England will appoint its first maternity and neonatal commissioner to drive urgent improvements in childbirth care, following a government-commissioned review by Lady Valerie Amos that found the system is plagued by poor care, racism, and discrimination.
Commissioner to Oversee Reforms
Health Secretary James Murray announced the move in response to the Amos review, which concluded that the maternity and neonatal system in England is no longer fit to consistently deliver high-quality, compassionate care. The commissioner will pursue hospitals over persistent failures and co-chair the national maternity and neonatal taskforce, which is due to present an action plan in December.
Donna Ockenden, who led last week's inquiry into the Nottingham maternity scandal, is widely expected to become the commissioner.
Key Findings of the Amos Review
Lady Amos's 181-page report, based on a nine-month investigation, found that for many women, 'the care they receive is not good enough and can result in avoidable harm.' She noted that women of colour have experienced racism or discrimination, leading to delays, unsafe care, and devastating outcomes. The report also highlighted a lack of pain relief during caesareans and assisted births, and a system that is 'confusing, inflexible and unresponsive to women and families.'
Amos made eight main recommendations, including an urgent overhaul of maternity triage services, the right for families to seek independent investigations, and replacing the 'brutal' and 'cruel' compensation system with one where hospitals admit errors immediately.
'Having a baby should be one of the happiest moments of a family's life. For most women in England, it is. But for too many – depending on where they live, who they are or simply the day they give birth – the care they receive is not good enough and can result in avoidable harm,' Amos said.
Government Response
Murray pledged that the report would be 'a turning point' and that the commissioner would 'drive lasting change and make sure women and families are never ignored again.' The announcement comes amid growing pressure after a series of maternity scandals, including the Nottingham case.
Amos highlighted that stillbirths and neonatal deaths are at near-record lows, but progress has stalled since 2020. She also noted that many previous recommendations have not been implemented or proved short-lived, and that some maternity units are so old they are now 'unsafe'.
Resignation of Clinical Adviser
The report was overshadowed by the resignation of clinical adviser Dr. Bill Kirkup, a renowned maternity safety expert, hours before publication. Kirkup disagreed with the report's section on 'normal birth ideology,' which holds that women should give birth vaginally without intervention as far as possible.
