The road divides on maternity

The publication of the latest reports by Donna Ockenden and Baroness Amos has reignited debate about the future direction of maternity services in England. While both identify deep-rooted problems in safety, culture and accountability, they propose different paths towards reform. In this opinion piece, Neil Stewart examines the emerging divide, exploring the arguments for a Maternity and Neonatal Commissioner versus a judge-led public inquiry, and asks which approach is most likely to deliver lasting improvements for women, babies and maternity professionals.

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Which way for maternity service improvement and safety? Two reports in two weeks and the sudden, and surprising divide into a choice between two roads ahead.

The Maternity Rights Commissioner road proposed in the Amos report or the full Judicial Review/Public Enquiry road demanded by the families in the Ockenden reports. How has it come to this as a divide?

The Ockenden report on Nottingham University Trusts maternity units and the Baroness Amos’ investigation and report into 12 Maternity Units seemed to agree on so much and mostly to complement one another.

Women not listened to, professional misogyny, evasion and cover up by management, lack of accountability, racism and discrimination, poor standards, incompetence not following basic tests and checks, women being sent away not admitted, women and babies being discharged too quickly with missed signals, poor communication and outright disrespect and cruelty towards women as well as breakdowns in professional discipline, staffing shortages and “toxic” cultures, midwifery education not designed for stressed units or for 50% C section rates. The cost of compensation now bigger than the cost of the maternity service. The list is all there in both reports.

Donna Ockenden had signed the Birth Trauma petition for a Maternity Rights Commissioner. She is now moving on to her next enquiries into Leeds and Sussex where everyone expects she will find more of the same.

But the families and their support groups have attacked Baroness Amos and see her commissioner proposals as competing with their proposal for a legal investigation.

What perspective to look at all this through? Numbers are always a good place to start. Donna’s review of NUH covered the period 2012 to 2025 when Nottingham Universities Trusts two maternity sites had 122,022 births of babies (plus @ 122000 mothers making around 240,000 patients) Of these 2500 cases came forward or were contacted by Donna’s team and were reviewed, some were self-selected, some were “opted in” by her team to build the numbers to get a working sample. 88 contacted declined to take part.

Of the 2500 cases reviewed the Ockenden review found 520 in which there was “avoidable harm” implying in the remaining 2000 cases what happened was unexplained or “unavoidable” a reminder that we still do not know the causes of many stillbirths and serious incidents and the causes of harm in childbirth and there is still no 100% guarantee.

The Ockenden report then goes on to focus on these difficult/avoidable cases and draw lessons, conclusions and recommendations from their testimonies and experiences.

Of these 136 were still births, 104 were brain injuries and serious long-term harm and 9 were maternal deaths of which six were considered avoidable with the remainder varying degrees of avoidable unacceptable physical and psychological trauma even if the mother and child survived. 76 cases were neonatal cased and 31 are identified as deaths of a newborn, although the corelations between whether these were all in neo natal is not clear. It appears that of the 520 that were level 2/3 about half were then judged to be “avoidable harm”.

The individual stories are harrowing and a necessary reminder of the consequences of professional failure and its impact on lives and families. They show up the weaknesses in reporting and the professional and management tendency to cover up and avoid scrutiny and accountability, plus the learning that should come from it.

But to read the press and watch TV you could get the impression that NUH maternity units were failing all the time at every level for most pregnant women and did not deliver safe care for the vast majority, which they clearly do for the majority of the 122,022 pregnant women who passed through their care over the period 2012 – 2025.

There is no doubt that behind the Ockenden figures will be many more unreported cases of birth trauma across the range suggested by the Brith Trauma Association and the work of Theo Clarke, the former MP who raised the call for a maternity commissioner in the last parliament.

Donna Ockenden’s first report on Shrewsbury and Telford did much to help the public and policy makers discover the long tail of birth traumas that affect women in childbirth even when both mother and baby come through alive. But is also reignited the debate about “an ideology of normal birth” in the media.

So what in the Baroness Amos report has led to the fierce backlash against its central recommendations which many would find consistent on an organisation wide basis for tackling the issued made visible in Ockenden.

The two that are making headlines are first that the Amos recommendation for a Maternity and Neonatal Commissioner is being portrayed as a block or alternative to a “full judicial review” or a “Judge led enquiry” or “public enquiry” presumably on the model of the Post office Enquiry or Grenfell Tower. Spokespeople and commentators for some of the families have even gone so far as to call relying on a single Commissioner “dangerous”.

The Second objection is that Baroness Amos finds that the bias towards “normal birth at any cost” among midwives that has been claimed as a key cause of harm over the past decade, resisting escalation to medics, arguing against C sections is not proven.

“The evidence we gathered did not allow us to determine the national prevalence of normal birth ideology.”
Amos Report, 30 June 2026

“We also heard from women who felt pushed towards intervention without adequate discussion of their preferences or the evidence base. Midwifery and obstetric staff in the trusts we visited told us that they did not recognise a ‘normal birth at any cost’ ideology being present in their own units.”
Amos Report, 30 June 2026

“I don’t recognise it. When I read that midwives don’t call in the doctors if they’re worried and stuff, I’ve never seen it. I’ve never felt it. I’ve never seen it. Ever. So, we absolutely do not have that here, and I can say that with my hand on my heart.”
Staff member

Amos has also attracted some negative comments about A&E and Maternity Triage where she highlights the inadequacy and goes on to make specific recommendations about round the clock staffing, with senior midwives and medical in attendance 7 days a week, day and night available to review any women’s care. Similar to the implications of Ockenden’s recommendation that Martha’s Law for a second opinion is mandated.

