Interim report reveals that changes to improve maternity and neonatal care have been too slow

Baroness Valerie Amos, who is chairing the National Maternity and Neonatal Investigation, released an interim report on 9 December 2025 exposing urgent and systemic failures in England’s maternity services.

Her review, informed by visits to seven NHS trusts and hearing from over 170 families, found a ‘staggering’ 748 recommendations had been made to improve maternity and neonatal care over the past decade, yet transformative change remains elusive. Baroness Amos has highlighted deeply disturbing accounts: women left unattended in hospital bathrooms, wards plagued by unsanitary conditions, inadequate communication, and discrimination against women of colour, younger mothers, and those with mental health issues.

Key findings from the interim report

Baroness Amos described a landscape far worse than anticipated, with families reporting that even basic needs – meals, catheter care, and emotional support – were neglected. Many mothers felt their concerns, such as reduced fetal movement, were dismissed. Instances of neglect included babies being placed alongside women who had experienced pregnancy loss, and staff showing distressing indifference to parental grief.

She urged reflection on the sheer volume of unimplemented recommendations, repeatedly asking, ‘Why has change been so slow?’, and affirming the urgency of systemic reform.

Earlier support for the investigation from the Nursing and Midwifery Council (NMC)

The NMC issued a clear, supportive statement in September, ahead of the interim report, embracing the investigation’s approach and focus. Paul Rees MBE, NMC chief executive and registrar, welcomed that women and families would be at the centre of the investigation. He emphasised that ‘every woman, baby and family has the right to safe, effective and compassionate care’. He confirmed the NMC’s commitment to working with Baroness Amos and other partners to ensure that learnings from this review translate into safe, quality care practices across England.

Reaction from the Royal College of Obstetricians and Gynaecologists (RCOG)

The RCOG, led by its president Professor Ranee Thakar, expressed support for the interim report’s stark revelations and underscored the pressing need for rapid improvement. Thakar noted that chronic issues, including staff shortages, insufficient training time, and outdated equipment, undermine care quality, leading to harm and staff attrition.

While affirming the RCOG’s commitment to supporting the process through educational programs, clinical guidance development, and quality improvement initiatives, Thakar cautioned against ignoring the broader system-wide challenges of underfunding and workforce scarcity. She welcomed the formation of the National Maternity and Neonatal Taskforce, chaired by the Secretary of State for Health and Social Care, affirming the RCOG’s readiness to collaborate on implementing actionable recommendations.

Broader professional and public reaction

Frontline bodies such as the Royal College of Midwives (RCM) and Sands (Stillbirth and Neonatal Death charity) echoed the report’s urgency. The RCM, led by chief executive Gill Walton, described the findings as ‘deeply distressing’ and insisted that chronic staff shortages and resource constraints are undermining care delivery.

Sands highlighted parents’ long-standing frustrations, arguing that ‘recommendations on their own change nothing’, calling instead for decisive systemic reform driven by determined leadership.

The data reinforcing Baroness Amos’ concerns

A Care Quality Commission review of 131 maternity units found:

• 36% were rated ‘requires improvement’;
• 12% were rated ‘inadequate’;
• only 4% were rated ‘outstanding’;
• safety assessments showed 47% required improvement and 18% were rated ‘inadequate’ for safety.

As highlighted previously, disparities in outcome remain stark: Black babies are twice as likely to be stillborn, and Black women face a two to three times higher risk of maternal death. The organisation Five X More has highlighted these disparities, and its stated mission is to ’empower, support, and advocate for Black women, ensuring they receive the respectful, equitable and high-quality care they deserve during pregnancy and beyond’.

A focus on a normal birth ideology in several trusts has recently been highlighted by The Times as a potential cause of harm in the maternity space, ‘with midwives and doctors waiting too long to intervene in labour or putting parents through the use of forceps and other interventions to avoid a caesarean’. For example, Leeds Teaching Hospitals NHS Trust had the lowest rate of caesarean sections in the country between 2012 and 2023, but its rate of stillbirths and newborn baby deaths soared over the same period to become the worst nationally. An inquiry into the maternity care at the trust was announced earlier this year, following the Care Quality Commission (CQC) downgrading its maternity services to ‘inadequate’.

What’s next

Baroness Amos’ interim report serves as a powerful wake-up call. The investigation’s next steps include an evidence call in January 2026 and further visits, culminating in a more comprehensive update in February and a final report with national recommendations in spring 2026. The newly formed National Maternity and Neonatal Taskforce is expected to translate the recommendations into policy and delivery changes, with cross-sector collaboration crucial to reversing persistent failings.

Conclusion

Baroness Amos’ interim findings paint a harrowing portrait of England’s maternity care landscape: repeated failings, ignored recommendations, and inequality in care. Responses to the interim report affirm commitment to change, but emphasise that meaningful progress hinges on addressing staffing, funding, and accountability. As the investigation progresses, families and professionals alike will be watching closely to see whether the realisation of reform finally matches the clarity of the interim report’s revelations.

Families affected by maternity care issues may wish to seek legal advice to understand their options. Our specialist team is available to provide guidance and support in navigating these complex and sensitive matters.