Recommendations & Conclusions
20 items
1
Conclusion
3rd Report - Black Maternal Health
Accepted
Safe maternity care for Black women is dependent on a workforce equipped to understand and respect their needs. Given the current disparities in maternity outcomes for Black women it is indefensible that cultural competency training is optional for NHS staff and leaders working in maternity services, and especially midwives. (Conclusion, …
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Safe maternity care for Black women is dependent on a workforce equipped to understand and respect their needs. Given the current disparities in maternity outcomes for Black women it is indefensible that cultural competency training is optional for NHS staff and leaders working in maternity services, and especially midwives. (Conclusion, Paragraph 26)
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Government response AI summary
The government recognises cultural competency's importance, highlights NHS England's national Perinatal Equity and Anti-Discrimination Programme, and commits to a new statutory and mandatory training competency framework for all NHS staff, due to go live by April 2026, which will set out mandated subjects.
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Department of Health and Social Care
2
Recommendation
3rd Report - Black Maternal Health
Deferred
We recommend the Department work with the NHS, the Royal College of Midwives, and the NMC to introduce mandatory, ongoing cultural competency training for all midwives, informed by co-production. A working group should review and update training materials to ensure they meet the needs of all ethnic groups. (Recommendation, Paragraph …
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We recommend the Department work with the NHS, the Royal College of Midwives, and the NMC to introduce mandatory, ongoing cultural competency training for all midwives, informed by co-production. A working group should review and update training materials to ensure they meet the needs of all ethnic groups. (Recommendation, Paragraph 27)
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Government response AI summary
The government agrees that NHS trust leaders should set clear expectations for tackling racism and outlines work on leader accountability and the establishment of a College of Executive and Clinical Leadership. However, it does not commit to mandatory, ongoing cultural competency training specifically for all …
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Department of Health and Social Care
3
Conclusion
3rd Report - Black Maternal Health
Accepted
NHS leaders have a vital role in improving maternity outcomes for Black women and addressing the underlying culture and racism that underpin those outcomes. However, the current system does not incentivise leaders to focus on this issue or effectively hold to account Trusts that fail to make progress.(Conclusion, Paragraph 36)
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NHS leaders have a vital role in improving maternity outcomes for Black women and addressing the underlying culture and racism that underpin those outcomes. However, the current system does not incentivise leaders to focus on this issue or effectively hold to account Trusts that fail to make progress.(Conclusion, Paragraph 36)
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Government response AI summary
The government agrees on the importance of diversifying NHS leadership and details existing initiatives like NHS England's Diversity in Health and Care Partners Program and the CapitalMidwife Anti-Racism Framework. They also mention the ongoing development of the 10 Year Workforce Plan, which included a call …
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Department of Health and Social Care
4
Conclusion
3rd Report - Black Maternal Health
Accepted
The NHS leadership framework should set clear expectations for tackling racism and fostering an inclusive culture, reflected in chief executives’ performance agreements. It must also equip Ministers to hold Trust leaders accountable for creating anti-racist organisations and improving maternity outcome inequalities. (Recommendation, Paragraph 37)
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The NHS leadership framework should set clear expectations for tackling racism and fostering an inclusive culture, reflected in chief executives’ performance agreements. It must also equip Ministers to hold Trust leaders accountable for creating anti-racist organisations and improving maternity outcome inequalities. (Recommendation, Paragraph 37)
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Government response AI summary
The government strongly agrees that progress in Black maternal health has been too slow, announcing a national independent investigation into NHS maternity and neonatal services, with Baroness Amos appointed as chair. Its recommendations will inform a national action plan developed by a new National Maternity …
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Department of Health and Social Care
5
Conclusion
3rd Report - Black Maternal Health
Deferred
Addressing the current lack of diverse representation within NHS leadership and midwifery education is one practical action that can be taken to address concerns. When those entrusted with shaping clinical knowledge and practice and leading our healthcare organisations overwhelmingly reflect a single demographic, it limits the breadth of what is …
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Addressing the current lack of diverse representation within NHS leadership and midwifery education is one practical action that can be taken to address concerns. When those entrusted with shaping clinical knowledge and practice and leading our healthcare organisations overwhelmingly reflect a single demographic, it limits the breadth of what is taught, prioritised, and thus, how care is delivered. (Conclusion, Paragraph 38)
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Government response AI summary
