Her Independent National Maternity and Neonatal Investigation's interim report also identifies structural racism and discrimination as major challenges.
Baroness Valerie Amos said: ‘It is clear from the meetings and conversations I have had with hundreds of women, families and staff members across the country, that maternity and neonatal services in England are failing too many women, babies, families and staff.'
The report identifies staffing challenges with services sometimes lacking the right skill mix, seniority and continuity, and some staff suffering burnout and low morale.
When things go wrong, the report found families too often faced defensive and inadequate responses, with no, slow or poor-quality investigations leaving them without answers and causing further distress. Access to independent scrutiny in relation to stillbirths and neonatal deaths was also inconsistent.
The report highlighted the critical role of culture, leadership and the physical estate in shaping safety and experience. It said co-ordinated, system‑wide action is required to improve safety, equity and accountability, and to ensure the voices of women and families were heard.
Recommendations from the first stage of the investigation will be published in spring 2026. The investigation's call for evidence remains open until 17 March.
Reaction
Layla Moran, chair of the Health and Social Care Committee, said: ‘The findings in this report are sadly all too familiar, but seeing all the issues outlined side by side underlines the challenge to Government in turning this around at a national and systemic level. The committee's message to ministers is clear: don't wait to start making changes – especially with the workforce plan imminent. The excuses for any more delay have run out.'
Rory Deighton, acute director speaking on behalf of the NHS Confederation and NHS Providers, said its members recognised ‘unacceptable failings in maternity and neonatal care and are committed to doing everything within their power to ensure these are not repeated'.
Deighton added: ‘National support will also be needed to tackle the more systemic issues, such as around physical estate and staffing levels, as these will require sustained investment to put right.'
"Our members are keen for this review, and the national recommendations in the spring, to be a turning point for women, babies and their families so that everyone gets the high quality and safe maternity and neonatal care they deserve."
Health and social care secretary Wes Streeting said: ‘Baroness Amos's report lays bare the systematic, sustained, and recurring failures in maternity and neonatal care across the country, which have left too many mothers, babies and families as victims of avoidable NHS tragedies.
‘I will shortly launch and chair a new National Maternity and Neonatal Taskforce to develop a new national action plan, which will draw on Baroness Amos's interim findings and will be further informed by the recommendations of her final report due in the spring.'
Streeting said the Government had recruited 800 more midwives, invested over £140m in addressing critical safety risks on the maternity estate and rolled out guidance to tackle the leading causes of maternal death.
