Thank you for inviting organisations to offer evidence to the investigation.
AIMS has welcomed this investigation, and we stand ready to support it, drawing on our particular expertise. A good summary of our initial stance on the investigation is here: Open letter from AIMS about the National Maternity review and later - from one of our Campaigns Team volunteers - here A personal reflection on the Amos Review Update, December 2025.
Our welcome letter to Wes Streeting after the change of Government is also relevant, aims-letter-wesstreeting2024-08.pdf
Since 1960, AIMS has been a leading advocate for improvements in UK maternity care. We are a lay-led organisation with national and international links, and a membership that includes health and care professionals as well as lay people. Collectively, our volunteers have decades of experience researching, advocating and campaigning for improvements in UK maternity care. We run an email and telephone helpline for women as they seek to navigate the maternity services, and we offer a range of information resources. We have a large network of people, via our volunteers and members, who engage regularly with mothers, health care providers and others. We use our knowledge, influence and experience to work collaboratively with others to support policy change at local and national level.
We are fiercely proud of our independence in terms of funding: we are accountable only to our charitable AIMS and beneficiaries. This means that we can speak without fear or favour. We persistently highlight transparency as a key driver of improvement in the maternity services - we have often found the maternity service bizarrely secretive. We seek to demonstrate transparency in our approach to our work. For example, this submission will be made public on our website. We believe that stakeholder collaboration is key to sustainable improvement, and that this is a key area for improvement: there is often not enough of it during the policy formulation stage. We welcome the fact that you will also hear from a diverse and growing service user sector of the maternity services improvement community in your investigation: this is vital. Many of these organisations represent specific groups of service users: our approach is to consider systems wide improvements that should benefit everyone, importantly taking the risk of unintended negative consequences into account.
We are a longstanding member of NHS England’s Maternity and Neonatal Stakeholder Council, where we actively contribute as ‘a critical friend’ to NHS England as they seek to effect positive change in the maternity services. Our sense is that NHS England are doing their best to design and implement a wide range of initiatives to improve the maternity services, following previous investigations, but that together these fall short of the full-scale transformation necessary. Our sense is also that Trusts are not always as co-operative in implementing agreed national initiatives as they might be, and that lack of effective collaboration too often impedes progress.
In this role, we were hopeful about the implementation of Better Births, but as the years went on we came to understand - like others - that performance across our NHS Trusts was much poorer than we had understood in 2016, and wasn’t ‘implementation ready’. We thus supported the Three Year Delivery Plan as a remedial measure, understanding that this should be delivered before transformation efforts would recommence.
In crafting your recommendations, we urge you and your team to understand the progress that has been made with this Delivery Plan - sadly we have not got access to an up-to-date implementation report (and the reports we have had previously have been extremely thin).
Our evidence - organised to meet your terms of reference - follows. But we’d like to highlight two points in particular:
First, please look into the well researched quality improvement initiative of midwifery continuity of carer. This is a whole-service relational model of care, where a midwife is effectively the ‘key account holder’ for every woman who engages with the maternity services. It means that there is always someone in the system that truly ‘has our back’. That midwife would be supported by the whole staff team, so this is not about valuing midwives over other professionals. We commend it to you, and trust that the LEAP team in South London have given evidence about the vital difference this model of care makes to outcomes. They have produced a couple of short videos that capture the essence of this model of care really well: the NHS England team will be able to point you to them.
Second, please take care when you see the vilification of those who show an interest in supporting women to have a ‘normal birth’. At AIMS, we are frankly amazed at how much maternity service routines work to disrupt rather than protect the physiological processes of labour, birth and the early postnatal period. Sometimes this is because we don’t have enough research on what supports - and what are the benefits of - normal physiological processes, but too often it is because midwifery knowledge is ignored and devalued. We really hope that your report will put an end to misunderstandings around this issue.
Thank you to you and your team for your work on this investigation. We know that you have a solid team of experts supporting you. We hope that all of our observations are already well known to you. Please don’t hesitate to contact us if you have any queries.
As a next step, we are pleased to have been invited to be represented on the subsequent Taskforce via our membership of the Charities and Third Sector Expert Reference Group. In that context, we wonder whether you should be joint chair of the Taskforce, as we greatly valued the role that Julia Cumberlege was able to play as she retained a role overseeing the implementation of Better Births. It would be good to see you in a similar role.
We attach our detailed response to your invitation to address issues flagged in your terms of reference.
