A powerful maternity commissioner will be appointed to push through an urgent transformation of childbirth care in England after a major review concluded that it had multiple failings.
Ministers have bowed to growing pressure by agreeing to recruit the UK’s first commissioner for maternity and neonatal care. Whoever takes on the role will pursue hospitals over persistent 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.
James Murray, the health secretary, announced the move in response to Valerie Amos’s government-commissioned inquiry of maternity care, which concluded it was a system characterised by poor care and a failure to listen to women, and was plagued by racism and discrimination.
“The maternity and neonatal system in England is no longer fit to consistently deliver high-quality, compassionate care to every woman and family, and requires urgent reform to put safety at its centre, embed a focus on listening to women and ensure anti-racist practice at every level,” she found.
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.
The appointee will also co-chair with the health secretary the government’s national maternity and neonatal taskforce. It is drawing up an action plan to improve care, which is due in December.
“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.
In her report, Lady Amos made eight key recommendations to improve care. Photograph: Mark Thomas/Alamy Live News
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 that:
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.
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.
