Maternity Commissioner

I beg to move,

That this House has considered e-petition 751174 relating to a Maternity Commissioner.

It is a privilege to serve under your chairship, Sir Alec. The petition calls for the appointment of a maternity commissioner to improve maternity care for mothers and babies. I thank the petitioners, Louise Thompson and Theo Clarke, two formidable women and campaigners who have raised this issue relentlessly over several years. They have spoken powerfully, alongside many others, including the Birth Trauma Association, the MASIC Foundation, Make Birth Better, the Maternal Mental Health Alliance, Five X More and Mumsnet. I also thank the more than 153,000 people, including 203 of my constituents in Folkestone, Hythe and Romney Marsh, who signed Louise and Theo’s petition so quickly after it was launched.

We should remember that most births in the UK are safe, and I acknowledge and thank the NHS midwives, nurses and doctors on the frontline, and all those working across the health service, who do outstanding work to care for mothers and babies across our nation every day. However, at the same time, there are clear, deep-rooted and long-standing problems in our maternity and neonatal services, in connection with which I will mention four statistics.

First, the maternal death rate in the UK is one of the highest in western Europe, and UK stillbirth rates are also high. Secondly, the NHS currently spends more on payouts for medical negligence than on the entire frontline maternity service budget. That money should be going towards safer frontline care, not litigation. Thirdly, according to the Care Quality Commission’s latest national review of maternity services, almost half the maternity units it inspected between 2022 and 2023 were rated as “requires improvement” or “inadequate”, with only 4% rated as “outstanding”.

Fourthly, over the past two decades, we have seen a heartbreaking succession of maternity scandals. There was the same pattern across Morecambe Bay, Shrewsbury and Telford, East Kent—which serves my constituency—and now Nottingham: women raised concerns, saying that something was wrong and that they were in pain or frightened, but were not listened to. That failure to listen is a theme running through every major maternity report of the last decade, with around 750 recommendations across those various reports reflecting that failure, alongside the issues of unsafe care, toxic culture and weak oversight.

Unfortunately, those were the experiences of petitioner Louise Thompson, who advocated for a C-section but was denied it, resulting in a massive obstetric haemorrhage. My constituent Jo Page also experienced those systemic failures when her son was born at William Harvey hospital in Ashford some years ago. A birthing injury was misdiagnosed and she did not receive the right treatment and support for what was, in fact, a fourth-degree tear. As a result, she has suffered years of pain and indignity, cannot stand for long periods and needs to use the toilet frequently. She had to give up her career and cannot do normal activities, such as taking a flight to go on holiday. Her life has been utterly changed.

Jo now works with MASIC, which supports mothers with anal sphincter injuries, to run a support group for local women in Folkestone, Hythe and the wider Kent area. She also trains midwives and doctors to correctly diagnose tears, and was recently involved in the Sky News production, “Birth Trauma: The women who weren’t listened to”, which tells the traumatic stories of three mothers who were cared for in NHS England hospitals. Jo, you are truly inspiring, and I know that the whole House would join me in expressing thanks for all the work that you do for women up and down the country.

When I spoke to Jo last week, she told me that she continues to receive messages from women who have experienced misdiagnoses and did not feel listened to during their birthing experiences. Those women include a police officer and a social worker who had both been so badly injured during birth that they had to give up their careers, got into debt and suffered immeasurably. I am sad to say that, just last month, I was contacted by a constituent who experienced the same failings that they had read about in the Kirkup report into maternity services at William Harvey hospital.

When I spoke to petitioner Louise Thompson, she said that she is constantly hearing from women who have post-partum physical injuries and mental health issues, and has known people who have committed suicide following maternity service and post-partum system failures. She also spoke of the profound strain on partners, who must support a recovering mother, assist in caring for a newborn and continue to work, all at the same time. She pointed out that a third of women in the UK who give birth experience it as traumatic, and that every year between 4% and 5% of them develop post-traumatic stress disorder, which is around 30,000 women in total. The impact of trauma can last a lifetime, affecting a mother’s bond with her baby, her relationship with her partner, her ability to work and her long-term mental health.

