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Maternity Commissioner
(1 day, 9 hours ago)
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Westminster Hall is an alternative Chamber for MPs to hold debates, named after the adjoining Westminster Hall.
Each debate is chaired by an MP from the Panel of Chairs, rather than the Speaker or Deputy Speaker. A Government Minister will give the final speech, and no votes may be called on the debate topic.
This information is provided by Parallel Parliament and does not comprise part of the offical record
Tony Vaughan (Folkestone and Hythe) (Lab)
I beg to move,
That this House has considered e-petition 751174 relating to a Maternity Commissioner.
It is a privilege to serve under your chairship, Sir Alec. The petition calls for the appointment of a maternity commissioner to improve maternity care for mothers and babies. I thank the petitioners, Louise Thompson and Theo Clarke, two formidable women and campaigners who have raised this issue relentlessly over several years. They have spoken powerfully, alongside many others, including the Birth Trauma Association, the MASIC Foundation, Make Birth Better, the Maternal Mental Health Alliance, Five X More and Mumsnet. I also thank the more than 153,000 people, including 203 of my constituents in Folkestone, Hythe and Romney Marsh, who signed Louise and Theo’s petition so quickly after it was launched.
We should remember that most births in the UK are safe, and I acknowledge and thank the NHS midwives, nurses and doctors on the frontline, and all those working across the health service, who do outstanding work to care for mothers and babies across our nation every day. However, at the same time, there are clear, deep-rooted and long-standing problems in our maternity and neonatal services, in connection with which I will mention four statistics.
First, the maternal death rate in the UK is one of the highest in western Europe, and UK stillbirth rates are also high. Secondly, the NHS currently spends more on payouts for medical negligence than on the entire frontline maternity service budget. That money should be going towards safer frontline care, not litigation. Thirdly, according to the Care Quality Commission’s latest national review of maternity services, almost half the maternity units it inspected between 2022 and 2023 were rated as “requires improvement” or “inadequate”, with only 4% rated as “outstanding”.
Fourthly, over the past two decades, we have seen a heartbreaking succession of maternity scandals. There was the same pattern across Morecambe Bay, Shrewsbury and Telford, East Kent—which serves my constituency—and now Nottingham: women raised concerns, saying that something was wrong and that they were in pain or frightened, but were not listened to. That failure to listen is a theme running through every major maternity report of the last decade, with around 750 recommendations across those various reports reflecting that failure, alongside the issues of unsafe care, toxic culture and weak oversight.
Unfortunately, those were the experiences of petitioner Louise Thompson, who advocated for a C-section but was denied it, resulting in a massive obstetric haemorrhage. My constituent Jo Page also experienced those systemic failures when her son was born at William Harvey hospital in Ashford some years ago. A birthing injury was misdiagnosed and she did not receive the right treatment and support for what was, in fact, a fourth-degree tear. As a result, she has suffered years of pain and indignity, cannot stand for long periods and needs to use the toilet frequently. She had to give up her career and cannot do normal activities, such as taking a flight to go on holiday. Her life has been utterly changed.
Jo now works with MASIC, which supports mothers with anal sphincter injuries, to run a support group for local women in Folkestone, Hythe and the wider Kent area. She also trains midwives and doctors to correctly diagnose tears, and was recently involved in the Sky News production, “Birth Trauma: The women who weren’t listened to”, which tells the traumatic stories of three mothers who were cared for in NHS England hospitals. Jo, you are truly inspiring, and I know that the whole House would join me in expressing thanks for all the work that you do for women up and down the country.
When I spoke to Jo last week, she told me that she continues to receive messages from women who have experienced misdiagnoses and did not feel listened to during their birthing experiences. Those women include a police officer and a social worker who had both been so badly injured during birth that they had to give up their careers, got into debt and suffered immeasurably. I am sad to say that, just last month, I was contacted by a constituent who experienced the same failings that they had read about in the Kirkup report into maternity services at William Harvey hospital.
When I spoke to petitioner Louise Thompson, she said that she is constantly hearing from women who have post-partum physical injuries and mental health issues, and has known people who have committed suicide following maternity service and post-partum system failures. She also spoke of the profound strain on partners, who must support a recovering mother, assist in caring for a newborn and continue to work, all at the same time. She pointed out that a third of women in the UK who give birth experience it as traumatic, and that every year between 4% and 5% of them develop post-traumatic stress disorder, which is around 30,000 women in total. The impact of trauma can last a lifetime, affecting a mother’s bond with her baby, her relationship with her partner, her ability to work and her long-term mental health.
Why is this happening? The petitioners believe that one key reason is a lack of unified leadership and consistency across maternal care in the UK, over many years. When petitioner Theo Clarke was the hon. Member for Stafford, she chaired the first ever birth trauma inquiry with the hon. Member for Canterbury (Rosie Duffield). They heard from 1,300 patients, including patients from marginalised communities, and from professionals about their experiences of maternity services across the four nations of the UK. The inquiry was prompted by Theo Clarke’s own traumatic birth experience, which she bravely and publicly spoke about in the House, describing it as:
“the most terrifying experience of my life.” —[Official Report, 19 October 2023; Vol. 738, c. 495.]
In submissions to that inquiry, mothers reported being mocked or shouted at, being denied the most basic assistance such as pain relief, and being left feeling “terrified”, “humiliated” and “ashamed”. The word “broken” appeared more than any other. The inquiry’s May 2024 report was called “Listen to Mums: Ending the Postcode Lottery on Perinatal Care”, and its 14 recommendations were headed by a call on the Government to publish a national maternity improvement strategy, led by a new maternity commissioner reporting to the Prime Minister. The petitioners believe that these measures would fill a void.
Ben Coleman (Chelsea and Fulham) (Lab)
I am most grateful to my hon. and learned Friend for calling this important debate. I am also very grateful to my constituent Louise Thompson for having the guts and the decency to parlay what was an absolutely horrible experience into a determination to make life better for women across this country and improve maternity services for everybody. I am very grateful for what she is doing—she is in Public Gallery today and I very much welcome her.
As my hon. and learned Friend may be aware, I am a Member of the Health and Social Care Committee. Recently, we produced a report on black maternal health and many of the issues that he has described today also emerged in that report. There is a huge amount to be done.
When it comes to making these changes and making them stick, I echo my hon. and learned Friend’s support for a national maternity commissioner to drive them through. However, if the Government are not minded to appoint a maternity commissioner, how else does he think we might get the drive and the determination to make the changes stick right across Government permanently?
Tony Vaughan
I thank my hon. Friend for his intervention, and I echo his comments about the petitioner Louise Thompson and her advocacy on this issue.
The petitioners’ analysis is that there has been a vacuum of leadership and accountability across the system. I know that the Government are considering how best to address that, and we will hear more from the Minister later about that; but whatever happens, there has to be a structural way of providing that leadership and avoiding fragmentation and different interpretations of different guidance documents across the system. We need clear systemic change to cure this, because it has been an ongoing problem for many years and so far no answer has been put forward.
The petitioner Theo Clarke told me a story that illustrates the point about the postcode lottery in maternity care, which the petitioners strongly believe would be prevented by measures to create expert national leadership and tighten up the rules. She told me that an obstetrician in London who she had spoken to recently told her that there are 87 different pieces of guidance that apply in maternity care. That does not sound like a framework; to many people, it sounds more like a large number of disparate documents, which leads to variations in interpretation between different areas. Theo Clarke’s strong view is that that leaves room for interpretation, which results in different approaches to care in different areas. In practical terms, that means that something as basic as training midwives in recognising and treating birthing injuries varies hugely between different areas.
My constituent who I spoke about a moment ago trains midwives on this issue, but that training is not available everywhere, and certainly not in the same way as delivered by MASIC.
Jess Brown-Fuller (Chichester) (LD)
The hon. and learned Gentleman is making an important point about the disparity in the guidance. If there is someone at the top of an NHS trust who is passionate about maternity care, that is more likely to trickle down, but that is not the same in every trust, and therefore we can end up with a postcode lottery. In Chichester, mothers going to give birth would have a totally different experience if they went to Chichester, Guildford or Portsmouth because they are three totally different trusts with totally different guidance and rules about when mothers should present or the sort of treatment they should get at hospital. Does the hon. and learned Gentleman agree that introducing a maternity commissioner would give us strategic oversight across the country of the experiences that mothers should expect to have?
Tony Vaughan
Certainly, the petition is clear that without expert, national-level oversight, there is no way of turning that thicket of different guidance and frameworks into a coherent, enforceable standard of care. Whatever structural change the Government put forward has to do that job. I spoke to my constituent Jo Page earlier, and she told me that there are people in Folkestone and Hythe who are going to Tunbridge Wells to access maternity services because of their concerns about the local standards of care. Obviously, that has to be fundamentally addressed.
The powerful evidence from the various maternity investigations that we have seen show that when everyone is responsible, nobody is accountable. Appointing a maternity commissioner could well mean that there is somebody with whom the buck stops—a dedicated expert responsible for turning the 750 recommendations, or the 87 guidance documents, into a single national maternity strategy and ensuring that it is implemented. That is not the only way that that could be done; Baroness Amos will shortly publish her report on the national maternity and neonatal investigations in NHS services. The petitioners strongly believe that her report should commit to a maternity commissioner and a maternity strategy. I look forward to hearing from the Minister how the Government currently view that proposal. I also ask her to commit to providing an update on which of the previous recommendations committed to may be taken forward.
In conclusion, the Government’s recent decision to introduce a women’s health strategy is hugely welcome and is an important acceptance that women’s health has been neglected for far too long. The petitioners strongly believe that it would make a real difference to women giving birth if that strategy encompassed a maternity commissioner with the authority, expertise and focus to end the postcode lottery in maternity care and break the cycle of avoidable harm once and for all.
Several hon. Members rose—
Sir Alec Shelbrooke (in the Chair)
I am grateful to Members for bobbing to indicate they would like to take part in the debate.
Olly Glover (Didcot and Wantage) (LD)
It is a pleasure to serve under your chairship, Sir Alec. I thank the hon. and learned Member for Folkestone and Hythe (Tony Vaughan) for introducing this important and sensitive debate with his customary eloquence.
I thank the 464 of my constituents who signed the e-petition, placing my constituency in the top 25 nationally for signatories. I also want to thank the many constituents who have been in touch with me and my team—many of whom I have met at constituency surgeries—about their maternity experiences.
This debate is important because of the familial and societal importance of safe, reassuring and comfortable pregnancy and childbirth, and all the anxiety and exhilaration that comes with that. I know that not from my own experience, but from that of friends and constituents. I have never seen people cry so much or so intensely as at the funeral of my friend Steve and Yue’s daughter. They, along with my friend Joel, who also lost a baby, have been superbly supported by Sands, the stillbirth and neonatal charity. They have all now experience successful births.
I want to emphasise what this debate should be about. It is definitely not about criticising hard-working and dedicated individual midwives and health workers, who so often do an amazing job in very challenging circumstances. It is about improving the top-level leadership, culture, staffing levels and processes that affect maternity units.
In my constituency, we have local maternity units in community hospitals in Wantage and Wallingford. These are welcomed by many constituents who would otherwise have to make what is often a long journey to Oxford. Otherwise, births happen in the maternity unit at Oxford’s John Radcliffe hospital. I visited the department in September 2025 and was given a comprehensive tour, including the new bereavement ward. I thank all the staff I met, who were committed to improving the care there. The department-level leadership was receptive to feedback and acknowledged that care at the John Radcliffe hospital has at times gone wrong. That is important, given the many constituents who have contacted me about their experiences at the John Radcliffe hospital.
I have met a number of constituents who have been affected by the traumatic and deeply tragic circumstances of stillbirth, complicated births that have resulted in lifelong and serious disabilities for children, post-traumatic stress disorder for mothers or a lack of support. I will tell some of those constituents’ stories; I am grateful for their consent that I do so.
I met Julie Ray at a constituency surgery some months ago. Her granddaughter Harper Rose was stillborn at the John Radcliffe hospital in May 2023. Julie believes that her death could have been avoided. The mother had a high body mass index. Although it was highlighted early on in her pregnancy, the midwife-led care she received did not always appreciate the potential for serious complications at birth. She was supposed to receive consultant-led care, but that did not happen and important decisions were left to midwives.