AIMS Campaigns Team
15 March 2026
AIMS listens to the lived experience of women and their families when they contact us on the AIMS helpline, write about their experiences for our quarterly journal and when we meet them in person at conferences or meetings.
We note the recurring themes that emerge including the good experiences and what was key for achieving these, as well as the problems that they frequently encounter.
People contacting the helpline generally want help with one or more of the following:
Finding unbiased, evidence-based information that will help them to make a fully informed decision. Without this they are unable to give consent to a procedure in a legally valid way. They may want information about:
The ‘risk’ status they have been allocated and what this means in real terms. For example, we hear people say that they have been told they are ‘high risk’ because they are over 35, or because they are considered obese, but that the doctor or midwife was unable to quantify the actual level of risk.
The condition they have been diagnosed with, the actual level of risk this implies, and whether or not this should restrict their options. For example, they may have been told that they cannot give birth in a midwifery unit (M(L)U) because they have borderline gestational diabetes, but that the doctor or midwife was unable to explain why giving birth in the M(L)U would not be safe.
The other options for care in any given situation. For example, we hear women say that they were coerced into having an unwanted vaginal examination or into being induced and that they were not given an option.
Knowing their rights in expecting support for their fully informed decisions. This may be in relation to:
Their decision about where they give birth. For example, we receive a lot of calls from women wanting it confirmed that they have a right to give birth at home or in a midwifery unit, and asking if they have a right to be attended by a midwife if they are giving birth at home against the doctor’s advice.
Their decision to decline aspects of care. For example, we have calls from women who want to know if they have a right to be supported in a decision not to have ultrasound scans, or vaginal examinations.
Their preference for an element of care. For example, we receive calls from women who want it confirmed that they have a right to an elective caesarean.
Unfortunately we often hear that detailed information is not provided by the doctor or midwife, even when it is directly requested. Women tell us that questions are often met with vague answers such as, ‘Yes, you can wait, but it is much riskier’, or with words that feel like a threat, amounting to, ‘Yes, you do have a right to decline but your baby may die if you don’t do as we say’.
Women often use the words, ‘coerced’ or ‘bullied’. For example, women who tell us that they wanted to go home rather than be induced often report that they are told that this will be the doctor’s decision, or that they cannot go without speaking with the doctor first, and then they are ‘made to’ wait for hours with different doctors and midwives all repeating and amplifying the risk of declining the induction. Other women write to us expressing their anxiety and distress that support for their home birth has been, or is under threat of being, withdrawn, and we hear from women who are in fear following the threat of a referral to social services for non-compliance.
Women often contact us after an experience of maternity care that has left them feeling traumatised. They call because they want validation and confirmation that their experience was in breach of their rights and of what is considered to be good care. Very often they are requesting our help in making a complaint. We are also contacted when the response to a first complaint has been dismissive, which has compounded the trauma and the sense of helplessness.
At the root of almost all of these calls is the woman’s experience of not having been listened to, respected and truly supported in her decisions at the time. Women tell us that an ‘after-thoughts’ service or complaints response that says ‘we are sorry that you feel this way but…’ reinforces the first experience of not being listened to.
Conversely, women (or their partners) who contact us while the events are unfolding sometimes report care that transforms their experience to a really positive one.
When women feel that a midwife or doctor has really listened to them, believed them, and advocated for them, and when they have received respectful support for their decisions, they write to us about the huge sense of relief and trust that comes from this. They tell us about experiences that were joyful and meaningful for them. Continuity of Carer would ensure that this quality of care was consistent throughout the perinatal period.
Unfortunately, we hear from some midwives that their support for personalised care can be undermined, as this study confirms.
Some mothers write for the journal about their lived experiences.
One woman wrote about her experience of obstetric violence. Her story shows how shockingly insensitive care is too frequently seen as ‘normal care’. When birth feels like rape.
Another mother wrote about her wonderful experience of personalised care. My experience of physiology-informed maternity care as a pregnant woman living with diabetes
Non-consensual care, feeling ignored, dismissed, disrespected, bullied, coerced and cornered is traumatising.
AIMS believes that this need never happen. Emotionally intelligent and trauma-informed care that results in the opposite of these feelings can happen with Continuity of Carer, through which, a relationship of trust can build. Midwives and doctors need to be supported in offering this. Services need to be staffed adequately so as to be able to provide it.
