Independent Investigation into Maternity and Neonatal Services Interim Report: Key findings and next steps

On 26 February 2026, Baroness Valerie Amos published the Interim Report of the Independent National Maternity and Neonatal Investigation (the ‘Interim Report’), building on the Reflections and Initial Impressions report, published in December 2025.

This is a significant moment, not least because unlike previous investigations and reviews, this investigation is national in scope with a "whole system view - looking at people, culture, organisation, processes, infrastructure and the wider factors impacting on the care delivered by maternity and neonatal services."

The Interim Report provides powerful insights from further engagement with women and families, community organisations and staff, making it clear to all that the system, nationally, is under extraordinary strain and that a step change, based on a family first, whole system approach is urgency required to ensure the provision of safe, consistent and equitable care. 

The Interim Report sets out important context and identifies six key factors which could be contributing to the pressures on the maternity and neonatal system. However, the final report, with one set of national recommendations, is not expected until Spring 2026. The Secretary of State for Health and Social Care will then chair a National Maternity and Neonatal Taskforce whose role it will be to design and deliver an Action Plan informed by the report findings and its recommendations. 

This article provides an overview of the Interim Report findings and how to access some practical steps that NHS Trusts with maternity units may wish to take now, to begin to address the issues which have been identified in the Interim Report and to be as well placed as possible to implement the recommendations and Action Plan once published.

The context: A system under unprecedented pressure

The landscape in which maternity and neonatal services are operating has changed significantly. The Interim Report highlights the importance of understanding this, not only to identify the urgent systemic issues that must be addressed but to enable these issues to be taken into account when designing the delivery of maternity and neonatal services for the future. This includes:

• Fluctuations in the rates of still births, neonatal mortality and brain injuries and a concerning increase in maternal mortality rates.
• Changes to the social and health profile of women using maternity - women are giving birth at older ages; there is an increase in pre-existing health conditions; and clear evidence demonstrating inequalities in healthcare reflecting the effect of discrimination, racism and deprivation.
• Increases in clinical complexity – changes in the nature of interventions, including an increase in the rates of caesarean sections (both elective and emergency).

Six key factors contributing to the pressures on the maternity and neonatal system 

1. Capacity pressures

The Interim Report highlights capacity pressures at every stage of the maternity journey, alongside inconsistencies between individual units and in the birth choices available to women, with some services (for example home births) having been depleted or even stopped because of capacity pressures.

Pressures include redeployed staff not always being familiar with the working practices in a different setting and inefficient IT systems that are often not intuitive or interoperable with each other or with wider hospital IT systems.

2. Culture and leadership

Like other reports that have gone before, the Interim Report identifies culture as a key component of safe and effective care. However, issues still persist, with evidence of poor working relationships across teams and poor behaviour from some clinicians not always dealt with effectively.

The Interim Report also reiterates the importance of good, effective leadership and how strong relationships between maternity and neonatal leadership enable an integrated approach to be taken, citing the positive step taken by some trusts to introduce family integrated care (FiCare) models which actively involve families in decision-making and in supporting their baby’s care. 

3. Racism and discrimination

Systemic and interpersonal racism within maternity and neonatal care is widely recognised and cited as a factor contributing to racial inequities in maternity and neonatal outcomes. National data from MBRRACE-UK demonstrates consistently higher maternal mortality rates for Black and Asian women: Black women are almost three times as likely to die during pregnancy or up to six weeks after birth compared with White women, and Asian women are 1.3 times more likely to die during the same period. Women living in the most deprived areas have twice the rate of maternal mortality compared with those in the least deprived areas. 

The Interim Report cites examples of harmful stereotypes being applied to women from Black and Asian backgrounds, and women being expected to advocate for themselves more forcefully because of their ethnicity. In addition, some families experienced a lack of sensitive and culturally competent communication, particularly when clinicians discussed risks in pregnancy or recommended additional care.

The Interim Report also highlights that staff experience racism and discrimination, including staff being turned away from giving care to patients because of their ethnicity, and about systemic racism within trusts.

There is more limited information available on outcomes for women and families with disabilities, refugee and asylum women, LGBTQ+ people, and people from Gypsy, Roma and Traveller backgrounds which means that some forms of discrimination remain under-recognised. However, the Investigation is engaging with a wide range of families and stakeholders to understand the experiences of minority and marginalised communities.

4. Poor responses and lack of accountability when things go wrong

The Interim Report indicates that some families continue to experience a lack of transparency, clear communication and learning when things have gone wrong – including not being offered the chance to be involved in investigations from the outset, not being advised when investigations have concluded, or not being sent copies of reports. In addition, access to investigations remains inconsistent and issues remain with the content and quality of some investigation reports.

Some families also reported a reluctance on the part of trusts and professionals to admit mistakes and say sorry when things have gone wrong, despite the legal duty of candour with some families feeling no option but to pursue litigation to get answers. 

The Interim Report also explores the different experiences families have reported of the coronial process, and whether coroners should have a role in investigating when babies are stillborn.

5. The quality of estates

Buildings are an important element of delivering modern maternity and neonatal care. The quality of the estate in which services are delivered directly affects the ability to provide safe and effective care, protect dignity and manage infection control. 

The Interim Report documents stark examples of poor estate facilities directly impacting on care provision including leaking rooms, cold delivery units, some rooms not large enough to accommodate staff and equipment, including resuscitaires and inconsistent spaces and support for bereavement care.

6. Workforce

Staffing levels are key to ensuring a safe service and safe care requires an appropriate skill mix, supervision, relational continuity and psychological safety.

However, it is clear that staff are working in exceptionally pressured system and the Interim Report identifies that even in NHS Trusts that have achieved full staffing according to Birthrate Plus, staff report that maternity units do not consistently feel safely staffed in practice, due to factors such as high turnover of staff. The impact of reduced cover at night and at weekends also means that specialist care, such as bereavement or breast-feeding support, is not available 'out of hours.'

What comes next?

Based on the findings of the Interim Report we anticipate that the final report of the Independent Investigation into Maternity and Neonatal Services in England will set out recommendations for significant changes to the delivery of maternity and neonatal services in England.

As mentioned above, we will have to await publication of the final report in Spring 2026 for the recommendations and subsequent Action Plan. However, there are a number of pro-active steps NHS Trusts may want to consider doing now in response to the Interim Report findings to be as well placed as possible to implement the recommendations and Action Plan once published later his year.

If you would like us to share the suggested actions we have prepared in response to the Interim Report, or for more information on how our specialist maternity team can assist your healthcare organisation, please contact Kelly Buckley, head of our specialist maternity division.