Despite the plethora of maternity guidelines provided by bodies such as the National Institute for Health and Care Excellence, the Royal College of Obstetricians and Gynaecologists and the website perinatal.org.uk, Julie was surprised that there were no more specific and binding rules that hospitals had to follow. Julie wants to see a maternity system in place, designed to prevent avoidable death and injury. She also wants coroners’ offices to be used for the post mortems of babies. Harper’s post mortem was carried out by the John Radcliffe hospital’s own pathology laboratory, which creates concerns about a lack of independence and the potential for unconscious bias.
My constituent Anna lost her granddaughter Wyllow-Raine. Anna has met the noble Baroness Amos more than once and is actively engaged in the Amos review, for which all my constituents have expressed their gratitude. They have high expectations of the review. Anna’s daughter, the mother of Wyllow-Raine, wants to see real accountability being taken for mistakes. She believes that a blood sugar test should have been done on her baby, as per NICE guidelines, and if it had been, Wyllow-Raine would still be here. They question the value of guidelines if hospitals are not following them. Anna would like to see a national inquiry into the Oxford university hospitals trust and the John Radcliffe hospital specifically.
My constituent Joanna was left to give birth without a midwife or pain relief, so the safe arrival of her children was essentially down to luck rather than to proper maternity care. She has raised concerns around issues of consent, as well as long waiting times after requesting her notes from the hospital.
A constituent who wishes to remain anonymous had birth complications during the delivery of her son in 2019 that left him with extremely severe lifelong disabilities. He requires round-the-clock care and cannot meet any of his own needs. Engagement from the Oxford university hospitals trust has been lacking to date.
Finally, Natasha and her partner tragically lost their first-born son, Arlo Huxley Harewood. After experiencing a tremendously difficult pregnancy, she was left alone in a room with the news of her loss. She felt that she was “fearmongered” when she was informed that if things turned, she would need to go for an emergency C-section under general anaesthetic with a tube down her throat:
“I was being prodded and poked for blood samples, a catheter fitted, induced vaginally, given a blood transfusion, asked to sign away and deliver my passed baby boy, thankfully naturally.”
Aggravatingly, a few days after the birth of her stillborn child, there was mention of HELLP syndrome when she was in the bereavement ward. She has been left with feelings of self-blame, which no grieving mother should ever have to go through.
As we have heard, the petition is part of a wider campaign led by the former Conservative MP for Stafford East, Theo Clarke, and by reality TV star Louise Thompson. I join my constituents in thanking them for their work. This year, they launched this petition to appoint a maternity commissioner to improve maternity care for mums and babies. A 2024 inquiry, led by the birth trauma all-party parliamentary group and by Theo Clarke, recommended that a maternity commissioner be appointed alongside a national maternity strategy to ensure mums and babies are safe and looked after with professionalism and compassion. A maternity commissioner would oversee and introduce past recommendations. Advocates have emphasised that a maternity commissioner is necessary to restore public confidence in NHS maternity services and ensure accountability.
On average, a woman gives birth every 56 seconds in the UK, yet one in three women describe their childbirth experience as traumatic. Sadly, post-traumatic stress disorder affects one in 20 mothers after giving birth. The rate of women dying during or soon after pregnancy in the UK has increased by 20% over the past decade, a trend that I am sure we are all concerned about. A 2024 Care Quality Commission report based on an inspection of 131 maternity units found that 65% of them were not safe for women to give birth in. It also found that 47% of trusts require improvement in safety and a further 18% were rated inadequate. It stated that
“we are concerned about the potential normalising of serious harm in maternity.”
I am pleased that the Liberal Democrats have launched a maternity rescue package to make Britain the safest country in the world to have a baby, with high-quality care wherever we live. Our package has much in common with what the petitioners are calling for, and we hope that they will be encouraged that many of us in Westminster are listening.
A national maternity commissioner would oversee improved standards of care nationally, and a director of midwifery would be appointed in every maternity service alongside an extra 300 consultant midwives to drive clinical excellence. It would also see specialist doctors present on every maternity unit 24/7 and provide one-to-one midwifery care to every woman during labour. That would ensure that it is no more dangerous to give birth at night or at the weekend than at any other time. Previous research found that 73% of maternity units in England do not have a consultant present at night, despite most births taking place outside working hours. Many negligence claims for poor maternity care are linked to failings in care outside regular working hours.
Too many families have been affected by birth trauma, and reform is desperately needed. Since 2015, there have been many national reviews into the safety of maternity services, as well as high-profile investigations into care at individual maternity trusts, with calls for a national inquiry into maternity care. That is why I welcome Baroness Amos’s review, which will be valuable as a centralising piece of work, but it is the latest in a string of national and local reviews or inquiries, which together have produced over 700 recommendations. I hope the Minister will enlighten us as to why this latest review will be different.
The reviews show so many similar themes: failure to listen to women, lack of time for training and strengthening teamwork between staff, inadequate staffing and high levels of burnout, lack of proper assessment, poor management of risk, unsuitable estates and failure to learn when things go wrong. After so many reviews, it is clear that we need improved standards of care nationally.
The recommendation for a maternity commissioner is widely supported across the parties. My constituents want to see a clear timeline for the appointment of a commissioner, if that is something the Government decide to support, so that learning and change happen this time.
Andy MacNae (Rossendale and Darwen) (Lab)
It is a pleasure to serve under your chairship, Sir Alec. I will make some comments as the chair of the all-party parliamentary group on baby loss, but also as a bereaved parent: we lost our daughter Mallorie at the age of five days.
First, I want to thank everyone who responded to the petition. It shows the massive extent of concern about this issue. So many of us share that concern as something that is personal and requires immediate and comprehensive action. For the past two years, my all-party group has been listening to families, parents and professionals. We have heard about a litany of failures across the whole sector. I am sure that colleagues will refer to many of the issues and incidents, so I will not repeat them, but we have to recognise that these systemic failures often go very deep within the culture of the health service. We need to recognise that that results in fundamental inequalities in terms of ethnicity and deprivation, with families not being listened to and suffering outcomes that are truly unacceptable.
We also have to recognise that there are islands of very good practice. There are trusts and professionals who continue to do an amazing job. I can cite the birth centre at Burnley that my hon. Friend the Member for Ribble Valley (Maya Ellis) and I visited recently, where we saw how things can be done and what “good” actually looks like.
There is an undeniable case for urgent and immediate action, as I think we all agree. I think we also agree that we cannot repeat the cycle of reports, reviews and recommendations. As the hon. Member for Didcot and Wantage (Olly Glover) said, there have been 700 recommendations, and in many cases they were exactly the same, time after time. We cannot repeat that cycle, which is why it is so important that Baroness Amos’s maternity services investigation is different. I believe that she is entirely committed to addressing the underlying systemic issues across the sector and to bringing forward a report that focuses on the underlying systems and cultures that need to change, rather than just repeating the litany of what has gone before.
Crucially, we also have the Secretary of State’s commitment to establishing a taskforce following the work of that review, to deliver on its recommendations, with an immediate overlap and focus on action. That is why I believe we have a fundamentally different opportunity, right now, to get this right.
The focus on systemic changes must be accompanied by a real commitment to fixed and firm targets to reduce the harm and inequalities that we see today. Oversight and accountability will be a fundamental part of that. We recognise that we currently have an alphabet soup of organisations, with the CQC, NMC and GMC: the Care Quality Commission, the Nursing and Midwifery Council and the General Medical Council. The trusts themselves are essentially autonomous in choosing whether they follow guidelines, so introducing accountability and oversight must be a fundamental outcome of the review. I am absolutely sure that we will see clear recommendations on that point.
Having a maternity commissioner is not a magic sticking-plaster that can address this fundamental, systemic problem. Let us not fool ourselves that any single measure or recommendation will solve this problem. We need to see maternity safety rebuilt from the ground up, with a culture that listens to every single family and every single mother. We need to treat them all as individuals who have their own risk factors, concerns and challenges. We need to learn from the best practice that we see across the country. When bereavements occur, we need parents to be treated with the empathy and individualisation that they require, recognising that trauma does not just affect someone in the days or weeks after birth; it can have lifelong effects. We need to rebuild the regulators, as well as all the mechanisms that hold individual trusts to account, so that they are fit for purpose.
It is only when we get the foundations right—rebuilt from the ground up, with best practices embedded across the board—that a maternity commissioner might possibly be able to deliver the outcomes we want. Let us focus on listening to what Baroness Amos comes forward with, so we can deliver her recommendations and rebuild the culture from its base. Let us concentrate on listening to individual parents and families, so that we can respond to their personal risk factors. Let us make sure that we have a maternity safety system that we can all be proud of in the years to come.
Monica Harding (Esher and Walton) (LD)
It is a pleasure to serve under your chairship, Sir Alec. I congratulate the hon. and learned Member for Folkestone and Hythe (Tony Vaughan) on opening this important debate. I want to reflect the strength of feeling on this issue among my constituents in Esher and Walton; the fact that 568 people from my constituency added their names to this petition reflects a very real and deeply felt concern among families in my community about the state of maternity care in this country.
I am a mother of four, and I am very lucky to have given birth four times, but three of those were traumatic. My first birth was an emergency C-section, the second was a vaginal birth after caesarean that needed lots of intervention and the third was absolutely fine, but during my fourth the crash team had to attend because the midwife failed to pay attention to what I knew, as an experienced mother, was a problem. When I took baby Tom, who is now 14, home—[Interruption.]
Sir Alec Shelbrooke (in the Chair)
Order. It might be helpful to know that some Members have approached me to say they have spoken to Mr Speaker, as they may need to move around. They will ask to intervene if they want a Member to give way, and Members can give way if they are specifically asked.
Monica Harding
Thank you for that clarification, Sir Alec. I am trying to do my best on protocol.
When I took baby Tom, who is now 14 years old, home, hugging him ever more tightly, I told only my very close friends and family what had happened. I fear that the stats we see are only the tip of the iceberg, because many are not shared.
Behind all the signatures are stories—of women who feel they were not listened to, of traumatic births and, in some cases, of long-term psychological impacts. There are testimonies in my inbox. One constituent, Lisa—a paediatric nurse with nearly two decades of experience in the NHS—wrote to me after developing PTSD following a traumatic birth. She spoke not only as a mother, but as a healthcare professional who understands the system from the inside yet still feels let down by it. Another constituent, Rosie, who has worked for over 20 years supporting women through pregnancy and childbirth, described a system where too many women feel they must fight to have their voices heard, where decisions are not always fully respected and where trauma is becoming far too common.
Sadly, those are not isolated accounts; they are consistent with what we see in the national data and across the many reviews that have been conducted. One in three women now describes their childbirth experiences as traumatic. PTSD affects about one in 20 mothers. Maternal mortality has risen over the past 15 years, and the CQC has found that a majority of maternity units require improvement or are rated inadequate for safety.
We should be clear: the problem is not a lack of understanding of what is going wrong. Over 700 recommendations have been made across more than a dozen reviews of maternity services. They point again and again to the same issues of training time, poor communication, failures to listen to women, and systems that do not learn effectively.
All the while, workforce pressures are intensifying. At the end of 2025, the Nursing and Midwifery Council found that growth in the nursing and midwifery register had slowed sharply, driven by a nearly 50% drop in international recruitment. That risks putting further strain on maternity services that are already struggling with staffing and retention.
Further behind the headlines on staffing numbers, there is a quieter crisis in the day-to-day reality of the job. A constituent who works as a midwife told me that her colleagues work 12-hour shifts without proper breaks, often not stopping until 5 pm after starting at 7.15 am. They are expected to juggle the workload of two people, stay behind beyond their hours and move between demanding day and night shifts with little flexibility. At the same time, they are navigating constantly changing guidance, a heavy administrative burden and a culture where, too often, the fear is that if something goes wrong, the blame will fall on them. It is a toxic combination of pressure, exhaustion and anxiety, which is totally unsustainable and is driving people out of the profession.