Why is this happening? The petitioners believe that one key reason is a lack of unified leadership and consistency across maternal care in the UK, over many years. When petitioner Theo Clarke was the hon. Member for Stafford, she chaired the first ever birth trauma inquiry with the hon. Member for Canterbury (Rosie Duffield). They heard from 1,300 patients, including patients from marginalised communities, and from professionals about their experiences of maternity services across the four nations of the UK. The inquiry was prompted by Theo Clarke’s own traumatic birth experience, which she bravely and publicly spoke about in the House, describing it as:

“the most terrifying experience of my life.” —[Official Report, 19 October 2023; Vol. 738, c. 495.]

In submissions to that inquiry, mothers reported being mocked or shouted at, being denied the most basic assistance such as pain relief, and being left feeling “terrified”, “humiliated” and “ashamed”. The word “broken” appeared more than any other. The inquiry’s May 2024 report was called “Listen to Mums: Ending the Postcode Lottery on Perinatal Care”, and its 14 recommendations were headed by a call on the Government to publish a national maternity improvement strategy, led by a new maternity commissioner reporting to the Prime Minister. The petitioners believe that these measures would fill a void.

I am most grateful to my hon. and learned Friend for calling this important debate. I am also very grateful to my constituent Louise Thompson for having the guts and the decency to parlay what was an absolutely horrible experience into a determination to make life better for women across this country and improve maternity services for everybody. I am very grateful for what she is doing—she is in Public Gallery today and I very much welcome her.

As my hon. and learned Friend may be aware, I am a Member of the Health and Social Care Committee. Recently, we produced a report on black maternal health and many of the issues that he has described today also emerged in that report. There is a huge amount to be done.

When it comes to making these changes and making them stick, I echo my hon. and learned Friend’s support for a national maternity commissioner to drive them through. However, if the Government are not minded to appoint a maternity commissioner, how else does he think we might get the drive and the determination to make the changes stick right across Government permanently?

I thank my hon. Friend for his intervention, and I echo his comments about the petitioner Louise Thompson and her advocacy on this issue.

The petitioners’ analysis is that there has been a vacuum of leadership and accountability across the system. I know that the Government are considering how best to address that, and we will hear more from the Minister later about that; but whatever happens, there has to be a structural way of providing that leadership and avoiding fragmentation and different interpretations of different guidance documents across the system. We need clear systemic change to cure this, because it has been an ongoing problem for many years and so far no answer has been put forward.

The petitioner Theo Clarke told me a story that illustrates the point about the postcode lottery in maternity care, which the petitioners strongly believe would be prevented by measures to create expert national leadership and tighten up the rules. She told me that an obstetrician in London who she had spoken to recently told her that there are 87 different pieces of guidance that apply in maternity care. That does not sound like a framework; to many people, it sounds more like a large number of disparate documents, which leads to variations in interpretation between different areas. Theo Clarke’s strong view is that that leaves room for interpretation, which results in different approaches to care in different areas. In practical terms, that means that something as basic as training midwives in recognising and treating birthing injuries varies hugely between different areas.

My constituent who I spoke about a moment ago trains midwives on this issue, but that training is not available everywhere, and certainly not in the same way as delivered by MASIC.

The hon. and learned Gentleman is making an important point about the disparity in the guidance. If there is someone at the top of an NHS trust who is passionate about maternity care, that is more likely to trickle down, but that is not the same in every trust, and therefore we can end up with a postcode lottery. In Chichester, mothers going to give birth would have a totally different experience if they went to Chichester, Guildford or Portsmouth because they are three totally different trusts with totally different guidance and rules about when mothers should present or the sort of treatment they should get at hospital. Does the hon. and learned Gentleman agree that introducing a maternity commissioner would give us strategic oversight across the country of the experiences that mothers should expect to have?

Certainly, the petition is clear that without expert, national-level oversight, there is no way of turning that thicket of different guidance and frameworks into a coherent, enforceable standard of care. Whatever structural change the Government put forward has to do that job. I spoke to my constituent Jo Page earlier, and she told me that there are people in Folkestone and Hythe who are going to Tunbridge Wells to access maternity services because of their concerns about the local standards of care. Obviously, that has to be fundamentally addressed.

