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5 of the most shocking findings in the new national maternity care report

5 of the most shocking findings in the new national maternity care report

From allegations of cover-ups to stark racial disparities and fears over stillbirth classifications, Baroness Amos’ interim investigation reveals systemic failures across NHS maternity services.

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Published: February 26, 2026 at 6:24 AM

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The long-awaited interim findings of the Independent Investigation into Maternity and Neonatal Services have landed, and they paint a deeply troubling picture of a system under strain, struggling with accountability, and failing too many families.

Baroness Valerie Amos, appointed last year by the Health Secretary to lead the national review, says plainly that maternity care in England is “not working for women, babies and families, or for staff.”

After meeting more than 400 families, holding dozens of staff panels and receiving over 8,000 responses to a public call for evidence, the investigation says the same themes are emerging again and again.

Here are five of the most shocking revelations so far, and why they matter.

1. Families say some trusts “cover up” mistakes instead of admitting them

Perhaps the most explosive finding relates to what happens after harm occurs.

Families repeatedly told the investigation that when babies were injured, died, or when mothers experienced traumatic care, they were met not with openness but with defensiveness.

Some described being excluded from investigations. Others said they were not told when investigations concluded, or were never given copies of reports.

Most seriously, some parents alleged that medical records were amended, redacted or difficult to obtain.

One family member speaking to the investigation said:

You are battling to get your own notes. It shouldn’t have this kind of cloak and dagger over your notes. It’s personal information.

One family member speaking to the investigation

Baroness Amos describes this approach as deeply troubling — not only because it compounds trauma, but because it prevents learning.

When families feel forced into lengthy litigation simply to get answers, she notes, the system becomes adversarial rather than compassionate.

This echoes themes seen in previous maternity scandals in East Kent, Shrewsbury and Telford, and Morecambe Bay — where failures were compounded by cultures of denial and delay.

2. Black women are still almost three times more likely to die

The report lays bare the stark and persistent racial inequalities within maternity care.

Black women are almost three times as likely to die during pregnancy or within six weeks of birth compared with white women.

Asian women are 1.3 times more likely to die.

Women living in the most deprived areas face double the maternal mortality rate of those in the least deprived areas.

Babies of Black ethnicity are more than twice as likely to be stillborn, and neonatal mortality rates are higher for Black and Asian babies.

These disparities have been documented for years. Yet families told the investigation that lived experience has not improved fast enough.

Women described racial stereotyping influencing how their pain and concerns were treated.

I was begging for help… I was made to feel like I was that aggressive, angry Black woman. But that isn’t me.

One mother speaking to the investigation

Others described being perceived as having “tough skin” or being better able to tolerate pain.

Baroness Amos writes that there is “no place for racism and discrimination in an NHS which belongs to the people” — but acknowledges that racism can be both interpersonal and structural.

For campaigners who have been raising concerns for years, the data is not new. The persistence of these disparities is.

3. Fears babies may be recorded as stillborn to avoid coroner scrutiny

One of the most serious and sensitive concerns raised relates to how baby deaths are classified.

Under current law in England and Wales, coroners can only investigate if a baby is believed to have been born alive and then died. Stillbirths do not automatically trigger a coroner’s inquest.

Families told the investigation that this legal distinction can create a lack of independent scrutiny — and in some cases, what they believe may be an incentive to record deaths as stillbirths.

Baroness Amos does not conclude that trusts are deliberately misclassifying deaths. However, she acknowledges that some families felt the system “incentivised the recording of deaths as stillbirths” because it prevents coroner investigation.

You don’t resuscitate a stillborn baby. But you register a baby as stillborn, you have no investigation, an independent investigation. You’re constantly fighting because of the stillbirth registration.

One family member speaking to the investigation

Some parents described ambiguity over whether their baby showed signs of life at birth. Others said they felt pressured to accept stillbirth registration in order to arrange a funeral.

The investigation will now examine whether coronial law needs reform — a change that bereaved families have long campaigned for.

4. Maternity units described as outdated, cramped and unfit for modern care

During visits to 12 NHS trusts, investigators reported significant variation in the physical condition of maternity and neonatal units.

Some facilities were described as modern and well-designed. Others were described as dilapidated.

Investigators heard of leaking roofs, cold delivery rooms, cramped spaces too small to safely accommodate emergency equipment, and wards where women had to walk down corridors in bloodied gowns to reach showers.

In one unit, staff reportedly included the weather forecast in labour ward handovers due to concerns about heavy rain causing leaks.

The report asks bluntly how such conditions can be considered acceptable in 2026.

Beyond dignity, estates matter for safety. Physical layout can delay emergency responses, hinder teamworking and increase infection risk.

For families already experiencing trauma, the environment can amplify harm.

5. Midwives describe burnout, fear and loss of pride

Alongside family testimony, staff accounts reveal a workforce under extreme pressure.

Midwives described being redeployed between community and hospital settings to plug staffing gaps. Senior reviews were reportedly delayed due to rota shortages. Some staff described tensions between obstetric and midwifery teams affecting care.

The emotional toll was evident.

Please, can you tell them we need help to put pride back into our profession?

One midwife speaking to the investigation

Staff told investigators that relentless public scrutiny, litigation fears and internal blame cultures are contributing to burnout.

I feel embarrassed to say I am a midwife now.

One midwife speaking to the investigation

Baroness Amos stresses that pressure does not excuse poor behaviour — but argues that leadership and culture must change if compassionate care is to be delivered consistently.

What happens next?

This is an interim report; final recommendations will follow later this year.

The Health Secretary has pledged that a National Maternity and Neonatal Taskforce will design an action plan once the final findings are published.

But for many families, the key question remains whether this report will break what Baroness Amos describes as a cycle of repeated reviews and partial reform.

Her central conclusion is stark:

The system is not working for women, babies and families, or for staff.

Baroness Valerie Amos

After more than a decade of maternity scandals, rising litigation costs and persistent inequalities, the pressure is now on government and NHS leadership to prove that this investigation will not become another report that identifies the same problems, without delivering lasting change.