Maternity care is broken. Who can fix it?

This article is republished from The Financial Times

Laura-Beth Thompson was 36 weeks pregnant and in hospital after being admitted for dehydration when she was told that she was probably suffering from pre-eclampsia, a potentially fatal condition, and that the baby needed to be delivered immediately.

What followed at Burnley General Teaching Hospital in Lancashire in January 2022 was a cascade of complications, including a failed induction, a patchy epidural that spread too high up her spine, an incision intended to minimise tearing and finally an instrumental delivery.

The new mother lost 4 litres of blood and suffered a severe third-degree tear — something she said she was not told about until six weeks later, when she saw a private gynaecologist after weeks of being unable to empty her bowels and struggling with bladder control.

“I still feel disgusted that I could have such significant injuries and nobody told me or advised me on how to look after myself, resulting in permanent injuries,” says Thompson, who still suffers with lasting physical damage as well as severe post-traumatic stress disorder.

Thompson’s experience is shocking but increasingly commonplace.

Every day, women in England are giving birth in a health system that is under immense pressures.

Midwives are stretched to exhaustion, hospitals juggle complex cases with inconsistent guidance, and families navigate a postcode lottery of care.

The result is that the standard of pre- and postnatal care is slipping.

After Thompson’s son was born, over the course of three days, four different healthcare professionals dismissed her and her partner’s concerns that he was yellow and might have jaundice.

On the evening of the fifth day, she said, “we got a call asking us to attend the hospital immediately” as her son’s bilirubin levels were so high “he was critically ill”.

The hospital’s trust says it has worked with Thompson and put improvements in place since her experience.

For women, giving birth is becoming riskier.

Maternal deaths in the UK have increased since the pandemic and are now higher than they have been for more than a decade, according to the latest data.

The maternal mortality rate was about 12.8 deaths per 100,000 in 2021-23, compared with around 10.6 per 100,000 in 2009-11.

Recent research cited by the all-party parliamentary group on birth trauma suggests that 4-5 per cent of women develop postnatal post-traumatic stress disorder, while up to one in three report finding aspects of their birth experience traumatic, the equivalent of 30,000 women a year in the UK.

4-5 % of women develop postnatal post-traumatic stress disorder, while up to one in three report finding aspects of their birth experience traumatic

Successive governments have made statements about fixing the crisis.

Almost a year after entering government, in June 2025, Labour appointed Baroness Valerie Amos to lead an independent investigation into maternity and neonatal services.

In an interim report published in December, ahead of her final report due this spring, the peer said the failings uncovered so far were “much worse than I anticipated”.

Past investigations into a number of scandals in hospital maternity departments, including in East Kent, Shrewsbury and Morecambe Bay, have produced detailed recommendations — more than 700 have been made in the past decade — and yet there have been few measurable improvements in care.

“One issue is that there are simply too many recommendations, creating the problem we call ‘priority thickets’ — action is paralysed by lack of clarity on the most important things to be addressed,” says Professor Mary Dixon-Woods, director of The Healthcare Improvement Studies Institute (This).

The inquiries have exposed the same systemic failings: families navigating inconsistent standards of care, repeated failures to act on women’s concerns, exhausted staff and weak leadership.

While many countries are grappling with stretched health services and demographic changes — women are giving birth later in many rich countries — the UK falls behind in measures such as maternal mortality despite spending more on healthcare.

The UK spends around 11.1 per cent of GDP on healthcare, above the OECD average of 9.3 per cent, yet countries such as Norway, which spends 9.7 per cent of GDP on health, have lower maternal and neonatal mortality.

Japan also reports strong outcomes in childbirth, while spending 10.6 per cent of its GDP on healthcare, which suggests the safety of women and babies depends not only on financial investment but on whether the right systems and culture are in place.

Patient safety experts point to the UK’s long waiting times and sustained strain on the NHS as the main causes of different outcomes.

As the UK awaits the findings of Amos’s report, which will draw together lessons from previous inquiries to create a “single national set of actions to improve care”, some question whether these latest proposals will finally lead to meaningful change, or if the system is beyond repair.

Theo Clarke, a former Conservative MP and chair of the all-party parliamentary group on birth trauma inquiry, which published its own set of recommendations in May 2024, says she believes the government is merely “kicking the can” down the road.

“It just doesn’t want to spend the money, and it doesn’t want to prioritise women’s health or maternity care.”

