England maternity failings put new pressure on NHS and ministers

England’s maternity services are facing renewed scrutiny after reviews found that poor care contributed to deaths and serious harm involving mothers and babies. The findings have put pressure on the NHS and the government to address staffing, safety and culture in childbirth services.

A review led by midwife and childbirth expert Donna Ockenden found that 444 women and 76 newborn babies had “potentially avoidable” outcomes over 13 years at Nottingham University Hospitals Trust. The review examined maternity care at Queen’s Medical Centre and Nottingham City Hospital.

The Ockenden review looked at the deaths of 27 mothers in the Nottingham area between 2006 and 2024. It found failures in care that may have affected the outcome in six of those deaths.

What the reviews found

According to the Ockenden review, families reported poor, cruel or bullying treatment, while staffing shortages continued across the trust’s maternity units. The review said women in labour were sometimes sent home when they should not have been, and that the units lacked enough staff and capacity for the volume and complexity of cases.

The review also cited failures in listening to women and families, continuity of care, clinical governance, information-sharing and access to imaging for women with concerning neurological symptoms. In one case, the review said a baby who died early in gestation was mistakenly disposed of as clinical waste after a post-mortem examination.

Ockenden’s review said the trust’s response to complaints showed an instinct to conceal problems rather than examine failings. It also said several clinicians did not respond to questions from the inquiry.

The Nottingham Maternity Families group, which represents 600 harmed and bereaved families, called that refusal appalling and urged ministers to hold a statutory public inquiry into maternity failures across England. Tommy’s chief executive Kath Abrahams said the report was harrowing and that families and healthcare staff who raised risks had been ignored.

A separate review led by Baroness Valerie Amos also found that maternity services had failed women and babies. The Amos review said racism and discrimination were embedded across the system, with women and families describing unequal treatment, stereotypes, racial abuse, Islamophobia and antisemitism. Staff also reported racism at work, according to the review.

Wider concerns

Concerns are not limited to Nottingham. In Leeds, an independent inquiry followed a BBC investigation that said at least 56 baby deaths and two maternal deaths between 2019 and 2024 might have been preventable at Leeds Teaching Hospitals.

The Care Quality Commission rated Leeds Teaching Hospitals “inadequate” and raised concerns about low staffing levels and infection control. In March, Ockenden was appointed to oversee another review covering hypoxic injuries and maternal deaths at Leeds Teaching Hospitals from 2011 to 2025.

Research published in January by Oxford University put the UK maternal mortality rate for 2022-2024 at 12.8 deaths per 100,000 maternities. The research said that was 20 percent higher than in 2009-2011, meaning the government had missed its goal of halving maternal mortality.

MBRRACE, which audits maternal and baby deaths across the UK, said 252 women died from direct or indirect causes during or soon after pregnancy among 1,969,321 maternities in 2022-2024. It found blood clots were the leading cause of maternal death up to six weeks after pregnancy, followed by heart disease and mental health-related causes.

MBRRACE also reported wide inequalities. It said the maternal death rate among Black women in 2022-2024 was nearly three times that of white women, and that women in the most deprived areas had a rate nearly twice that of women in the least deprived areas.

Government response

Health Secretary James Murray told Parliament on Tuesday that the Amos review marked a “watershed moment”. He said ministers would seek to change damaging workplace dynamics, improve morale and support teamwork among midwives, doctors and other clinicians.

Murray said the government would create a statutory maternity and neonatal commissioner accountable to Parliament. The commissioner will co-chair a National Maternity and Neonatal Taskforce with the health secretary and will influence policy, safety protocols and NHS resource allocation, according to the government.

The health secretary also announced 41 million pounds, or $54.75m, for maternity and neonatal safety improvements. He said the government would create 1,000 temporary midwifery posts and publish new national standards for emergency maternity care.

This story draws on original reporting from Al Jazeera.