Baroness Amos interim report

Baroness Valerie Amos has published her Interim Report as Chair of the independent National Maternity and Neonatal Investigation (England). This interim update does not yet make final recommendations, but it shares the clearest picture so far of what women, birthing people, babies, families and staff are experiencing, and the systemic conditions that allow poor and excellent care to coexist.

What this investigation is

Baroness Amos describes a national, whole-system investigation looking at people, culture, organisations, processes, infrastructure and the wider societal context shaping maternity and neonatal care. It is drawing on local trust visits alongside system-wide evidence to identify what drives consistent, safe, equitable and compassionate care, and how it can be replicated nationally.

Engagement so far includes meetings with hundreds of family members, over 8,000 public responses to the call for evidence (so far), and staff panels alongside thousands of staff responses submitted via trust-distributed links.

The recurring themes families and staff keep raising

Across the report, several themes echo repeatedly. Families describe not being listened to in pregnancy and labour, including being dismissed when raising concerns. There are reports of a lack of kindness, compassion and dignity, particularly in the aftermath of trauma or bereavement. Many speak of a reluctance to admit mistakes, apologise, and clearly explain what happened, leaving families without answers and sometimes wrongly blaming themselves. The report also highlights a fragmented “postcode lottery”, where the care you can access, and how safe it feels, can depend heavily on where you live. Baroness Amos is clear that this cycle of repeating the same failings identified in previous reviews must stop.

Part 1: the changing context of maternity and neonatal care

The report sets out three major shifts shaping services now: outcomes over time, demographics, and clinical complexity.

Outcomes and safety ambitions

The report notes national ambitions set from 2016 onwards to reduce stillbirth, neonatal mortality, maternal mortality and brain injuries, alongside a separate ambition on preterm birth. It also highlights how progress reversed or stalled during and after COVID-19, with some indicators improving again more recently, while maternal mortality has increased in the latest reported period referenced.

Demographics and health needs

Women are giving birth at older ages, with the report citing 2024 ONS data, and more women are entering pregnancy with pre-existing health conditions. This increases the likelihood of complications and the need for services equipped for a changing population.

Inequalities remain stark

The report reiterates persistent disparities, including significantly higher risks for Black and Asian women and for women living in the most deprived areas. These risks are linked to long-standing inequality, racism and discrimination.

Interventions have changed

There have been major shifts in intervention patterns over the past decade, including large increases in caesarean birth rates and changes in how labour begins. The report cautions against simplistic conclusions, noting that intervention can be necessary and that failure to intervene appropriately has caused harm in previous reviews.

It also flags the complexity of oversight and accountability structures, including LMNS, ICBs, NHS England regional and national oversight, and neonatal ODNs. Misaligned boundaries and changing structures can make consistent improvement harder.

Part 2: six system pressures driving risk and poor experience

Baroness Amos examines six factors creating pressure across the maternity and neonatal system.

1. Capacity pressures across the whole pathway

The report describes capacity problems at every stage. These include antenatal appointments that are too short for meaningful discussion, particularly for women with complex needs; long waits in maternity day assessment and triage; delays to admissions, induction progression and planned caesareans; and the redeployment of community midwives into hospitals, undermining continuity and community care. Some areas have suspended homebirth services due to staffing pressures. Postnatal care is also under strain, worsened by increased complexity and higher caesarean rates, alongside variation in transitional care models and neonatal outreach.

Triage and day assessment have become focal points for acute care without consistent senior decision-making capacity or estate provision required for safe 24-hour services. Some units have redesigned triage to improve flow, including more senior staffing and better call handling, but this is not consistent nationally.

The report also highlights how inefficient IT systems add pressure. Records are often spread across multiple systems and sometimes duplicated on paper, creating time burden and patient safety risk. Families reported distress when notes appeared incomplete or not reviewed, particularly when they had to repeat traumatic histories.

2. Culture and leadership

The report links organisational culture directly to safety, outcomes and experience. It describes poor team relationships in some settings, including between midwifery and obstetric teams and between maternity and neonatal teams. There are concerns about inconsistent leadership support, limited training and insufficient protected time for clinical leaders. It also references poor behaviour by some senior clinicians not being addressed, including bullying and racist behaviour, alongside the toll of scrutiny on staff wellbeing, morale and burnout.

There are, however, examples of more positive experience where leadership is strong and supported at executive level, including implementation of Family Integrated Care models in neonatal settings.