Amos has a wide range of observations not just about individual treatment of women and babies but about the buildings, the technology, the bed numbers, theatres, the staffing, the relationships between midwives and medical staff and importantly the relationships and working practices between maternity units and neonatal units and their services.
Her report, following the focus of an earlier Select Committee Report, includes neo natal units and her recommendations call for much better integration.

Social media comments have been quick to point out the huge implications of this for staffing, medical staff rotas, work life balance for staff, impacts on training routine consultations and increased numbers of midwives and medical staff in training to make this possible.

These protests are understandable, but the basic fact remains that pregnant women do not give birth according to an outlook calendar on Monday to Friday and services need to reconfigure to be 7/24 and this will need a significant change in services and resources.

Dr Bill Kirkup, who resigned from the Amos enquiry over the “normal birth” conclusions observed in a recent Roy Lilley podcast that in his practice days he expected to be dealing with 5% of at-risk women and midwives leading on the other 95% of births. He also observed with some surprise that the length of stay in a maternity unit had now dropped to below 2 days.

Midwives will recognise that maternity units no longer resemble that old profile, with up to 50% C Section rates in many units and none of the longer admission and then lying in available to women decades ago and still practiced in France and other comparable countries.

The other feature of the dividing road is the calls for the involvement of the police, the courts and calls for accountability, often meaning prosecution of senior managers and clinicians. There is currently a police investigation (Operation Perth) into Nottingham, and two people at the Nottingham Mortuary have been arrested on what is reported as “misconduct in a public office” and there have been three senior Nottingham midwives in receipt of CBE’s named in the press, with the implication that they should face some recall, accountability or punishment.
The idea that the police and the judicial route should be the one followed stems the justifiable frustration of the families at management cover ups and evasion and delay and the inability of the NMC and GMC to look beyond individual conduct to the surrounding circumstances, or the CQC reports to prompt evidence to improvement, to the point where 2/3 of maternity units are bundled together as unsafe or inadequate in the press.

But policy makers will also be aware that the judicial route is also the preferred route of lawyers, the media and some charities for their own reasons.
Which route – Commissioner or the Courts can force the pace of change?

We already have some examples. East Kent was taken to court, where they pleaded guilty and were fined £735,000. Similarly, Nottingham have been taken to court, pleaded guilty and were fined over £1 million. These are puzzling cases as the fines simply go into government coffers – the family in East Kent got a victim’s payment of £175. Is this to frighten other managements to take maternity more seriously or is it public admission to give some families a closure? The jury is out, as they might say.

But the bigger question is the impact of the fear that mistakes and errors, whether from staff shortages, missed signals, tech and record failures which can result in a criminal conviction is the right way to deal with the medical risks of childbirth.

There will be medical cases where a Dr Shipman or a Nurse Letby is convicted of deliberate and premeditated injury or murder, but even the Letby case is already throwing up questions of whether correlation (she was there at time) proves causation (she did it deliberately or negligently).

We already see the impact of legal action in maternity on medical and midwifery practice with defensive medicine being practiced, with interventions rising in the past few years way beyond comparable maternity service in developed countries with equal or better still birth or maternal mortality rates than the UK. In practical terms demanding more staff time, more theatres, overwhelming some facilities, as Amos described in grim detail about maternity wards.

The legal experts have a phrase that “hard cases make bad law” and that is partly what maternity services are already living through. Are we going down a road which leads to arrests for unintentional, unprofessional mistakes and errors, trying to prove that it was intentional, premeditated or malicious. I don’t think Donna Ockenden is going down that road even from the distressing cases reviewed by her team.

The compensation system which necessarily focusses on the hard cases, and which Amos calls for it to be amended to no blame and learning from other countries, is delaying resolution, delaying learning from mistakes, suspending professional careers and families lives, driving defensive practice and yet the still birth rate has not recovered to its pre COVID rate and nowhere near the target of being halved by 2030, and the maternal death rate is rising.

It is a chilling reminder of the Harvard University/Ariadne Labs work of Dr Neel Shah in 2017 who in a mass study concluded, in a more medicalised system, “A women in the US is now 50% more likely to die in childbirth than her mother” And a decade later we have now overtaken the US in C section rates, USA is 32% the UK is 44%.
Which way to go. Donna Ockendens’ inquiry reports have the merit of leading public discovery of the horrors of some women and families’ experiences and refreshing the public mind about the failings in the system.

Baroness Amos’ report look at the whole system and proposed not just improvement to professional practice and accountability, but reconfiguring of services and appointing a Commissioner to help drive the Secretary of States’ Task force to make the change.

Midwifery Education

A final observation about both Ockenden and Amos reports is on the state of Midwifery Eduction and whether it is fit for purpose, are we training student midwives for a world where 75%- 85% of women give birth vaginally, like Iceland and other European countries or for a more medicalised, interventionist system with women with more co-morbidities’ as well as older age with 50% interventions and surgery.

Donna Ockenden has called for a reset to the position where midwives came from the nursing profession, having trained and practiced as a nurse first. The contention being that women with more general health condition need nursing as well as maternity, looking after by staff with skills that would be more associated with nursing than midwifery.

The Midwifery courses are supposed include 50% of student time in practice on maternity wards, which is also how nurses are now trained.

The Maternity & Midwifery Festivals have heard from Nicky Clarke, formerly LME at Hull the extensive problems in midwifery education including the problems co ordinating University systems and pay with NHS trusts, supervision of students, completing attending the 40 births requirement.

The system does need urgent reform but it is a surprising call against a report which highlights how midwives now need to understand society better, be more inclusive in their practice, be more psychologically aware or mental health issues, recognise racism, domestic abuse, impact of poverty and all the things that were never taught in old style nursing courses.

The next few weeks will determine which road maternity service reform will go down. Let us just hope that the politicians do not try to go down both roads at the same time.

Neil Stewart
Editorial Director, Maternity & Midwifery Forum

July 2026