The UK government has announced the appointment of a national maternity commissioner to lead reforms following a rapid review that uncovered repeated failures in NHS maternity care. The review, led by Baroness Valerie Amos, highlighted widespread issues including poor communication, racism, and insufficient staffing that have caused avoidable harm to women and families.
Key Findings of the Amos Review
The review gathered evidence from over 450 families and more than 10,500 responses to a public call, with 12 NHS trusts visited and over 9,000 staff contributing. It found that women and birthing people were often not listened to, with serious consequences for safety and quality of care. Racism and discrimination were described as "embedded throughout the maternity and neonatal system," leading to poorer outcomes for some groups.
Specific issues included inadequate triage, fragmented care, and a lack of accountability. Families reported that internal investigations were like "marking their own homework," with trusts often downplaying failings. The review also noted that staff experienced racism and worked in unsafe environments, with long shifts and insufficient breaks.
Government Response and Commissioner Role
Health Secretary James Murray said the first ever maternity and neonatal commissioner will "drive lasting change and make sure women and families are never ignored again." The commissioner will be accountable to Parliament and focus on improving safety, setting national standards, and ensuring effective governance. The Department of Health will publish a national action plan on maternity in December.
Among the recommendations are improved triage systems, with dedicated trained staff and national standards within a year. The review also called for a move away from fixed risk categorisation of pregnancies and for every family to receive a debrief after birth.
Concerns Over Independence
The Maternity Safety Alliance, representing bereaved families, criticised the commissioner role as "fundamentally dangerous" and not "meaningfully independent," reiterating calls for a statutory public inquiry. The Birth Trauma Association described the review as "disappointing for families" and a "huge missed opportunity."
Additional Government Measures
The government also committed to rolling out a national perinatal equity and anti-discrimination programme. Over £10 million in funding will support 1,000 temporary roles to help newly-qualified midwives join the NHS. The review comes less than a week after an inquiry into Nottingham University Hospitals NHS Trust found over 500 mothers and babies suffered avoidable harm due to systemic failures.
Baroness Amos said her report sets out "practical action" to improve care, adding that "lives will be saved and harm reduced" if triage is improved. She emphasised that families deserve safe, compassionate, and equitable care wherever they live.
