A second major report into maternity services in England, published within a week of another damning review, has reinforced concerns that care remains inconsistent, unsafe in places, and in urgent need of reform.
The final findings of an independent investigation led by Valerie Amos conclude that maternity and neonatal services are “no longer fit to consistently deliver high-quality, compassionate care to every woman and family” and require urgent action to place safety, listening, and anti-racist practice at the centre of the system.
Commissioned in July last year by then health and social care secretary Wes Streeting, the investigation followed high-profile failings and rising negligence claims. An interim report published in March documented accounts of distress, harm and racism. Its conclusions closely mirror the earlier independent review into maternity services at Nottingham University Hospitals NHS Trust, led by senior midwife Donna Ockenden, which exposed severe and systemic failures.
Ockenden review exposed over 500 cases of harm and avoidable death
That Ockenden review found that more than 500 mothers and babies experienced death or serious harm due to potentially avoidable failures. It identified 444 women and 76 babies affected by poor care, including cases where failures likely contributed to maternal deaths and where newborns might have survived with timely treatment. Investigators highlighted repeated clinical errors such as poor fetal monitoring, delays in scans, failure to escalate concerns, and misinterpretation of signs of distress, alongside chronic understaffing and unsafe workloads.
Across both reports, a consistent picture emerges of systemic breakdowns in care. Amos said women, babies and families are frequently not listened to, harm is repeated, and accountability is unclear. The Ockenden findings similarly described a “toxic culture” in which staff warnings were ignored and bullying discouraged escalation of safety concerns.
The Amos investigation gathered extensive evidence, including testimony from more than 450 families, over 10,500 public responses, and input from more than 9,000 staff. It also drew on interviews with 38 national leaders, analysed over 9,500 documents, and visited 12 NHS trusts across England.
Key themes included fragmented services, entrenched racism and inequality, and a system that is slow to respond to changing demand and safety risks. Both reports highlight failures in leadership, governance, and organisational culture.
Extensive evidence base highlights scale of concerns
Amos sets out eight recommendations: establishing a statutory national maternity and neonatal commissioner; strengthening women’s and families’ voices; improving incident response; creating a national service framework; tackling racism and inequality; enhancing governance and regulation; improving leadership, culture and teamwork; and modernising estates and digital infrastructure.
She urged full implementation, warning that only sustained reform can ensure accountability, prevent repeated harm, and create a system capable of learning when things go wrong.
“Equitable care is still not reality,” says senior legal expert and advocate
Geeta Nayar Senior Associate at Irwin Mitchell, Advocate for the MASIC Foundation, Birth Trauma Association and Make Birth Better Champion has been a part of these statistics having sustained a 3c tear during the birth of her daughter, which hugely impacted my life and left me with permanent injuries.
Sharing her opinion, she said, “Equitable and safe maternity care should be a right for all women. However, stark ethnic disparities in maternal outcomes have continued to persist despite advancements in healthcare due to structural systemic issues.
“Evidence indicates that one of these disparities, often not talked about is that South Asian women are at much greater risk of suffering an OASI (obstetric anal sphincter injury). For most women tears are relatively minor and heal quickly. However, a deeper tear also known as third or fourth degree tear can have devastating long term consequences including bowel incontinence, chronic pain, sexual dysfunction, psychological trauma and can impact family relationships and employment.”
About what needs to change, she added, “The focus needs to be on what we can positively change to improve these outcomes. Training needs to be provided on the greater risk of OASI for South Asian women so that labours can be safely managed for this cohort, who also have a higher rate of instrumental delivery, one of the causes of OASI. We need to ensure the OASI care bundle is embedded which has been proven to reduce OASI rates in all women. It is vital there is continued investment in Perinatal Pelvic Health Services (PPHS) that are being rolled out nationally offering early physiotherapy and specialist clinics.”
She is now leading the organisation of the UK’s second South Asian Maternal Health Conference, which will focus on the significant disparities in maternal and neonatal outcomes affecting South Asian women.
The programme features a distinguished line-up of speakers, including the President of the Royal College of Obstetricians and Gynaecologists, Alison Wright, Dr Nighat Arif, broadcaster and author, Kate Brintworth, and Lesley Regan, alongside many other prominent healthcare professionals (HCPs) contributing to the agenda.
