The Path to Safer Beginnings in Wales: National Assurance Assessment of Maternity and Neonatal Services

The appointment of national Clinical Directors or leads in obstetrics, neonatology, neonatal nursing and obstetric anaesthetics. These roles should form a National Perinatal Team, working alongside the Chief Midwifery Officer to advise the Welsh Government, drive policy development and implementation, and provide strengthened clinical oversight and accountability of Health Boards and other perinatal service providers.

A National Strategic Oversight Board should include all relevant national stakeholders with responsibility for perinatal services, the national perinatal team, and a service user representative, with the aim of providing comprehensive oversight and shared accountability. The Board should meet regularly to provide a single, coordinated mechanism for monitoring and acting on multiple intelligence sources. It should advise Welsh Government on policy and practice gaps, identify and address inequalities in outcomes, share and scale good practice, and oversee delivery of improvement programmes through a co produced National Framework for Improvement aligned to the Quality Statement for Maternity and Neonatal Services. Clear terms of reference should be agreed and published to ensure transparency of remit and accountability. The Board should be supported by two specialist subcommittees: one focused on frequent review and action on quality and critical safety signals, and a second overseeing Health Boards' delivery of the perinatal National Reportable Incident process and the dissemination of learning.

We recommend that the planned National Maternity and Neonatal Voices Panel also includes representatives from community advocacy organisations representing populations at increased risk of poorer experiences and outcomes in perinatal services, and that it elects a representative to sit on the national strategic oversight Board.

The assurance assessment panel has benefited significantly from advice and challenge provided by a wider stakeholder group. We recommend this group is formally retained, meeting quarterly with clear terms of reference to inform the national strategic oversight Board, and that its membership is expanded to include educators, researchers and student representatives. We recommend that the national perinatal team convenes an annual, in person collaborative event with the National Strategic Oversight Board, the National Women, Parents and Communities Maternity and Neonatal Group, and the Perinatal Stakeholder Group. This event should agree national improvement priorities, set shared approaches to delivering change, and review progress against actions from the previous year.

Urgent prioritisation of the national Beacon dashboard, with routine use embedded to support whole system learning and improvement, and regular public reporting. A real-time safety signals dashboard, overseen by a clinically and academically informed subgroup of the national oversight group to enable early identification of risk and timely intervention.

A comprehensive, accessible governance map, accompanied by a clear narrative explanation of roles, responsibilities, decision-making routes and escalation pathways, should be developed and published within six months of the publication of this report.

We recommend that current rates of continuity of care by midwives are assessed in 2026–27, and that a meaningful, co produced plan is developed to increase continuity of care.

All maternity, neonatal and relevant education providers to actively progress through the stages of UNICEF UK Baby Friendly Initiative accreditation.

Health Boards should ensure that a birth discussion takes place with a suitable member of the multidisciplinary team involved in their care, before discharge from maternity services.

We recommend that Welsh Government supports Health Boards by providing clear, accessible and evidence-based public information resources, to enable consistent, accurate and timely communication with women, families and communities at a regional and local level.

Welsh Government should progress at pace in 2026 with commissioning and implementation of the national triage line and publish a standardised national model for in person triage.

A national service specification should be developed to ensure consistent alignment with evidence-based guidance on informed decision-making, care planning and timely access to care. This should include a standardised service model setting out admission pathways, place of care, dedicated staffing, and routine consideration of induction capacity and flow within daily multidisciplinary perinatal huddles.

A multidisciplinary maternity workforce planning tool should be developed and implemented to align and integrate with BAPM standards for neonatal services. This tool should cover the full maternity pathway and include adequate provision for allied health professionals, psychology and pharmacy, as well as services for women with additional social and cultural needs.

Health Boards must address immediate staffing pressures while national workforce specifications for maternity services are redeveloped. Health Boards must undertake a comprehensive review of obstetric workforce capacity taking account of service complexity, links with gynaecology, geography, and workforce sustainability. Health Boards should review midwifery and neonatal nursing staffing levels and skill mix to ensure compliance with Birthrate Plus and BAPM standards, taking account of staff absence, and assess the sustainability and impact of time-limited specialist roles.

A review of clinical pathways for rare but serious pregnancy-related conditions, to ensure clear, consistent and commissioned routes to expert care within Wales or, where required, across the UK.

Should review maternity theatre estate, capacity and staffing to ensure theatres are appropriately located, equipped and resourced for planned and emergency surgery.

Develop and publish a national service specification for perinatal mental health pathways covering common and moderate to severe mental health needs, services for fathers/partners, and parent–infant relationships.

Health Boards should embed trauma-informed training for all perinatal staff and those involved in incident processes and work collaboratively with staff to understand wellbeing needs and coproduce effective, monitored support arrangements.

The NHS Wales Joint Commissioning Committee should urgently complete analysis and commissioning decisions on neonatal cot configuration, neonatal transport and transitional care capacity.

The Welsh Government should accelerate implementation of a national maternity bed and neonatal bed/cot locator with 24/7 availability, dedicated staffing, senior clinical oversight and a single point of access.

A clear, accessible and publicly available Standard Operating Procedure for maternity and neonatal incident response should be published for Wales underpinned by family-centred, trauma-informed and restorative approaches.

A specialist sub-committee of the National Strategic Oversight Board should oversee Health Boards' delivery of the perinatal National Reportable Incident process, ensure timely, multidisciplinary and family-centred responses, and produce national thematic learning.

A national perinatal incident repository to enable systematic learning from local and national reportable incidents.

Improve how women's, families' and communities' experiences and views are heard and acted on by optimising the implementation of the Perinatal Engagement Framework.

Improve how the experiences and views of staff are heard and acted upon by implementing meaningful involvement approaches that are co-produced with staff groups.

A programme of research on the costs and short, medium and long-term consequences of the current and emerging model of care.

Test and evaluate initiatives to reduce inequalities of experience and outcome, particularly relating to poverty and ethnicity, and share findings.

Commission an evaluation of the impact and outcomes of the priorities recommended here.