Is England making progress to improve maternity care?

Safety ambition: Halve the neonatal brain injury rate 

National data is no longer collected on the rate of neonatal brain injury, so this safety ambition is difficult to track. Definitions of neonatal brain injuries (across all gestational ages) changed in England in 2012, at which point the rate was 4.25 per 1,000 live births. The rate peaked in 2014 at 4.68 per 1,000 live births before decreasing to 4.18 per 1,000 live births in 2021 (the latest data). Neonatal brain injury can result from hypoxia (a lack of oxygen) during labour or at birth, as well as from infection. Hypoxia is less likely to cause injury if detected and acted on quickly during birth. A single source for national data on perinatal brain injury is no longer collected (but multiple separate records exist), which experts argue is challenging efforts to reduce the rate of neonatal brain injury.

Due to limited progress on core safety ambition metrics, and an independent review rating the government’s progress against its maternity policy commitments in England in 2021 as 'requires improvement', the government developed a new three-year maternity delivery plan in 2023, which expanded the priorities for action beyond safety. The following section assesses any measurable progress against the plan’s four priority themes.

What are current priorities and plans to improve maternity services?

In March 2023, in the context of an increasingly concerning picture of maternity care with more reviews underway and metrics not showing signs of improvement (see targets table above), the then government put in place a three-year delivery plan for maternity and neonatal services. The plan prioritised four themes for action, alongside objectives, outcomes and progress measures, which focused on: (1) listening to women; (2) growing and supporting the workforce; (3) developing and sustaining safety cultures in hospitals; and (4) applying standards and structures that underpin safer and more equitable care. A progress update on the delivery plan was carried out one year after the plan launched, which acknowledged there was much work left to do. We now look at each of the four themes in more detail three years on.

Listening to women and families with compassion 

The first theme focuses on providing personalised care, improving equity, and working with service users to improve care. Outcomes are being tracked through national experience surveys, such as the CQC’s annual maternity experience survey. Several of these markers are positive. For example, in 2025, during labour and birthing, 82% said that they felt their concerns were ‘always’ taken seriously (up from 81% in 2024, though not a statistically significant increase). After birth, 75% said the midwife or midwifery team ‘always’ took the respondents’ personal circumstances into account when giving advice (up from 72% in 2024, though again, not a statistically significant increase). 

However, experiences vary across different sociodemographic groups in the survey, suggesting some voices are still not being heard. Statistically significant poorer experiences were reported across several questions among women who:

• were younger (aged 16 to 26)
• gave birth for the first time
• had less midwife continuity
• had an assisted vaginal delivery (which was noted in the Birth Trauma Report) or planned or emergency caesarean delivery
• spoke English as their main language (this is an unexpected result but could reflect that they felt more able to voice their concerns than people who spoke English as an additional language or not at all).

The maternity safety ambition metrics point to specific ethnic and socioeconomic groups who may also have difficult experiences – some of which are detailed in separate reports such as the 5XMore Black Maternity Experiences 2025 report or the second interim report of the Amos Review, which highlighted several examples of racial and ethnic stereotyping and systemic racism. These inequalities will require careful examination by the National Investigation, which should cross-reference findings from multiple sources to accurately assess progress.

Growing, retaining and supporting the workforce

Women and their babies are cared for by a diverse team, including midwives, obstetricians, maternity support workers, neonatal doctors, nurses and other health professionals (e.g., health visitors, social workers, physiotherapists, mental health specialists). This theme is focused on growing, retaining and supporting all the maternity and neonatal workforce, and investing in skills. The success metrics are being captured using tools such as the NHS Staff Survey, the National Education and Training Survey, and the General Medical Council national training survey. 

Across many staff groups in maternity and neonatal services, staffing has been an ongoing challenge. For example, in the 2024 NHS staff survey (the latest available data), just 19% of midwives felt their organisation was staffed well enough for them to do their job properly. The Royal College of Midwives (RCM) has estimated that midwives are providing an average of 100,000 hours of free labour a week. For babies who need additional care, a 2024 audit revealed one in five Neonatal Intensive Care Unit shifts are not sufficiently staffed, with local and regional variation. 

