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Mothers ignored, racism exposed and cover-ups alleged in damning NHS review

Mothers ignored, racism exposed and cover-ups alleged in damning NHS review

Baroness Amos’ interim report finds repeated failures, racism and poor accountability across maternity care in England.

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Ruairidh Pritchard

Published: February 26, 2026 at 12:21 AM

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The NHS maternity system in England is “not working for women, babies and families, or for staff”, according to the stark interim findings of the Independent Investigation into Maternity and Neonatal Services.

Baroness Valerie Amos, who is leading the national review ordered by Health Secretary Wes Streeting last summer, says she has heard consistent accounts of women being disregarded, not listened to, and met with defensiveness when harm occurs.

While this is not the final report, the themes emerging will feel deeply familiar to many families who have followed previous maternity scandals over the past decade.

For the first time, a national investigation is examining not just individual hospitals, but the maternity system as a whole, from leadership and staffing to racism, estates and accountability. Midway through the process, the message is clear: fundamental change is needed.

“The system is not working”

Since her appointment in August 2025, Baroness Amos and her team have met more than 400 families and received over 8,000 responses to a public call for evidence. They have also held dozens of staff panels and interviews across 12 NHS trusts.

In her foreword, she writes that families continue to describe being ignored during pregnancy and labour, experiencing a lack of kindness and compassion, and encountering reluctance from professionals to admit mistakes or say sorry.

She also highlights the psychological toll when clear explanations are not provided. In the absence of answers, many women blame themselves when their babies are harmed or die.

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

Baroness Valerie Amos, Chair of the Independent National Maternity and Neonatal Investigation

Ten years on from the Better Births vision for safer, more personalised care, Baroness Amos concludes that the maternity system is struggling to meet rising pressures and increasing clinical complexity, at times with devastating consequences.

Read more:

Why this feels so familiar

Investigations into Morecambe Bay, Shrewsbury and Telford, and East Kent uncovered repeated failings, from ignored warning signs to poor leadership and cultures of fear. Campaigners have long argued that recommendations are made but not embedded.

In her interim report, Baroness Amos echoes that concern. Families have told her it is a source of “continuing distress” that areas identified in previous reviews “do not seem to have been addressed or have only been partially addressed”.

“This cycle must stop,” she writes.

The investigation is explicitly examining why negligent, poor, good and excellent practice can coexist within the same system, and why learning has not always translated into sustained improvement.

Maternal deaths rising in a changing system

The context in which maternity care operates has shifted significantly.

While stillbirth and neonatal mortality rates have begun to fall again after the pandemic, maternal mortality has increased. The rate rose from 8.8 deaths per 100,000 maternities in 2017 to 2019, to 12.8 per 100,000 in 2022 to 2024. Each statistic represents a woman who did not come home to her family.

Women are also having babies later in life. In 2024, 61% of live births were to women aged 30 or older, and 26% were to women aged 35 or older. More women are entering pregnancy with pre-existing health conditions, increasing clinical complexity.

Intervention rates have changed dramatically too. Caesarean section rates have risen from 25% of births in 2011 to 2012 to 45% in 2024 to 2025, with planned caesareans doubling in that period. The report does not suggest this represents inappropriate care, but it highlights how services must adapt to safely manage this shift.

Persistent and stark inequalities

One of the most troubling sections of the interim report focuses on inequality.

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.

Baroness Amos writes that there is “no place for racism and discrimination in an NHS which – in the opening words of the NHS Constitution – ‘belongs to the people’.”

Black women described feeling stereotyped and dismissed when raising concerns about pain or complications. One mother speaking to the investigation described how racial bias shaped her experience of care.

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

Families also described discrimination linked to religion, disability, weight, age and sexuality. Muslim parents reported being told to turn down Qur’anic recitation.

Disabled women described inaccessible facilities and a lack of reasonable adjustments.

LGBTQ+ families said services often focused narrowly on “mothers” and “fathers”, failing to reflect diverse family structures.

The report warns that such experiences erode trust and may delay women from seeking help, increasing risk.

Birth trauma and the hidden aftermath

The interim report lands in a wider context of growing concern about birth trauma and postnatal support.

Earlier this year, Make Birth Better’s National Birth Trauma Survey revealed that 55% of GPs feel their training has not adequately prepared them to recognise or respond to birth trauma. Only 1.5% said they felt very confident signposting parents to appropriate help.

Around 1 in 3 women in the UK experience some form of birth trauma, equating to roughly 200,000 new parents each year.

One GP respondent reflected on the gap in medical education.

This wasn’t taught at medical school when I was there – not even recognised at that time.