The question is not whether there is a problem, but whether we are prepared to act on what we already know. That is why I support the call for a maternity commissioner, who would provide national leadership, accountability and, crucially, oversight of the implementation of the many outstanding recommendations. Without clear ownership, it is all too easy for reports to be published, welcomed and then quietly set aside. Many of the constituents who have written to me are healthcare professionals themselves. They speak of a system under intense pressure, of understaffing and burnout and of not having the time or resources to deliver the level of care they know that patients deserve. If we want to support those staff, we must fix the system in which they are working.
That is why the Liberal Democrats have set out a maternity rescue package to make Britain the safest place in the world to have a baby. It includes appointing a maternity commissioner, and would ensure that we had a 24/7 consultant presence on maternity units and one-to-one midwifery care during labour. It would invest in the workforce, including hundreds more midwives, restore funding for vital services and guarantee access to perinatal mental health support. It would address the unacceptable disparities that persist in maternal outcomes, with black women three to four times more likely to die during pregnancy or shortly after birth than white women. And it would ensure that when things do go wrong, families are treated with compassion, transparency and proper support.
While the Amos review is important and should be welcomed, it is the 14th major review of maternity services. We need delivery. The families in my constituency who signed the petition are asking not for more reports, but for change. They are asking for a system where they feel safe, listened to and cared for at one of the most important moments of their life. No birth is easy; it is a major, demanding, intense and very painful process, but in 2026, in the fifth largest economy in the world, it should not be dangerous, and it should be equitable.
Michelle Welsh (Sherwood Forest) (Lab)
It is a pleasure to serve under your chairmanship, Sir Alec. For complete openness and transparency, I am a harmed mother. I have been involved in the Nottingham inquiry, I sit on the national maternity and neonatal taskforce, and I am the chair of the APPG on maternity.
I want to place on record my personal and sincere thanks to Louise Thompson and Theo Clarke. After the most traumatic and horrific birth trauma, they chose to speak out, not just for themselves—in fact, not for themselves at all—but for countless other women. That courage matters, because for every voice we hear, there are more still unheard. Courage after trauma should not be a necessity for change. That is why today’s debate is so important.
I do not want to pre-empt the findings of the Baroness Amos review, but I welcome the national taskforce—it is the first of its kind—and the work the Government are doing. Maternity services are systematically failing too many women and babies, and we cannot ignore what is happening across the country. Families having raised concerns for years and years, but those concerns were not acted on soon enough. It is not about one hospital or one failure, but about a pattern of women not being listened to, warning signs being missed, fathers and birthing partners being ignored, and poor practice continuing unchecked, sometimes for years.
We must be honest about this: the system of oversight has failed. That is certainly true in Nottingham, where the Care Quality Commission failed, the Nursing and Midwifery Council failed and the General Medical Council failed. When the system fails, it is about not just frontline care but the structures designed to keep people safe.
Inequalities are profound and, quite frankly, a disgrace. Black and Asian women are significantly more likely to have birth complications and poorer outcomes. If safe care is not equitable, we do not have any safe care at all. That must change.
Maternity systems are failing, but this did not happen overnight. There is also a societal problem. When did childbirth and maternity became a second-class health service? Past Governments allowed it to become overstretched and underfunded. When did we, as a society, become so apathetic towards birth? I stand here as the proud Member of Parliament for Sherwood Forest, but first and foremost—this was the path that brought me here—I was a harmed mother who was dismissed and told she did not understand her own body, and who is still living with the consequences.
Through my work, I have spoken to over 1,000 families and hundreds of organisations with different stories and circumstances from different hospitals. The same themes come up again and again: women not being listened to, their concerns being dismissed and opportunities to intervene being missed. The message is clear and urgent: we need accountability without a culture of fear. We need a system where staff can speak up, families are heard the first time and learning drives improvement.
But we must also confront something deeper: we have to change societal attitudes towards childbirth. Too often, women are dismissed, their pain is minimised and they are told, “This is normal” when something is wrong. That culture then seeps into our systems, and when it does, it becomes dangerous.
Listening to women is not optional; it is fundamental to safe care. That is why we need a maternity commissioner. This cannot be a figurehead role: it must have real authority and independence, and the power to act, access data in real time, identify patterns early and intervene when warning signs appear. We cannot continue with a system where tragedies happen, reviews are written and then we move on. Rising baby loss, serious incidents and repeated failings must trigger action immediately. A maternity commissioner must ensure that poor practice is not allowed to continue unchecked; that people cannot hop from trust to trust to trust when they have caused harm, but that that is followed and tracked; that warning signs are not ignored; and that families are not left to fight for answers after the harm has already been done.
That is one of the most horrific things: families go through the most horrendous situation possible. I was lucky: I walked out of the hospital with my baby. But when my baby was born, he was not breathing. I nearly died as well, but I walked out of the hospital. When I did, I was told it was not known whether my son would have developmental delays. I was also told he was deaf, which was incorrect as well. It was the most horrendous situation, but I walked out of the hospital with my baby. Thousands and thousands of women do not, and it is about time we started to face that reality, rather than using it as a political football. Our maternity services are systematically failing.
Alongside that, we must recognise that there are profound examples of outstanding care across the country—dedicated midwives, doctors and other healthcare professionals going above and beyond every single day to keep women and babies safe. They are working under pressure and short-staffed and still delivering exceptional care. But they cannot do it alone. They need safer staffing and time to care. They need leadership and support. They need a system that works, a system that backs them, a system that protects them when they raise concerns and a system that enables them to deliver the care they know is needed.
This is not about blame; it is about building something better—a system that is accountable without fear, a system driven by data and early intervention, a system that listens to women, families and staff, and a system that acts when it matters most. Maternity care should never be a postcode lottery; it should never depend on where women live and it should never, ever come down to luck. Every woman deserves to be heard. Every baby deserves to be safe. Every family deserves dignity, compassion and answers. Yes, we need a maternity commissioner, but we need more than that: we need a system and a society that finally listen to women, finally act and finally put safety where it belongs—at the heart of every birth.
Jamie Stone (Caithness, Sutherland and Easter Ross) (LD)
It is a real pleasure to serve under your chairmanship, Sir Alec. I want to share a cautionary tale with everyone, and I will just set out the geography. I have the biggest constituency in the UK; it stretches from John O’Groats, way down to just north of Inverness—I invite Members to think about that huge area of Scotland.
What I am about to say in no way reflects on the midwives in Caithness and other parts of my constituency. Some years ago the Scottish Government, in their infinite wisdom, decided to downgrade a consultant-led maternity service based in Wick, which is at the top of the UK, near John O’Groats, to a midwife-led service. That meant that mothers would have to travel more than 100 miles—in each direction—to Inverness to give birth. Travelling from Caithness to Inverness on a sunny day is one thing; travelling in winter is a very different proposition. The A9 gets blocked during many winters and people cannot get through. What happens if a pregnant mother in an ambulance on her way to give birth in Inverness cannot get through? They get hold of the emergency helicopter. But what if there is a road traffic accident in another part of the highlands—say in Lochaber, Skye or Morayshire—and the choppers have gone in different directions? I have posed that question to the Scottish Government again and again and said, “You could have a tragedy on your hands.” I have asked for a safety audit again and again, but there has been no safety audit whatever. What about winter? What about when the chopper does not—cannot—fly? What about when the ambulance cannot get through?
Back in 2018, a mother of twins was on her way down in an ambulance and gave birth to the first baby in Golspie, about 50 miles through a 100-mile journey. A second ambulance had to be called and she was driven on to Inverness to give birth to the second child. I ask Members to imagine how traumatic and awful that was for the mother. Both children and the mother survived—thank God. I well remember somebody called Nicola Sturgeon saying at the time, “This is very serious; we will look into it,” but nothing happened.
Today, the statistics speak for themselves: in the most recent period we have looked at, six babies were born in Caithness general hospital in Wick and 166 were born in Raigmore hospital in Inverness. Think about all those return journeys. Think about a mum coming to see her daughter and the little baby. Where do they stay? It is expensive. We had a superb local service, and we do not have it any longer. Fundamentally, I find that simply dreadful.
Eventually, at the tail end of last year, there was a motion in the Scottish Parliament to hold an independent inquiry into maternity services in the north of Scotland. It passed, and the local population said, “Hallelujah! At long last, it’s going to be addressed.” But then what happened? In their infinite wisdom, the Scottish Government said, “Actually, despite the fact that there was a majority decision by the Scottish Parliament, we’re not going to do an independent inquiry; we’ll have a little in-house look at what’s happening here.” That is where we are today. Can Members imagine what message that sends to mums and families in the north of Scotland?
I have gone on and on about this in this place—as I am sure you know, Sir Alec—and yet it is a devolved matter, so we are completely powerless to do anything. I hope that all the sentiments expressed today about a commissioner come to be reality, I hope that the Scottish Government are told to look at it very closely indeed, and I hope that they are shamed—it is as simple as that—into doing something and sorting out a truly shocking situation, and one that is extremely dangerous. It is a miracle that neither a child’s life nor a mother’s life has been lost yet. I am sorry if I do not mince my words, but I feel very strongly about it indeed.
Lizzi Collinge (Morecambe and Lunesdale) (Lab)
It is a pleasure to serve under your chairship, Sir Alec. I thank my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) for introducing this important debate.
It is hard to fathom but, over the course of this speech, at least four babies will be born in England—they will come into the world, their tiny hands stretching out and a whole future beginning for them with their first breath. The births of my children were among the most significant moments of my life, as is the case for most parents, but alongside the joy comes something that I think every birthing parent will recognise: just how vulnerable you are in that situation and how frightening childbirth can be. You are placing your life and your baby’s life in the hands of others, in the hands of chance and in the hands of the brutal reality of natural processes.
I first became involved in maternity advocacy after the frankly quite awful birth of my first child in 2014. Only when that happened did I realise how much harm had been done to someone close to me when she gave birth in 2011. I remember apologising to her with a newborn in my arms: “I’m so sorry; I had no idea how bad it is.” This has happened to women up and down the country. Today, I represent Morecambe Bay, where both those births took place, and where baby Ida Lock was born and died in 2019. Ida and her parents are always on my mind when we talk about issues such as this.
I feel obliged to say that the vast majority of maternity care is safe. We talk about all the failings and all the horrors that women have seen, but I do not want that to frighten families. We have to accept that the worst tragedies are exceptions, but the experience of parents who have seen avoidable harm to themselves and their babies is the reason we are here today debating the pros and cons of a maternity commissioner.
I will be honest: I do not necessarily have fixed views on this. It has been really interesting to hear colleagues speak, and I look forward to hearing more. I am also very interested in the outcome of Baroness Amos’s investigation. But we cannot just keep trying to learn lessons; we need to take action right now. We have had review after review and inquiry after inquiry, and yet here we are.
Jess Brown-Fuller
The hon. Member is making a powerful speech, and she is absolutely right. We had the Bill Kirkup review, which made multiple recommendations; across all parties, the House said, “Now we need to implement those recommendations,” but that never happened. Then we had the Donna Ockenden review, which contained immediate and essential actions; we need to implement those, but the Government have not come forward and said that they will make them mandatory. Now we have Baroness Amos’s review. Does the hon. Lady agree that this must be the last review, for the sake of every single mother who has come and every single mother who is to come, so that they know that they are being well supported when they go into hospital settings?
Lizzi Collinge
I absolutely agree. There is work to do to prioritise the actions that have come out of all those inquiries, because trying to do too much will lead to it all being done badly. There must be a real focus on what will make the difference to women’s safety and experience.
Countless national and local maternity reports have revealed persistent issues with care, a failure to listen to expectant mothers, staffing pressures, a lack of transparency and institutional cultures that have encouraged cover-up. That is against the background of increased medical complexity in pregnancy and birth, wider aspects of public health having worsened, and the racism and misogyny that still permeates our society.
