This commentary considers the National Maternity Review (Better Births, 2016) through the lens of NHS governance, commissioning, regulation and system leadership.
It draws on the review’s recommendations, the subsequent Maternity Transformation Programme, the Three Year Delivery Plan, and findings from later national inquiries up to the 2026 Amos investigation.
It is research synthesis and commentary based on publicly available information.
It is not governance advice, regulatory guidance or legal advice.
NHS leaders, commissioners and regulators should refer to current statutory duties, national frameworks and their own legal and professional responsibilities.
Introduction
Better Births was unusual among policy documents in that it was explicitly framed as a response to a major safety investigation (Morecambe Bay) while also seeking to place women’s experiences and choices at the centre of service design. Its governance recommendations addressed boards, commissioners, regulators and national bodies.
Key governance recommendations
The review proposed:
- Provider boards should have a board-level champion for maternity services who routinely monitors quality and safety information and takes necessary action.
- Boards should promote a culture of learning and continuous improvement.
- Rapid referral protocols should operate between professionals and organisations.
- Teams should collect and use data on quality and outcomes, benchmark performance, and participate in multi-professional peer review.
- A national standardised investigation process should exist when things go wrong, supported by systems of rapid resolution and redress.
- Payment systems should be reformed to be fair, incentivise efficiency and quality, support women’s choices, and reflect the fixed costs of maintaining 24/7 obstetric units.
- Community hubs should bring together maternity and other family services.
- Local maternity systems (later evolving into Local Maternity and Neonatal Systems within Integrated Care Systems) should cover populations of 500,000–1.5 million, working to common standards.
- Clinical networks should operate at larger scale for specialist services and shared learning.
- Commissioners should be accountable for outcomes and reducing inequalities.
The review also recommended significant investment in perinatal mental health and postnatal care, and national roll-out of electronic maternity records with appropriate information governance.
What was taken forward
NHS England established the Maternity Transformation Programme to implement Better Births. Local Maternity Systems (later LMNS) were created. The Saving Babies’ Lives Care Bundle was rolled out.
There has been work on maternity dashboards, a Maternity Services Data Set, and some progress on digital records and standards. Workforce transformation strategies were published.
Perinatal mental health services received additional investment.
Community hubs and Maternity Voices Partnerships were developed in many areas.
Payment reform has been partial. The full Personal Maternity Care Budget model was not implemented at scale. Tariff arrangements have been adjusted but have not fully resolved the tensions between supporting choice, recognising fixed costs, and incentivising quality across different settings.
Regulatory oversight has intensified.
The Care Quality Commission inspects maternity services with a strong focus on safety.
NHS England has used regional and national oversight mechanisms, including the Maternity Improvement Programme and Recovery Support Programme for trusts with significant concerns.
Persistent challenges identified in later inquiries
Despite these structures, subsequent independent reviews have identified recurring governance and cultural issues. The Ockenden reviews (Shrewsbury and Telford, and later Nottingham), the Kirkup investigation into East Kent, and the 2026 Amos National Maternity and Neonatal Investigation all found evidence of:
- Failures to listen to women and families and to escalate concerns appropriately.
- Variable safety cultures, with defensive or closed behaviours in some settings.
- Weaknesses in how organisations respond when things go wrong – including investigation quality, learning, and support for families.
- Persistent inequalities in outcomes and experience, particularly for Black, Asian and minority ethnic women and those in deprived areas.
- Fragmentation across the pathway and between maternity, neonatal, primary care and mental health services.
- Data that is incomplete, untimely or not used effectively for improvement.
The 2026 Amos report described a system that is fragmented, overly complex and far too slow to learn. It recommended, among other measures, a statutory national Maternity and Neonatal Commissioner, systematic listening to women and families, improved responses when things go wrong, and a modern service framework with national standards.
These findings come after more than a decade of policy initiatives flowing from Better Births. They suggest that the expansion of governance mechanisms – dashboards, bundles, local systems, national programmes, enhanced regulatory scrutiny – has not been sufficient on its own to address the underlying issues of culture, relational care, and organisational learning.
Implications for boards, ICBs and national bodies
For provider boards and Integrated Care Boards, the evidence points to the importance of sustained board-level focus on maternity quality and safety, not only through metrics but through understanding the experiences of women and staff.
The recommendation for a board maternity champion remains relevant.
Regular triangulation of quantitative data, incident reports, complaints, staff survey results and patient feedback is necessary to identify problems early.
Commissioners and system leaders need to address workforce sustainability as a core governance issue. Continuity models and personalised care require adequate staffing, appropriate skill mix and organisational support. Payment and contracting arrangements should support integrated working across community and hospital settings rather than creating perverse incentives.
Regulators and national bodies face the challenge of balancing accountability with the creation of conditions in which professionals can provide relational, learning-oriented care.
Overly punitive or compliance-heavy approaches risk driving defensive behaviours, which inquiries have repeatedly linked to poorer safety.
The pattern across inquiries suggests that governance responses to failure have often involved adding more structures, guidance and reporting requirements.
While each has legitimate aims, the cumulative effect can be a system in which significant energy goes into demonstrating compliance rather than into the relational and clinical work of understanding the individual woman and responding to her situation.
Litigation, learning and redress
Better Births noted the high cost of maternity litigation and the risk that fear of claims inhibits openness. It recommended systems of rapid resolution and redress.
Progress has been made through the work of HSIB (now MNSI) on maternity investigations, but inquiries continue to find that families sometimes experience protracted, adversarial processes and that learning is not always embedded.
Effective governance in this context requires organisations to separate the need for accountability and compensation from the need for open, timely learning and support for families.
This remains an area of ongoing development.
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 (2016).
- NHS England Maternity Transformation Programme documentation and progress reports.
- Three Year Delivery Plan for Maternity and Neonatal Services.
- Baroness Amos, National Maternity and Neonatal Investigation (2026).
- Ockenden and Kirkup independent maternity reviews.
- CQC inspection reports and national maternity surveys.
- Nuffield Trust and parliamentary briefings on maternity services (2025–2026).
- MBRRACE-UK and ONS outcome data. All sources are publicly available. This is commentary on publicly reported findings.