Staffing challenges have an impact on trainees and the newly qualified too. 64% of trainee midwives said in 2024 that staffing levels had negatively impacted their experience of clinical supervision. In 2025, 40% of obstetrics and gynaecology trainees (and trainers too) said that training was adversely affected because rota gaps were not dealt with appropriately (among the highest across medical specialities). One-third of recent midwifery graduates report not having secured a position due to ongoing recruitment freezes and financial constraints, despite chronic staffing shortages. 

A range of factors beyond the numbers contribute to the workforce challenges, which we’ve captured in the graphic below.

The RCM has outlined solutions to improve trainee numbers, including reducing student debt and increasing quality of training. For those entering midwifery, an apprenticeship programme for maternity support workers aims to ease access to midwifery training and retain valuable experienced staff, and the Turning the Tide mentorship programme supports minoritised ethnic staff to reach senior levels in maternity services. The RCOG’s 2025 workforce census suggested that flexible working and protected time for education, training and leadership for senior clinicians could further increase staff retention. To enhance maternity and neonatal services’ workforce, it is essential that NHS workforce plans and the National Investigation specifically address effective approaches for improving staffing levels.

Developing and sustaining a culture of safety learning and support 

This theme aims to develop and sustain a culture of safety, learning, and support. However, the delivery plan suggests, correctly, that culture is inherently difficult to measure, and progress under this theme is to be inferred indirectly through staff and patient feedback, incident response processes and qualitative evidence rather than through clearly defined outcome metrics. Thus, the main sources of evidence for outcomes are the CQC annual maternity survey and the annual NHS Staff survey – the same data sources used in the two previous themes. 

Culture is complex and can be described in a myriad of ways, but probably most simply as ‘the way we do things around here’. Describing culture in maternity services is particularly complex. It is widely acknowledged that polarised ideologies exist between midwifery and obstetrics team members, which can affect the effectiveness of joint working. So, if improvement efforts assume that the ‘culture’ of delivering maternity and neonatal care is a single variable that can be manipulated by management (an approach popularised by mainstream corporate management handbooks), this narrow lens ignores the unspoken social rules, small ‘p’ political contexts, and professional dynamics that influence safety culture. Care should be based on the best available evidence, rather than personal or professional ideology. Practical frameworks such as THIS’s Seven features of safety in maternity units can help, giving services evidence-based areas of focus to improve safety culture. 

The National Investigation will no doubt need to look deeply into safety culture when consolidating a summary of national challenges and recommendations – moving past the simplistic diagnoses around culture and prescriptions that lack depth and specificity, which have been seen in previous maternity and neonatal investigations. 

Standards and structures to underpin safer, more personalised, more equitable care

This theme aims to apply the national standards and structures in the Maternity and Neonatal Safety Improvement plan Programme to make care safer, more personalised and more equitable across all groups of women and babies. Plans encourage use of evidence-based best practice approaches, such as the maternal care bundle to decrease maternal mortality and maternal morbidity, observation escalation tools to detect deterioration faster for mothers and babies, the Saving Babies Lives Care Bundle to reduce preterm births and stillbirths, as well as the Avoiding Brain Injury in Childbirth (ABC) toolkit to minimise risks of brain injury. Outcomes are being measured using the maternity safety ambition metrics, but as described above, action is not equating to progress against metrics. 

The theme also encourages using data to inform learning, and a key part of that is the new Maternity Outcomes Signal System (MOSS) tool, which allows near-real-time data to be brought together at a national level (as well as at ICB and trust level) triggering alerts based on patterns and trends to prompt immediate review and action in maternity units. Another key objective is making better use of technology by enabling women to access their records and interact with their plans digitally. It is too early to understand the impact of the new MOSS tool and expanded digital access.

Is England making progress on promises to improve maternity care?

The evidence presents a bleak and incomplete picture. Maternal mortality rates have risen rather than fallen, and progress on reducing stillbirths, preterm births, and neonatal deaths has stalled – suggesting maternity and neonatal care is worse for all women (regardless of ethnicity). Brain injuries during or soon after birth remain stubbornly high, with no single source of data to measure against the 2025 target. Despite reported improvements in patient experience scores via the CQC maternity survey, we know that experiences vary significantly across demographic groups, and serious concerns continue to be raised by advocacy organisations representing Black women and bereaved families. The delivery plan is unlikely to drive improvement without clear plans to address the socioeconomic risk factors that underpin many of the inequalities visible in maternity and neonatal outcomes. Focusing on listening to women and safety without fully understanding what’s driving different experiences and outcomes is unlikely to improve care for everyone. 