These failures are a long time in the making. Failed regulation contributed to the historic problems at Morecambe Bay—and that was under a Labour Government. Structural changes to our care system and wider society under successive Conservative Governments have impacted care. Due to austerity, we had a £37 billion capital investment shortfall in the 2020s compared with our peer countries. We know that increased poverty affects maternal and neonatal mortality, and as a nation we have become more poorly over the past 15 years. It is now on us and the Government to fix the problem.
As a member of the patient safety all-party parliamentary group, as well as through my own work as a constituency MP, I have seen that tragedies are often partly or completely avoidable, whether through effective diagnostics, timely or better treatment, or simply listening to women when they say that something is wrong. The consequences of these failures are devastating. A study by the Royal College of Obstetricians and Gynaecologists showed that up to 75% of pre-term babies who died could potentially have been saved with different care. Even when the worst is avoided, bad experiences can leave lasting damage. They can erode trust in services and make families more anxious about seeking care in the future.
I want to touch on a couple of aspects of this issue that have not had the concerted operational effort put into them that they ought to have had. The first is the conditions that midwifery and obstetric staff work in, including the wider picture of the health of the nation. Most midwives, doctors and support staff are doing their absolute best in challenging circumstances, and most people go into maternity care because they want to deliver babies safely into this world and support families. They often go above and beyond, but they are being stretched too thin by the demands of their jobs. They are looking after ever more complex cases on every shift, and in 2023 alone, midwives and support workers put in over 100,000 hours of overtime. Even hospitals that are rated highly for maternity care feel the strain, with staffing gaps leading to interrupted handovers, missed checks and limited time for training. Over time, that pressure leads to burnout, staff leaving, and the loss of the experience that the system depends on. When the system is stretched like that, it is staff and patients who feel the consequences. I hope that the Minister will ensure that while we drive down waiting lists in elective care, we support maternity staff, improve their work environment and do not lose sight of the wider improvements to public health that we need to make to reduce complexity and comorbidities.
The second thing I want to talk about is culture, particularly the ability of staff to speak up, the need for brave and open leadership, and the need for lessons truly to be learned. I am not saying that is easy to do—it is quite tricky, and it takes concerted effort and skilful leadership—but culture simply means, “The way we do things around here.” It can be a tangible thing that we can affect. Unfortunately, long-term failures and the spotlight that comes with them can cause staff to feel under attack, defensive and unsupported. Even where they have not been part of any particular case, staff groups can become entrenched. During the problems at Morecambe Bay and since, we have found that people working in opposition to each other in entrenched staff groups has caused huge amounts of harm.
Poor leadership compounds the effect. I have spoken many times about the harm caused by cultures of silence, where staff do not feel able to come forward to raise concerns, problems are not addressed head on, and families are left without proper answers when things go wrong. We need to create environments where people are able to speak up, raise concerns early and be open when mistakes happen, because if staff do not feel safe to tell the truth and fear being blamed or punished, problems are hidden instead of being fixed. More than that, staff need to be supported when they raise a concern or even when they cause harm, because staff do not listen to what the leadership say; they see what they do, look at their actions and behave accordingly.
To be clear, human beings will make mistakes, and patients will be harmed by those mistakes. That is inevitable. Not all cases of harm can be prevented, but they can always be learned from. In any organisation, culture is set from the top. The leadership have to show through actions that concerns are taken seriously and that no one will be penalised for speaking honestly. Working as a maternity advocate, I was shocked that organisations that are meant to be care organisations would respond to a bereaved family not by reaching out, caring for them and holding them, but by keep them at arm’s length, lying to them and even, when it came to coroner’s inquests, being adversarial. It beggars belief.
Linked to that is the fact that families often feel the need to take legal action simply to get answers. That costs huge amounts of money, still sometimes does not get them answers, and sets up an adversarial approach that can cause further harm to families. I hope that the Public Office (Accountability) Bill, also known as the Hillsborough law, will shift the legal risk for organisations. The current legal risk to many hospital trusts appears to be telling the truth—that seems to be how they see it. I hope that the new law will shift the legal risk so that it is far riskier to obfuscate than to be candid.
There are so many different aspects of maternity safety that I could talk about all day, such as the way that “normal” birth culture still permeates the education of our midwives and some practice, despite having been shown to be harmful. The wider culture around birth seems to say that it must be a joyful, wonderful experience at all times, when in reality it is messy, brutal and quite often unpleasant, even when it all goes well.
We should be learning from other countries. For example, Japan has no-fault compensation for profound cerebral palsy. That separates the process of giving compensation from the process of investigating what happened and what went wrong. It appears to have lowered the legal costs associated with maternity care, but more importantly, it seems to have reduced the number of babies born with profound cerebral palsy.
We all know that maternity care needs to be improved in this country, whether through the appointment of a maternity commissioner or actions such as implementation of recommendations in the Amos review. I thank my colleagues for their contributions, and their constituents for sharing their stories. To make maternity care safe, we need to ensure that services are properly staffed, creating the conditions for safe care, where handovers can be done properly and staff have time to do their jobs well and are supported to rest and recover. That also means making sure that women are listened to, that concerns are taken seriously and that, when things go wrong, they are handled with honesty and care. It means accountability for leaders as well as frontline staff. I urge the Minister to consider whether the leadership of a maternity commissioner can give us the change that our constituents deserve.
Steve Yemm (Mansfield) (Lab)
It is a pleasure to serve under your chairmanship, Sir Alec. I am pleased that we are having this important debate on an e-petition that secured more than 100 signatures from my constituents in Mansfield. Indeed, after meeting the Nottingham Maternity affected families group on a number of occasions since I became the Member of Parliament for Mansfield, I have become acutely aware of how important these issues are to families in Nottinghamshire and my constituency. Although consideration of a maternity commissioner is important, it must be accompanied by something more fundamental.
Donna Ockenden’s work, both in Nottinghamshire and in other parts of the country, has exposed patterns that we cannot ignore: families not listened to, concerns frequently dismissed and failures repeated over many years. What has been most troubling is not just what went wrong in one place, in Nottinghamshire, but how familiar those failings are across multiple trusts. Similar issues have emerged in different parts of the country, at different times and under different leaderships. That points not simply to isolated breakdowns, but to systemic weaknesses that demand a national response.
A maternity commissioner could play a vital role in ensuring accountability, ensuring that recommendations are implemented, giving families a voice and providing leadership to drive improvement. However, a commissioner alone cannot answer the deeper questions: how did this happen repeatedly, in various hospitals, right across the UK, for decades? That is a deep set of questions relating to multiple failures. That is why a full national and public inquiry—more than a taskforce, although that is very welcome—is necessary. An inquiry could compel evidence, hear directly from families and staff, and examine culture as well as clinical practice. That would bring together the experiences of those affected not in fragments but as a whole. Too often learning has been localised and therefore somewhat limited. As a number of hon. Members have already said, reports are written and lessons are identified, but the wider national system fails to absorb them.
The creation of a maternity commissioner, the establishment of a full and proper national inquiry, and action on the outcomes of past and ongoing inquiries are not alternatives; they can be complementary in driving change and properly understanding the failures that have occurred over many years. We owe it to the families in Nottinghamshire and right around the country, and to my constituents, who have suffered life-changing harm and in many cases the deaths of children and mothers, as well as to those who rely on these services, to do all those things. I therefore welcome today’s debate, and I hope that the Government will take note of the points made.
Bell Ribeiro-Addy (Clapham and Brixton Hill) (Lab)
It is a pleasure to serve under your chairship, Sir Alec. I thank my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) for expertly introducing the debate, and the petitioners, Louise Thompson and Theo Clarke, who I was pleased to work with on the birth trauma inquiry, for their continued work on these issues.
As many hon. Members will know, maternity care is an issue of great importance to me. It is also of great importance to my constituents, as demonstrated by the hundreds who signed the petition. I wholeheartedly support the call for a maternity commissioner; as I am the chair of the all-party parliamentary group for black maternal health, I am sure that that will surprise no one.
This week is Black Maternal Health Week, so I will speak about the continuing racial disparities in maternity care and why a commissioner would work to address them. Each Black Maternal Health Week, I usually start by addressing the statistics around black maternal health, which make for grim listening. When Five X More, the secretariat of the APPG, was first founded, black women were five times more likely to die in pregnancy and childbirth than white women. Now, the most recent MBRRACE-UK report shows that black women are three times more likely to die at that time. Although awareness has made an impact, unfortunately that statistic is not necessarily because less black women are dying but because more of all women are experiencing that horrible situation. Black women are still twice as likely to experience stillbirth and baby death. Although the disparities remain unacceptable, I recognise the work that is being done by NHS trusts to identify some of the shortcomings and address racial bias. As Members know, it is not just the death rate where racial disparities exist.
Last year, Five X More conducted its second black maternity experiences report, a large-scale survey collecting the experiences of black women during their pregnancies and childbirth. Of the 1,000 respondents, 54% experienced challenges with healthcare professionals, 28% of women reported discrimination, mostly racial, and 49% stated that their experiences during labour and birth were not properly addressed. I cannot stress enough how deeply concerning it is that women are going through this intensely vulnerable experience and when they raise concerns they are being dismissed or ignored.
The survey also said that 23% of black women did not receive the pain relief they requested, and just one in five women had been informed of how to make a complaint, with only 8% going on to pursue a formal process. The report has many more harrowing findings and I encourage Members to read it.
I recognise the fact that action is being taken to address the overall crisis in our maternity care, and I welcome the Government’s national maternity and neonatal investigation, led by Baroness Amos, which I was pleased to feed into with the APPG for black maternal health. It is a much-needed investigation that I hope will provide some understanding as to why our maternity services are failing so many mothers and babies, as well as give clear recommendations to improve the state of maternity care.
As we have heard many times in this debate, however, it cannot just be another report where we wring our hands and recommendations are produced that are simply ignored. In this country, in 2026, we cannot keep reeling off these statistics in debates such as this one. It makes no sense that a country like ours should be experiencing these issues and that so many women and their babies should be dying.
Can the Minister specifically inform the Chamber whether a clear target to end the racial disparities in maternity care is expected to be included in the recommendations from the forthcoming report—something that appeared in our Labour party manifesto? Was the investigation tasked with offering advice on an attainable target, or will the Government develop a target based on the report’s findings and recommendations? During last year’s Black Maternal Health Week debate, the responding Minister, my hon. Friend the Member for West Lancashire (Ashley Dalton), insisted that the Government were working towards setting an evidence-base target, but she was not forthcoming about when one would be announced. I hope the Minister will give some indication of that today.
The call for a maternity commissioner is about accountability. A dedicated maternity commissioner would, for the first time, create a single accountable authority, with the mandate, resource and institutional weight to confront the systemic failures driving the black maternal health crisis. Right now, we are seeing a situation where the responsibility is completely diffuse—a commissioner would change that. They could drive the implementation of the recommendations that have been sitting in reports for years; they could ensure that trusts are training staff to recognise and challenge racial bias in clinical settings. They would have a mandate to bring together disaggregated data collection, so that the disparities cannot be buried in averages.
This is about accountability, and about setting clear direction and focus. What I have realised over the years when challenging these issues, particularly in black maternal health, is that without a dedicated focus, black maternal health remains everyone’s concern and nobody’s priority. I have often said that addressing the racial disparities in maternity care will improve the state of maternity care for all women and babies. Establishing a maternity commissioner will make it someone’s job not just to monitor the problem but to actually fix it. We cannot continue to fail women in this way; it has to be somebody’s sole responsibility to fix this issue.
Mr Connor Rand (Altrincham and Sale West) (Lab)
It is a pleasure to serve under your chairship, Sir Alec. I thank my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) for securing the debate, and I thank everyone in Altrincham and Sale West who signed the petition.
I am especially grateful to those people who wrote to me to bravely share their often harrowing stories of maternity care failures. Their stories were worryingly similar: avoidable trauma, avoidable complications and, in many cases, avoidable tragedy. That is the reality of our maternity services and it is not good enough. There was a common theme behind each of the failings that my constituents suffered, and that was women not being listened to, their pain not being treated as urgent, and their worries being dismissed. That meant that they went without the compassion, care and understanding that they deserved.
