The inquiry heard repeatedly that racism is ‘one of the core drivers' of poor maternal outcomes for Black women.

Acting chair of the Health and Social Care Committee, Paulette Hamilton, said: ‘In-built structural racism in maternity services repeatedly fails Black women. Acknowledging this and addressing racial disparities in maternal outcomes must be one of the investigation's core aims. This has to be the turning point for England's maternity services and particularly for Black women if we are to achieve equity.'

The report acknowledges that failings in care for Black women are taking place in the context of a maternity system that is failing women more broadly, with the NHS in England having paid £27.4bn in maternity negligence since 2019.

The Committee says it is ‘indefensible' that cultural competency training is optional for NHS staff and leaders working in maternity services, including midwives. The report urges the DHSC to work with the NHS, the Royal College of Midwives and the Nursing and Midwifery Council to introduce mandatory cultural competency training for all midwives, which they say should be informed directly by the experience of Black women.

Along with recommendations to address culture, leadership and racism, the report identifies the workforce, a shortage of data and cuts to funding as key areas of concern.  

A DHSC spokesperson said: ‘Racism in any form is completely unacceptable and we are determined to reduce the shocking disparities that this report addresses.

‘Every woman deserves safe, compassionate care and that's why the health and social care secretary commissioned a rapid investigation to start tackling maternity failings, so that no more families have to suffer.

‘As part of the investigation, Baroness Amos will publish recommendations to reduce inequalities including racism and discrimination in maternity and neonatal care across the country.

‘We're already taking action to improve maternity care, including launching an anti-discrimination programme, training thousands more midwives, and introducing new standards to tackle leading causes of maternal mortality.'