Amos Review findings demonstrate the failings in maternity care
The Birth Trauma Association, the leading UK charity for supporting parents with traumatic birth experiences, cautiously welcomes the findings of the interim report of the Independent Investigation into Maternity and Neonatal Services in England, published today.
The review, led by Baroness Amos, has identified a number of key failings in maternity. These will be familiar to anyone who has read previous reports into maternity over the last 10 years. They include capacity pressures; cultural problems, including poor team-working; racism and discrimination; and a lack of accountability.
There are some shocking examples within the review of how families are harmed by poor maternity care, and the lack of compassion with which they’re treated. It’s disturbing to read of a woman being told that she was ““too fat to have children,” for example. We’re also grateful that Amos has highlighted the discriminatory attitudes towards disabled women, women from marginalised racial groups and young women.
We were pleased to see Amos identify flaws in the systems for investigating serious incidents, noting that many families whose babies were stillborn had failed to receive a full explanation of what had happened, and that for many parents the current system of investigation “feels deeply unfair” and “can exacerbate trauma”. This matches what we hear from the parents we support.
It is also clear that some staff are working in a toxic environment, in which bad behaviour by senior clinicians is left unchecked. Amos heard accounts from staff of “verbal aggression, refusal to carry out designated functions such as attending handover rounds or callouts at night, and sometimes bullying and racist behaviour.” It is impossible for a maternity unit to function adequately while behaviours like this are allowed to flourish.
Nonetheless, we feel that the report fails to address some of the deep-rooted problems in maternity services.
Dr Kim Thomas, CEO of the Birth Trauma Association, said: “We are grateful to Baroness Amos for her investigation, and her willingness to listen to families’ concerns about their care. Her findings – including a lack of compassion, poor team-working, a lack of transparency in communicating to parents – match what women have been telling us for years about their experiences. These findings also reflect the findings from other major reports into maternity, such as the East Kent inquiry, the Shrewsbury and Telford inquiry and the 2024 birth trauma inquiry, for which we were the secretariat.
“We would like to have seen more in the report about the problems caused by these failings. We know that a failure to listen to women, and a failure by some maternity staff to escalate problems, leads to adverse outcomes, including stillbirth, babies born with brain injuries and women experiencing lifelong health problems such as incontinence. The personal, social and economic cost of these failings is substantial.
“We were also surprised to see little mention of the failings in postnatal care, which have led to many women being neglected on the postnatal ward without necessary support, sometimes leading to cases of serious diagnoses such as sepsis being missed. The report touches on mental health, but does not address the inadequacy of the support available to women with serious mental health problems after birth. As this is an interim report, we hope that these issues will be addressed more fully in the final report.
“Given that, to a large extent, the interim review has not identified anything we didn’t know already from previous reports, our hope now is that the final review tackles the important question of how to implement change. We are grateful to Baroness Amos for taking evidence from a wide range of sources, but the real test of her investigation will be whether she is able to make serious, substantial recommendations that will lead to real and lasting improvements in maternity care.”
Further information
For more information, contact Dr Kim Thomas at kim@birthtraumaassociation.org or Rachael McGrath at rachael@birthtraumaassociation.org
The Birth Trauma Association, founded in 2004, is a charity supporting parents experiencing psychological trauma symptoms after birth. You can find our website at www.birthtraumaassociation.org.
Follow us on X at @BirthTrauma, on Facebook at Birth Trauma Association – UK and on Instagram at birth_trauma_association_uk.
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