England to get powerful maternity commissioner after ‘shocking’ failings

Announcing creation of a maternity commissioner, James Murray says Amos report highlights ‘toxic’ culture in some NHS units

Analysis: Transparency, standards and a new commissioner – but does maternity review go far enough?

Valerie Amos’s devastating indictment of maternity care has to be a “watershed moment” for how the NHS treats pregnant women and babies, the health secretary has said.

James Murray pledged that Lady Amos’s report would lead to significant improvements and that “toxic dynamics” which damage relationships between hospital staff providing childbirth care would be dismantled.

A powerful maternity commissioner will be appointed to push through an urgent transformation of childbirth care in England .

The Amos report found that maternity care in England had not kept up with major changes such as older motherhood and the dramatic rise in the proportion of women having a caesarean section.

Speaking in the Commons on Tuesday, Murray also took aim at a “culture” which means that, when mistakes are made, maternity units prioritise their reputation above their duty of openness to families, and urged NHS bosses to help banish it.

“Culture is where so much of the responsibility lies. That culture is the most deep-rooted cause of the failures we have seen, and the most fundamental thing we must change,” he told MPs.

“We will dismantle toxic dynamics, boost staff morale and support better teamwork between midwives, doctors and other clinicians.

“We need not only the right policies, procedures and processes to be put in place but also a fundamental reset in the culture of a service that too often puts the desire to protect itself above the duty to protect women and babies.”

Amos identified a host of “shocking” failings in maternity care in her 181-page report, including women being ignored, poor triage of mothers-to-be, putting lives at risk, and chronic understaffing of services.

“That culture change must come from the top. It is time that trust leaders, executives, and senior clinicians pay attention to what is happening on their watch. Put professional tribalism aside, lose the bunker mentality when things go wrong, and make sure the safety of women and babies always comes first.

Murray continued: “This has to be a watershed moment. We must break the cycle of recommendations sitting on a shelf gathering dust.”

The new maternity commissioner will play an important role in transforming childbirth services. Whoever is chosen will co-chair with the health secretary the government’s national maternity and neonatal taskforce, which is drawing up an action plan for safer and better care. It is due to be published in December.

“Their role will be to champion the voices of women, babies and families to make sure those voices are heard within government when decisions are made and implemented,” Murray said.

Ministers bowed to growing pressure by agreeing to recruit the UK’s first commissioner for maternity and neonatal care. They will pursue hospitals over failures in care, ensure wide-ranging improvements are made and try to restore the faith of families in a maternity system in England that has been rocked by a series of scandals.

Lady Amos’s report is the second in less than a week to advise ministers to instigate a dramatic overhaul to reduce the risk of mothers and babies suffering harm or dying because of errors and receiving inadequate care from the NHS. Donna Ockenden, the author of last week’s inquiry into the Nottingham maternity scandal , is widely expected to become the new commissioner.

“I still find it shocking that women and babies have been harmed or have died, sometimes as a result of failings in the maternity and neonatal care provided. We are a wealthy country. It should not happen,” Amos said in the 181-page report of her nine month-long investigation.

“Having a baby should be one of the happiest moments of a family’s life. For most women in England, it is. But for too many – depending on where they live, who they are or simply the day they give birth – the care they receive is not good enough and can result in avoidable harm.

“Every instance of avoidable harm is one too many. The emotional toll and cost to families is indescribable. As a country, as a community, we cannot continue like this,” said Amos, a Labour peer and former cabinet minister.

Murray pledged that Amos’s “landmark” report would prove “a turning point” in efforts to ensure that every woman received safe and high-quality care during pregnancy, labour and birth.

“Appointing the UK’s first ever maternity and neonatal commissioners will drive lasting change and make sure women and families are never ignored again,” he added.

The maternity system in England was “confusing, inflexible and unresponsive to women and families”, according to the report. Mothers told Amos how they had been dismissed when they raised concerns, “leading in some cases to avoidable harm or unsafe care”, and treated with a lack of compassion. A lack of pain relief meant some suffered pain and distress during a caesarean section or assisted vaginal birth.

Women of colour have experienced racism or discrimination. That has led to them “receiving unfair or unequal treatment, leading to delays, unsafe care with, at times, devastating outcomes” and becoming reluctant to engage with childbirth services.

Amos said she had been asked during her inquiry if women and families should trust their local maternity service to look after them properly. However, she did not give an answer and said only that she did not want to discourage anyone from getting pregnant and having a baby.

She made eight main recommendations to improve care, including:

Maternity triage services – the childbirth equivalent of A&E – need an urgent overhaul, including more staff on duty, so that women’s concerns are acted on more quickly.

Families should get the right to seek a fresh, independent investigation when things go wrong if they are not happy with the hospital’s own inquiry.

The NHS’s “brutal” and “cruel” system of agreeing compensation with harmed and bereaved families should be replaced by a new process in which hospitals admit errors immediately.

The NHS must root out racism and discrimination that is “embedded throughout the maternity and neonatal system”.

Maternity care has not kept pace with major changes in recent years, such as the shift towards older women giving birth, the fact that more mothers-to-be have an underlying health condition and the dramatic recent rise in medical intervention such as induction of labour and caesarean sections, she added.

Amos highlighted that many of the multiple recommendations made by a series of previous reviews to improve maternity care had not been implemented or proved short lived. Some maternity units are so old they were now “unsafe”. Widespread understaffing was compromising quality of care and leaving maternity personnel suffering “trauma and moral injury from failures in care”.

In a rare positive finding she noted that stillbirths and neonatal deaths were at near-record lows, but added that progress on both fronts had stalled since 2020.

The report was overshadowed by one of Amos’s clinical advisers, Dr Bill Kirkup, a renowned maternity safety expert, resigning on Monday, hours before it was published, in a row over its section of “normal birth ideology”. Amos said Kirkup disagreed with the wording.

However, the Health Service Journal reported that he had quit “because of a disagreement of principle” over that belief, which holds that women should give birth vaginally, without intervention, as far as possible.