Nobody wants better for women and babies than the thousands of NHS midwives and maternity staff who work so hard to ensure that the vast majority of births are safe. It is clear that the system is not working for too many mums, dads and babies. The experience of my constituent Lauren illustrates that. Lauren gave birth at Wythenshawe hospital in January. Her experience was a litany of failures and, in her own words, for all the hard work of NHS staff, she often felt like an afterthought during her own childbirth.
The failings started when Lauren discovered that her baby was in the breech position at 28 weeks. That was not followed up on. When she saw a midwife before the birth, they seemed too busy to check their notes and they thought that the baby was head down. It was not until Lauren was a good way through labour that her medical team were aware that the baby was breech. By that point, it had become an emergency. Lauren, who was in incredible pain, was suddenly surrounded by frantic doctors and midwives asking her questions that she was in no real state to answer, and she was told she had 10 minutes to make a decision on the birth of her baby. She had an emergency C-section, which was supposed to happen within 30 minutes but took two hours, and throughout that time she was without pain relief as overworked midwives desperately tried to care for others. I cannot begin to imagine what her experience was like—the pain, the panic and the unanswered questions leading into one of the biggest procedures that a person can have.
Thankfully, Lauren’s baby was born safely, but it was a birth that did not need to be such a traumatic emergency. Unfortunately, Lauren’s care only got worse after the baby was born. She was dumped in a C-section ward and her partner was forced to leave, meaning she was alone for hours at a time without any pain relief. She was barely able to move, unable to stand up, and unable to respond to her crying baby. At a time of maximum vulnerability she had minimal care. Doctors spoke about her, but they never spoke to her. She had no explanations, no support and, frankly, no one was listening. The ordeal has, completely understandably, put Lauren and her partner off ever having another baby.
Lauren’s experience speaks to so many of the problems that we have heard today: we have a system that is not putting mothers first, that is riven with inequalities and inconsistencies in care, and, for all the Government’s much-welcomed funding, in which staff are overstretched. As someone who works closely with the campaign group the Dad Shift, I also point out how Lauren’s ordeal highlights the way in which dads are often failed by maternity services, with their ability to support their partner undermined as a result. That is particularly true—as it was with Lauren—when mothers have had traumatic births and their partners are still sent home, leaving them without emotional or practical support when they are at their most vulnerable. I hope that the Minister and the Government are looking at that as part of the Government’s much-needed work to turn around our maternity services. I know that that work is progressing, not just through the investigation of Baroness Amos, as we have heard from others, but through the national maternity and neonatal taskforce and through greater funding, support and accountability for underperforming maternity units.
One of those units is at Wythenshawe hospital, which serves my constituents. I will forever be grateful for the care that my partner Catherine and I received at Wythenshawe, where my two sons were born, but I know that that has not been the experience for too many of my constituents.
Gideon Amos (Taunton and Wellington) (LD)
The hon. Gentleman is doing right by his constituents, if I may say so; I am sure they will appreciate the account that he is giving. Would he agree that some of the issues with maternity departments can sometimes be much more mundane? For example, at Musgrove Park hospital in Taunton, water is coming through the ceilings and there are temperatures of 30°C in the summer.
Given that the Secretary of State said, when speaking about Musgrove Park hospital,
“if I can bring forward the timetables of these schemes…we will”,
must the Government not do everything they can to hasten their hospitals programme so that maternity services, and the conditions in which mums give birth and staff work, can be improved as quickly as possible?
Mr Rand
I absolutely agree. The environment and conditions within which maternity units are set are clearly of huge importance to mothers, their partners and babies—to the whole system of maternity care. This Government have made significant capital investment into the NHS estate, having inherited a hospital-building programme that had no funding and no clear timetable for building. I am sure the Minister is giving the hon. Gentleman’s request due consideration.
On Wythenshawe hospital, I am pleased that the Government will not tolerate a poor standard of care for my constituents and I am immensely grateful for the recently announced £40 million in funding that the hospital is set to receive to tackle the issues in its maternity care. However, the problems, both at Wythenshawe and across the country, go beyond funding. We are talking about systemic failings that have harmed women and their babies over an extended period. As others have said, in that time we have had countless scandals, reports and recommendations, but no progress. My constituents believe that a maternity services commissioner could contribute to the change we need, and I hope the Government will give that due consideration.
Maya Ellis (Ribble Valley) (Lab)
It is a pleasure to serve under your chairmanship, Sir Alec. I thank my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) for introducing this debate. A huge thank you to Louise Thompson, Theo Clarke and the 150,000 people who signed this petition, for keeping maternity services on the agenda.
The petition before us is motivated by a very real and deeply painful issue: the loss of trust in maternity services following preventable harm and trauma. I welcome the passion behind this petition. However, I fear that maternity care may be too complex, too nuanced and too diverse to be well served by a single national maternity commissioner, and that focusing our energy on that risks allowing the Government to tick a box, when what would make the greatest difference is sustained, courageous investment in maternity services themselves, as many of my colleagues have highlighted.
Much of the current maternity debate understandably centres on trauma, risk and dissatisfaction. Those things matter, and I know others today have focused, and will focus, on how we reduce that. But when those become the only things we measure, we distort the entire system. I will therefore focus my comments today on women themselves, because how women experience birth is not a “nice to have”; it has profound consequences for mental health, family wellbeing and long-term outcomes. Around one in four women experiences perinatal mental health problems, costing the UK £8.1 billion annually when left untreated. That is true no matter what a birth is like.
I would like to put my hand up today and say that I am a bit fed up with people rolling their eyes at the concept of a birth plan, for example. Of course women know that things might not happen exactly as they had hoped; a woman’s birth plan is about being prepared for all eventualities, expressing her wishes and being empowered. Anyone who suggests otherwise is undermining the right of women to feel in control and prepared for this huge change in their lives.
I have had some beautifully powerful discussions with my colleagues over the past few months on the topic of giving birth. Some of them have felt looked down on for having a C-section, and some, like myself, have felt looked down on for wanting a home birth. The fact is that all those choices are completely valid. The problem is not someone’s birth choice; it is anyone judging them for it.
On that point, I want to gently address an elephant in the room. The concept that midwives have sought “the pursuit of normal birth at any cost” entered public policy following the Morecambe Bay investigation in 2015. It was never intended as a literal description of all midwifery practice, yet it became a powerful and damaging shorthand. The report described a “seriously dysfunctional” service, which was
“influenced by a small number of dominant individuals”,
where poor leadership, weak clinical skills and failures in basic risk assessment created a “lethal mix”. The problem was not support for physiological birth; it was unsafe practice and toxic culture.
However, over time, that nuance has been lost. Supporting physiological birth became conflated with recklessness. Midwifery philosophy was portrayed as being in opposition to safety, rather than working in partnership with it, as professional standards make very clear. The result has been a false binary in policy-thinking—safety versus choice, intervention versus physiology, or risk management versus women’s autonomy. That false binary still shapes decision making today, and it contributes to women feeling that birth is something done to them, rather than by them. If we continue talking in this way, I fear that we are making women’s bodies a political football. I believe that we and this Government are capable of better.
I have heard directly from senior clinicians that rising intervention rates are linked to older mothers or decreasing health standards, yet the data does not back that up. The average age of a birthing mother has risen by less than a year since 2014, and the percentage of women giving birth over 35 went up from 23% to just 25%. That small increase cannot explain a 45% increase in interventions over the same period. We have to move away from anecdote and ensure that we are using the data. If this debate becomes another iteration of that same binary, we risk repeating the very mistakes that brought us here. While I welcome the clear passion behind the ask for a maternity commissioner, I worry that it would not capture the nuance of opinion and experience in the birthing space.
There is so much more that I would love to say about how brilliant and resilient midwives are; about how brave every person who experiences and supports someone through childbirth is, even when we are expected to just crack on and deal with it; and about how great it is that our new women’s health strategy focuses on the importance of women being listened to. However, in the interest of time, I will finally focus on what we need from this Government.
If we are serious about improving outcomes, we already know where to look. Continuity of midwifery care is recommended by both the World Health Organisation and NICE, and it is associated with fewer pre-term births, lower rates of loss and significantly higher satisfaction from families. Randomised control trials show that those benefits apply to women at both lower and higher risk. Despite a national commitment to rolling out a continuity of carer model, progress stalled because there were not enough staff to deliver it safely. In 2022, NHS England formally removed the target date, citing “insufficient staffing”. Many qualified midwives have left the profession, but evidence suggests that a significant number would return if they were able to provide relationship-based, compassionate care, with time to do their jobs properly.
Let me conclude by speaking directly to Ministers. The question before us is not whether the Government recognise that maternity services are under strain—that has already been well established. The question is whether Ministers are prepared to act at the scale required. A maternity commissioner may feel tangible and responsive, but it does not avoid the hard truth: women’s experiences will not change without investment, workforce stability and systematic redesign.
As other colleagues have said, there are over 700 recommendations on maternity safety already in existence. If the Government are serious about restoring confidence in maternity services, I ask Ministers: will they publish a fully funded workforce plan for maternity, including midwifery, retention and return to practice? Will they commit to resourcing continuity of carer models, rather than quietly shelving them when staffing pressures bite? Will they address the £27 billion maternity negligence bill not through litigation management, but through prevention?
This Government must decide whether they want to preside over a system that simply manages failure, or whether they are willing to take the brave step of long-term investment to make the UK a place where women’s choices and bodily autonomy are respected, where safety is paramount, where joy and empowerment are not incidental but expected, and where professionals are supported to deliver humane, relationship-based care. We do not need another review, and I am not sure that we really need another title. We need staff, time, continuity, trust and investment. If we get that right, outcomes will improve, costs will fall, trust will return, and maternity care in this country can once again be something that we are all proud of.
Paul Waugh (Rochdale) (Lab/Co-op)
It is a pleasure to serve under your chairmanship, Sir Alec. I thank my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) for leading this debate. I pay tribute to Louise Thompson, Theo Clarke and the other petitioners for raising the profile of the issue of birth trauma and for helping so many other women to share their own experiences and, crucially, to fight for the changes that will prevent others from having to go through the same trauma. I also put on the record my thanks to my hon. Friend the Member for Sherwood Forest (Michelle Welsh), who has done a brilliant job with the all-party parliamentary group on maternity and who explained today, by outlining her own personal experience, just what birth trauma can mean.
This debate is fundamentally about how we ensure that women are being heard—genuinely heard—by the national health service. However, it is also about how we raise the levels of care, so that the best care is not an exception but the rule. One of the missions for this Government is restoring trust in maternity care. We know that that trust has been eroded by traumatic experiences, poor standards of care and—even more importantly—women feeling that no one is listening to them.
[Christine Jardine in the Chair]
As has already been said, the rise in maternal mortality is seen in the data produced by MBRRACE-UK between 2021 and 2023 compared with that between 2009 and 2011. That is simply unacceptable. What is particularly stark is the increased risk for women from minoritised communities and for those from disadvantaged backgrounds. In 2023, women living in the most deprived areas were dying at almost twice the rate of those in the least deprived areas. Alongside that data, there has also been an increase in obstetric haemorrhage, which I know worries both mums-to-be and health professionals. Women who want a second child need to know the risks of severe bleeding and placenta previa caused by previous caesarean sections, which are well-documented.
The NHS is not good enough at not only monitoring maternal deaths and morbidity, but monitoring trends in those areas. It is very good at identifying a trend in stillbirth or maternal death, but it is not so good at spotting trends in postpartum haemorrhage and admissions to intensive therapy units, which need the same attention.
The Government have a responsibility to ensure that whatever choice women make, that choice is informed and that the procedures are safe. If women want a home birth, let us make that a real choice; if they want a C-section, let us make that a real choice; and if they want a midwife-led unit or an obstetrician to care for them, let us make that a real choice. I agree with my hon. Friend the Member for Ribble Valley (Maya Ellis), who was absolutely spot on in saying that we should move away from making choice in this area a binary decision between safety and choice.
