which sets out national standards to consistently achieve high quality maternity and neonatal care
- Tackling racism, discrimination and inequality
- Improving culture and teamworking, and strengthening leadership at all levels of the system and across professions
- Improving system governance and accountability structures and regulatory oversight
- Delivering estates and digital systems that are fit for modern maternity and neonatal care
The Investigation also identified additional actions that can start now, including NHS trusts urgently reviewing their maternity triage processes, the ‘Emergency Department’ for maternity care.
Further actions recommended include guidance for situations where women decline recommended clinical care.
Looking ahead
The report stresses the critical need for strengthened national leadership and accountability measures to learn from adverse events and ensure equitable care.
Baroness Amos emphasised that implementing these recommendations is crucial for lasting transformation across the country.
Baroness Amos said:
“Women, babies, and families deserve maternity and neonatal care that is safe, compassionate, and equitable wherever they live. Too often, this Investigation heard that people were not listened to, that harm was repeated, and that families were left without clear answers or accountability when things went wrong.
“This report sets out practical action to change that. It recommends stronger national leadership, clearer accountability, better listening, safer service design, improved investigations, stronger teamworking and leadership, and investment in the buildings and digital systems where families receive care and deliver it.
“These recommendations must be implemented in full. They are designed to deliver lasting system change, strengthen accountability, and create a system that learns when harm occurs.”
Overseen by the National Maternity and Neonatal Taskforce, chaired by the Secretary of State for Health and Social Care, a new national action plan will be developed in response to these findings.
12 NHS Trusts were visited as part of the review
The investigation analysed over 9,500 pieces of evidence, including data and documentation, and undertook a review of previous recommendations to understand why previously proposed changes have not been implemented or sustained.
Visits to 12 NHS trusts, selected to reflect geography, socio-economic variation, trust type, case mix and feedback from families, provided direct insight into frontline care, leadership, culture and operational pressures.
The Trusts involved were:
Barking, Havering and Redbridge University Hospitals NHS Trust
Blackpool Teaching Hospitals NHS Foundation Trust
Bradford Teaching Hospitals NHS Foundation Trust
East Kent Hospitals NHS Foundation Trust
Gloucestershire Hospitals NHS Foundation Trust
Oxford University Hospitals NHS Foundation Trust
Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
Sandwell and West Birmingham Hospitals NHS Trust
Somerset NHS Foundation Trust
University Hospitals of Leicester NHS Trust
University Hospitals of Morecambe Bay NHS Foundation Trust
University Hospitals Sussex NHS Foundation Trust