The powerful evidence from the various maternity investigations that we have seen show that when everyone is responsible, nobody is accountable. Appointing a maternity commissioner could well mean that there is somebody with whom the buck stops—a dedicated expert responsible for turning the 750 recommendations, or the 87 guidance documents, into a single national maternity strategy and ensuring that it is implemented. That is not the only way that that could be done; Baroness Amos will shortly publish her report on the national maternity and neonatal investigations in NHS services. The petitioners strongly believe that her report should commit to a maternity commissioner and a maternity strategy. I look forward to hearing from the Minister how the Government currently view that proposal. I also ask her to commit to providing an update on which of the previous recommendations committed to may be taken forward.

In conclusion, the Government’s recent decision to introduce a women’s health strategy is hugely welcome and is an important acceptance that women’s health has been neglected for far too long. The petitioners strongly believe that it would make a real difference to women giving birth if that strategy encompassed a maternity commissioner with the authority, expertise and focus to end the postcode lottery in maternity care and break the cycle of avoidable harm once and for all.

I am grateful to Members for bobbing to indicate they would like to take part in the debate.

It is a pleasure to serve under your chairship, Sir Alec. I thank the hon. and learned Member for Folkestone and Hythe (Tony Vaughan) for introducing this important and sensitive debate with his customary eloquence.

I thank the 464 of my constituents who signed the e-petition, placing my constituency in the top 25 nationally for signatories. I also want to thank the many constituents who have been in touch with me and my team—many of whom I have met at constituency surgeries—about their maternity experiences.

This debate is important because of the familial and societal importance of safe, reassuring and comfortable pregnancy and childbirth, and all the anxiety and exhilaration that comes with that. I know that not from my own experience, but from that of friends and constituents. I have never seen people cry so much or so intensely as at the funeral of my friend Steve and Yue’s daughter. They, along with my friend Joel, who also lost a baby, have been superbly supported by Sands, the stillbirth and neonatal charity. They have all now experience successful births.

I want to emphasise what this debate should be about. It is definitely not about criticising hard-working and dedicated individual midwives and health workers, who so often do an amazing job in very challenging circumstances. It is about improving the top-level leadership, culture, staffing levels and processes that affect maternity units.

In my constituency, we have local maternity units in community hospitals in Wantage and Wallingford. These are welcomed by many constituents who would otherwise have to make what is often a long journey to Oxford. Otherwise, births happen in the maternity unit at Oxford’s John Radcliffe hospital. I visited the department in September 2025 and was given a comprehensive tour, including the new bereavement ward. I thank all the staff I met, who were committed to improving the care there. The department-level leadership was receptive to feedback and acknowledged that care at the John Radcliffe hospital has at times gone wrong. That is important, given the many constituents who have contacted me about their experiences at the John Radcliffe hospital.

It is a pleasure to serve under your chairship, Sir Alec. I will make some comments as the chair of the all-party parliamentary group on baby loss, but also as a bereaved parent: we lost our daughter Mallorie at the age of five days.

First, I want to thank everyone who responded to the petition. It shows the massive extent of concern about this issue. So many of us share that concern as something that is personal and requires immediate and comprehensive action. For the past two years, my all-party group has been listening to families, parents and professionals. We have heard about a litany of failures across the whole sector. I am sure that colleagues will refer to many of the issues and incidents, so I will not repeat them, but we have to recognise that these systemic failures often go very deep within the culture of the health service. We need to recognise that that results in fundamental inequalities in terms of ethnicity and deprivation, with families not being listened to and suffering outcomes that are truly unacceptable.

We also have to recognise that there are islands of very good practice. There are trusts and professionals who continue to do an amazing job. I can cite the birth centre at Burnley that my hon. Friend the Member for Ribble Valley (Maya Ellis) and I visited recently, where we saw how things can be done and what “good” actually looks like.

There is an undeniable case for urgent and immediate action, as I think we all agree. I think we also agree that we cannot repeat the cycle of reports, reviews and recommendations. As the hon. Member for Didcot and Wantage (Olly Glover) said, there have been 700 recommendations, and in many cases they were exactly the same, time after time. We cannot repeat that cycle, which is why it is so important that Baroness Amos’s maternity services investigation is different. I believe that she is entirely committed to addressing the underlying systemic issues across the sector and to bringing forward a report that focuses on the underlying systems and cultures that need to change, rather than just repeating the litany of what has gone before.

