MAMA Academy Responds to Publication of the National Maternity Inquiry Final Report
Published on: 30/06/2026
MAMA Academy Welcomes The National Maternity Inquiry Final Report and Calls for Implementation to Deliver Safer Maternity Care Across the UK
Today Baroness Amos published the final report from the National Maternity Inquiry. This inquiry represents one of the most significant national reviews of maternity and neonatal care undertaken in recent years.
Its scale and depth reflect the importance and urgency of improving outcomes for women, birthing people, babies and families across the UK. The inquiry placed the voices and experiences of women, birthing people and families at the centre of its work. It heard directly from more than 450 families across the country, received over 10,500 responses through its public Call for Evidence, visited 12 NHS Trusts, and gathered insight from more than 9,000 maternity staff through surveys, site visits and one-to-one discussions. This level of engagement demonstrates both the scale of concern across maternity services and the collective commitment from families, frontline professionals, charities and organisations to improve care and outcomes.
We recognise the courage of every family who shared their experiences, many of whom revisited deeply painful and traumatic events in the hope that future families might be spared similar harm.
We also recognise the contribution of staff, charities, clinicians, researchers and maternity organisations who brought evidence, expertise and practical solutions forward throughout the inquiry process.
MAMA Academy was proud to contribute to this work by providing evidence, insight and recommendations for change based on our lived experience, national engagement and delivery of practical interventions designed to improve outcomes and reduce preventable baby loss.
This report marks an important moment for maternity care and presents an opportunity to move beyond recognising problems and towards meaningful implementation and lasting change. MAMA Academy is also encouraged to see that the recommendations are accompanied by indicative timescales for delivery and implementation. Too often within maternity improvement, important reviews identify problems and produce recommendations, but progress becomes difficult to monitor and momentum is lost over time. Including implementation timeframes creates greater clarity, accountability and opportunity for meaningful measurement of progress. We hope this helps ensure recommendations translate into visible action for families and frontline staff and supports a stronger culture of delivery, transparency and continuous improvement.
We would also like to mention that this inquiry rightly focuses on reducing avoidable harm and preventing avoidable deaths, so it is important to recognise that not all pregnancy and baby loss is preventable. Many families experience devastating outcomes despite excellent care and despite there being nothing that could reasonably have changed the outcome. Preventing avoidable deaths must never diminish compassion, support or recognition for families whose losses were unavoidable. Where opportunities exist to identify risk earlier, improve communication, strengthen systems or intervene sooner, there is a responsibility to act.
MAMA Academy welcomes the report’s recognition that improving maternity outcomes requires stronger implementation, clearer accountability, national coordination and sustained oversight.
We are particularly encouraged to see recommendations focused on:
1. Improving transparency, communication and family involvement in care
2. Strengthening investigations and ensuring lessons are implemented nationally
3. Greater openness when harm occurs, including acknowledgement and meaningful apologies
4. Reviewing triage processes so concerns are heard and acted upon appropriately
5. Improving access to antenatal education and information for families
6. Independent evaluation of fetal growth surveillance approaches and growth monitoring methods
7. Better use of maternity data and stronger oversight of outcomes and improvement
8. Long-term investment in maternity infrastructure and service improvement
9. Tackling inequalities in access, experience and outcomes
10. Treating racism and discrimination as a critical safety issue
Alongside the national recommendations, the accompanying investigations across 12 NHS Trusts reinforce why these changes matter. Across multiple services, families described concerns not being listened to, symptoms being dismissed, fragmented communication and feeling excluded from decisions. Many described raising concerns about pain, reduced movements or feeling that something was not right — but not feeling heard. Others described confusion and distress following harm, including poor communication, lack of explanation and uncertainty about whether learning would occur.
These findings reinforce an important principle:
Listening to women and families is not simply an experience issue — it is a patient safety issue.
MAMA Academy therefore strongly welcomes the report’s focus on improving investigations, strengthening transparency and communication with parents, ensuring learning is shared nationally and increasing independent challenge and oversight. We are particularly encouraged to see recognition of maternity triage as a safety-critical area and recommendations for Trusts to review how concerns are assessed and escalated.
We also welcome the recommendation for independent evaluation of the accuracy and effectiveness of different approaches to measuring fetal growth. Independent assessment of fetal growth surveillance has long been an area MAMA Academy has advocated for and represents an important opportunity to strengthen confidence in earlier identification of babies at increased risk.
