Baroness Amos National Maternity and Neonatal Investigation Interim Report Analysis

Maternity report

Jo Moore & Amelia Williams

On 26 February 2026, Baroness Amos published her Interim Report as Chair of the independent National Maternity and Neonatal Investigation. The Investigation was set up in June 2025 to drive urgent improvements in patient care and safety.

Evidence has been gathered via engagement with women and families, community organisations, MPs, NHS staff, national stakeholders and via a public call for evidence. The Chair is supported by a panel of expert advisors in nursing and midwifery, obstetric and neonatal care, and public health.

The context of the Investigation, set out at Part 1 of the Interim Report, includes:

• The trajectory of outcomes for women and babies over the last decade has been variable. Stillbirth, neonatal mortality, and preterm birth rates fell between 2016 and the pandemic, then stalled, then started to fall again slightly. The maternal mortality rate however has increased since 2016.
• The demographic, social and health profile of women using maternity services has changed, with women having babies older, and with higher maternal mortality rates for Black and Asian women. Women living in the most deprived areas have twice the rate of maternal mortality compared with those in the least deprived areas.
• The nature of interventions has changed. Most significantly, rates of caesarean birth (both planned and emergency) have increased significantly from 25% of births in 2011/12 to 45% in 2024/25. This report, published midway through the investigation, identifies six factors which the Chair currently considers could be contributing to the pressures on the maternity and neonatal system:

1. Capacity pressures
2. Culture and leadership
3. Racism and discrimination
4. Poor responses and a lack of accountability when things go wrong
5. The quality of estates
6. Workforce The full interim report can be found here.

Capacity Pressures

The report notes evidence of birth choices and services being restricted in some cases due to capacity issues, including:

• Antenatal appointments being too short for meaningful discussion;
• Long waits in Maternity Day Assessment Units and triage;
• Some antenatal wards and delivery units being stretched, with an impact on admissions, progression for induction, and planned caesarean sections
• Suspension of home births due to staff availability
• Redeployment of staff from community midwifery and postnatal wards to delivery units, giving rise to concerns due to lack of familiarity with hospital working practices and staffing in the services from which they are drawn;
• Variability in the provision of transitional care on maternity units
• Varied approaches across trusts in how soon a baby can be discharged home after receiving specialist input post-birth, and differences in options for babies who needed neonatal palliative care. The report also noted frequent reports of delays in early senior clinical review, and practical issues with the layout and geography of maternity units, and issues with insufficient IT systems and record keeping and information sharing.

Concerningly, day assessment and triage areas are noted to “ have become focal points for acute and sometimes emergency antenatal care, often without the staffing levels, senior decision-making capacity or estate provision required to deliver safe, high-quality care on a 24-hour basis.”

Culture and leadership

The investigation “heard troubling accounts from staff of poor relationships between team members” in some Trusts, along with evidence from families of “striking shortcomings” in organisational culture.

The evidence on leadership was varied, with some reports of positive leadership, and strong support for the head of midwifery, being visible, accessible, and involved in Board decisions. However there was also evidence of harmful workplace culture including aggression, resistance to carry out tasks, and some bullying and racist behaviour. Further, there was concerning evidence of staff experiencing burnout and midwives who have lost pride in their roles.

Racism and discrimination

The investigation “heard about unacceptable racism and discrimination across the maternity and neonatal system”, with both families and staff reporting having experienced racism and discrimination. The evidence demonstrated that stereotypes were being used in maternity and neonatal services.

The examples of discrimination were wide-ranging, with the report highlighting accounts from Muslim parents, families with pre-existing physical or mental health conditions, families who speak English as an additional language, or who require British Sign Language interpretation, LGBTQ+ families and young parents.

Poor responses and a lack of accountability when things go wrong

Families reported a number of concerns about the response when things went wrong, including a lack of (a) compassion, (b) transparency, (c) clear communication, and (d) learning. A number also raised concerns about the investigation process, having been excluded from the investigation or not being sent copies of reports, and some families emphasised their desire for investigations to be conducted independently from trust staff. Families felt that staff had been reluctant to admit that care had not met the expected standards, leaving families feeling that there had been a cover up and defensiveness from NHS Trusts.

Worryingly, a number of families also reported that there was ambiguity regarding whether their baby had been born alive, creating distress and long-lasting trauma for families.

The quality of estates

The investigation raises a number of concerns about the quality of the estates, including the impractical layout of some estates (including modern estates), rooms which were not large enough to accommodate staff and equipment, and delays in basic repairs being carried out. Cramped neonatal units were also identified, and the spaces and support for bereavement care were reported to be inconsistent.

Workforce

The accounts revealed a highly pressurised work environment, with poor morale, incivility and stress for the staff. There has been a loss of experienced frontline staff in recent years.

There was reported difficulty in filling neonatal nursing roles, and the report found that the provision and quality of bereavement support varied. The evidence demonstrated that how medical cover is provided in maternity units is inconsistent across the country, with some units reporting difficulty maintaining safe obstetric rotas, particularly overnight or at the weekend.

Next Steps

Part 3 of the report deals with Next Steps. The intention is to continue the investigation process and then recommendations will be published, which will be designed to enable a “step change in the provision of maternity and neonatal services in England, rooted in the delivery of safe, consistent care.” Considering the content of the interim report, it is anticipated that these changes could be significant, but we will have to wait for the publication of the final report (said to be anticipated in Spring 2026) to consider them.

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Last updated on April 8, 2026