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Major review calls for urgent overhaul of NHS maternity care after families raise safety concerns

Major review calls for urgent overhaul of NHS maternity care after families raise safety concerns

An independent investigation has made sweeping recommendations to improve maternity services across England after hearing from thousands of parents.

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Ruairidh Pritchard

Published: July 1, 2026 at 9:58 AM

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A major independent investigation into maternity and neonatal services in England has called for sweeping changes to the NHS, warning that too many women and babies continue to experience avoidable harm.

The review, led by Baroness Valerie Amos, examined why serious incidents continue to happen despite years of previous inquiries. After hearing from more than 450 families, over 9,000 NHS staff and receiving more than 10,500 responses to a public call for evidence, it concludes that the maternity system needs urgent reform to deliver safer, more consistent care.

For parents expecting a baby, the recommendations focus on issues that many families say matter most, including being listened to when concerns are raised, improving communication, tackling inequalities and making sure lessons are learned when things go wrong.

Why was this maternity investigation carried out?

The independent investigation was commissioned to examine why avoidable deaths and serious harm continue to happen in England's maternity and neonatal services despite multiple previous reviews and hundreds of recommendations aimed at improving care. It was chaired by Baroness Valerie Amos.

To build its findings, the investigation spoke directly to more than 450 families, received over 10,500 responses to a public call for evidence, gathered feedback from more than 9,000 NHS staff, visited 12 NHS trusts and reviewed thousands of pieces of evidence. It also looked at previous maternity inquiries and examples from healthcare systems in other countries.

The report concludes that England's maternity and neonatal system is "not set up to deliver consistently safe, high-quality and compassionate care" and says meaningful reform is now urgently needed.

What did the investigation find?

The review found that many of the issues raised by families have appeared repeatedly in previous maternity investigations but have not been fully addressed.

Among the most common concerns were:

Women feeling they were not listened to when they raised concerns during pregnancy or labour.
Experiences of racism, discrimination and unequal treatment.
Wide variation in the quality of maternity care depending on where families live.
Poor communication between healthcare professionals and parents.
A lack of accountability and clear answers when something went wrong.

The investigation also heard from NHS staff, who described workforce shortages, increasing demand, outdated buildings, ageing IT systems and limited time for training as barriers to providing consistently safe care.

Baroness Amos writes in the report: "There is absolutely no justification for the tragic cases of unsafe care and avoidable harm we continue to see in England. Nor is it acceptable that so many women and families experience a poor response and lack of accountability when something has gone wrong."

There is absolutely no justification for the tragic cases of unsafe care and avoidable harm we continue to see in England. Nor is it acceptable that so many women and families experience a poor response and lack of accountability when something has gone wrong.

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

Why does the report say maternity care needs to change?

The report says maternity care has changed significantly over recent years, with women increasingly having babies later in life, more pregnancies involving existing medical conditions and higher rates of medical intervention, including inductions and caesarean births. Services, it says, have not kept pace with these changes.

It also describes a fragmented system where antenatal, labour, neonatal and postnatal care are not always joined up, making it harder for families to receive consistent care throughout pregnancy and after birth.

The report says the system needs to be redesigned around safety, with listening to women and tackling racism embedded throughout maternity services.

What changes have been recommended?

The investigation makes eight major recommendations designed to improve maternity and neonatal care across England.

These include:

Creating a statutory Maternity and Neonatal Commissioner to oversee national improvements.
Making listening to women, birthing people and families a core patient safety priority.
Improving investigations and accountability when serious incidents occur.
Developing a new Modern Service Framework with national standards for maternity and neonatal care.
Treating racism, discrimination and inequality as critical patient safety issues.
Strengthening leadership, governance and regulatory oversight.
Improving multidisciplinary training, teamwork and workplace culture.
Investing in maternity estates and digital systems to modernise services.

Alongside these longer-term reforms, the report calls for immediate action to improve maternity triage, the service pregnant women contact when they have urgent concerns. The investigation says improving triage could help identify problems earlier, reduce avoidable harm and ultimately save lives.

Listening to women is at the heart of the recommendations

One of the strongest messages running through the report is that too many women felt their concerns were dismissed when they sought help.

Families described symptoms being minimised, concerns about reduced baby movements not being acted on quickly enough and struggling to get clear explanations after serious incidents. The investigation concludes that these experiences undermine trust and can contribute to unsafe care.

Rather than expecting parents to advocate more strongly for themselves, the report argues the maternity system should be designed so staff have the time, support and processes needed to listen carefully, respond appropriately and escalate concerns without delay.

What could this mean for parents?

If the recommendations are adopted, families could see more consistent maternity care across England, clearer communication throughout pregnancy and birth, stronger national oversight of services and better support if something goes wrong.

The report also recommends offering every woman a postnatal debrief after giving birth, expanding trauma-informed psychological support for families affected by harm and improving antenatal education so it better reflects modern pregnancy and birth, including inductions, caesarean births and pain relief options.

While many of the proposed reforms would require changes across the NHS and Government, the investigation says several improvements, including reviewing maternity triage services and strengthening the way concerns are handled, should begin immediately.

Baroness Amos writes: "Every avoidable death of a baby, a woman, is one too many. Every instance of avoidable harm is one too many. The emotional toll and cost to families is indescribable."

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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.