On 26 February 2026, Baroness Amos published her Interim Report as Chair of the independent National Maternity and Neonatal Investigation. She was supported by a panel of expert advisers in nursing and midwifery, obstetric and neonatal care, and public health.
The report highlights a system that is severely under pressure, with evidence of staff shortages, a harmful workplace culture, and unacceptable racism and discrimination.
The investigation was established in June 2025 with the aim of driving urgent improvements in patient care and safety. Evidence was gathered through a public call from women and families, community organisations, Medical Protection Services, NHS staff, and national stakeholders.
While stillbirth, neonatal mortality and birth rates fell between 2016 and COVID-19, the maternal mortality rate has increased since 2016.
The demographic profile of women having children has also changed. More women are having children later in life, and maternal mortality rates for black and Asian women remain significantly higher than for white women. Those living in the most deprived areas face twice the rate of maternal mortality compared with those in the least deprived areas.
A particularly striking finding relates to the sharp increase in birth interventions. Rates of caesarean birth, both planned and emergency, have increased from 25% of births in 2011/12 to 45% in 2024/25. This raises questions about capacity pressures and the extent to which clinical decision-making is being influenced by system strain rather than patient choice or clinical need.
The report highlights six key factors that may be contributing to the pressures on maternity and neonatal services: capacity pressures; culture and leadership; racism and discrimination; poor responses and a lack of accountability when things go wrong; the quality of estates; and workforce pressures.
It is clear from the report that capacity pressures feature prominently throughout the evidence. Antenatal appointments were often reported as being too short to allow meaningful discussion, with long waits in triage and day assessment units. Some antenatal wards and delivery units were described as overstretched, leading to delays in inductions and planned caesarean sections. In some areas, home births were suspended due to staff shortages.
The report highlighted that day assessment and triage areas are increasingly delivering acute antenatal care without the staffing levels, senior decision-making capacity or physical space required to do so safely on a 24-hour basis. Delays in senior clinical review were frequently reported, alongside challenges caused by poor layouts and inadequate IT systems.
The investigation found serious concerns about workplace culture in some Trusts. While there were examples of positive leadership, there was also evidence of bullying, aggression and racist behaviour. Burnout among staff and a loss of professional pride among midwives were identified as ongoing concerns.
Racism and discrimination were repeatedly reported by families and staff alike. Evidence suggested that stereotypes continue to influence care, with accounts from Muslim families, families with disabilities, LGBTQ+ parents, young parents and those who speak English as an additional language.
Families also raised concerns about how Trusts respond when care goes wrong, particularly around poor communication, a lack of transparency and limited learning from adverse events. Some families reported being excluded from investigations or left uncertain about key aspects of their baby’s birth, causing lasting trauma.
What happens next?
The investigation is ongoing, with final recommendations expected in spring 2026. Those recommendations aim to deliver a step change in maternity and neonatal care across England. For many families, the findings will be worrying but not unexpected.
Potential civil claims
Families who have suffered harm as a result of poor maternity or neonatal care may be able to bring civil claims for damages. These claims can provide compensation for the harm experienced and help meet the costs of ongoing and future care and support. Our Head of Clinical Negligence, Ally Taft, would be happy to speak to anyone affected in confidence.
