UNICEF UK Baby Friendly Initiative responds to the National Maternity and Neonatal Investigation final report

The findings of the Independent National Maternity and Neonatal Investigation, led by Baroness Amos, describe serious and unacceptable failures and unsafe care experienced by too many women, babies and families across England. Every family deserves safe, high-quality and compassionate care during pregnancy, birth and the earliest days of a baby’s life. The final report makes it clear that, despite examples of good practice, too many families are still being let down. 

We are deeply moved by the courage of the families who shared their experiences, including bereaved parents and those who have experienced harm. Their voices must remain central to the government’s response and to the lasting change that must follow. 

Many of the themes highlighted in the investigation – women and families not being listened to, fragmented care, workforce pressures, poor communication, racism, discrimination and inequality – echo what families and staff have raised over many years. They also reflect issues we hear through our own Baby Friendly assessment, accreditation and quality improvement work with maternity, neonatal and community services. 

We welcome the report’s focus on listening to women and families, strengthening continuity of care, family-integrated neonatal care, and ensuring protected time for staff learning and development. Just as importantly, the report reinforces the need to address racism, discrimination and inequality as central issues of patient safety and care quality, not as separate concerns. These priorities are embedded within Baby Friendly standards, which support services to provide evidence-based, compassionate and equitable care, strengthen staff knowledge and confidence, and involve parents as active partners in their baby’s care. 

As the Government’s new National Maternity and Neonatal Taskforce develops and oversees a national maternity action plan which will respond to these findings, this must be a moment for sustained investment, accountability and service improvements. Infant feeding support and close, loving parent-infant relationships should be recognised as integral to safe, high-quality maternity and neonatal care, not as separate from it. 

Clinical safety in pregnancy and birth is overseen through clinical governance and regulation. But safe, high-quality maternity and neonatal care cannot be separated from how well families are supported to feed their babies and build close, loving relationships with them in the earliest days. Parents’ experiences shared through the investigation show both excellent support and significant gaps, including inconsistent advice, fragmented pathways and insufficient support after discharge. 

UNICEF UK Baby Friendly stands ready to work constructively with government, NHS trusts and partners to help ensure every baby has the best start in life, and every parent receives care that is safe, respectful, equitable and compassionate. 

Dr Philip Goodwin, Chief Executive Officer of UNICEF UK, said: “The findings of the Independent Maternity and Neonatal Investigation are deeply concerning. In one of the richest countries in the world, unsafe and unequal maternity and neonatal care is costing lives, and too many babies and parents are experiencing avoidable harm and trauma. 

“Every baby has the right to a safe, healthy start in life, and every parent has the right to high-quality care, delivered with compassion, dignity and respect. 

“The UK Government must take immediate action to improve safety, tackle deep-rooted inequalities, and invest in maternal and child health.”