‘A huge missed opportunity’: the Birth Trauma Association responds to the Amos review
30 June 2026
The UK’s leading birth trauma charity, the Birth Trauma Association, has described the final report of the Independent Investigation into Maternity and Neonatal Services in England – the Amos review – as “disappointing for families” and a “huge missed opportunity”.
The investigation was tasked with reviewing maternity and neonatal services in England as a whole and looking in detail at 12 individual trusts. (These 12 trusts are dealt with in a separate report.) Its public Call for Evidence received 10,500 responses, and the investigation also met with groups of families, charities, parliamentary groups and other stakeholders, as well as with staff working in maternity.
Despite the wealth of evidence amassed by the investigation, the report does a poor job of reflecting families’ experiences. Although many women shared their experience of the devastating impact that physical injuries such as third- or fourth-degree tears have had on their lives, physical injuries are not mentioned at all in the main report. Forceps – often the cause of such injuries – are not mentioned once. There is no mention of post-traumatic stress disorder (PTSD) or the psychological impact of traumatic birth on women or their partners. The only mention of brain injury to babies – one of the most distressing and traumatic birth outcomes imaginable – is in the context of litigation and safety investigations.
We were also immensely disappointed that the separate report looking at 12 individual trusts devotes more space to staff views than to patient experiences. While we recognise that staff working in a busy, under-resourced system sometimes feel harassed and overworked, we do not think that this excuses the downright cruelty and negligence with which women tell us they are sometimes treated. Similarly, we believe that too much weight is given to the poor condition of the physical estates: again, this is important, but far from being the most important problem in maternity.
Kim Thomas, CEO of the Birth Trauma Association, said: “When the health secretary launched the Independent Investigation into Maternity and Neonatal Services in England last year, many of us were hopeful that finally this would mean harmed women and families would be listened to, and that change would be forthcoming. The review collected evidence from thousands of people, and we know that many shared their deeply harrowing and distressing personal experiences in good faith.
“It is devastating, therefore, to see that so little of what women told Baroness Amos is reflected in the report. There is no mention of birth injuries – the third- and fourth-degree tears that leave women incontinent and in pain. Yet only this week new data has shown an increase in the number of this type of injury in England.
“There is no mention of forceps – the cause of a particularly traumatic birth experience for many women who come to us – and no mention of the psychological injury caused by traumatic birth. We know that many women told Baroness Amos that they have experienced PTSD as a result of their birth, but this doesn’t appear in the report.
“Similarly, there is almost no mention of babies with brain injuries, except in the context of litigation. Yet we know that a brain injury at birth means that parents have to devote the rest of their lives to looking after a harmed child, often giving up their own jobs to do so.
“It was particularly disappointing to see the views of staff given so much weight, when for many of the women who come to us, staff were the direct cause of their trauma. However much we recognise that under-resourcing is a problem in maternity, this cannot justify the cruelty many women tell us they have experienced at the hands of staff. This approach is in marked contrast to Donna Ockenden’s review into Nottingham maternity services last week, which put families at the heart of the report.
“There are elements in the report we welcome. The eight top-level recommendations are broadly ones we agree with. In particular, we are pleased to see a recommendation to appoint a maternity commissioner – something first proposed two years ago in the birth trauma inquiry report, for which the Birth Trauma Association was the secretariat. We welcome the recommendation to listen to mothers and to simplify the fragmented system of regulatory oversight, as well as the requirement to tackle racism and discrimination within maternity. We also wholeheartedly agree with the recommendation to create a modern service framework setting out national standards to achieve consistently high-quality maternity and neonatal care. Indeed, this is crucial if we want to make lasting improvements to maternity.
“It was encouraging to see Baroness Amos recognise the importance of addressing poor triage processes. Failings in triage can and do lead to tragic outcomes including the deaths of babies – and this is something that Donna Ockenden also noted last week in her review of maternity care in Nottingham. As Amos’s report says: ‘If triage services are improved, lives will be saved and harm reduced.’ We hope that the inconsistent and poor quality of triage throughout maternity is now addressed as a matter of urgency.
“Overall, however, the report was extremely disappointing for families and a missed opportunity to identify the scale of harm in maternity services. Our heart goes out to women and families who gave evidence to the investigation in good faith but now feel that their voices have not been heard. We hope that the health secretary moves to act on the key recommendation in the report, to appoint a maternity commissioner with the power to effect real and lasting change.”
Further information
For more information, contact Dr Kim Thomas at kim@birthtraumaassociation.org or 07779 275032.
The Birth Trauma Association, founded in 2004, is a charity supporting parents experiencing psychological distress after traumatic 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
