Theo Clarke
Former MP and Chair Birth Trauma InquiryTheo Clarke is the former MP for Stafford and chaired the cross-party Birth Trauma Inquiry in Parliament in 2024. She is the author of Breaking the Taboo: Why We Need to Talk About Birth Trauma and hosts a popular related podcast on women’s health.
The National Maternity and Neonatal Investigation (NMNI), led by Baroness Amos, published its interim findings yesterday.
It said nothing we did not already know and only reinforced how much work there is to do to improve care for new mothers in this country.
Baroness Amos said that nothing had prepared her for the unacceptable care families currently receive. It is therefore deeply disappointing that these interim findings have been published instead of a full rapid report with concrete recommendations to tackle the national maternity scandal – a scandal that is harming women and babies and leading to unnecessary deaths right now. That full rapid report is what the Health Secretary promised in June, with a report due this December.
The failure of the Government’s so-called rapid inquiry – now due in the spring – continues to highlight the bluster and prevarication it has employed about maternity care since being elected. They have done nothing in 17 months. Wes Streeting says it keeps him up at night. Well, he must be getting used to insomnia.
The fact is that this not-so-rapid inquiry has simply kicked the can further down the road, while frustrated maternity campaigners like me look on in disbelief.
It will require a Herculean effort by the Baroness and her team to finish by spring. But what is most frustrating is that all the information the Health Secretary needs is already available – ready and waiting to be used, as Baroness Amos herself concedes.
In her reflections, she said:
“The NHS has recorded a staggering 748 recommendations relating to maternity and neonatal care, the majority of which have been made since 2015 via damning reports…This naturally raises an important question: with so many thorough and far-reaching reviews already completed, why are we in England still struggling to provide safe, reliable maternity and neonatal care everywhere in the country?”
It is a good point. However, what is alarming is that she and the Health Secretary appear to believe that yet another report, with yet more recommendations to be published who knows when, is going to make the difference and finally end the struggle for acceptable maternity care.
I find it impossible to believe this inquiry will reach any different conclusions from those of the many others going back a decade, including my own cross-party parliamentary inquiry into birth trauma in 2024.
Two of its key recommendations were to appoint a Maternity Commissioner for England and to implement a National Maternity Improvement Strategy. This person would not simply report and then move on to the next job, but work over years to implement those 748 recommendations, improve care and save lives – and not kick any cans down the road for even an extra day.
As I have said since the inquiry was announced, we already have all the information we need to stop this scandal – not in 2026 or at some undefined point in the future, but right now. What Donna Ockenden found at Shrewsbury and Telford, what other reports into maternity services have shown, and what my own inquiry co-chaired with Rosie Duffield demonstrated are all too common and tragic failures in NHS care. They speak of a systemic failure to follow guidelines, poor technical competence, dismissive and uncaring attitudes, and cover-ups. They speak of cultural and structural dysfunction: severe understaffing; misogynistic and dysfunctional hierarchical care models; and persistently poorer outcomes for Black, Asian and disadvantaged mothers that are costing lives.
Simply acting on the recommendations of our birth trauma inquiry report would be a huge step forward. Set our work alongside the abundant evidence we already have of terrible tragedies across the country and it is clear: we do not need another report – we need to get on with saving lives and preventing harm.
I am afraid we do not need another investigation from this Government. We need a Maternity Commissioner to implement the findings of existing inquiries, which already set out very clearly what change needs to happen in order to improve maternity safety now.
Breaking the Taboo: Why we need to talk about birth trauma is available at Biteback Publishing: www.bitebackpublishing.com/books/breaking-the-taboo