3. Racism and discrimination

The report is unambiguous that racism and discrimination are present across maternity and neonatal care, affecting both families and staff. It describes stereotypes and discriminatory attitudes impacting pain assessment, communication and escalation. Some families report feeling they must moderate their behaviour to avoid stereotyping. There are barriers for those who need interpreters, including lack of availability, unreliable remote systems and mismatched interpreter gender for sensitive discussions.

The report also highlights gaps in data and understanding for some communities, including disabled women, refugee and asylum-seeking women, LGBTQ+ families, and Gypsy, Roma and Traveller communities. As a result, discrimination can remain under-recognised. Trusted community organisations and outreach play an important role in reducing barriers and building trust, but support is inconsistent and often uncertainly funded.

4. Poor responses and lack of accountability when things go wrong

Families describe a lack of compassion after harm, trauma or baby loss. Some report not being involved in investigations from the outset, not being told when investigations conclude, or not receiving reports. There are concerns about defensiveness and a perceived culture of cover-up. Families also report difficulty accessing notes and raise concerns about notes being amended or redacted.

The report notes that internal investigations can feel arbitrary, poor in quality, or fail to result in meaningful change. Many families feel forced into litigation to get answers, and the current system can be long, costly and adversarial.

It also explores the legal framework around coroners and stillbirths, including family experiences of ambiguity and distress, and sets out why this area is being examined as part of the investigation’s wider work.

5. The quality of estates

There is wide variation in the quality of buildings and physical environments. The report describes outdated and dilapidated estates alongside modern builds that still do not meet clinical need. It includes examples of rooms out of action due to leaks, cold units, cramped corridors and inadequate space for essential equipment. Limited ensuite facilities compromise dignity and infection control. Partner and family facilities are often insufficient, including lack of seating and overnight accommodation. Some neonatal units are too cramped to deliver Family Integrated Care effectively. Bereavement spaces are deeply inconsistent, with some trusts having none, and reports of families being moved through delivery areas while hearing others in labour.

6. Workforce

Staffing is described as foundational to safety, continuity and personalised care. Concerns include units feeling unsafe even where staffing meets existing guidance, due to turnover and non-frontline roles being counted in figures. Increasing complexity and acuity are driving burnout and morale issues. There are rota pressures and inconsistent senior medical cover, particularly out of hours. Specialist services, including bereavement and breastfeeding support, are not always available outside office hours, despite the reality that baby loss and emergencies do not follow a nine-to-five timetable.

What happens next and how families and staff can feed in

Baroness Amos confirms that the investigation is continuing evidence gathering and analysis before final recommendations are published.

The call for evidence for women and families is open until 17 March 2026. The call for evidence for maternity and neonatal staff is open until 9 March 2026 and is being distributed via NHS trusts.

The report also confirms that the Secretary of State will chair a National Maternity and Neonatal Taskforce to turn final recommendations into a national action plan.

Government response and action to date

The Health and Social Care Secretary, Wes Streeting, has said a Taskforce will be established to develop a national action plan and that action cannot wait while the investigation continues.

Since July 2024, government and NHS England actions referenced in public updates and publications include investment to address critical safety risks on maternity estates; piloting Martha’s Rule, including in maternity and neonatal settings; work to improve perinatal culture and leadership; a maternity signal system intended to spot emerging safety concerns earlier; a Perinatal Equity and Anti-Discrimination Programme; extension of the Baby Loss Certificate scheme to include historic losses; and publication and rollout work focused on leading causes of maternal death and harm, including NHS England’s Maternal Care Bundle content. Where government statements cite workforce increases, readers are encouraged to review the latest NHS workforce statistics for the most current comparable figures.

MAMA Academy’s view

This interim report reflects what too many families and staff have been telling the maternity safety community for years: harm is not only about individual incidents. It is about whether systems consistently provide listening, timely assessment, clear information, respectful communication and a culture that learns quickly when things go wrong.

There is excellent care across the NHS, delivered with skill and compassion, often under immense pressure. There are also systemic failures that must be addressed urgently, especially where racism, discrimination, poor culture, unsafe estates and lack of accountability compound risk and trauma.

We will be following the next phase closely, including the announcement of Taskforce membership and what early “no regrets” actions are taken while the investigation moves towards its final report in Spring 2026.

You can read the full interim report here