Doctors and midwives, and the system within which they work, need to recognise women’s human rights - and staff need to be supported to act in accordance with these. (Birthrights letter to the National Maternity review 2015)
There needs to be genuine support for autonomy and informed decision-making; support for the mother’s decision even if doctors or midwives disagree with it. (AIMS position paper on decision-making in maternity).
Doctors and midwives, and the system within which they work, need to recognise systemic obstetric violence and ensure that this never happens. (AIMS position paper on obstetric violence)
We believe that a full pathway Continuity of Carer would go far to address these issues. (AIMS position paper on continuity of carer)
We hear from calls to our helpline that when parents complain about the quality and safety of the maternity care the mother or baby received, the complaints procedure is rarely effective at bringing about a change in practice.
Complaining about care needs to be an independent and accessible process, with clear and actionable suggestions for improvement made that can be monitored afterwards. For example, it might be suggested that staff receive specific training in legally valid consent, and the complaints procedure can remain open until this has been seen to have happened and evaluated in practice.
Parents often tell us about care that seems to be misaligned with professional standards.
Existing guidance about good, safe and consensual care could be more openly adopted by every unit, with visual reminders for both staff and parents in every birth room.
From the Standards of proficiency for midwives
1.20 - understand the importance of, and demonstrate the ability to seek, informed consent from women, both for herself and her newborn infant
1.21 - understand and respect the woman’s right to decline consent, and demonstrate the ability to provide appropriate care and support in these circumstances
1.22 - be able to advocate for the woman when her decision is outside of clinical guidance, in order to minimise risk and maintain relationships
From The Code
1.1 - treat people with kindness, respect and compassion
1.5 - respect and uphold people’s human rights
2.5 - respect, support and document a person’s right to accept or refuse care and treatment
4.2 - make sure that you get properly informed consent and document it before carrying out any action
Elements from these could be used to elicit service-user feedback about their perceived assessment of the quality and safety of the care received, and as a benchmark against which anyone, parent or health professional can measure good care.
Parents often contact us because they feel that unnecessary or unwanted medical procedures are being pushed upon them. Occasionally a woman will contact us because a procedure she senses is necessary is being delayed or even denied. The fact that both of these experiences can reduce the quality and safety of the women’s and baby’s experience was recognised in the Lancet series, Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide.
AIMS believes that Continuity of Carer and personalised care plans would effectively address these issues.
The people who contact our helpline sometimes tell us they believe that their care has not been as good as one would hope because they are Black, or young or neurodiverse.
AIMS believes that Continuity of Carer, personalised care, truly consensual care, and, by extension, care that would by design be ‘culturally’ safe and respectful, would help address these issues.
AIMS also believes that leaders and decision-makers in the maternity services throughout the UK need to recognise the problems of institutional racism and unconscious bias and ensure appropriate training for all staff.aims-position-paper-racial-inequalities-in-maternity-services.pdf
Local action plans to improve the equity of outcomes and experiences need to be co-produced with the affected communities.
We are also aware from people who have contacted us that language is a barrier to women with communication needs of all kinds having the benefit of nuanced and tailored discussions about care, particularly if the support of a properly qualified interpreter cannot be guaranteed for all appointments as well as during labour and birth.
This is especially a problem for deaf women and their deaf partners where there is no ‘Google translate’ and often a lack of qualified interpreters..
The AIMS journal issue, The deafness loop: a cycle of inequality, highlights the inequalities for deaf mothers and for the parents of babies found at birth, or soon thereafter, to be deaf.
AIMS welcomes many of the recommendations from previous reports including:
“The Better Births Vision, 2016 - Our vision for maternity services across England is for them to become safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances. And for all staff to be supported to deliver care which is women centred, working in high performing teams, in organisations which are well led and in cultures which promote innovation, continuous learning, and break down organisational and professional boundaries.”
This vision is aligned with AIMS own vision (as outlined in our position papers) but is clearly beset with barriers (see below).
NICE guidelines on decision-making
“Following this process makes sure the person understands the risks, benefits and possible consequences of different options through discussion and information sharing.”
“Supporting women to make decisions about their care is important during pregnancy. Healthcare professionals should ensure that women have the information they need to make decisions and to give consent in line with General Medical Council (GMC) guidance, the Nursing and Midwifery Council (NMC) Code and the 2015 Montgomery ruling.”