The Department of Health and Social Care says that it has launched Amos’s review “to drive urgent improvements to care and safety” and, once its recommendations are published, it will “urgently act on them”.

“We’re already investing over £130mn to make maternity units safer, rolling out programmes to reduce avoidable brain injury and piloting Martha’s Rule in maternity services,” a spokesperson adds, referring to the initiative that provides patients with a second medical opinion on request.

At the heart of the crisis lies a long-standing tension between birth as a physiological process and birth as a medically managed event.

While the creation of the NHS and universal access to maternity care “dramatically improved safety”, says Maxine Palmer of the National Childbirth Trust, services became “increasingly shaped by institutional systems and pressures, which makes it harder to provide truly personalised, women-centred care”.

From the 2010s, women had increased access to midwife-led birth centres and home birth services.

However, this progress stalled and in many areas reversed following sustained funding cuts from 2010 during the years of austerity.

Birth centres closed, staffing levels fell, and community services were increasingly covered by overstretched hospitals.

Of the 131 units inspected by the Care Quality Commission, the industry regulator, between August 2022 and 2024, 36 per cent were rated as “requires improvement” and 12 per cent as “inadequate”.

At the same time, a wide variation in local trust policies has created a “postcode lottery” in care.

Unlike many other areas of the NHS, women’s maternity care does not have a single national protocol, even though guidance exists, which can lead to variation in practice between hospitals.

“There is no standardised package of care, or national maternity strategy,” says Clarke, who herself experienced a serious birth injury — a third-degree tear — and later developed PTSD.

NHS hospitals interpret guidance individually and very little is mandatory, which means care is not joined up or consistent, she adds.

NHS hospitals interpret guidance individually and very little is mandatory, which means care is not joined up or consistent

“When I asked a frontline hospital obstetrician where policy guidance came from, he told me he referred to around 80 different documents to work out how to practise safely on a ward,” Clarke says.

Until very recently, hospital trusts in England had 147 different ways of calculating an obstetric early warning score, which uses a woman and baby’s vital signs to assess how a birth is progressing.

NHS England is now standardising the score, but the discrepancy created a situation where there were enormous variations in what counted as something as basic as a fever or a low temperature, or what counted as a high heart rate.

“Systems are a really, really important part of this,” says Dixon-Woods. “I always say with these kinds of things, we should design them once, do it right, and then everybody more or less does the same thing. But instead we leave it up to everyone to do things locally and that produces massive variation with potentially adverse consequences.”

The report into failings in maternity and neonatal services in East Kent Hospitals University NHS Foundation Trust concluded in 2022 that the outcomes in half of the 202 cases reviewed would have differed had care been given to nationally agreed standards.

As many as 45 of the 64 deaths and 12 of the 18 brain injuries in babies could have been avoided, as could 23 of the 32 maternal deaths, it said.

Such failures on maternity wards have knock-on effects for the health service.

Every year, the NHS pays out vast sums in compensation — so vast that, in some cases, they rival or dwarf the annual budgets of individual maternity services across the country.

Last year alone, the NHS paid out £1.5bn for claims involving brain injuries at birth, while other paediatric failings cost the taxpayer-funded service £325mn.

In Clarke’s final report, which was informed by evidence given by over 1,300 families, she called for a national maternity improvement strategy — a single, publicly accessible document setting out exactly what policy is.

She is also campaigning for the appointment of a maternity commissioner to provide consistency and oversight of any reforms.

“We talk about the ‘national’ health service, but in maternity care it isn’t truly national,” Clarke says.

A central contradiction in maternity care is that outcomes have deteriorated or stalled despite falling birth rates and rising numbers of midwives.

Over the past 15 years, the burden on midwives has eased as the average number of births has fallen, and the country now compares favourably with several European peers on staffing ratios.

The average annual number of births per midwife — a measure which includes those not actively delivering babies — dropped from a peak of 34.7 in 2007 to 25.8 in 2022.

By comparison, France recorded 31.3 births per midwife in 2021, Germany 31.8, and Spain 34.3.

At the same time, maternal deaths have risen.

This increase reflects, in part, the growing complexity of births, as women are having children later in life.

Last year, the Royal College of Obstetricians and Gynaecologists warned that the maternity workforce was struggling to cope with rising levels of birth complexity, with more than half of all births involving medical intervention such as caesarean sections or forceps.