It is time for us to be proactive and not reactive, and to put into place the processes that will protect future mums from negative experiences of maternity care. That is why I am glad that the national maternity and neonatal taskforce, announced by the Government last year, is focused on long-term systemic reform that actually addresses the systematic failures identified by the CQC. The conversation must include midwives who, more than anyone else, want best practice and care for all the mums they work with. It must also ensure that there are oversight, accountability and robust reporting mechanisms that support midwives as well as mums.
Not many people know that word “midwife” is middle English. It literally means “with woman”, which is the crucial point. Midwives across the UK are advocating for women, supporting women and sharing their expertise with women all the time. However, that is also why we need to make continuity of care a reality for women, so that midwives can be “with woman” throughout the pregnancy and the birth. There must also be the investment in staffing that is needed to allow for rotas that provide the gold standard of staffing that everyone wants, both for pregnant women and for midwives.
Earlier this year, I was proud to host a drop-in event for the Royal College of Midwives with my hon. Friend the Member for Bishop Auckland (Sam Rushworth). I put on the record that my wife is a midwife; in fact, she is one of the main reasons why I am in this building today. I came into politics to change the situation for women who are suffering, but also to help to get more midwives in the profession. It has not been explicitly said today, but let us be honest—the last Government failed to invest in the NHS, including in the right number of midwives.
My wife came home night after night saying, “We simply are understaffed. We are chronically understaffed.” She was really worried about the standard of care that would be provided, and about whether it was safe or not. I said that, instead of writing about the maternity crisis, I want to do something about the maternity crisis. That is why I became an MP—to invest real, hard money into the NHS, including in staffing, but also to ensure that we change the procedures and reform the system.
It is worth saying that this is not just about staffing. It is also about having the right culture and leadership, and about whether obstetricians and midwives talk to each other and are on the same side and. Crucially, it is about whether women are listened to throughout the process. There has been far too much avoidable trauma for far too many women, as several inquiries have found.
For my constituents, Royal Oldham hospital maternity services are often of high quality. I have met senior midwives who are trying to provide innovative solutions to the challenges they face, but let us be honest: there are too many times when women are let down at the Royal Oldham. The CQC survey of patient experience, published in December 2025, found some unacceptably poor levels of care. On labour and birth, the hospital scored much worse than expected compared with other trusts. On staff care and on care in hospital after birth, it was much worse than expected compared with other trusts. On that last measure, it had an appalling score of 5.4 out of 10.
It is clear from the debate that a huge amount of work has been undertaken to deliver what we all want: maternity services that are well informed, personalised and safe for all women, regardless of race or background. We owe it to every family to provide maternity services where mums are given a full range of informed choice, backed by medical evidence, where they are genuinely listened to and where compassionate healthcare is at the heart of every birth. There is excellent care in the NHS, and we should say that again and again, but we need to make sure that every area, every trust and every woman has the high quality of care they truly deserve.
Dr Beccy Cooper (Worthing West) (Lab)
It is a pleasure, Ms Jardine—it is not Sir Alec any more—to serve under your chairship. I want to speak in the debate as a member of the Health and Social Care Committee and as the Member of Parliament for Worthing West.
At a local level, University Hospitals Sussex NHS foundation trust has implemented huge improvements, following the raising of the alarm about the safety of our maternity services after a number of heartbreaking, avoidable baby deaths came to light. For the families affected, life will never be the same again. There will now be a review, led by Donna Ockenden, to make sure that the truth of those times is fully heard and understood, that the indescribable experience of those families is documented to best effect and that the lessons are embedded in future practice.
The review will also contribute to improvements that are already making a difference in maternity services at University Hospitals Sussex, including at my own hospital in Worthing. In a recent CQC inspection, maternity services were rated as good. That reflects the maternity survey, in which 98% of women said they felt they had been treated with dignity and respect during labour and birth, and 95% felt involved enough in decisions about their care. We have heard from many colleagues this afternoon about the many times when that has not happened, so I take great hope from the fact that the survey is so positive.
Improvements in those maternity services have included 24/7 birth supporters working with experts by experience to create a restorative culture, bespoke antenatal pathways for asylum seekers and refugees, and specialist midwifery support for Traveller communities. There is strengthened staffing capacity, with 40 additional qualified midwives recruited across the trust’s maternity units, which are now fully staffed, compared with a 15% vacancy rate at the time of the previous inspection. What a difference that has made.
That level of service improvement and delivery needs to be a requisite for all maternity services in this country. The soon to be published Amos review recommendations, which we have heard about this afternoon, will undoubtedly provide a clear blueprint for the national maternity and neonatal taskforce to move things forward. But let us be in no doubt: as has been said, we have had 700 recommendations to date, and we probably know what will be in the Amos review, so let it be the last one.
The tragic fact, despite the excellent improvements I have seen in my local area, is that between 2022 and 2024 the overall rate of maternal death in the UK was 20% higher than it was from 2009 to 2011, when the Government of the day set an ambition to halve the rate of maternal mortality in England. Although the life of a precious baby is priceless, clinical negligence does have a price tag. The NHS has faced an estimated £27.4 billion bill for maternity negligence in England since 2019. That figure exceeds the total maternity budget for the same period, and reflects the devastating toll of preventable deaths and life-altering injuries to mothers and babies.
There has been significant investment in increasing the number of midwives over the past 18 months under this Labour Government, with an extra 800 midwives recruited since December 2024, but that is not enough on its own. As we have heard so sensibly from my colleagues, there needs to be widespread system change and a continuum of care.
We heard from my hon. Friend the Member for Clapham and Brixton Hill (Bell Ribeiro-Addy) about the issues around black maternal health. The Health and Social Care Committee highlighted those issues in its inquiry, when we saw that black women in England continue to face disproportionately poor outcomes in maternity care and the highest maternal mortality rates. Babies born to black women are more than twice as likely to die in their first year, compared with babies born to white women—a fact that I find incredible in this day and age, as somebody who has worked in the NHS as a doctor and who is now a public health consultant. It is entirely unacceptable that that continues to be the case.
The task, therefore, is accountability and co-ordination, and ensuring that evidence-based recommendations drive rapid improvement for women, their babies and hard-working staff. The women’s health strategy, published last week, recognises that women’s birth experiences and outcomes are a fundamental aspect of high-quality healthcare. Maternity services need to be embedded in a model that is based on relationships and wider care. That is essentially what health services live or die on: if we do not have good relationships and good wider care, our health services will struggle.
How we organise our services also needs to change, and that is a core mission of our Government in shifting to community-based care and a neighbourhood health model. Some £200 million has been invested in the healthy babies programme to improve perinatal mental health, parent-infant relationships and infant feeding in 75 local authorities. That is part of the £900 million that has been allocated to Best Start family hubs. The best start in life campaign includes information on pregnancy, but we must ensure that maternity healthcare is fully embedded in the shift to neighbourhood care. Members should be in no doubt: we have talked about moving from hospital to community throughout the 20 years that I have been in public health and medicine, and we have yet to do it. So I am under no illusions that this is incredibly difficult, but the focus we have this time is welcome.
Considering the improvements that have been made in my own area by University Hospitals Sussex; the significant steps being taken by the Government in establishing the taskforce led by the Secretary of State; and the investment in midwives and, more broadly, in women’s health and community-based care, I think that positive action is starting to take hold. Following the publication of the Amos review, the Minister may want to consider the possibility of a maternity commissioner to carry out the work of the taskforce, but the primary driver of that decision must be the aim of embedding the progress that is being made now, and sustainably embedding across maternity services a safe, holistic, person-centred approach that can endure and adapt for many generations to come.
Anna Dixon (Shipley) (Lab)
It is a pleasure to serve under your chairship, Ms Jardine. I echo the thanks given by my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) to all the petitioners who signed the petition, including 262 of my Shipley constituents.
My interest in maternity safety goes back to the time, over a decade ago, when I was director of policy at the King’s Fund. We set up an inquiry into the safety of maternity services, which was chaired by Baroness Professor Onora O’Neill. Despite the fact that that work was done more than a decade ago, the failures that we hear about today are sadly all too familiar. What struck us at that time was that there had been many reports in the preceding decade, including confidential inquiries into maternal and infant deaths, and that the recommendations had not been implemented. It makes me angry that there has been another decade of more inquiries and reviews, with the recommendations going unheeded.
That is why I am pleased to be an officer of the all-party parliamentary group on patient safety, and why I have worked with my hon. Friend the Member for Morecambe and Lunesdale (Lizzi Collinge) and the right hon. Member for Godalming and Ash (Sir Jeremy Hunt) to make maternity safety one of our priorities on the APPG. It has been fantastic to join colleagues, including my hon. Friends the Members for Sherwood Forest (Michelle Welsh) and for Rossendale and Darwen (Andy MacNae), across all-party parliamentary groups to share our insights and to contribute to the Amos investigation. There are still some of the same issues we heard about in the King’s Fund inquiry a decade ago: poor teamwork, weak accountability, defensive cultures and a failure to translate learning into sustained action.
Like many Members, I hear a range of stories as a constituency MP. Those are mainly centred on Bradford Royal infirmary, and I want to share the story of a constituent whose son was born with complications from the umbilical cord being wrapped around his neck. A late crash call was made after he had been delivered, but sadly he suffered catastrophic brain injury and was in a minimally conscious vegetative state. The women and her son were sent home with no diagnosis, and the child has grown up with epilepsy and other problems due to his brain injury. Sadly, it seems that midwives falsified the Apgar scores on the record and the time of the crash call. We have heard about defensive practice. We need a culture that changes it.
My constituent wrote to me:
“I have encountered significant barriers in navigating the NHS complaints system, particularly for marginalized communities. Language barriers further complicate the process, often leading to the dismissal of legitimate concerns.”
I am pleased to say that Bradford Royal infirmary has recently received good and outstanding ratings from the Care Quality Commission, for maternity and neonatal care respectively. I know that staff are not complacent about the care they give.
Others have mentioned the clinical negligence complaints system. I am a member of the Public Accounts Committee, and we have looked at how issues with that system have not only a human but a financial cost. One of our conclusions was that patients often pursue legal action because the complaints system itself is so confusing and unresponsive, which echoes the thoughts of my constituent. It is therefore vital that there are timely apologies from clinical staff and that we put in place effective, compassionate local resolutions. That will reduce claims, but is also ethically the right thing to do.
I would be grateful if the Minister could update us on the progress of the David Lock KC review, which we heard a lot about at the Public Accounts Committee. Alongside a better complaints system, we also talked about reform of litigation and potentially a no-fault compensation scheme, which would certainly go some way to creating a better environment. At the moment, families often experience long legal battles following harm, which leads to clinicians and organisations becoming defensive.
I want to finish with a brief example of what happens when people are failed but want to share any learnings with the NHS. My friend Martha’s second child died. It was a homebirth with complications. She started labour at 2.30 am. At 5.30 am she called the delivery suite, and staff told her to call back in a few hours. When she did, they sent out a midwife team who did not reach her until 9.40 am. A few moments later, her waters broke and she gave birth to her second daughter, but there was meconium in her discharge. As Members who are clinical will know, that is a sign of baby distress. The midwives called an ambulance immediately. It was another 19 minutes after the 999 call until the ambulance arrived and oxygen was given. Those minutes after birth were crucial, and that length of time without oxygen would have caused global brain damage and severe disability had their daughter survived. Sadly, she died in the care of Great Ormond Street hospital just a couple of days later.
The point of telling that story is that there are many missed opportunities to provide safer care. If the midwives had carried birthing equipment when they were attending, they could have provided immediate care. If the ambulance had prioritised the call from the midwife, it could have prevented the deterioration.
Anna Dixon
I am sorry but, respectfully, I am not going to give way.
If the ambulance had routinely carried a neonatal meconium aspirator, that could have prevented the death of my friend’s daughter. My friend said:
“I was not told who we could complain to following these experiences, or when we should do so.”
Whether it is through a maternity commissioner or another way, we need to learn systemically from women’s experiences so that safety recommendations can be implemented. When we hear from Baroness Amos’s investigation, I hope that Ministers will finally act swiftly to implement her recommendations and back them up with investment, so that families can have confidence that when tragedies like those of my friend and those of my constituent occur, the system will genuinely learn, improve and take action.
