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A comprehensive investigation into maternity and neonatal care in England has unveiled alarming failures that have put mothers and infants at risk. The final report, conducted by Labour peer Valerie Amos, highlights systemic issues within the National Health Service (NHS) that have resulted in unacceptable care, leading to avoidable stillbirths, serious injuries, and maternal fatalities. As the nation grapples with these revelations, the report calls for urgent reforms to ensure the safety and dignity of childbirth in the UK.
Disturbing Trends in Maternal Health
Recent statistics reveal that maternal mortality rates in the UK have surged to approximately 12.8 deaths per 100,000 maternities, a figure that has risen by 20% since the government set an ambitious goal to halve these rates in 2009-2011. This places the UK among the highest in maternal mortality rates across Europe, with mothers in the nation being three times more likely to die during or shortly after pregnancy compared to their counterparts in Norway.
Moreover, the report indicates a significant increase in serious complications following childbirth. For instance, the incidence of postpartum haemorrhage has escalated from 27 to 32 cases per 1,000 births between 2020 and 2025, marking a 19% rise. Additionally, the occurrence of severe perineal tears during delivery has risen from 25 to 29 per 1,000 births, reflecting a troubling trend in maternal health outcomes.
The Catalyst for Change: A National Investigation
The Amos review was initiated in June 2025 by former Health Secretary Wes Streeting, who sought to address the systemic failures within NHS maternity services. The investigation focused on 12 specific NHS trusts, aiming to uncover the root causes of the poor care that has affected countless women, babies, and families. This inquiry was prompted by a series of high-profile maternity scandals, including the Shrewsbury and Telford NHS Trust, where a 2022 review revealed that 300 babies suffered brain damage or died due to avoidable circumstances.
The investigation’s urgency was underscored by a recent report from midwife Donna Ockenden, which found that over 500 mothers and babies suffered severe harm due to inadequate care at Nottingham University Hospitals NHS Trust. In light of these shocking findings, the government has commissioned Ockenden to carry out further reviews at other NHS trusts, with the aim of preventing similar tragedies in the future.
Unpacking the Systemic Failures
The Amos report paints a grim picture of the current state of maternity care in England, attributing many failures to chronic understaffing and systemic inequalities. The Royal College of Midwives has indicated a shortfall of approximately 2,500 midwives across the country, exacerbated by one-third of newly qualified midwives struggling to secure employment.
Compounding these issues are established ethnic and socioeconomic disparities. The report highlights that Black women are nearly three times more likely to die during childbirth compared to white women, while those from the most deprived backgrounds are twice as likely to face fatal outcomes in comparison to their more affluent peers. Additionally, a shift in delivery methods, with more than 45% of births now occurring via caesarean section—historically associated with higher complication rates—has further complicated the landscape of maternal health.
The Path Forward: Recommendations for Reform
The Amos report is described by Health Secretary James Murray as a potential “watershed moment” for NHS maternity care. It calls for the establishment of a powerful maternity commissioner with the authority to implement transformative changes across the board. This initiative is aimed at dismantling the “toxic dynamics” that have tainted relationships between healthcare professionals and patients, fostering a culture where accountability and transparency prevail.
Such reforms are crucial, as the report emphasises that maternity services have failed to adapt to significant demographic shifts, including the rise in older mothers and changing preferences for delivery methods. The findings echo those of previous reviews, highlighting a persistent pattern of negligence that must be addressed if the NHS is to regain the trust of the communities it serves.
Why it Matters
The revelations from the Amos report are not just statistics; they represent real lives affected by a healthcare system that has repeatedly let down its most vulnerable. As the UK faces rising maternal mortality rates and unacceptable care standards, it is imperative that immediate reforms are enacted. The wellbeing of mothers and their babies must be prioritised, ensuring that no family suffers due to systemic failures in the maternity care system. This report serves as a clarion call for action, demanding a renewed commitment to safe, compassionate, and equitable care for all.