The recommendation on commissioning and delivering antenatal education and accessible information for families is also very encouraging. Access to clear, practical and consistent information should not depend on geography or which Trust someone attends. MAMA Academy believes parent-held resources have an important role to play in delivering this ambition. Our Pregnancy Passports were developed to support families by combining accessible safety information with essential pregnancy information that remains available wherever care is delivered. Importantly, they also address a growing challenge highlighted across maternity services — fragmented digital systems. As more Trusts move away from handheld notes, families and clinicians increasingly face difficulties accessing key information across organisations.
Pregnancy Passports provide a practical bridge by ensuring essential information remains accessible to parents and available when care is delivered across different services. Midwives can record important information directly into the passport, allowing parents to quickly access guidance without needing to navigate digital platforms during periods of anxiety or urgency. The passports also support continuity for ambulance services and urgent care teams who may not otherwise have access to maternity records. Importantly, they help reduce inequalities. Each passport signposts families to MAMA Academy’s website, where safety information and pregnancy resources can be accessed in more than 100 languages, helping improve accessibility and ensuring more families can receive evidence-based information regardless of language barriers. The passports can also be tailored to local services whilst maintaining nationally consistent evidence-based messaging, reducing duplication for Trusts and supporting implementation at scale.
We have already seen encouraging impact. Recent stillbirth statistics in Derby demonstrated a 38% reduction in stillbirths associated with the implementation of Pregnancy Passports, reinforcing the value of practical, scalable interventions that improve communication, continuity and parent empowerment.
MAMA Academy remains committed to working collaboratively across the maternity sector to support implementation of the inquiry findings and help make the UK one of the safest places in the world to have a baby.
As a national charity focused on reducing preventable baby loss and improving maternity outcomes, MAMA Academy works closely with NHS England and national stakeholders to support evidence-based improvement and safer care. We are proud to be part of the National Maternity and Neonatal Collective, a member of the APPG on Baby Loss and the APPG on Maternity, and an active member of the Pregnancy and Baby Charity Network.
Alongside identifying opportunities for improvement, we must also recognise that exceptional maternity care is happening every day across the UK. Across hospitals, community services and specialist teams, thousands of dedicated healthcare professionals deliver compassionate, innovative and life-changing care for women, babies and families. At MAMA Academy, we believe improvement comes not only from identifying where systems fail, but also from recognising and spreading examples of excellence. Through The MAMA Podcast, we actively showcase examples of outstanding maternity practice and share learning from clinicians and services so others can gain inspiration and adopt successful approaches.
Areas MAMA Academy Believes Require Further Focus During Implementation
While welcoming the report, MAMA Academy believes implementation should also consider:
- Dedicated national focus on fetal growth restriction prevention and surveillance
- National monitoring and publication of small-for-gestational-age detection rates
- Stronger process measures alongside outcome measures
- Recognition and recording of fetal growth restriction as a contributory factor where relevant to improve learning
- Practical parent-held solutions alongside digital transformation
- Faster access to maternity safety data
- Independent auditing of implementation and stillbirth prevention measures
Quote – Heidi Eldridge, Founder and CEO of MAMA Academy
“Today’s report represents an important moment for maternity care and for every family who contributed. I want to recognise the extraordinary courage shown by bereaved and harmed families who relived deeply traumatic experiences to help create a safer future for others. I also want to thank the charities, clinicians, researchers and organisations who contributed their expertise and lived experience. We welcome the report’s recognition that implementation, accountability, transparency and national learning must improve if outcomes are to change.
We are particularly encouraged by recommendations around listening to parents, improving investigations, strengthening triage, improving antenatal education and ensuring learning is shared nationally. We must also recognise that exceptional maternity care is happening every day across the NHS and that there are outstanding professionals delivering extraordinary care under immense pressure. Through our Pregnancy Passports and sharing examples of excellence through The MAMA Podcast, we remain committed to helping turn recommendations into real-world improvements.
Reports alone do not save lives. Families should not have to repeat their stories for change to happen. The true measure of success will be whether recommendations are implemented and translated into meaningful change. The government needs to act quickly – thousands of families, maternity professionals, charities and organisations have contributed their voices, experiences and expertise to this process and will continue to support, challenge and hold the system to account to ensure these recommendations lead to lasting change. Our ambition remains clear: to help make the UK one of the safest places in the world to have a baby because every baby deserves the safest possible start to life.”
Read the full National Maternity Inquiry Report here.