Helen Morgan (North Shropshire) (LD)
It is a pleasure to serve under your chairship, Ms Jardine. I thank the hon. and learned Member for Folkestone and Hythe (Tony Vaughan) for his excellent opening speech. I declare an interest as a member of the all-party groups on patient safety, on baby loss, on maternity and on birth trauma. Campaigners such as Theo Clarke, Louise Thompson and many more mothers and families over the years have been fighting tirelessly for the improvements that we desperately need in our NHS maternity services.
Adam Dance (Yeovil) (LD)
After lots of campaigning and hard work by NHS staff, Yeovil maternity unit will reopen tomorrow. The lessons learned from the closure of our unit will be included in the current national review into maternity services, but does my hon. Friend agree that the only way recommendations from the review will be properly implemented is with a national maternity commissioner and more consultant midwives?
Helen Morgan
I thank my hon. Friend for his intervention—he was quick off the mark. Yes, I agree that it will be useful to have a maternity commissioner to share those experiences and ensure that people learn from them.
The campaigners, Theo and Louise, have shared their heartbreaking experiences. I commend their work in securing this important debate. Liberal Democrats wish to be their allies. As a previous co-chair of the APPG on baby loss, I am all too familiar with the acute need for better standards of care for mothers across the country. I was also a member of the APPG on birth trauma when it was headed so ably by Theo Clarke, when the need for a maternity commissioner was first discussed and recommended. I am delighted to see the traction that this proposal has had thanks to the campaigning of Theo, Louise and many others.
Last month, the Lib Dems launched our maternity rescue package, which would guarantee high-quality care wherever people live and would make Britain the safest country in the world to have a baby.
Helen Maguire
I have a constituent who had a history of rapid births. She wanted the safety net and support of a home birth team alongside the community team, as recommended, but she was unable to have both teams involved. Does my hon. Friend agree that it is difficult to have confidence in a safe birth if the right medical support simply is not there?
Helen Morgan
My hon. Friend makes a good point. Patient voice—listening to women, understanding their wishes and understanding the risks that their wishes might represent and how to manage them best—is such a critical part of safe maternity care.
In drawing up our rescue package, I have drawn from my experience on the all-party groups on birth trauma, on maternity and on baby loss. There is so much common ground with the cause of the petitioners. We hope that they are buoyed by the fact that someone in Westminster is listening. With our package, a national maternity commissioner would oversee improved standards of care nationally, while a director of midwifery would be appointed in every maternity unit, alongside an extra 300 consultant midwives, to drive clinical excellence in each unit.
Our plans would invest £600 million to tackle these vital staffing requirements, but the NHS could save billions of pounds on maternal clinical negligence claims, which cost more than £1.3 billion in 2024 alone. Those huge clinical negligence costs have consistently been reflected in the findings of local and national reviews, but most importantly, the package would save babies’ lives and spare families the trauma of injury or worse happening to mum and baby at what should be the most joyous time of their life.
Liberal Democrats welcome the recent interim review by Baroness Amos. The findings of the review were devastating, showing that too many mothers are not receiving the level of care that they need, with devastating consequences for women, babies and their families. But this is the latest in a string of national and local reviews and inquiries, which have produced more than 700 recommendations. Those reviews, with their myriad but similar recommendations, illustrate why we need a maternity commissioner—someone who can bring together the learnings from past failings, along with the best practice from around the country, and oversee a step change in training and culture that will enable all the health professionals in maternity to work as effective teams and give women the personalised and high-quality care that is needed.
People across the country were truly shocked by the findings of Donna Ockenden’s review of the Shrewsbury and Telford hospital trust, which serves my constituents. The review found that the deaths of more than 200 babies could have been prevented. Over the years, I have heard—sometimes as a friend, sometimes as an MP—from traumatised and grieving parents, each with their own experience of birth trauma, injury to their baby or worse. They have told me how important it is to them that the reports and inquiries spark the vital change that is needed, and do not lead only to warm words from politicians followed by decades of gathering dust on the shelves of the Department of Health.
Since the Ockenden review, the Shrewsbury and Telford hospital trust has accepted and taken steps to implement almost all the immediate and essential actions that Donna Ockenden recommended. While that process has not been perfect, it has clearly been conducted with appropriate focus. The latest CQC rating for maternity at SATH is good, showing that with the right recommendations and leadership, positive change can happen. The team at SATH should be commended for that achievement. They demonstrate the value of focusing on the steps needed to get care right.
As we found out subsequently, however, unsafe maternity care was not unique to Shropshire, or indeed to Morecambe, East Kent or any of the other places about which we have heard such awful stories. We know that women all over the country are still not receiving the care they need. None of the services that the Care Quality Commission inspected in its national review was rated outstanding. Some 65% of maternity units were unsafe for women to give birth in. It is a scandal that mothers in this country have to settle for potentially dangerous levels of care at what should be one of the happiest moments in their life.
The introduction of a maternity commissioner is not a quick fix, but a commissioner would provide the leadership required for serious change to the way women and staff on maternity wards are listened to. That commissioner could look at disparities in maternity care and the poorer outcomes that we see for black and Asian women and those in deprived communities, and drive the change needed to make having a baby safe, no matter what your background is. Other improvements are needed, too.
Our proposals are to guarantee specialist doctors on every maternity unit 24/7, and one-to-one midwifery care for every woman during labour to respond to the desperate need for safe staffing highlighted in each of the reviews and in the inquiries by the all-party groups that deal with maternity care. Previous research found that 73% of maternity units in England do not have a consultant present at night, despite most births taking place outside working hours. Many negligence claims for poor maternity care are linked to failings in care outside regular working hours.
The proposals come alongside a new capital investment programme to fix crumbling maternity units in need of urgent repair and to deliver new dedicated bereavement suites. We would start with the 7% of maternity units that are at risk of imminent breakdown, and would restore the 42% of units in need of major repairs. These crucial steps come alongside many other proposals to improve staff training, to invest in bereavement support, neonatal specialists and pre-conception services and to eliminate maternal health disparities.
It is really, really, really important to say that the vast majority of babies are delivered safely, even when things do not go to plan. But we should not dismiss those instances where they go wrong, and we should be tireless about making the improvements required. I congratulate the campaigners on the success of the petition so far. I continue to urge the Government to demonstrate that recommendations will be turned into actions, and that the cries for help from countless mothers and families will be listened to.
Dr Caroline Johnson (Sleaford and North Hykeham) (Con)
It is a pleasure to serve under your chairmanship, Ms Jardine. I declare an interest as an NHS consultant paediatrician. I have attended more than 1,000 deliveries of babies over my career. More recently, they have been more likely to be the ones where things were going wrong and where there were more concerns about the baby, as my role is about looking after the infant.
I have also had my own three children. The hon. Member for Esher and Walton (Monica Harding) described having a mixed experience; I had three healthy children, but the first one was a normal delivery, the second a somewhat chaotic emergency caesarean section and the third a nice and smooth, peaceful elective caesarean section, so I had a range of experiences.
I congratulate the hon. and learned Member for Folkestone and Hythe (Tony Vaughan) on his opening speech. I particularly thank Theo Clarke—my friend and former colleague—and Louise Thompson for their campaign on maternity safety. They have shown incredible bravery in talking about their experiences and challenging the taboos around the troubles related to pregnancy. In particular, I commend Theo for her talk about perineal injuries, because this has been something spoken about in hushed tones and quietly among women and not something discussed in the public arena, but once it is spoken about in the public arena, that courage enables other women to find the courage to come forward and talk about it. That is how we will ensure that these injuries become less likely and the treatment becomes better, so I thank them for their work on that.
Since the petition was launched, it has received more than 150,000 signatures, including 270 from my constituency. As a parent, I know that bringing a child into the world is one of the most rewarding and exciting experiences in life. As has also been said, it generally goes well—reasonably smoothly, if not completely smoothly—and the outcome is generally good. But for too many women, their experience is deeply traumatic. Every year, 30,000 women suffer negative experiences during pregnancy, and one in 20 of those goes on to suffer from PTSD.
The APPG on birth trauma ran an inquiry into birth trauma, soliciting 1,300 submissions. What it detailed painted a shocking picture. It spoke of mothers left unattended to in hospital beds and some left in their own blood or faeces for hours on end; vaginal examinations undertaken without consent and in some cases triggering a mother’s waters to break; mothers belittled; concerns torn from the records; a baby dying during delivery after concerns were raised 44 times in vain; and significant mental health consequences and debilitating effects of perineal injury.
Every single failing we have heard about today is one too many. As I have said, maternity care is generally safe, but it is not safe enough yet. I am proud that the previous Government identified maternity care as a priority and began making some improvements. There is a way to go, but the previous Government launched a maternity and neonatal safety strategy, funded the saving babies’ lives care bundle, setting out evidence-based practices for providers and commissioners of maternity care in England, and rolled out maternal medicine networks in 2023. They established 17 centres of excellence to help women with high-risk conditions to get the care that they need when they need it. The previous Government’s reforms were backed by £127 million of investment specifically for maternity and neonatal care, and much of that was focused on the workforce.
Because of these efforts, more babies are delivered safely than ever before. Between 2010 and 2022, stillbirths fell by 25% and maternal mortality fell by 17%. The improvements were in large part overseen by my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt). He has saved countless lives with these improvements and deserves much credit for that.
I am concerned about the trajectory that we are currently on, because as has been said, there is still quite a lot left to do. In June, the Health Secretary agreed. He said that
“we’re not making progress fast enough on the biggest patient safety challenge facing our country”,
but he has responded with another inquiry. He did say that it would be a rapid inquiry, but it took months—in fact, till September—to decide which trusts would be involved in that inquiry, and then that was changed in and of itself. It was announced almost a year ago, has been much delayed and has still not reported. Hopefully it will be a great report when it has reported, but the delay means that action is not taking place quickly enough.
As has been mentioned, Baroness Amos found in her interim report that 748 recommendations had been made over the last decade, but progress in delivering on them had been too slow. Could the Minister update the House on how many remained undelivered on at the point of the general election and how many she has delivered on since?
In June, Ministers also announced a maternity and neonatal taskforce; and in November, I tabled questions asking how many times the taskforce had sat and who was on it. The answer was that they had not decided yet. In January, the question was raised again and they still had not decided. It took until last month for the Government to decide who was going to be on their urgently created taskforce from last year.
Michelle Welsh
Does the hon. Member agree that working with the families to get the taskforce right, which has never happened before with any Government, is key? Getting the taskforce working and getting the right people on that taskforce is essential as well.
Dr Johnson
I completely agree with the hon. Lady that it is important to get the taskforce right, I am just not sure that it needed to take quite so long to do so. We heard a statistic earlier about how many babies are born and how often; I think about how many babies have been born in the intervening time, while the membership of the taskforce was being finalised.
Michelle Welsh
There are more than 2,500 families involved in the Nottingham inquiry, some of whose cases were never reported appropriately. Given that, does the hon. Member agree that it is important to get the taskforce right, because so many bad things happened under the previous Government’s watch that were not reported to the inquiry and are not in the statistics and data that she has spoken about?
Dr Johnson
I understand the hon. Lady’s point, but putting together a taskforce should not take months and months, because it is too important that we get on with it quickly. The Minister may be able to give us a reason for the delay because, if this is hitting the ground running, the Government must be wearing lead boots.
I also want to talk about the workforce. The Labour party manifesto included a commitment to train thousands of additional midwives. Can the Minister confirm how many more midwives are in training than under the previous Government, how many additional study places have been funded for each year, and how many places will be available this September? Some midwives have spoken about a lack of more senior midwives on shifts and the balance of care. Can the Minister tell us what figures she has on the number of midwives who are now in more senior roles and not providing clinical care, and what proportion of midwives are still spending at least a day a week providing clinical care?
We know that many midwives are not happy with the Government’s proposed 3.3% pay award—health unions have called it a betrayal and an insult. With resident doctors already striking, what is the Minister doing to avoid yet another industrial dispute, which I worry would contribute to poorer maternity care? At the same time, the Government’s plans to reorganise NHS services and ICBs have put them under financial pressure. Can the Minister confirm what effects she thinks that will have on maternal services and maternal mental health services used by women?