Another fundamental challenge in assessing and achieving progress is the lack of clear success criteria for some outcome measures. For indicators like the CQC maternity survey and NHS staff survey, there are no government-defined targets for 'successful achievement'. Without agreement on what good looks like, or what is realistic in the context of increasing resource pressures, it becomes impossible to determine whether any incremental improvements on survey questions represent meaningful progress or falling short of what's needed. 

Perhaps more fundamentally, the maternity and neonatal services sector is operating under an overwhelming proliferation of recommendations. Over the past decade, multiple inquiries and reviews have generated hundreds of recommendations, creating a fragmented landscape that risks diluting efforts and increasing administrative burden on already-pressured services. Workforce challenges persist underneath increasing requirements, and while addressing substandard care is essential, avoiding blame culture is important to enabling positive change. Different stakeholders – each with their own organisational priorities focused on particular sections of various plans – may have vastly different views on what should be prioritised and what constitutes 'good’ and ‘fair’. Securing consensus across this crowded space will be incredibly challenging.

What is needed now?

There have been concerns expressed over how aspects of the National Investigation are being conducted, but in a context of increasing public and political pressure for action, there is an opportunity for meaningful change – if it brings coherence to improvement efforts, with a prioritised set of national actions based on engagement with families including bereaved families and staff.

Three things are essential if the National Investigation, the taskforce recently assembled to take action on the investigation’s findings, and any future maternity and neonatal policies are to succeed.

First, it is imperative that the National Investigation process and any future government plans place the voices of women and families who have had poor experiences of care, and have been harmed or bereaved, at its very centre. Their perspectives must be respectfully listened to and learning from ‘adverse outcomes’ must be meaningfully incorporated into both the assessment of existing challenges and the development of solutions. Within that, it is essential to prioritise working with women and families facing the highest risk factors and poorest outcomes (and often poor experiences of care). Without fully understanding and valuing all insights and embedding an inequities and inequalities lens across all parts of any future government policies, future policies risk repeating past mistakes, missing critical opportunities for improvement, and sustaining the unfair differences in outcomes. Ensuring robust engagement and compassionate support for those affected should be a clear and non-negotiable priority, during the National Investigation and after it has been published. Inquiries and investigations in hospitals or across the whole NHS shouldn’t be the only opportunities to allow women and families to share their stories and voice recommendations for improvements. An ongoing dialogue is needed to ensure that women and families are continually given opportunities to voice their concerns and experiences.  

Second, explicit attention to reducing ethnic and socio-economic inequities and inequalities is essential. This will require a systemic and co-produced approach, considering the wider determinants of health. Without a sustained and system-wide focus, the cycle of inquiry recommendations, and limited implementation is at risk of continuing. Strong, visible leadership to drive and monitor delivery will be essential to achieving meaningful results. This is particularly important in the current context of structural change in the national and local systems, including the loss of Local Maternity and Neonatal Systems (LMNSs). Establishing an ambitious yet realistic set of targets for all quality, safety and experience metrics as well as clear timelines, aligned with a manageable number of prioritised recommendations, will be important to avoid overwhelm and direct resources to where they are needed most. 

Third, workforce investment must be sustained alongside cultural change. Even a streamlined set of priorities will only be achievable with adequate staffing – as well as staff who are well supported and feel empowered to drive positive change. The previous NHS Long Term Workforce Plan's projections have been widely questioned – with the predicted growth being labelled 'a fiction', as we await new workforce planning from government. Alongside increasing staff numbers and wellbeing, the difficult work of consistently strengthening safety culture, improving reporting, and embedding learning from incidents will be more likely to succeed if fairness is prioritised over blame culture – recognising that systemic issues are usually at the core of safety incidents. This requires long-term resources and sustained leadership commitment, not quick fixes. 

The families who have experienced preventable harm, avoidable bereavements, and poor experiences of care deserve better. As do the health care professionals working under immense pressure to deliver safe care despite systemic challenges. A more focused, evidence-based, system-wide and adequately resourced approach that tackles inequalities, with women and people who give birth at its heart, is needed to make meaningful progress on promises to improve maternity and neonatal care in England.