The Maternity and Newborn Safety Investigations programme (MNSI) welcomes today’s publication and recommendations that call for safe staffing levels, mandatory training on trauma-informed care and universal access to specialist maternal mental health services.

The report from the All-Party Parliamentary Group on Birth Trauma reviewed more than 1,300 submissions from people who had experienced traumatic birth, as well as nearly 100 submissions from maternity professionals. It also held seven evidence sessions, in which it heard testimony from both parents and experts, including maternity professionals and academics. MNSI submitted written evidence and are pleased to see many of our findings echoed in the report.

Sandy Lewis, MNSI Director said:

“Sharing experiences and learning from maternity care is an important mechanism to ensure improvements are made and MNSI welcomes today’s report and recommendations. Sadly, there were a huge number of experiences of traumatic birth shared with the inquiry. We acknowledge the significance of trauma and injury, as we see the impact frequently in our own investigations. This is an area which is often not discussed within current or subsequent pregnancies and impacts on women and their families experience.

We are pleased to see the recommendation calling for universal access to specialist maternal mental health services across the UK. MNSI investigations have found that these services aren’t always readily available or accessible to all. In 2022, we reviewed a small number of maternal collapses at one trust; these highlighted some concerning areas of the care women receive. All the women we reviewed experienced life changing physical and psychological injuries. These included permanent disability and the diagnosis of post-traumatic stress disorder (PTSD). We found that the follow up was limited or not undertaken at all, the communication from the trust was inconsistent and signposting to other services did not occur.

I want to thank the mothers and families that came forward to share their experiences. I have no doubt this will have been profoundly difficult. Their openness and commitment to support improvements in this area of care is both brave and humbling.

The report echoes themes of MNSI’s national learning report published just last week. We know that increased work demands and reduced capacity to respond are leading to poor outcomes for mothers and babies. This finding is not new, and we hear frequently that staffing shortages have a significant impact on safety and quality of care.”

We look forward to collaborating across the sector to take forward the recommendations made today. MNSI has a unique insight into many cases of birth trauma and we hold a responsibility to those families we work with to share learning that supports service improvements.

Related news

Baby Loss Awareness Week

Family involvement in safety investigations: reflections for Baby Loss Awareness Week

This Baby Loss Awareness Week, now in its 22nd year, we join with families and communities across the country to remember the babies who have died and to honour all those affected by loss.In this art…
Read the full article

Understanding the context of maternal deaths: Reflections on the MBRRACE-UK Report

In this article, Louise Wake, Maternity Investigator – London East Team and Health Equity, Diversity and Inclusion Lead at MNSI, reflects on the latest MBRRACE-UK findings, how they align with themes…
Read the full article

MNSI Annual Report and Recommendations 2024/25

The Maternity and Newborn Safety Investigations (MNSI) programme has today published its Annual Report 2024/25, highlighting a year of activity aimed at improving safety for women, babies, and famili…
Read the full article

Safety Spotlight: Therapeutic cooling practices

MNSI is aware of maternal deaths from anaphylaxis.
Read the full article

Ensuring safe beginnings: The imperative of patient safety in maternity and newborn care

This World Patient Safety Day 2025, the focus is on “Safe care for every newborn and child.”At MNSI, our ambition is to make maternity and newborn care safer by learning from safety events and suppor…
Read the full article
© 2025 MNSI. All rights reserved.