It is hard to find the words to describe the agony for those who have experienced preventable baby loss, injury or maternal death. Understandably, families who have been through this have campaigned relentlessly for local and national investigations. Every family deserves to know what caused their loss or trauma, but current and past reviews have failed to deliver on resolution and accountability.
The vital debate about how to ensure safe maternity care has intensified since the publication of two reports, led by Valerie Amos and Donna Ockenden, and the appointment of Yvette Cooper as secretary of state for health and social care, offering a golden opportunity for system-wide change. For women and families, cumulative systemic problems have resulted in failures of compassionate care, with distressing examples described in both reports. Where behaviour is unkind or unprofessional, this is inexcusable, and the life-changing physical and psychological trauma caused by poor care must continue to be acknowledged.
We also owe it to all staff groups, particularly midwives, who are often blamed in the media, to recognise that they provide high-quality care to many women every day, despite intense workplace pressures. The Amos inquiry found that just 22% of midwives reported having sufficient time to do their job well, while a Guardian report last month highlighted increasing numbers leaving the profession because of burnout. Undermining and villainising midwives helps no one.
They are the only professional group working with women, babies and families throughout the entire maternity journey across hospital and community settings, providing the platform on which other services depend. For women and babies to be safe, all staff must work in supportive, well-managed and adequately resourced environments. The public criticisms of maternity services over the past decade suggest poor care is common, but regular national surveys by Oxford University report high and relatively stable rates of overall satisfaction with care between 2006 and 2024.
Poor outcomes do not necessarily equate to poor care. The Ockenden review included over 700 maternity cases with poor outcomes, including stillbirth, severe perineal trauma or major haemorrhage among more than 41,000 births between 2020 and May 2025. In over 80% of cases, care was judged to be in line with best practice, or it was considered that different management would not have altered the outcome.
Work from the Neonatal Data Analysis Unit at Imperial College London found that the number of babies born at term with brain injury caused by oxygen deprivation declined between 2015 and 2021, and stillbirth rates have fallen. These are important gains, but reports from the National Perinatal Epidemiology Unit at Oxford University show that in 2022-2024 the overall rate of maternal death in the UK was 20% higher than it was in 2009-2011 and the Amos inquiry also found persistent inequalities, overt racism and continuing reports of physical and psychological trauma. Piecemeal initiatives have produced unintended consequences.
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