Baroness Amos's investigation found that NHS maternity units often cover up harmful errors in childbirth, with trusts falsifying medical records and denying bereaved parents answers, according to the report. The report stated that the system incentivises recording deaths as stillbirths to prevent coroner investigations, a claim supported by families. " She added that families reported feeling there had been a "cover-up" and defensiveness from NHS trusts, with instances of medical notes being amended or redacted.
Maternal deaths in the UK have hit a 20-year high, with 257 women dying in the two years to 2023, according to MBRRACE-UK. Black women are three times more likely to die than white women during pregnancy or shortly after birth, and Asian women also face significantly higher risks, the MBRRACE programme reported. Baroness Amos said ethnic minority and poorer women have worse outcomes due to racism and discrimination.
None of us think that care is in the right place. We don't think things are good enough. But we are starting to see improvements in safety with all the packages of care we have put in.
" Six factors contribute to pressures on the maternity system: staff shortages, capacity issues, culture and leadership, racism and discrimination, lack of accountability, and poor condition of NHS buildings, according to the investigation. Staff shortages lead to long delays for assessment, planned caesareans, and induction. Community midwives are moved to delivery units to cover staffing gaps, creating patient safety issues, and staff from postnatal wards are frequently redeployed to delivery units, sources said.
Women and families report waiting hours for medical assessment in day assessment units and triage areas. Antenatal appointments are often too short for meaningful discussion, especially for women with complex health needs, the report noted. Mothers are sent home after birth without proper assessment and cannot get through when they phone for advice.
It's a terrible anguish to lose a child. I think it's one of the worst things that can happen to a human, and our responsibility as leaders in maternity is to make sure those families don't experience that anguish.
Negligent care has devastating emotional and psychological consequences for families, Baroness Amos said. According to the Birth of Distrust report, every four minutes a mother's trust in the NHS is broken following birth, and every six minutes a mother leaves maternity care more frightened of healthcare than before. Nearly six out of 10 women with a poor birth experience say it affected their trust in Government, and nearly half are more anxious about returning to healthcare settings.
Nearly half of mothers who suffered a poor birth say it made them less likely to have more children. Two in five women reported lasting physical and mental health consequences. One in five women who needed postnatal mental health support never received it.
Every death during or after pregnancy is a tragedy, especially when differences in care may have changed the outcome.
Poor maternity care has cost the NHS over £6 billion in compensation in the last decade, with nearly 8,000 families receiving compensation, according to NHS Resolution data. 2 billion) went to cases where babies were injured at birth. In response, Health Secretary Wes Streeting will chair a new taskforce to improve NHS maternity and neonatal care in England, including family representatives, senior NHS leaders, campaigners, and academics.
The Nursing and Midwifery Council will integrate anti-racism, bias awareness, and cultural competence into midwifery degree programmes by the next academic year. NHS England announced that all pregnant women will be offered an early risk assessment for blood clots before their first antenatal appointment, women with epilepsy will have access to a local specialist team, routine mental health assessments will be offered, and women experiencing haemorrhage after birth will receive care from specialist obstetricians and anaesthetists sooner. The new measures will be rolled out in March 2027.
We still see symptoms of serious medical problems being missed, especially for Black and Asian women.
" Senior Conservative James Cartlidge demanded a 'culture of openness' from the NHS after the report. Despite nearly 60 official reports producing 748 recommendations aimed at improving maternity care, Baroness Amos noted that rises in older motherhood and obese women having babies have contributed to maternity care becoming more complicated. She concluded: "It is a source of continuing distress to families, and great frustration to staff, that the areas identified in previous reviews and investigations as requiring action do not seem to have been addressed or have only been partially addressed.