We understand that the NICE guidance on ‘shared decision making’ recognises that it is always the patient/woman who legally makes any final decision about which aspects of care are accepted or declined, but this is not what the women who contact AIMS experience in reality. The term ‘shared decision making’ is misleading in implying that the decision is 'shared' when in fact it should be made by the woman and supported by her doctors and midwives. Doctors and midwives need to feel safe and supported to follow this guidance.
NICE Intrapartum care Quality statement 1 - Choosing birth setting
“Women at low risk of complications during labour are given the choice of all 4 birth settings and information about local birth outcomes.”
We hear from women all around the UK that the choice of a home birth in particular, and to some extent, a midwifery unit birth is being denied or made uncertain - often at a very late point in the pregnancy.
NICE antenatal care Quality statement 3 - Continuity of carer
“Pregnant women have coordinated care from a small team of midwives.”
When this happens, and continues throughout the perinatal period, we hear much happier stories - both from the women and their families, and from midwives. However, the majority of women tell us that they see lots of different people throughout the course of their care and often receive conflicting advice. This can be very distressing.
The Lancet series on Midwifery - executive summary
“The Series provides a framework for quality maternal and newborn care (QMNC) that places the needs of women and their newborn infants at its centre.“
The series acknowledges that many of the essential needs of childbearing women are still not being met, decades after they have been recognised and that new solutions are required.
The Principles for supporting women’s choices in maternity care
“The principles are designed to support women in receiving kind, compassionate, high quality and safe, personalised care throughout the childbirth continuum and have been developed in collaboration with a wide range of interdisciplinary and multiagency key stakeholders.”
AIMS supports the key messages in this document.
As mentioned in our introduction, we have supported the recommendations of the Three Year Delivery Plan.
This plan was intended to bring previous recommendations into one place, for ease of implementation and monitoring.
We look forward to seeing any challenge you may have of this Plan, and where we have made progress with the recommendations: our sense that it is a good plan, but does not go nearly far enough.
We are also concerned about its patchy implementation, in particular the resistance to the implementation of a continuity of carer model of care for those most vulnerable to poor outcomes, as per the CORE20+5 framework. This model of care should be in place now: what does it say about the system’s commitment to equity that it is not? Indeed, this might be a good case study of the system’s resistance to change, and we suspect that financial incentives for this initiative have not been used locally for their intended purpose.
Enabling Safe Quality Midwifery Services and Care In Northern Ireland | Department of Health
AIMS letter to Professor Mary Renfrew in support of this review:
“AIMS has been a longstanding supporter of relational care as a fundamental building block of safe, personalised and equitable maternity service, and we are delighted to read the many references to Continuity of Carer throughout the report. We continue to prioritise this model of maternity care in our campaigning work with the governments in all Four Nations in the UK.”
Renewed commitment to the recommendations from the Better Births report. This was the result of a wide-ranging National Maternity Review and the recommendations are as valid and even more urgent than when it was first published. We would like to again remind you of that vision:
“Our vision for maternity services across England is for them to become safer, more personalised, kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances.
And for all staff to be supported to deliver care which is women centred, working in high performing teams, in organisations which are well led and in cultures which promote innovation, continuous learning, and break down organisational and professional boundaries.”
We are sorry that the system was reluctant to set up metrics to demonstrate progress - or indeed backsliding - against every element of this vision statement.
Physiology-informed services. Student Midwives tell us that there is often little emphasis on physiology in their theoretical training, and that even when this is covered well, it is possible to go through three years of training today with little or no practical experience of seeing or supporting a truly physiological birth. The same will be true for obstetricians.
There is the opportunity to turn this around before it is too late by developing an approach to care for all women that is informed by a much deeper understanding of physiological birth, how to support it and how it is disrupted - on the understanding that the principles that support physiological birth, enhance every type of birth.
These principles include:
Consensual care
Personalised care that truly reflects the woman’s needs and wishes - including respect for their cultural safety
Known midwives and one to one care in labour
A calm and personalised birth environment
Privacy and lack of disturbance
Antenatally, this approach to care is facilitated best by:
Self-referral
Care and education offered in community hubs - such as ‘pregnancy circles’.
Active support for midwives and doctors to support the woman’s decisions. Midwives tell us that there is a tension between the law regarding consent and the pressure to work in accordance with hospital guidelines.
When AIMS informs women about their rights we are aware that it can be difficult for staff to support these.
