The final report of England's national maternity and neonatal investigation, led by Labour peer Valerie Amos, was published on Tuesday, revealing that patients received unacceptable care that led to stillbirths, serious injuries, and maternal deaths. Health Secretary James Murray described the report as a 'watershed moment' and pledged significant improvements, including the appointment of a powerful maternity commissioner to drive urgent transformation.
Current Safety of Childbirth in the UK
The rate of maternal death during or shortly after childbirth in the UK stands at approximately 12.8 deaths per 100,000 maternities, according to the most recent data. This figure is 20% higher than in 2009-11, when the government set an ambition to halve the maternal mortality rate. Compared with other European countries, the UK's maternal death rate is high; a 2022 study found the UK had the second highest maternal death rate among eight European nations, with UK mothers three times more likely to die around pregnancy than those in Norway.
The number of women experiencing serious complications after labour has also risen. The proportion of mothers in England experiencing postpartum haemorrhage increased from 27 per 1,000 births in 2020 to 32 per 1,000 in 2025, a rise of 19%. Additionally, the number of mothers sustaining third- or fourth-degree perineal tears rose from 25 per 1,000 in June 2020 to 29 per 1,000 in June this year, a 16% increase.
Why the Review Was Commissioned
Last June, then health secretary Wes Streeting announced a national investigation into NHS maternity services in England, led by Lady Amos. The investigation was tasked with examining maternity and neonatal care across the country, specifically scrutinizing services at 12 NHS trusts, and addressing what Streeting called the 'systemic causes of unacceptable care affecting women, babies and families.'
The investigation followed a series of high-profile maternity failings at several trusts. At Shrewsbury and Telford NHS trust, a 2022 review by midwife Donna Ockenden found 300 babies were left brain-damaged or dead due to avoidable outcomes. Last week, Ockenden's review into Nottingham University hospitals NHS trust revealed over 500 babies and mothers died or were injured due to inadequate care. Ockenden has also been commissioned to review maternity services at Leeds teaching hospitals NHS trust and University hospitals Sussex NHS foundation trust, with reports due in the coming years.
Amos's investigation aims to develop one set of national recommendations to drive improvements in maternity and neonatal care across England.
Factors Leading to Failures in NHS Maternity Care
Inadequate maternity care remains a key issue. Across England, many maternity wards fall short of required standards, with Care Quality Commission inspections finding 36% of NHS maternity services required improvement and 12% rated inadequate. These problems stem from understaffing and deeper systemic issues such as institutional racism. The NHS in England has a shortage of 2,500 midwives, according to the Royal College of Midwives, while one in three graduate midwives report struggling to find a job.
Recent changes in delivery methods may also contribute to poorer outcomes. Last year, caesarean section births overtook vaginal births for the first time, with almost half (45%) of births by caesarean, which carry higher complication risks than vaginal delivery. About a quarter of all births in England are delivered via emergency C-section.
Ethnic and socioeconomic inequalities persist. Black women are almost three times more likely to die during childbirth than white women, and women from the most deprived areas are twice as likely to die than more affluent counterparts.
Key Findings of the Amos Report
The report is a devastating indictment of maternity care, according to Health Secretary James Murray, who pledged to dismantle 'toxic dynamics' that damage relationships between hospital staff. A powerful maternity commissioner will be appointed to push through urgent transformation. The Amos report found that maternity care in England has not kept up with major changes such as older motherhood and the dramatic rise in caesarean sections.
Amos published two interim reports with findings similar to Ockenden's reviews: many women and babies received unacceptable and negligent care leading to avoidable stillbirths, serious injuries, and maternal deaths, while hospital trusts often covered up mistakes and denied bereaved families answers.