As a result, fewer than half of women now go into labour spontaneously, a marked decrease from around 70 per cent at the start of the century, according to NHS England’s Maternity and Neonatal Infrastructure Review.

Births by caesarean section have also increased at an average annual rate of 4.6 per cent since 2005, while inductions of labour have risen by 2.9 per cent a year over the same period.

Rising levels of immigration to the UK have presented new challenges, including language barriers and gaps in medical history, that can affect care.

“Many women don’t fully understand the information provided, and they don’t have the resources to do their own research,” says one midwife.

Black women are nearly three times as likely as white women to die in childbirth, while neonatal mortality among the most deprived part of society is more than double that of the least deprived.

“We’ve had a really very substantial change in the population using maternity services,” says Dixon-Woods. “It’s now completely different from what it was like 50 years ago.”

Black women are nearly three times as likely as white women to die in childbirth

More and more women in England and Wales are giving birth later in life.

Between 2023 and 2024, the largest increase was among women aged 35 to 39, whose live births rose by 2.7 per cent, according to the Office for National Statistics.

At the same time, NHS data shows that 26.2 per cent of women were living with obesity in early pregnancy in 2023-24, up from around 19 per cent of women in 2015.

Dixon-Woods adds that the service is being shaped by a minority of very experienced midwives and a generation of younger midwives who have not necessarily been trained in the same way as their forebears and need time to gain experience.

“Because of the way we’ve ended up with this reporting-heavy culture, many of the more experienced midwives end up doing a lot of the data and reporting work, and it’s the younger ones who are out on the floor,” she says.

“So you’ve got this combination of a higher-risk population and a less experienced workforce looking after them.”

Midwives also develop different skills depending on whether they work in high-risk obstetric units or community settings.

The frequent redeployment between the two means staff are often required to work outside their skill sets, particularly in the context of rising induction rates, which now account for around one-third of all births in England.

While continuity of care, which means a woman has the same midwife or small team throughout pregnancy, birth and after, would improve care, staffing pressures mean this is also becoming increasingly uncommon.

Midwives themselves say their working conditions can be borderline dangerous.

In the UK, midwives are subject to the working time directive, which means they shouldn’t work more than 48 hours a week, and are entitled to 11 hours rest between shifts.

However, midwives tell the FT that being on call overnight on a shift, which can be punctured by emergency situations, can mean working for over 24 hours straight.

Midwives themselves say their working conditions can be borderline dangerous

Community midwives’ shifts can run from 8am to 6pm, followed by on-call duties from 6pm to 8am, often leaving midwives exhausted yet expected to return to work the next day.

On-call hours are not included in contracted hours, and refusing them can result in owing shifts.

One midwife describes returning from an all-night call on Easter Monday, then completing paperwork and home visits, only to feel “hungover from sheer exhaustion”.

Driving home after these shifts is particularly dangerous, she adds.

“It makes you wonder, if women knew how exhausted we are, would they feel safe having us attend their birth?”

When complications arise, midwives say that responsibility is often placed on them, with management sometimes obscuring what happened.

They report being forced to handle high-risk cases, including twins and premature or small babies, sometimes alongside newly qualified midwives on call for the first time.

“It’s just an absolute shambles,” says one.

The lack of oversight and support, she explains, means that “patient safety becomes a real concern”.

Leah Hazard, a midwife and author, has recently launched a campaign calling for better protection of midwives’ working hours.

“Midwives’ working conditions are women’s birthing conditions, and it’s time that the government acknowledged that,” she says.

Experts say that high sickness rates, burnout, unstable rotas and lack of basic staff facilities such as toilets and break rooms are not merely workforce issues.

They can impact safety, morale and the retention of midwives.

“Maternal and neonatal safety cannot and will not improve until midwives are supported and resourced to give the gold-standard care we’ve been trained to give,” says Hazard.

For Lucy Jones, author of Matrescence, which explores societal understanding of motherhood, the roots of the crisis are more fundamental.

There is an “assumption that trauma is simply what birth is, something women should just endure

There is an “assumption that trauma is simply what birth is, something women should just endure”, she says.

The way we think about birth has long shaped both policy and funding decisions in the UK, she adds.

“All of this leaves me wondering: is the problem ultimately money, culture or accountability — or all three? And why, despite everything we know, is maternity care still not treated as the priority it so clearly should be?”

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