The government provides statistics on increases in the overall midwifery workforce and discusses rising complexities in births and potential digital tools for care. It mentions the 10 Year Workforce Plan but refers to a previous response for details, thereby deflecting from the specific recommendation about …
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Department of Health and Social Care
6
Recommendation
3rd Report - Black Maternal Health
Deferred
The Government should also ensure the forthcoming workforce plan explicitly includes targets and strategies to diversify NHS leadership, specifically maternity service leaders and educators. This must be 32 accompanied with robust monitoring mechanisms that can be used to track progress and hold Trusts to account for their performance. (Recommendation, Paragraph …
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The Government should also ensure the forthcoming workforce plan explicitly includes targets and strategies to diversify NHS leadership, specifically maternity service leaders and educators. This must be 32 accompanied with robust monitoring mechanisms that can be used to track progress and hold Trusts to account for their performance. (Recommendation, Paragraph 39)
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Government response AI summary
The government details NHS England's collaboration with the RCOG to ensure optimal staffing levels for high-quality maternity care and its work on job planning principles for obstetric consultants. It does not address the recommendation to include targets and strategies for diversifying NHS leadership in the …
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Department of Health and Social Care
7
Conclusion
3rd Report - Black Maternal Health
Accepted
While there have been multiple initiatives aimed at improving Black maternal health, progress remains too slow. We welcome the announcement of a rapid national investigation into maternity and neonatal care and the Secretary of State’s commitment to inequality being an integral part of its work. (Conclusion, Paragraph 43)
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While there have been multiple initiatives aimed at improving Black maternal health, progress remains too slow. We welcome the announcement of a rapid national investigation into maternity and neonatal care and the Secretary of State’s commitment to inequality being an integral part of its work. (Conclusion, Paragraph 43)
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Government response AI summary
The government commits to developing a new surveillance system for severe maternal morbidity (PRiSMM) and implementing a ‘Maternal Care Bundle’ to standardise care across five clinical areas from April 2026. Additionally, NHS England is due to launch a Maternity and Neonatal Equity and Equality Dashboard.
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Department of Health and Social Care
8
Conclusion
3rd Report - Black Maternal Health
Accepted
We hope that the national investigation will serve as a turning point for the country’s maternity services, and particularly the experience of Black women, by laying the foundation for a more transparent, accountable, and equitable maternity system. We will monitor the progress of the inquiry closely and intend to revisit …
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We hope that the national investigation will serve as a turning point for the country’s maternity services, and particularly the experience of Black women, by laying the foundation for a more transparent, accountable, and equitable maternity system. We will monitor the progress of the inquiry closely and intend to revisit its findings, with a view to undertaking further scrutiny at an appropriate stage. (Conclusion, Paragraph 44)
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Government response AI summary
The government committed to having a new PRiSMM system regularly report severe maternal morbidity data by region, ethnicity, and deprivation from June 2026, and to creating a new data platform for detailed patient records to help trusts monitor these rates.
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Department of Health and Social Care
9
Recommendation
3rd Report - Black Maternal Health
Rejected
We recommend that addressing racial disparities in maternal outcomes is one of the investigation’s core aims, and that this features prominently in the terms of reference for the second stage. We recommend that the investigation aligns with the priorities outlined by the Health Services Safety Investigations Body, specifically the defining …
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We recommend that addressing racial disparities in maternal outcomes is one of the investigation’s core aims, and that this features prominently in the terms of reference for the second stage. We recommend that the investigation aligns with the priorities outlined by the Health Services Safety Investigations Body, specifically the defining of an accountability framework for maternity and neonatal services. Additionally, we recommend that the review carefully considers the impact of the significant reduction of ringfenced funding as outlined in this report. (Recommendation, Paragraph 45) Workforce
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Government response AI summary
The government rejected the premise that maternity funding has been cut, stating that the same level of funding is provided but the ring-fence was removed to allow Integrated Care Boards (ICBs) more local flexibility. It did not directly address the recommendation to make racial disparities …
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Department of Health and Social Care
10
Conclusion
3rd Report - Black Maternal Health
Accepted
Workforce shortages remain a major barrier to safe maternity care, despite recent recruitment progress. We are disappointed the Government suspended its continuity of carer target, which is especially important for marginalised women, including Black women, who face greater challenges in being heard by the healthcare system. (Conclusion, Paragraph 62)
