ENGLAND — Lady Amos concluded a national review into England's maternity and neonatal services, stating the system is no longer fit for purpose. The review recommends sweeping reforms, asserting that their full implementation will result in a material and sustainable improvement in overall safety and quality.

The review identifies systemic racism, discrimination, and structural inequalities within the maternity and neonatal system across England. It recommends that the Department of Health and Social Care, the General Medical Council, NHS trusts, and the Nursing and Midwifery Council must address racism, discrimination, and inequality as a critical maternity safety issue within a year. According to the review, Black mothers are almost three times more likely to die in childbirth than white counterparts, and Black babies are twice as likely to be stillborn as white babies. Last month, the Nursing and Midwifery Council published new anti-racist principles.

The review described failures within maternity triage as deeply concerning. Lady Amos stated that maternity triage services have been severely understaffed and have lacked physical space. The review calls for maternity triage to be formally designated as a safety-critical clinical environment with binding national standards. It also calls for binding national standards for maternity care overall.

For families dissatisfied with internal NHS trust investigations, the review recommends an automatic right to request an independent investigation. This follows a case in 2016 when Harriet Hawkins was stillborn. Nottingham University Hospitals NHS Trust initially stated that her death was unavoidable, but an independent external review later revealed it was due to failures at the trust. Donna Ockenden's review of the Nottingham NHS trust was published last week.

The review recommends the appointment of a maternity commissioner to provide leadership and oversight for a redesigned maternity and neonatal system. Michelle Welsh was appointed as the government's first maternity adviser in May.

A representative for the Birth Trauma Association described the review as a "huge missed opportunity" and "disappointing for families." The association noted that the review did not mention the impact of forceps, post-traumatic stress disorder, or the psychological impact of traumatic birth on women or their partners.

Why It Matters

The findings from the review indicate a need for reform within England's maternity and neonatal care system. The recommendations, if implemented, would introduce national standards for maternity care and triage services, as well as an automatic right to independent investigations for families. These changes could affect how maternity and neonatal services operate across the country, aiming to improve safety and quality.

The review also highlights issues of systemic racism and discrimination regarding childbirth outcomes for different racial groups. Implementing the recommendations regarding racism and discrimination would require action from multiple health organizations to address these disparities within a year, potentially influencing policy and practice within the National Health Service.