A series of inquiries has further exposed the depth of the crisis in UK maternity and neonatal care, with years of underfunding, staff shortages, and cultures of bullying and discrimination.
This pattern has been established by inquiries spanning over a decade: in Morecambe Bay (2015), East Kent (2022), Shrewsbury and Telford (2022), and now Nottingham last month, where the largest maternity inquiry in NHS history has identified over 500 mothers and babies who died or came to harm as a result of inadequate care.
Before the findings of the Ockenden review from Nottingham were released, a new inquiry had already been announced. This scandal affecting maternity services in Leeds, the Sunday Times reports, may affect an even greater number of mothers and babies than the scandal in Nottingham.
These scandals are not isolated failures. Maternal mortality has risen to around 12.8 deaths per 100,000 women giving birth, about one-fifth higher than in 2009-11, leaving the UK performing substantially worse than many comparable western European countries. Progress in reducing stillbirths and neonatal deaths has stalled since the pandemic.
Review
Baroness Amos has now published the findings of her review into the national causes of these recurrent scandals. Rather than uncovering new problems, this review concluded that multiple inquiries have produced remarkably similar findings: workforce shortages, poor leadership, racism and discrimination, fragmented services, poor accountability, and a failure to learn when harm occurs. Its recommendations include appointing a national maternity commissioner, better staffing, binding standards, and stronger independent investigations when babies or mothers die or are seriously harmed.
The Amos review points to how services have not kept pace with changes in pregnancies, as more women give birth later in life, with more chronic health conditions and more often by caesarean section. Yet comparable countries like Norway have not seen a corresponding increase in maternal mortality.
Even within the UK, the burden is not shared equally. Maternal mortality is twice as high for those living in the most deprived parts of England compared to those in the least deprived areas. Black women remain almost three times as likely to die during pregnancy or shortly afterwards as white women, while Asian women face around twice the risk. Babies born to Black families are significantly more likely to be stillborn or die shortly after birth. Amos concluded that racism and discrimination are patient safety issues that are embedded in the way services operate.
Coincide
These outcomes coincide with years of workforce shortages and underinvestment. In response to the Amos review, the Royal College of Midwives (RCM) said, “Chronic understaffing and a decade of under-investment have left midwives unable to consistently deliver the care every woman and baby deserves. A poll published last week found that nine in ten of our members say unsafe staffing is directly affecting the quality of care – day in, day out. This is a staffing emergency.”
According to the RCM, the NHS across England has a shortage of 2,500 midwives, while one in three graduate midwives have reported struggling to find a job. The union last month succeeded in winning 1,000 new posts for newly qualified midwives.
Last year the government and NHS England cut ringfenced funding for maternity services from £95m in 2024-25 to just £2m in 2025-26, with the reallocated funds to be used more flexibly by local integrated care boards. The RCM described the cuts as “more than shocking […] they will rip the heart out of any moves to improve maternity safety.”
Successive scandals also demonstrate why workers’ control matters. Many inquiries describe staff who recognised dangerous practices but felt unable to speak out because of bullying, fear of reprisals or a widespread belief that management would not act. Genuine accountability means strengthening trade union organisation, protecting whistleblowers and giving frontline workers a decisive voice over staffing, safety and service organisation.
Mothers deserve to be properly listened to and families deserve accountability. Justice also relies on those who actually deliver maternity care having the resources and democratic power to shape it, and to end decades of discrimination, underinvestment, poor staffing and neglect. §
• References in online version bit.ly/wf-mat
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