One GP respondent to the National Birth Trauma Survey

Campaigns Lead Evelien Docherty previously told MadeForMums that birth trauma needs far greater visibility within the health system.

We need birth trauma to be as well-known as postnatal depression and the menopause.

Evelien Docherty, Campaigns Lead at Make Birth Better

Concerns deepened last year when the government’s 10-Year Health Plan made no mention of trauma-informed maternity care, despite clear recommendations in the 2024 Birth Trauma Inquiry.

Laura-Rose Thorogood, CEO of Make Birth Better, said at the time that the organisation was “incredibly concerned” by the omission, warning that reform must be systemic and not piecemeal.

A rapid investigation is not going to unpick what is already inherently ingrained in our NHS. It needs to be part of the 10-Year Plan, with a clear strategic vision of how it will be achieved — with the service user voice at the heart of it.

Laura-Rose Thorogood, CEO of Make Birth Better

Dr Kim Thomas, CEO of the Birth Trauma Association and author of the 2024 inquiry’s report, also urged ministers to go further.

There is so much more that needs to be done in maternity, and we would love to see the implementation of the recommendations of the Birth Trauma Inquiry report.

Dr Kim Thomas, CEO of the Birth Trauma Association

When things go wrong: transparency and accountability

Perhaps the most distressing theme in the interim report is what families describe as poor responses when harm occurs.

Families reported not being invited to investigations, not receiving copies of reports, and struggling to access their own medical records. One family member speaking to the investigation described discrepancies between paper and electronic notes.

So I’d initially requested my medical notes on paper format. What I have on paper doesn’t also match what they sent electronically. So I can see the amendments made. There is a lot that are redacted.

One family member speaking to the investigation

Other families said they felt forced into lengthy litigation simply to obtain answers. Maternity claims represent a significant portion of the NHS clinical negligence bill, particularly in cases involving brain injury at birth requiring lifelong care.

Baroness Amos warns that defensiveness and lack of transparency compound trauma and prevent learning that could stop similar harm happening again.

Families who experienced stillbirth also described feeling excluded from independent investigation processes under current coronial rules. One parent speaking to the investigation said:

You register a baby as stillborn, you have no investigation, an independent investigation… You’re constantly fighting because of the stillbirth registration.

One parent speaking to the investigation

Staff burnout and unsafe environments

Alongside families’ experiences, staff panels painted a picture of exhaustion, burnout and fear.

Midwives described being redeployed to plug staffing gaps, long waits for senior review, and units stretched beyond safe limits. Some maternity buildings were described as outdated or dilapidated, with leaking roofs and rooms too small for emergency equipment.

One midwife speaking to the investigation appealed for urgent support.

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

One midwife speaking to the investigation

Another midwife described the emotional toll of working in a system under intense scrutiny.

I feel embarrassed to say I am a midwife now.

One midwife speaking to the investigation

Baroness Amos stresses that understanding pressure is not an excuse for poor behaviour, but leadership and culture are critical to ensuring compassionate, safe care.

The emotional cost for families

The report also acknowledges the long-term impact when things go wrong. Families described psychological trauma, relationship strain, depression and loss of trust. The wider societal costs include impacts on employment and, in cases of lifelong disability, the need for ongoing support from health, education and social care services.

Many families said they were reliving traumatic experiences because they hoped it would prevent the same thing happening to someone else. One family member explained why they chose to take part.

I will be at peace when changes are made and I’ve been able to contribute to this. That is the driving force for me.

One family member speaking to the investigation

If you’re pregnant right now

Reading about systemic failings can be frightening, especially if you are currently pregnant or planning a baby.

Baroness Amos stresses that alongside unacceptable examples of care, there is also good practice across the NHS. Many families report compassionate and supportive experiences.

If you are worried about your care:

Speak to your midwife or obstetrician and ask for clear explanations
Contact your trust’s Patient Advice and Liaison Service
Seek support from charities specialising in birth trauma or baby loss

Pregnancy and birth should be safe and respectful experiences. While this investigation highlights serious concerns, it also aims to drive the changes families have long demanded.

What happens next?

This is an interim report. Final recommendations will follow later in Spring 2026 after further evidence gathering and analysis.

The Secretary of State will then chair a National Maternity and Neonatal Taskforce to design and deliver an action plan informed by the findings.

For many families who have campaigned for years, this moment represents validation. But validation is not reform. Whether this investigation finally breaks the cycle of repeated failings now rests on what happens next.

Authors

Ruairidh PritchardDigital Growth Lead

Ruairidh is the Digital Lead on MadeForMums. He works with a team of fantastically talented content creators and subject-matter experts on MadeForMums.