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Workforce shortages remain a major barrier to safe maternity care, despite recent recruitment progress. We are disappointed the Government suspended its continuity of carer target, which is especially important for marginalised women, including Black women, who face greater challenges in being heard by the healthcare system. (Conclusion, Paragraph 62)
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Government response AI summary
The government reiterated that maternity services are an ICB priority and that funding remains consistent despite the ring-fence removal. It stated it will monitor ICB investment and is exploring how various health system parts can collaborate to address pre-pregnancy risk factors, listing several existing local …
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Department of Health and Social Care
11
Recommendation
3rd Report - Black Maternal Health
Deferred
The Government must give firm commitments in the refreshed Long Term Workforce Plan to deliver safe staffing levels for maternity services. Without this, safe and sustainable maternity care will remain out of reach. As part of the workforce plan the Government must commit to rapidly reaching a level of staffing …
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The Government must give firm commitments in the refreshed Long Term Workforce Plan to deliver safe staffing levels for maternity services. Without this, safe and sustainable maternity care will remain out of reach. As part of the workforce plan the Government must commit to rapidly reaching a level of staffing that will allow it to recommit to its continuity of carer target. (Recommendation, Paragraph 63)
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Government response AI summary
The government highlights increases in the midwifery workforce and reiterates commitment to the continuity of carer model. Regarding firm commitments in the refreshed Long Term Workforce Plan, they state they are working through how the plan will articulate changes for different professional groups, including midwives …
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Department of Health and Social Care
12
Conclusion
3rd Report - Black Maternal Health
Acknowledged
Suspending adoption of RCOG’s safe staffing tool has left Trusts without clear guidance on safe staffing levels, perpetuating poor workforce supply and undermining efforts to stabilise and support maternity teams. (Conclusion, Paragraph 64) 33
Government response AI summary
NHS England acknowledges the importance of clear staffing guidance and is collaborating with the RCOG to produce a set of principles and expectations for obstetric consultant job planning, which they aim to share soon to support optimal staffing levels in maternity services.
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Department of Health and Social Care
13
Recommendation
3rd Report - Black Maternal Health
Accepted in Part
We urge the Department to update and publish the tool produced by RCOG in time for the rollout of the upcoming refreshed Workforce Plan, so that every maternity unit can use it to plan effectively, ensure appropriate staffing and deliver consistent, safe care to all mothers and their babies. (Recommendation, …
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We urge the Department to update and publish the tool produced by RCOG in time for the rollout of the upcoming refreshed Workforce Plan, so that every maternity unit can use it to plan effectively, ensure appropriate staffing and deliver consistent, safe care to all mothers and their babies. (Recommendation, Paragraph 65) Data
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Government response AI summary
NHS England is collaborating with the RCOG to produce a set of principles and expectations to guide job planning for obstetric consultants at trust level, aiming to share this work as soon as possible to support planning for optimal staffing levels, rather than explicitly updating …
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Department of Health and Social Care
14
Conclusion
3rd Report - Black Maternal Health
Acknowledged
Collecting robust, consistent, and equity-focused data on ethnicity and maternal morbidity is essential to enable health services to monitor and improve their services guiding improvements in maternal outcomes. Without it, it is significantly harder to produce accurate comparisons across all ethnic groups and evaluate disparities in maternal outcomes amongst different …
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Collecting robust, consistent, and equity-focused data on ethnicity and maternal morbidity is essential to enable health services to monitor and improve their services guiding improvements in maternal outcomes. Without it, it is significantly harder to produce accurate comparisons across all ethnic groups and evaluate disparities in maternal outcomes amongst different ethnicities, and gaps may obscure the true extent of disparities in outcomes for Black and other minority ethnic women. (Conclusion, Paragraph 79)
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Government response AI summary
The government strongly agrees on the essential role of robust ethnicity data for improving maternal outcomes and outlines the Ethnicity Recording Improvement Plan, including five areas for action, a new PRiSMM surveillance system by Q1 2026, and a Maternal Care Bundle by April 2026.
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Department of Health and Social Care
15
Conclusion
3rd Report - Black Maternal Health
Acknowledged
We are pleased that the Government has agreed an Ethnicity Recording Improvement Plan and look forward to seeing the details when it is published. (Conclusion, Paragraph 80)
Government response AI summary
The government strongly agrees on the importance of robust ethnicity data and provides details of the Ethnicity Recording Improvement Plan, which includes 5 areas for action, a new PRiSMM surveillance system by Q1 2026, and a Maternal Care Bundle by April 2026.
