Women and babies across England are being left traumatised, disabled, or dead due to poor NHS maternity care, according to a major new review.

The independent investigation, led by Baroness Valerie Amos, concludes that NHS birthing units are “not fit for purpose”. It highlights systemic failures where women’s concerns are routinely ignored, a toxic workplace culture prevents issues from being resolved, and racism and discrimination are “embedded” in the system.

Key Findings

• Women’s voices during pregnancy and labour are frequently dismissed or not believed.
• Racism and discrimination directly impact the quality of medical care.
• Staff and hospital trusts often refuse to take responsibility or explain what went wrong.
• Poor coordination between services (GPs, community care, and hospitals) creates dangerous gaps.
• Severe short-staffing, overworked medics, and a culture of fear among junior staff exacerbate the problems.

Baroness Amos stated: “As a country we cannot continue like this.” She emphasised that there is “absolutely no justification for the tragic cases of unsafe care and avoidable harm we continue to see in England.”

Real Stories of Harm

The report includes heartbreaking accounts, such as:

• Elleasha Varia (Leicester, 2022): Despite repeated warnings about her high-risk pregnancy due to a genetic condition, staff dismissed her severe pain and vomiting blood. Doctors reportedly told her she “shouldn’t have got pregnant if [she] couldn’t handle pain.” She suffered a perforated bowel, required emergency surgery, and was separated from her premature baby. She was left with permanent damage.
• Emmie Studencki and Ryan Parker (Nottingham): Their baby Quinn died at just two days old after staff denied a requested C-section, lost ambulance notes, and failed to act on signs of placental abruption and fetal distress.

Recommendations and Government Response

Baroness Amos has proposed eight key recommendations, including:

1. Appointing a statutory national Maternity and Neonatal Commissioner to drive urgent reform.
2. Systematically listening to women, birthing people, and families.
3. Tackling racism, discrimination, and inequality.
4. Improving governance, accountability, culture, leadership, staffing, buildings, and digital systems.

In response, the government has announced it will appoint the UK’s first Maternity and Neonatal Commissioner for England to hold the system accountable and rebuild trust. Significant funding has also been committed to improve maternity safety.

This national review follows closely on the heels of the recent Nottingham maternity scandal report and confirms that similar serious problems exist across multiple NHS trusts.

Health leaders and professional bodies have welcomed the findings, calling it a critical turning point that demands immediate, system-wide action to prevent further avoidable harm to mothers and babies.