It is a pleasure to serve under your chairship, Sir Alec. I congratulate the hon. and learned Member for Folkestone and Hythe (Tony Vaughan) on opening this important debate. I want to reflect the strength of feeling on this issue among my constituents in Esher and Walton; the fact that 568 people from my constituency added their names to this petition reflects a very real and deeply felt concern among families in my community about the state of maternity care in this country.

I am a mother of four, and I am very lucky to have given birth four times, but three of those were traumatic. My first birth was an emergency C-section, the second was a vaginal birth after caesarean that needed lots of intervention and the third was absolutely fine, but during my fourth the crash team had to attend because the midwife failed to pay attention to what I knew, as an experienced mother, was a problem. When I took baby Tom, who is now 14, home—[Interruption.]

Order. It might be helpful to know that some Members have approached me to say they have spoken to Mr Speaker, as they may need to move around. They will ask to intervene if they want a Member to give way, and Members can give way if they are specifically asked.

Thank you for that clarification, Sir Alec. I am trying to do my best on protocol.

When I took baby Tom, who is now 14 years old, home, hugging him ever more tightly, I told only my very close friends and family what had happened. I fear that the stats we see are only the tip of the iceberg, because many are not shared.

Behind all the signatures are stories—of women who feel they were not listened to, of traumatic births and, in some cases, of long-term psychological impacts. There are testimonies in my inbox. One constituent, Lisa—a paediatric nurse with nearly two decades of experience in the NHS—wrote to me after developing PTSD following a traumatic birth. She spoke not only as a mother, but as a healthcare professional who understands the system from the inside yet still feels let down by it. Another constituent, Rosie, who has worked for over 20 years supporting women through pregnancy and childbirth, described a system where too many women feel they must fight to have their voices heard, where decisions are not always fully respected and where trauma is becoming far too common.

Sadly, those are not isolated accounts; they are consistent with what we see in the national data and across the many reviews that have been conducted. One in three women now describes their childbirth experiences as traumatic. PTSD affects about one in 20 mothers. Maternal mortality has risen over the past 15 years, and the CQC has found that a majority of maternity units require improvement or are rated inadequate for safety.

We should be clear: the problem is not a lack of understanding of what is going wrong. Over 700 recommendations have been made across more than a dozen reviews of maternity services. They point again and again to the same issues of training time, poor communication, failures to listen to women, and systems that do not learn effectively.

It is a pleasure to serve under your chairmanship, Sir Alec. For complete openness and transparency, I am a harmed mother. I have been involved in the Nottingham inquiry, I sit on the national maternity and neonatal taskforce, and I am the chair of the APPG on maternity.

I want to place on record my personal and sincere thanks to Louise Thompson and Theo Clarke. After the most traumatic and horrific birth trauma, they chose to speak out, not just for themselves—in fact, not for themselves at all—but for countless other women. That courage matters, because for every voice we hear, there are more still unheard. Courage after trauma should not be a necessity for change. That is why today’s debate is so important.

I do not want to pre-empt the findings of the Baroness Amos review, but I welcome the national taskforce—it is the first of its kind—and the work the Government are doing. Maternity services are systematically failing too many women and babies, and we cannot ignore what is happening across the country. Families having raised concerns for years and years, but those concerns were not acted on soon enough. It is not about one hospital or one failure, but about a pattern of women not being listened to, warning signs being missed, fathers and birthing partners being ignored, and poor practice continuing unchecked, sometimes for years.

We must be honest about this: the system of oversight has failed. That is certainly true in Nottingham, where the Care Quality Commission failed, the Nursing and Midwifery Council failed and the General Medical Council failed. When the system fails, it is about not just frontline care but the structures designed to keep people safe.

Inequalities are profound and, quite frankly, a disgrace. Black and Asian women are significantly more likely to have birth complications and poorer outcomes. If safe care is not equitable, we do not have any safe care at all. That must change.