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A comprehensive investigation into England’s maternity and neonatal services has revealed serious shortcomings that have led to devastating outcomes for mothers and infants. The final report, released by Valerie Amos, a Labour peer and former diplomat, underscores a crisis in care, highlighting unacceptable practices that have resulted in preventable stillbirths, injuries, and maternal deaths. This pivotal review aims to catalyse change within the National Health Service (NHS) and address systemic issues that have long plagued maternity care.
Rising Maternal Mortality Rates
The report reveals that the UK’s maternal mortality rate currently stands at 12.8 deaths per 100,000 maternities, a figure that has surged by 20% since 2009-11, when the government aimed to halve this statistic. Alarmingly, the UK ranks among the poorest in Europe when it comes to maternal health, with a 2022 study indicating that British mothers are three times more likely to die around the time of pregnancy compared to their Norwegian counterparts.
Complications during childbirth have also escalated; for instance, the rate of postpartum haemorrhage has risen from 27 to 32 per 1,000 births between 2020 and 2025. Additionally, the incidence of severe perineal tears has increased from 25 to 29 per 1,000 deliveries in the same timeframe. These figures paint a troubling picture of the current state of maternity care in England.
Underlying Causes of Care Failures
The investigation was prompted by a series of high-profile maternity scandals, notably at the Shrewsbury and Telford NHS Trust, where a 2022 review led by midwife Donna Ockenden disclosed that 300 babies were either brain-damaged or died due to preventable errors. Recently, Ockenden’s further review of Nottingham University Hospitals NHS Trust revealed that over 500 mothers and infants experienced life-altering injuries or fatalities due to substandard care.
The Amos review sought to identify the systemic issues contributing to these alarming trends. Key findings indicate that a staggering 36% of NHS maternity services require improvement, with 12% deemed inadequate. Chronic understaffing is a significant factor, exacerbated by a shortage of 2,500 midwives, as reported by the Royal College of Midwives. Furthermore, one-third of newly qualified midwives are struggling to secure employment.
Compounding these challenges are existing ethnic and socioeconomic disparities. Black women face nearly three times the risk of maternal death compared to white women, and those from disadvantaged backgrounds are twice as likely to die during childbirth than their more affluent peers.
Key Recommendations from the Amos Report
Amos’s findings serve as a clarion call for urgent reform within the NHS. The report has been described as a “watershed moment” by Health Secretary James Murray, who has vowed to dismantle the “toxic dynamics” that hinder effective care delivery. Among the report’s key recommendations is the appointment of a powerful maternity commissioner tasked with spearheading transformative changes in childbirth care across England.
The investigation also highlights the need for the NHS to adapt to evolving trends in maternal health, such as older motherhood and the increasing prevalence of caesarean deliveries—now comprising nearly half of all births, which inherently carry greater risks compared to vaginal deliveries.
A Commitment to Change
The Amos report is a vital step towards achieving accountability and improvement in maternity services. By addressing the systemic failures that have led to tragic outcomes, there is hope that future generations of mothers and babies will receive the quality of care they deserve. The commitment from the government to implement substantial changes signals a potential turning point for the NHS.
Why it Matters
The findings of this review are not merely statistics; they represent lives affected and families shattered by preventable tragedies. The urgent need for reform in maternity and neonatal care highlights a broader societal issue regarding the treatment of vulnerable populations within the healthcare system. The implications of this report extend far beyond the realm of health policy; they touch upon the rights of women and the fundamental obligation of the NHS to provide safe, equitable care. As we move forward, it is crucial that these revelations catalyse meaningful change to ensure that every mother and child receives the support and care they rightly deserve.