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Department of Health and Social Care
16
Recommendation
3rd Report - Black Maternal Health
Accepted
We recommend that this Plan should include details on staff training, support for data collection, and accountability measures to ensure Trusts meet their responsibilities. The Government must establish transparent mechanisms to monitor compliance and address failures in timely, accurate reporting, and outline these in its response to this report. (Recommendation, …
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We recommend that this Plan should include details on staff training, support for data collection, and accountability measures to ensure Trusts meet their responsibilities. The Government must establish transparent mechanisms to monitor compliance and address failures in timely, accurate reporting, and outline these in its response to this report. (Recommendation, Paragraph 81)
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Government response AI summary
The government accepts the recommendation, outlining that its Ethnicity Recording Improvement Plan includes staff training resources, regular reviews of ethnicity data completion, and improvement work to ensure accurate recording and monitoring of inequalities. A new PRiSMM surveillance system and a Maternal and Neonatal Equity and …
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Department of Health and Social Care
17
Recommendation
3rd Report - Black Maternal Health
Accepted
We are concerned that progress on developing a maternal morbidity indicator has been unacceptably slow, despite a Government commitment to do so over two years ago. We recommend the Department work with the National Institute for Health and Care Research to accelerate development and provide a clear timetable in response …
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We are concerned that progress on developing a maternal morbidity indicator has been unacceptably slow, despite a Government commitment to do so over two years ago. We recommend the Department work with the National Institute for Health and Care Research to accelerate development and provide a clear timetable in response to this report. (Recommendation, Paragraph 82) Funding
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Government response AI summary
The government agrees that developing a severe maternal morbidity indicator is critical and commits to it regularly reporting by June 2026. It details ongoing work with researchers and the PRiSMM system to update the indicator and create a new data platform for monitoring.
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Department of Health and Social Care
18
Conclusion
3rd Report - Black Maternal Health
Rejected
We are concerned by the Government’s decision to cut the Maternity Service Development Fund from £95 million to £2 million. While ICBs still have access to this funding, maternity services must now compete with other local priorities. While performance metrics in the 2025–26 NHS Assessment Framework aim to ensure accountability, …
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We are concerned by the Government’s decision to cut the Maternity Service Development Fund from £95 million to £2 million. While ICBs still have access to this funding, maternity services must now compete with other local priorities. While performance metrics in the 2025–26 NHS Assessment Framework aim to ensure accountability, they do not guarantee sufficient funding will be directed towards maternity services. Without sustained oversight and dedicated investment, maternity care risks losing momentum, 34 widening disparities, including in Black maternal care, and compromising critical reforms. We are also concerned about how the dissolution of NHS England and its absorption into the Department of Health and Social Care might impact the NHS’s ability to monitor maternity spending and maintain national oversight of progress. (Conclusion, Paragraph 90)
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Government response AI summary
The government asserts that maternity funding has not been cut, explaining the ring-fence was removed to provide local ICBs with greater autonomy and flexibility to meet local needs, a move consistent with wider policy. They clarify that NHS England does not commission maternity services, which …
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Department of Health and Social Care
19
Recommendation
3rd Report - Black Maternal Health
Rejected
We strongly recommend that the Government restore the dedicated ring- fenced funding for the Service Development Fund for maternity care to £95 million. Properly targeted we believe this investment has the potential to reduce the substantial cost of maternity negligence claims to the NHS and more than pay for itself. …
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We strongly recommend that the Government restore the dedicated ring- fenced funding for the Service Development Fund for maternity care to £95 million. Properly targeted we believe this investment has the potential to reduce the substantial cost of maternity negligence claims to the NHS and more than pay for itself. (Recommendation, Paragraph 91)
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Government response AI summary
The government rejected the recommendation to restore ring-fenced funding for maternity care, explaining that while funding levels are maintained, the ring-fence was removed to provide local healthcare system leaders with greater autonomy and flexibility.
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Department of Health and Social Care
20
Recommendation
3rd Report - Black Maternal Health
Acknowledged
More broadly, the Government must ensure that maternity services continue to be a priority within ICB funding allocations. We ask the Government to set out in its response to this Report how it will monitor ICB investment in these services, including the impact of the removal of the ringfence if …
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More broadly, the Government must ensure that maternity services continue to be a priority within ICB funding allocations. We ask the Government to set out in its response to this Report how it will monitor ICB investment in these services, including the impact of the removal of the ringfence if that decision is not reversed, and how it will intervene if it sees evidence that ICBs are underinvesting in maternity services. (Recommendation, Paragraph 92) 35
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Government response AI summary
The government states that maternity services remain a core priority for ICBs and commits to continuing to monitor ICB investment in these services. They highlight existing national priorities and efforts to address pre-pregnancy health factors, but do not provide specific new details on how monitoring …
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Department of Health and Social Care