“Women's autonomous choices in pursuit of physiological childbirth are sometimes limited by the midwife's willingness to support those choices, particularly when those choices are contrary to recommendations or outside of guidelines.”
There is an opportunity for a system change that respects and prioritises consensual care. Every hospital treatment protocol already has consent embedded in it so this could happen overnight.
Development of Community Hubs
The Better Births report recommended the establishment of community hubs “where maternity services, particularly ante- and postnatally, are provided alongside other family-orientated health and social services provided by statutory and voluntary agencies.”
We would like to see these go further and be integrated with support for community-based births – both homebirths and births in freestanding birth centres.
Ideally these hubs would be not only for maternity care but ‘women’s health hubs’ providing services for women’s whole life course, covering sexual and reproductive health as well as all aspects of perinatal care. Services should include pre-conception care, antenatal and parenting education, breastfeeding support, post-natal contraception and perinatal mental health services. We would like these to be not only places where women would go for medical care but also resource centres, providing information in accessible formats, providing support with issues such as housing, and acting as social centres along the lines of existing breastfeeding cafes, but available to all mothers.
Lack of effective change management skills and accountability
AIMS believes that the scale of the challenge in reforming maternity services must not be underestimated. It requires buy-in at every level to a transformation of culture, organisation and ways of working. This will not happen without a properly structured change management process that includes transparent monitoring and accountability for action, as well as adequate ring-fenced funding.
THIS Institute: How to design and plan large-scale programmes so they work
Fundamental gaps in midwives’ knowledge of legal consent - This requires training and the active support of senior staff to put this into practice. https://pubmed.ncbi.nlm.nih.gov/35869010/
Understaffing and work stress is a barrier to Continuity of Carer. It is frequently stated that lack of staff hinders the implementation of changes such a Continuity of Carer, or the provision of a full range of choices of birthplace.
Other barriers and enablers of transition to Continuity of Carer are analysed here. MCoC-evaluation-final-report-20.5.24.pdf
Loss of autonomy for midwives. Lack of autonomy for midwives, has led to barriers in supporting consensual care and physiological birth.
When midwives feel forced to comply with protocols rather than practice as autonomous professionals, it makes it hard for them to support maternal autonomy.
Over time, lack of autonomy has led to lack of experience, making it even harder to support women, especially in ‘out of guidance’ decisions. This ‘out of guidance’ terminology reframes personalised care planning as a form of deviance on the woman’s part
The majority of women find themselves classed as high risk.
Accusations of ‘normal birth ideology’ made against any midwife who actively takes a stand in supporting women in their decision to have a physiological birth has become a barrier.
Many midwives have settled into the role of obstetric nurses
Loss of experienced midwives, including those who become independent midwives or doulas in order to practice in the way they want.
Lack of senior posts in hands-on midwifery roles.
Not listening to women or taking their concerns seriously.
The current hospital-centric maternity system is at odds with the NHS plan for Neighbourhood Health services. A radical reframing which pays proper attention to the ways in which provision of midwifery care before, during and after birth can support better outcomes for women and babies, supporting health equity, would involve paying proper attention to a wide range of existing evidence including:
Continuity of carer
RCM position statement
A Midwife of My Own: Public Support for Implementation of Midwifery Continuity of Carer
Community based care:
Antenatal care in the form of Pregnancy circle
Home birth care - Is_home_birth_safe
The Albany centre practice
A retrospective analysis
AIMS review of the analysis of their data
Midwifery-led care - Midwife Led Units: Transforming Maternity Care Globally
Structuring and staffing care to properly meet women’s needs will take investment because services have experienced under-investment for decades.
Investing in the process change to implement full pathway Continuity of Carer for all will need to include proper funding for availability of care at home births, in freestanding and alongside midwifery units, and in obstetric units. For too long, NHS Hospital Trust Boards have failed to understand that the provision of home birth care, midwifery units, and obstetric units as a package is not a luxury but a necessity if care is to be safe and of high quality for all women. NICE is clear on this.
We hope that this page is of interest, especially to our colleagues in the maternity services improvement community.
The AIMS Campaigns Team relies on Volunteers to carry out its work. If you would like to collaborate with us, are looking for further information about our work, or would like to join our team, please email campaigns@aims.org.uk.
Please consider supporting us by becoming an AIMS member or making a donation. We are a small charity that accepts no commercial sponsorship, in order to preserve our reputation for providing impartial, evidence-based information.
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.