The final report of England's national maternity and neonatal investigation, led by Baroness Valerie Amos, was published on Tuesday, revealing widespread failures in care that have resulted in avoidable stillbirths, serious injuries, and maternal deaths. The report, commissioned by former health secretary Wes Streeting in June 2024, examines systemic issues across NHS maternity services and specifically at 12 NHS trusts.
Maternal Mortality Rates Remain High
According to the most recent data, the maternal death rate in the UK stands at 12.8 deaths per 100,000 maternities, a figure 20% higher than in 2009-11 when the government aimed to halve the rate. A 2022 study found the UK had the second highest maternal death rate among eight European countries, with UK mothers three times more likely to die around pregnancy than those in Norway.
The number of women experiencing serious complications after labour has also risen. The proportion of mothers in England experiencing postpartum haemorrhage increased from 27 per 1,000 births in 2020 to 32 per 1,000 in 2025, a 19% rise. Similarly, third- or fourth-degree perineal tears rose from 25 per 1,000 births in June 2020 to 29 per 1,000 in June 2025, a 16% increase.
Background and Context of the Review
The investigation follows a series of high-profile maternity failings, including at Shrewsbury and Telford NHS trust, where a 2022 review by midwife Donna Ockenden found 300 babies left brain-damaged or dead due to avoidable outcomes. Last week, Ockenden's review into Nottingham University hospitals NHS trust revealed over 500 babies and mothers died or were injured from inadequate care. Ockenden has also been commissioned to review maternity services at Leeds teaching hospitals NHS trust and University hospitals Sussex NHS foundation trust.
Amos's investigation aims to develop one set of national recommendations to drive improvements across England. Health secretary James Murray stated the report is a “watershed moment” and pledged significant improvements, including dismantling “toxic dynamics” between hospital staff. A powerful maternity commissioner will be appointed to push through urgent transformation.
Key Factors Behind Failures
Inadequate care remains a key issue, with Care Quality Commission inspections finding 36% of NHS maternity services required improvement and 12% were inadequate. Understaffing is a major factor: the Royal College of Midwives reports a shortage of 2,500 midwives, while one in three graduate midwives struggle to find jobs. Systemic issues like institutional racism also play a role.
Changes in delivery methods may contribute to poorer outcomes. In 2024, caesarean sections overtook vaginal births for the first time, with 45% of births by caesarean, carrying higher complication risks. About a quarter of all births are via emergency C-section.
Ethnic and socioeconomic inequalities persist: Black women are almost three times more likely to die during childbirth than white women, and women from the most deprived areas are twice as likely to die than more affluent counterparts.
Findings of the Amos Report
The Amos report found that maternity care has not kept up with major changes such as older motherhood and the rise in caesarean sections. Two interim reports revealed similar findings to Ockenden's reviews: many women and babies received unacceptable and negligent care leading to avoidable stillbirths, serious injuries, and maternal deaths. Hospital trusts often resorted to covering up mistakes and denying bereaved families answers.