The Government promised 1,000 speciality training places; how many of those that have now been cancelled were for obstetrics and gynaecology? Will the delayed workforce plan, when it comes, have details of the number of obstetrics and gynaecology trainees that are needed, and will the Government have a plan to deliver the right number so that we have the best number of doctors for care?
Hon. Members talked about how births are becoming more complex—there are fewer births, but there are more complex births. What are the Minister’s plans for prevention, for example by ensuring that women have folic acid? We know that around four in five women take folic acid, but what can be done to improve that? I give the Government credit for the Tobacco and Vapes Bill, but what is being done to reduce smoking in particular among women who are planning a pregnancy or who are pregnant? Obesity and the effects of chronic illness are also important in making pregnancies as healthy as they can be. Given the Government’s focus on prevention, can the Minister update the House on what is being done in those areas?
The speech by the hon. Lady for Morecambe and Lunesdale (Lizzi Collinge) explained the workforce culture extremely effectively. Where errors happen—I agree with her that errors will always happen—it is important that the response is honest, open and transparent. Those who blow the whistle should be safe to do so, and the balance between accountability and blame needs to be in the right place so that we get improvements in maternity care. I share the hon. Lady’s concerns about the “normal birth” culture.
As many hon Members have said, listening to women is important. I asked the Minister about the abolition of Healthwatch the other day, but I do not think I got an answer. Organisations will always try to represent their interest group as effectively as they can, but there may be women who fall through the cracks. The benefit of Healthwatch is that it will listen to all and any women, whereas groups will just represent cohorts of women.
On travel, it is not uncommon, where there is a baby with a cardiac or neurological condition or extreme prematurity requiring surgery, for the baby to have to be transported significant distances, sometimes hours away from their parents’ home, in order to receive the best care. That can be very challenging for people in the cost of travel, and accommodation local to those units. Some units have excellent accommodation onsite in the hospital for mothers and fathers who have a baby who is particularly sick, but others do not. I asked some written questions on this topic following the neonatal estate review, but I got answers back about bereavement suites, which are a different issue.
I have heard examples of women being asked to stay on the postnatal ward when they have a baby in the neonatal unit. One woman described to me being in a bay with three other women who all had their babies with them; that woman was told to stop pressing the buzzer for help after a caesarean section, as there were other women with babies who needed to be looked after—I thought that was particularly cruel.
In summary, I understand that the Minister is very dedicated to this cause, and I am sure that the Secretary of State is too, as we all are. However, I feel that the delay, the report and the endless inquiries are not creating the actions that we need, so I would be grateful for the Minister’s response.
The Minister for Secondary Care (Karin Smyth)
It is a pleasure to serve under your chairship, Ms Jardine. I thank my hon. and learned Friend the Member for Folkestone and Hythe (Tony Vaughan) for responding so ably on behalf of the petitioners. That thousands of people wanted us to talk about this subject, many of whom will be watching—many are in the Public Gallery—demonstrates how important the issue is and how it touches so many of our constituents. I am grateful to my own constituents for signing the petition.
I place on record my thanks to Theo Clarke, who is also in the Gallery, who did a lot of work in this area when she was an MP, based on her own experiences. I agree with the hon. Member for Sleaford and North Hykeham (Dr Johnson) that, by detailing injuries and raising some of the taboos, she did a great service to other women. I also thank Louise Thompson, also in the Gallery, for the time and effort that she has put into campaigning for improvements in maternity care following her own experiences. All the organisations that work on behalf of women, bringing forward their stories to national attention, do a great service—it is not an easy thing to do, and we thank them for it.
The hon. Member for Esher and Walton (Monica Harding), and my hon. Friends the Members for Morecambe and Lunesdale (Lizzi Collinge), for Altrincham and Sale West (Mr Rand) and for Shipley (Anna Dixon) all highlighted their constituents’ experiences. To be clear, the Secretary of State leads on this work directly, and a meeting has been set with Louise and Theo to discuss the issue of a maternity commissioner more thoroughly. I encourage both Theo and Louise to continue to engage with the national investigation chaired by Baroness Amos. Their campaigning, along with that of so many others, has led the Secretary of State to directly provide the leadership himself, ensuring that the issue gets attention. We look forward to Baroness Amos’s recommendations.
As many Members have said, the vast majority of births are safe, and there are some outstanding examples of care in the NHS. But where things do go wrong, it can have a devastating impact on women and their families, who are at their most vulnerable when giving birth. We are fighting systemic issues, entrenched inequalities in maternity care, a failure to learn from mistakes, and culture and leadership issues.
It is appalling, as we have heard again in this debate, how in the 21st century in Britain there could be such a difference in outcomes for mothers from different ethnicities and for those from deprived backgrounds, not least in constituencies such as mine. That was a point ably made, as ever, by my hon. Friend the Member for Clapham and Brixton Hill (Bell Ribeiro-Addy), who, in leading the APPG, does an amazing amount of work to highlight the issue. I confirm to her that we remain committed to setting a target to close that mortality gap, and will be informed by Baroness Amos’s recommendation. The issue of deprivation and ethnicity differences was also raised by my hon. Friends the Members for Rochdale (Paul Waugh) and for Worthing West (Dr Cooper). That issue is why the Secretary of State has launched the national investigation into NHS maternity and neonatal care, chaired by Baroness Amos. She is bringing together the findings from past reviews and local rapid reviews, and new evidence from families and staff, into one clear national set of recommendations.
As my hon. and learned Friend the Member for Folkestone and Hythe said, previous issues and scandals have produced many recommendations, including, as we have heard, well over 700 recommendations on maternity care since 2015. As my hon. Friend the Member for Shipley reminded us, some of the information from those investigations has been available for well over a decade.
We know what needs fixing, but changes to processes and procedures here and there are not enough. There is a risk that some recommendations might fix the symptoms, but not the underlying causes. Many colleagues have talked about culture. I agree with my hon. Friend the Member for Rossendale and Darwen (Andy MacNae): we cannot keep going round in the same cycle. There is an underlying cultural issue, and systemic change needs to happen. I commend my hon. Friend for the work that he does on the APPG and for sharing the loss that he and his family suffered. That loss is informing that work.
My hon. Friend the Member for Mansfield (Steve Yemm) also talked about that culture and the need for deeper questions. Other Members talked about the need to speak up. I agree with my hon. Friend the Member for Morecambe and Lunesdale, who highlighted the importance of that culture of encouraging people to speak up.
Anna Dixon
Does the Minister agree that training obstetricians and midwives together as a team is an important part of creating that unified culture that we know is so important to underpin safety for mothers and babies?
Karin Smyth
I agree. That is an important point about the culture in clinical roles and clinical leadership within the secondary care setting and across the entire pathway of supporting women. As part of our 10-year plan, we want to put patients across all parts of the NHS front and centre by building services around people instead of expecting people to build their lives around services.
In February, Baroness Amos published her interim report to share the insights she has gathered so far. She and her team have met with hundreds of families as part of the local investigations, and a national call for evidence from women and families has recently concluded. The surveys were open for eight weeks, hearing from women and families across the country about their experiences of maternity and neonatal care. Over 11,000 responses have been submitted.
A separate call for evidence for those who work in the maternity and neonatal pathway was also held recently. The workforce call for evidence received more than 9,000 responses from across 124 trusts. Baroness Amos’s final report, including one coherent single set of national recommendations, will be published in June.
Some of the women and families who have fed into the national investigation will have suffered terrible loss and harm. This subject is just about the hardest that any woman could ever talk about, and I want to thank all of those who have had the courage to share what they have been through. I thank again my hon. Friend the Member for Sherwood Forest (Michelle Welsh) for the inspiration that she has provided by, first, getting herself here, and then continuing to use her voice and doing it so well during her time in Parliament.
All those women and their families deserve to know that their voices will be heard and that action will be taken. That is why the Government have launched their new maternity and neonatal taskforce, chaired by the Secretary of State. It will be the taskforce’s job to translate the investigation’s final recommendations into action. The taskforce will also hold the system to account for improving outcomes and experiences for women and their families. It is all very well coming up with more reports, but we have had enough of those. The taskforce will develop an action plan so that recommendations from the investigation do not gather dust on a shelf. The taskforce held its first meeting on 24 March and it was very positive and constructive.
The terms of reference have been agreed, with meetings every six to eight weeks going forward. The taskforce is made up of experts and key partners from across the maternity and neonatal sector as well as from the wider health sector. It includes representatives from harmed and bereaved families, frontline clinicians, academics and royal colleges—those who can speak directly to health equity and international expertise. The voices of families, and women in particular, are paramount throughout this process. The taskforce will be supported by several expert reference groups, at least five of which include representatives from harmed or bereaved families. I agree with my hon. Friend the Member for Sherwood Forest that it is important that we get this right and work across this field, so that this becomes a once-and-for-all piece of work.
I think we all want to end the cycle of recommendations that do not deliver, and we have heard a lot about that this afternoon. That is what the taskforce is designed to do. It will ensure that the systemic and national changes we need to see are achieved following the investigation’s final report and recommendations, but we are not sitting on our hands until we get to that report. A number of initiatives are already in place to improve experiences and outcomes in maternity and neonatal care. We have already recruited more than 800 more midwives and begun investing more than £140 million to address critical safety risks on the maternity estate, and we are rolling out programmes to tackle discrimination, racism and avoidable brain injuries. We will improve the NHS consistently week on week, month on month and year on year.
The renewed women’s health strategy, which was published last week, will tackle head on the injustices women face. In that strategy, we acknowledged much of what we have heard during this debate, including the existence of medical misogyny, the fact that women are not listened to and the fact that the culture needs to change. As my hon. Friend the Member for Ribble Valley (Maya Ellis) noted, it is important that women have choice.
The strategy sets out how we will focus relentlessly on delivering women’s priorities. The challenge for this Government over the next couple of years is not just to build on the progress we are already making but to accelerate it. I want women who signed the petition to know that we have heard them loud and clear. We know that there is so much more that needs to be done, but I ask that they do not judge us on the strategies we publish or the people we appoint—we must be judged by our results. Baroness Amos has given us the blueprint for making things better, and the taskforce will hold us to account. We will not just have one person driving action; there will be 18 of them.
In the meantime, we will not make significant commitments that pre-empt the outcome of the investigation, which we will have in just two months’ time. If Baroness Amos wants to recommend, for example, a maternity commissioner, then we will consider that carefully. The taskforce, with the Secretary of State chairing it to drive accountability, will deliver the action that we all need to see.
Tony Vaughan
Thank you, Ms Jardine, and I thank all colleagues who have contributed to the debate today. I also thank petitioners Theo Clarke and Louise Thompson and the 153,000 signatories across the country who have brought this debate before Parliament. This opportunity to debate how we improve maternity care is crucial, and it has been brought about by the petition.
There has been unanimity among all speakers on the urgent need for action. The experiences of the petitioners and constituents and the mountain of evidence we have all heard leaves us in no doubt that action to address these long-standing and entrenched problems is long overdue and extremely urgent. The Minister and Baroness Amos have rightly accepted that the challenges we face are systemic and that a whole-system view, looking at people, culture, organisation, processes and infrastructure, is needed. We have heard many hon. Members talk about the ways that those problems have manifested themselves in their examples.
The Minister said that the Health Secretary will chair the taskforce composed of 18 experts to provide the accountability and oversight that the petitioners are calling for. I ask the Government to have the taskforce in place as long as is necessary for us to see these changes. The petitioners have asked for a maternity commissioner to be installed permanently. I do not know whether the taskforce has a time limit, but it is important that it is in place for as long as is necessary to see the change that we all want.
The women’s health strategy is to be welcomed. It is important that the strategy accounts for the needs of all groups, particularly minority groups, who suffer disparate impacts, and disabled people who are losing out because of the current system. I thank everyone who signed the petitions for participating. I think the Petitions Committee allows members of the public to participate in our democratic process quite successfully.
Question put and agreed to.
Resolved,
That this House has considered e-petition 751174 relating to a Maternity Commissioner.