This commentary analyses the National Maternity Review (Better Births, 2016) and subsequent public developments up to 2026. It draws on the review’s engagement with women, published evidence reviews, national data, and later inquiries. It is not medical, legal or professional advice. The content is for information and reflection only. Women and families should discuss their individual circumstances with their clinical team and seek independent professional advice where needed.
The 2016 National Maternity Review, chaired by Baroness Julia Cumberlege, was commissioned in the wake of the Morecambe Bay investigation. It spoke directly to women and families across England. The central message was clear: women wanted care that was safe, personalised, and built on relationships of trust. They wanted genuine choice, continuity with a known midwife or small team, and support that continued after birth – including for their mental health. They wanted to be listened to when they raised concerns about their own bodies or their babies.
What women said they needed
Women described repeating their stories because notes were not read. They wanted one midwife or a small team who knew them across pregnancy, birth and the postnatal period. Many felt decisions were made for them rather than with them. Postnatal care was frequently described as the weakest part of the pathway – rushed, fragmented, and insufficiently attentive to recovery, feeding, emotional wellbeing and the transition to life with a new baby.
The review also heard from women who had experienced loss or complications. Their accounts underscored the lasting impact of poor communication and the importance of honest, timely explanations when things went wrong.
The vision set out in Better Births
The review proposed a clear framework:
- Every woman should have a personalised care plan developed with her midwife and other professionals, kept up to date, and reflecting her decisions and wider health needs.
- Unbiased information should be available through a digital maternity tool so women could access their records and understand options.
- Women should be able to choose their provider of antenatal, birth and postnatal care, supported by an NHS Personal Maternity Care Budget (initially to be trialled).
- Every woman should have a midwife working in a small team of 4–6, providing continuity through pregnancy, birth and the postnatal period, with close links to obstetric and other services.
- Safety should be improved through better team working, rapid referral, consistent data, learning from incidents, and a national standardised investigation process when things go wrong.
- Postnatal and perinatal mental health care required significant investment and better resourcing.
- Services should work across boundaries through community hubs and local maternity systems, with multi-professional training and electronic records to support joined-up care.
The review was explicit that safe care and personalised care were not in tension; safe care is personalised care.
Progress and persistent gaps – the picture in 2026
Some elements have moved forward. Stillbirth rates fell in the years following the review, with targeted programmes such as the Saving Babies’ Lives Care Bundle contributing in early implementer sites. Maternity Voices Partnerships exist in many areas. Community hubs have been established in places. There has been investment in perinatal mental health services and workforce strategies.
However, national data and subsequent inquiries show that the core ambitions have not been realised consistently. The national maternity safety ambition to halve stillbirth, neonatal mortality, maternal mortality and serious brain injury rates by 2025 has not been met. Provisional figures indicate stillbirth rates remain above target levels, with marked variation and persistent inequalities, with the statistics showing that Black babies are more than twice as likely to be stillborn as White babies, and Black women almost three times more likely to die during or shortly after pregnancy.
Continuity of carer remains patchy. One analysis of data from 2020–2022 found that around 23% of women were placed on a midwifery continuity pathway by 24 weeks, with wide variation between trusts. Women consistently report that they do not experience the same midwife or team throughout, particularly after birth.
The 2026 National Maternity and Neonatal Investigation led by Baroness Valerie Amos found a system that is fragmented, overly complex and slow to learn. It highlighted failures to listen to women and families, unacceptable racism and discrimination affecting outcomes, and persistent weaknesses in how the system responds when things go wrong. These findings echo concerns raised a decade earlier in Better Births.
Postnatal care continues to be identified as under-resourced. Women often see multiple different midwives after birth, and handover to GPs and health visitors is not always smooth. Perinatal mental health support, while expanded, still shows geographical variation in access.
What this means for women and families today
The evidence from Better Births and later reviews points to several practical realities:
Women have a right to be involved in decisions about their care. This includes discussions about place of birth (home, midwifery unit or obstetric unit), pain relief, and interventions, with clear information about benefits, risks and alternatives. The law on informed consent has developed alongside these policy discussions; professionals must take reasonable steps to ensure a woman understands the material risks and benefits relevant to her.
Asking for a personalised care plan and a named midwife or small team is reasonable and aligns with national recommendations. Women can request to see their maternity records and ask for explanations in plain language. When concerns arise – for example about reduced fetal movements, pain, mood, or feeding – it is appropriate to seek review and to ask for escalation if not satisfied.
When things go wrong, families are entitled to honest explanations, an apology where due, and support. National frameworks for learning from incidents exist, though inquiries continue to find that these do not always operate effectively in practice.
Choice is real but constrained by local availability, staffing, and clinical circumstances. The evidence reviewed in 2016 (and subsequently) indicates that for low-risk women having a second or subsequent baby, planning birth at home or in a midwifery unit is associated with fewer interventions and no evidence of worse outcomes for the baby in most cases. For first-time mothers the picture is more nuanced, with higher transfer rates and a small increased chance of adverse outcome with home birth. These are population-level findings; individual decisions must be made with personalised clinical advice.
Women from minority ethnic backgrounds and those living in more deprived areas continue to face higher risks and, in some cases, poorer experiences. Addressing this requires both individualised care and system-level action on inequalities.
The wider context for women’s health
Maternity care is one of the few areas of the NHS explicitly organised around a female life event. Even here, the review identified fragmentation – between antenatal and postnatal care, between physical and mental health, and between maternity services and primary care. Women are often left to carry information between professionals and to advocate for joined-up understanding of their situation.
This pattern is relevant to the broader challenge of designing healthcare around women’s interconnected biology and lives rather than around institutional or specialty boundaries.
Pregnancy does not occur in isolation from a woman’s cardiovascular, metabolic, autoimmune or mental health history, nor from her social circumstances.
The review’s emphasis on personalised care plans and continuity was an attempt to address this within one episode of care.
The fact that similar concerns about listening, continuity and postnatal support recur in later inquiries suggests that structural and cultural barriers remain.
Women using maternity services today are entitled to care that is safe, respectful and responsive to them as individuals. The 2016 review set out a direction that many women recognised as right. Delivering it consistently has proved more difficult than the policy framework alone could achieve.
Understanding both the vision and the implementation gap helps women ask informed questions and advocate effectively for themselves and their babies.
Mandatory disclaimer
This article is for general information and discussion only. It is not medical or legal advice, nor a substitute for professional advice. To contribute evidence, ideas, or corrections, please email womenshealthproject@outlook.com . Please do not share personal data when emailing. Individual cases cannot be reviewed.
This project does not offer any form of legal service and cannot assist with complaints, claims or individual advocacy. This platform is independent and not affiliated with any law firm, regulator, inquiry or clinical body.
© 2026 Women’s Health Inquiry Project (WHIP). This article includes original analysis of material from publicly available national sources. It may not be reproduced without permission.
References
- National Maternity Review, Better Births: Improving outcomes of maternity services in England (NHS England, 2016).
- National Perinatal Epidemiology Unit evidence review for the National Maternity Review (2015).
- MBRRACE-UK reports on perinatal mortality and maternal death.
- ONS and NHS England maternity statistics and safety ambition monitoring (2025 data).
- Baroness Amos, National Maternity and Neonatal Investigation final report (June 2026).
- Nuffield Trust, “Is England making progress to improve maternity care?” explainer (updated 2025/2026).
- CQC Maternity Survey and inspection data.
- Healthwatch England feedback on maternity experiences (2026).
- RCOG and RCM workforce and clinical indicators publications. All sources are publicly available. This analysis interprets publicly reported findings and does not constitute advice.