Maternity and neonatal services in England are failing “too many” women, babies, families and staff, according to an interim report led by Baroness Amos.
Commissioned by the Government in 2025, the review has so far gathered evidence from more than 8,000 individuals and included direct engagement with over 400 families. Its final recommendations are due in April, with Wes Streeting pledging to act on the findings.
The interim conclusions present a stark picture of inconsistency, structural inequality and cultural dysfunction within parts of the system, despite examples of safe and high quality care in some trusts.
A Patchwork of Care
Baroness Amos described a system in which good and poor practice exist side by side. While safe and compassionate care is demonstrably achievable, it is not delivered consistently across England.
The review identifies six central areas of concern, spanning workforce, culture, infrastructure and accountability.
Capacity and Workforce Pressures
Workforce shortages and service pressures are identified as a significant driver of risk. Antenatal wards and delivery units are reported to be overstretched, with delays to admissions and the redeployment of community midwives into delivery settings in response to staffing gaps.
Many staff who contributed to the review said maternity units do not have sufficient personnel to provide consistently safe care. Capacity constraints have, in some cases, led to services being reduced or temporarily halted.
Poor Team Relationships and Bullying
The report highlights strained working relationships between obstetricians, midwives and other clinical staff. In some cases, senior clinicians were reported to have engaged in bullying or racist behaviour that was not effectively addressed by management.
The review suggests that such cultural failings undermine collaboration, weaken clinical decision making and directly impact patient safety.
Structural Racism and Inequality
Racism and discrimination are described as occurring throughout maternity and neonatal services.
Evidence submitted to the review includes accounts of Asian women being stereotyped as overly demanding, Black women being perceived as more able to tolerate pain, and Muslim families feeling unable to raise concerns due to fear of discriminatory treatment.
The interim findings link structural inequalities to higher risks of adverse outcomes for women from Black and Asian backgrounds and those living in more deprived areas. Disabled women, refugee and asylum seeking women, and LGBT families also reported discriminatory experiences.
The review frames these disparities not as isolated incidents but as systemic issues requiring structural response.
Compassion, Transparency and Learning
Families who experienced baby loss or serious harm described a lack of compassion and transparency in some trusts. The report notes that poor communication following adverse events can compound trauma, contribute to mothers wrongly blaming themselves and impede organisational learning.
“Mothers and babies should not die due to negligence – every life matters.” The principle sits at the heart of the response now being demanded by campaigners and sector leaders.
Infrastructure and Environment
Some maternity services are operating in outdated or poorly maintained buildings that, in certain cases, compromise clinical care. The review highlights insufficient or non existent bereavement spaces in some trusts, raising concerns about dignity and privacy for families experiencing loss.
Financial and Resource Investment
Alongside culture, workforce and accountability, the interim findings implicitly raise a fundamental question of resource. Persistent staffing gaps, ageing estates and uneven service provision are occurring against a backdrop of sustained financial pressure across the NHS. Rectifying the issues identified in the review will require more than policy statements – it will demand targeted, long term investment in workforce expansion, modern infrastructure, digital capability and leadership development.
A collaborative framework between government, NHS England, integrated care systems and frontline providers will be essential to ensure funding is aligned with safety priorities and measurable outcomes. While financial constraints are a lived reality for the system, the cost of inaction – both human and economic – is far greater.
Accountability and Reform
While the interim report does not constitute a statutory inquiry, it signals the need for systemic reform rather than isolated interventions.
Streeting previously announced plans to establish a maternity taskforce to drive improvements. That body has yet to be formally constituted, though the Department of Health and Social Care has indicated that details will follow shortly.
Responding to the interim findings, Joanne Bekis, Chief Executive and Co Founder of UK Healthcare and Life Sciences Innovation (UKHLSI), said:
“The disparities between great and poor experiences from families across the UK around neonatal interactions is damning. The review alone, whilst it highlights the core areas we need to address, is not substantial enough to lead a full programme of change, with requests for a statutory public enquiry mounting. It is unacceptable in the 21st century that we appear to be going backwards on subjects of toxic culture, racism and professional standards. UKHLSI is in support of immediate positive change and calls on the Government to put in place an active working group to begin delivering solutions to tackle disparities and lead positive change.”
Her comments reflect a growing view across the health and life sciences community that incremental reform will not be sufficient.
From Diagnosis to Delivery
The interim findings of the maternity review reinforce longstanding concerns about maternity safety, cultural leadership and inequalities in outcomes. They also raise broader questions about workforce planning, regulatory oversight and capital investment across the NHS estate.
The final report, due in April, will test whether ministers move from diagnosis to delivery – translating systemic critique into structural reform.
For policymakers, providers and innovators alike, the message is clear: safe and equitable maternity care is achievable. The challenge now is embedding that standard consistently across every trust, without discrimination, without tolerance of toxic culture and without delay.
What UKHLSI Is Doing: Innovation for Patient Safety
UK Healthcare and Life Sciences Innovation is now convening cross sector partners across NHS leadership, clinical innovators, data specialists and industry to examine how targeted innovation can strengthen maternity safety.
This includes exploring earlier risk identification through digital tools, improving escalation pathways, embedding transparent data dashboards to surface disparities in real time, and fostering cultural change through leadership development and workforce support. The aim is not innovation for its own sake, but practical adoption that improves outcomes, rebuilds trust and ensures that patient safety is measurable, accountable and consistent across every setting.
To find out more about getting involved with UKHLSI, contact Jo Bekis at jo.bekis@ukhlsi.co.uk.