Maternal deaths in the UK have climbed to a 20-year high, while stillbirth rates remain above pre-pandemic levels, signalling a clear regression in the safety of maternity care. The latest figures show that between 2013 and 2023 the maternal death rate rose by 50%, from 8.54 deaths per 100,000 pregnancies to 12.80 per 100,000 — a level not seen since 2005. In the two years to 2023, 257 women died during or shortly after pregnancy. Stillbirth rates, although they fell modestly between 2015 and 2023, are now on a trajectory that makes it unlikely the government’s 2025 target of halving 2010 rates will be met, and neonatal mortality rates are also projected to miss that target. These trends, described by the senior midwife Donna Ockenden as evidence that the country is “still going backwards”, have prompted renewed alarm about the depth of the crisis in NHS maternity services.
Ockenden, who chairs independent reviews into maternity care at Nottingham University Hospitals NHS Trust and Leeds Teaching Hospitals NHS Trust, made the remarks in response to the final report of the Independent National Maternity and Neonatal Investigation led by Baroness Valerie Amos. That investigation, which reviewed services at 12 NHS trusts and published its findings on 30 June 2026, identified familiar problems: women not being listened to, chronic staffing shortages, overwhelming demand and capacity pressures, and failures in leadership and governance. But Ockenden suggested the report offered little that was new. “But where we are now is, I think, there’s a real risk we’re still going backwards,” she said. “Nowhere near enough progress is being made.” The sense of déjà vu is striking given that Ockenden’s own review of Nottingham’s maternity services — the largest in NHS history, published on 24 June 2026 — had already catalogued a litany of systemic failings.
Systemic failures and avoidable harm
The Ockenden Review at Nottingham examined more than 2,500 family cases and spoke with over 800 clinicians. It found that 444 women and 76 newborn babies suffered “potentially avoidable” outcomes due to substandard care between 2010 and 2023. The review documented “cruel” clinical care, chronic understaffing, and a persistent “bullying and toxic culture” within the maternity units. Across the country, the same themes recur. The Amos review noted consistent evidence of staff burnout and stress. Women’s concerns were repeatedly dismissed, they were excluded from decision-making, and accountability was lacking when things went wrong. These are not new problems: numerous previous inquiries have made recommendations that were either not implemented or proved short-lived.
The reasons behind the rising maternal death rate are multiple and deeply embedded in the way maternity services operate. The leading causes of maternal death include blood clots, heart conditions, suicide, stroke, sepsis, and severe bleeding. Data from the Maternal Care Bundle, which sets best-practice standards across five areas of clinical care, shows that maternal mortality has increased by 21% since 2009–2011, or by 7% if deaths involving COVID-19 are excluded. Meanwhile, women in England are now at their highest risk of suffering serious injury during childbirth since records began in 2020: the rate of severe perineal tears rose to 31.1 in every 1,000 births in early 2026, and postpartum haemorrhage rates increased to 31.2 in every 1,000 births in 2025.
A critical factor is the failure of the system to listen to women and act on their concerns. This has been highlighted repeatedly in reviews and is linked to the wider culture within maternity units. Staffing shortages have become chronic, with heavy workloads and a lack of continuity of care that erodes trust and empathy. The pressures have contributed to widespread burnout among midwives and doctors. Leadership and governance failures at management level — including prolonged instability, a lack of action on warnings, and fragmented oversight — have allowed unsafe practices to persist. Some maternity units have been described as “unsafe” simply because of the age and condition of their facilities.
The COVID-19 pandemic worsened an already fragile situation. Maternity services were often overlooked in critical healthcare decisions during the pandemic, and visiting restrictions meant partners were sometimes excluded from scans, labour, and postnatal care. Remote care widened existing inequalities, with women from vulnerable groups disproportionately affected. Some women hesitated to report symptoms or attend appointments because they feared infection or were confused by mixed public health messages. The pandemic’s impact also exacerbated the stark disparities in outcomes that have long marred UK maternity care. Black women remain significantly more likely to die during pregnancy, birth, or the postpartum period than white women, and women in the most deprived areas face similarly elevated risks. Racism and discrimination, the reviews have found, are embedded within the system.
Government and NHS bodies have launched a series of initiatives intended to address the crisis. The Women’s Health Strategy, backed by Health Secretary Victoria Atkins, pledges to make women’s health a “top priority”, with a focus on improving maternity care, addressing birth trauma, and tackling disparities. In March 2024, £35 million was announced to boost maternity safety, fund specialist training, and recruit additional midwives, including a programme to prevent avoidable brain injuries in childbirth. Martha’s Rule, which allows patients and families to request a rapid, independent clinical review if they feel their concerns are being ignored, is being rolled out across all maternity settings in England. A new Maternity and Neonatal Taskforce, co-chaired by the Health Secretary, is developing an action plan. And a powerful maternity commissioner is to be appointed with the authority to pursue hospitals for persistent failures — a role Donna Ockenden is widely expected to take up.
Yet the scale of the challenge remains enormous. The Ockenden, Amos, and earlier reviews have all pointed to the same entrenched failures: a refusal to learn from past incidents, systems of oversight that are no longer fit for purpose, and a culture that blames individuals rather than addressing root causes. Against this backdrop, the continued rise in maternal deaths and serious injuries, and the failure to reduce stillbirths to target levels, place enormous strain on the frontline doctors and midwives who are expected to deliver safe care in an unsafe system. Ockenden’s warning was blunt: “Loading further pressure on frontline doctors and midwives is just not going to wash.”