From Crisis to Confidence: What UK Maternity Reviews Reveal About Safer Newborn Care

Purpose

As a midwifery academic, I’ve always seen myself as a teacher first. My current role is split between teaching and practice as a Senior University Practitioner, and a secondment with the University’s Strategic Teaching and Learning team. In a social conversation this week, a friend, and colleague, inadvertently I’d like to say, suggested that the practitioner role was one designed to down skill the academic workforce to practitioners who teach and mark, but do not research. I beg to differ.

To teach well, especially in a field as critical as midwifery, I need to be able to analyse, synthesise, and communicate evidence in a way that sparks curiosity and reflection. Though I stepped away from my PhD during a major restructuring last year, I’ve never stopped engaging with evidence and research. Today, while preparing for a teaching session on neonatal care, I found myself, once again, deep in the findings of multiple national maternity reviews. What I saw was both familiar and frustrating. The same themes. The same failings. The same heartbreak. As we face another, this time national, maternity review, I suspect we will not only find more of the same but will further fuel frustration, demoralization of the maternity workforce and fear in the families we serve. I’d like to hope that we could perhaps review the good practices that are out there, the places where things are going well, disseminate the findings and learn widely from them.

For today’s session, I concentrated on just four of the reviews we already have, there are more, which we’ll review in further taught sessions. The vignettes within them differ, but they all point to the same failings. That’s not a coincidence, that’s a call to action.Over 1,000 pages of evidence from hospitals big and small, urban and rural, paint a clear picture: the problems in neonatal care are consistent, and that means the solutions can be too. The focus of today’s teaching session was specifically neonatal care, others will consider other aspects of maternity care and perhaps I’ll do the same for them, but, for now, this blog distils the findings from Kirkup, Francis, Cwm Taf Morganwg and Ockendon into a practical roadmap for any maternity team ready to make change happen—starting today.

What the Reviews Say: Common Pitfalls

Across the reviews, the same seven issues keep resurfacing:

1. Understaffing – Thin rotas, staff covering multiple areas, and off-site consultants delayed critical care.

2. Weak escalation systems – Early warning signs were missed or ignored.

3. Resuscitation gaps – Equipment was unchecked, staff underprepared.

4. Poor communication – Obstetric red flags didn’t reach the wider multi-disciplinary team.

5. Governance without action – Lessons were logged but not learned.

6. Parents excluded – Families’ concerns were dismissed or overlooked.

7. Data blind spots – Incomplete records hid dangerous trends.

These aren’t new problems. They’re persistent ones. And the fact that they keep appearing in inquiry after inquiry tells us something important: we need to act on what we already know!

What Works: Practices That Save Lives

The good news? We already have the solutions. These twelve practices are backed by evidence and are already making a difference in some units:

- 24/7 on-site tier-2 clinicians

- Safe nurse-to-cot ratios

- Use of one unified early-warning chart

- Daily equipment checks

- Time-critical bundles (e.g., antibiotics within 60 mins)

- Warm delivery rooms especially, but not exclusively, for preterms

- Immediate skin-to-skin contact

- Rigorous infection control

- Joint governance meetings, sharing of incidents, NNAP and MMBRACE-UK benchmarking

- Structured reviews of NICU admissions—that are done in partnership with parents- Unified electronic records

- Protected teaching time each month that covers guideline updates, morbidity reviews and simulated scenarios.

These aren’t high-tech miracles. They’re simple, human-centred practices. But they require consistency, leadership, and a culture that values safety over speed.

A Moral Imperative

We’ve had more than a dozen national reviews into maternity care in the UK over the past two decades. Each one has cost time, money, and, most importantly, trust, and yet, the same recommendations resurface. There is now a moral imperative to stop reinventing the wheel. We owe it to families, to staff, and to the memory of those who were failed by the system, to implement what we already know works. Not next year. Not after the next inquiry. Now.

How to Start: A Sequence for Change

Creating safer neonatal care doesn’t require a complete system overhaul—it starts with small, focused steps. The first is to measure what’s currently happening in maternity units. This means taking a clear-eyed look at how well existing practices align with evidence-based standards. Once that baseline is established, the next step is to identify the area causing the most significant delays or risks—often, this is related to staffing or the use of early warning tools.

With that in mind, teams can test a small, targeted change using an eight-week Plan–Do–Study–Act (PDSA) cycle. The goal isn’t perfection, but progress. Crucially, the results, whether successful or not, should be shared openly; transparency builds trust and invites collaboration. When a change proves effective, it can then be scaled to address the next area of focus.

This is where education and educators can contribute. We can help teams interpret data, design meaningful interventions, and build the confidence needed to sustain improvement. Our ability to bridge evidence and practice, and the head space to do it, is a powerful catalyst for change.

The Game-Changer

While systems and protocols are essential, it’s culture that determines whether change will stick. Culture isn’t defined by posters or policies—it’s shaped by what people do when no one is watching. It’s the everyday behaviours, attitudes, and interactions that either support or sabotage safety.

To shift culture, practices must foster openness and trust. Blame-free debriefs after clinical events create space for honest reflection and learning. Cross-disciplinary huddles, brief, structured check-ins between obstetric, neonatal, and anaesthetic teams, break down silos and normalise early escalation. Leadership visibility matters too; when senior staff are present, listening, and modelling the behaviours they expect, it sends a powerful message.

Incorporating parents’ voices into governance meetings further reminds teams of the human impact behind every decision. Peer coaching builds confidence and connection among staff, while real-time feedback and recognition reinforce positive behaviours.

These aren’t grand gestures—they’re small, consistent actions that, over time, create a culture where safety is instinctive, not optional. Culture change doesn’t need to be grand. It needs to be daily. Small, visible, human acts that say: “We care. We’re learning. We’re in this together.”

From Reflection to Action

The UK’s maternity reviews don’t ask for perfection. They ask for consistency. They ask us to listen, to learn, and to lead.As someone who teaches our future midwives, I believe our greatest impact lies in connecting evidence to action. That’s the purpose of this blog: to contribute something practical and usable. If it helps even one person start a conversation, try a new approach, or feel supported in tackling the challenges we all face, then it’s been worthwhile.

Because every minute we gain can make a lasting difference to the babies and families in our care.