What the Nottingham Maternity Review Asks of Us
Yesterday, the largest maternity inquiry in NHS history was published. We have read it carefully. Here is what it found — and what we believe it asks of everyone who works alongside birthing families.
By Alexandra Burner, Founder 25 June 2026
Yesterday, Donna Ockenden’s independent review of maternity and neonatal care at Nottingham University Hospitals NHS Trust was published. It is the largest maternity inquiry in the history of the NHS. By the time the review closed, almost 2,500 families had come forward — families who had carried their experiences, sometimes for more than a decade, in the hope that telling them would mean something.
We want to begin there. Not with the statistics, though there are many, and not with the recommendations, though they matter enormously. We want to begin with the families.
Because behind every figure in this report is a person: a mother, a baby, a partner, a life altered or ended by care that should have been safer than it was. The fact that so many families had to fight to be heard is, in itself, one of the report’s most important findings.
The scale of what was examined
The review looked at 2,026 maternity cases and 937 neonatal cases spanning care delivered between 2012 and 2025. On average, around one in five maternity cases were graded as showing suboptimal care that probably affected the outcome. Of the 27 maternal deaths examined, reviewers concluded that failures in care may have substantially affected the outcome in six. Eleven of those deaths were of women living in the most deprived areas of the city; fourteen were of women who were not white British.
These are not abstractions to us. They map almost exactly onto the inequalities we teach our trainees to recognise, name and work against — and they sit within a national picture in which maternal deaths in England are at a twenty-year high, with women in the most deprived communities and Black women remaining at significantly greater risk.
This report makes clear that what happened in Nottingham is not anomalous. It is a warning about what happens when leadership, culture and governance fail across a whole system.
The themes we cannot look away from
Read in full, the review describes failures that recur across the entire maternity pathway. Several of them speak directly to the work we do and the practitioners we train.
Women were not listened to. Time and again, the report describes women who raised concerns — about reduced fetal movements, about pain, about a sense that something was wrong — and were met with false reassurance, poor communication, or a culture that discouraged them from coming in to be seen. Women whose first language was not English were repeatedly left without adequate interpretation or support. This is the single thread that runs through almost every other failure: a persistent failure to listen to and believe mothers and the people supporting them.
The physiological process of labour was too often replaced by poorly monitored intervention. The review raises particular concerns about the management of induction of labour and the latent (early) phase: inappropriate and untimely use of synthetic oxytocin, incorrect interpretation of fetal monitoring, delays in escalation, and inconsistent local guidelines. There is, in the report’s own framing, a clear pattern of the physiological process of labour being managed poorly and then displaced by intervention that was not adequately monitored.
We teach this distinction in detail, because it matters. Induction and intervention can save lives when they are clinically indicated, properly explained and carefully monitored. They cause harm when they are used to compensate for a system that has stopped paying attention. Helping families understand the difference — and supporting them to ask the right questions at the right moments — is core advocacy work.
Inequality was structural, not incidental. The report notes that only 8% of the trust’s midwifery workforce was from a global majority background, against 26% of the wider workforce and 34% of the obstetric workforce. Women from global majority populations faced compounded risk at every stage of their pregnancy and birth. Equitable care is not a matter of individual good intentions; it is a matter of who holds power, who is represented, and whose concerns are believed.
Culture and staffing failed the people inside the system too. Only 11% of staff felt there were enough of them to do the work safely. More than 40% had witnessed or experienced bullying as a regular part of their working life. Leadership was described as historically invisible, unapproachable and unresponsive to concerns raised. Tired, frightened, unsupported staff cannot deliver safe, compassionate care — and the report is unflinching about the toxic culture that persisted on the labour ward for much of the review period.
Dignity was not always protected, even in death. Among the hardest sections to read are those describing failures in bereavement and after-death care — dehumanising language, poor mortuary practice, and a profound loss of dignity for babies who died. The report also notes that the dedicated psychological support service for pregnancy and baby loss was defunded in 2025. This is a line we cannot move past quickly.
What the report does well
It would be wrong to read this only as a catalogue of failure. The review found genuinely good and exceptional practice too — obstetric anaesthetic care was assessed to a high standard in the large majority of cases, and neonatal care was broadly in line with national expectations, with a new, larger unit opening in December 2024. Naming what works is as important as naming what does not, because it tells us that safe, dignified maternity care is achievable. The question the report forces us to ask is why it was not delivered consistently, for everyone, for so long.
What this asks of us as doulas
Six previous external reviews of this trust were commissioned between 2015 and 2022. All were highly critical. Systemic change did not follow. That history is the reason we cannot treat this report as someone else’s problem, or as a moment to feel vindicated. The honest response is to ask what each of us does differently from tomorrow.
Listen and be the steady, informed presence. Doulas do not provide clinical care, and we are clear about that boundary. But someone who actively listens, provides continuity, calm and good information are exactly what was missing in so many of these accounts. A doula or advocate who helps a family understand their options, document their wishes, and escalate a concern is doing something this report shows can be life-changing.
Take informed decision-making seriously. The review calls for women to be at the centre of clinical communication and genuine informed consent. Our role is to protect the space in which families can ask questions, weigh evidence, and be heard — particularly around induction, monitoring and intervention.
Know the safety tools. The report calls for robust implementation of Martha’s Rule across maternity settings, so that families and staff can seek an urgent second clinical opinion. Birth workers should understand what it is and how families can use it.
Hold equity as practice, not aspiration. The disparities in this report are not new to anyone who works in birth equity. They are a mandate to keep doing the uncomfortable, ongoing work of culturally safe, anti-racist practice — and to keep crediting and deferring to the practitioners with the closest proximity to these experiences.
Protect bereaved families fiercely. Compassionate, competent care after loss is not an optional extra. It is a measure of whether a system sees the people it serves as fully human.
What we are committing to
For us, a report like this is never abstract. It lives in what we do alongside families, week after week — and it deepens our resolve to keep doing it well. We will keep offering clear, honest education, so that parents understand what is happening to their bodies and their babies, and which choices are genuinely theirs to make. We will keep being a steady, listening ear — the person who hears the worry beneath the words and takes it seriously, especially when no one else seems to. And we will keep practising advocacy that is real rather than performative: helping families ask their questions, hold on to their wishes, and be believed — through pregnancy, through birth, and through the tender, too-often-unwitnessed experiences of fertility and loss.
We will never tell a family to expect less of the care around them. We will simply keep standing beside them, so that no one has to walk through any part of this feeling unheard or alone. That is the work. It does not end when a report is published — it continues quietly, in living rooms and birth rooms, for as long as families need us there.
We will continue to hope.
Hope that these latest recommendations are enacted. Hope that maternity funding, staffing and care will improve for all future parents.
To every family in Nottingham who came forward, and to those who could not: thank you. You should not have had to fight to be heard. The least the rest of us can do is make sure the listening continues.
About The Original Birth Connection
The Original Birth Connection trains birth and postnatal doulas through an evidence-led, full-spectrum curriculum that holds physiology, advocacy, inclusion and bereavement care as central. Our work is grounded in a commitment to equity and structural reform in UK maternity care. If this report has raised questions for you about the support families deserve, we would be glad to talk.
Note on sources: figures and findings in this piece are drawn from the published Ockenden review of maternity and neonatal services at Nottingham University Hospitals NHS Trust (24 June 2026). We would encourage readers to consult the full report directly↗.