Baroness Valerie Amos has identified systemic failures and discrimination within NHS maternity services across England in a new independent review.
The findings highlight a critical breakdown in patient safety and equity. Because these failures contribute directly to maternal and neonatal deaths, the report demands an urgent overhaul of how the National Health Service treats expectant mothers.
The review examined maternity care across 12 NHS hospital trusts [1]. It found that systemic neglect and poor conditions have persisted for a significant period, affecting the quality of care provided to women and newborns.
Baroness Amos focused on the role of cultural factors in these failings. She said that wider cultural factors, including racism and discrimination, need to be addressed as a matter of urgency.
The report specifically identifies "unacceptable racism" faced by Black and Asian women in NHS maternity units. This discrimination, combined with other biases, has created a tiered system of care where marginalized women face higher risks.
Beyond racial discrimination, the review noted other forms of bias, including cases where women were dismissed based on their weight. These cultural failings have allowed a cycle of poor care to continue without sufficient intervention.
Baroness Amos emphasized the human cost of these institutional breakdowns. "The trauma that we are seeing has got to stop," she said.
Government responses to the report include the appointment of a maternity commissioner to oversee improvements. This role is intended to ensure that the systemic failures identified across the trusts are corrected to prevent further loss of life.
“"The trauma that we are seeing has got to stop."”
The findings suggest that maternity failures in England are not isolated incidents of clinical error, but are rooted in institutional racism and systemic neglect. By linking poor health outcomes to cultural biases, the report shifts the responsibility from individual practitioners to the structural framework of the NHS, necessitating a policy shift toward social equity to improve medical safety.
