How are NHS maternity services organised and funded in England?

Short answer

The NHS in England spent £5.79bn delivering maternity care in 2024/25, across about 542,000 hospital deliveries. Integrated care boards commission the care and around 120 NHS trusts provide it. Harm is paid for separately, through NHS Resolution's Clinical Negligence Scheme for Trusts (CNST). In the same year, NHS Resolution valued the maternity incidents it was liable for at £2.5bn. Care and harm are funded, governed and measured in different places, and that separation goes a long way to explaining why the same failures keep being found.

Maternity in England at a glance

These figures measure different things and should not be added together. The spending figure covers the cost of providing care. It excludes negligence payments, which come out of a separate scheme.

Why the structure matters

Most explanations of maternity services list the organisations involved. That's necessary, but it misses the more useful point. Maternity in England is a system where the people who decide how much care to buy, the people who provide it, the people who pay when it goes wrong and the people who investigate are almost all different. Each of them sees part of the picture. Until recently, no single body was accountable for seeing all of it.

That matters to a board. It means a trust can meet its contract, pass its incentive-scheme declaration and still be drifting towards harm. Nothing in the funding or assurance machinery is designed to join those signals up.

How care is organised

A woman's maternity care in England usually runs from a booking appointment around ten weeks into pregnancy, through antenatal checks, to labour and birth, and then postnatal care in hospital and at home. Most of it is provided by NHS trusts (120 submitted monthly maternity data in December 2024, according to NHS England Digital), through hospital obstetric units, midwife-led birth centres and community midwifery teams. Neonatal care for sick and premature babies is organised separately, through regional operational delivery networks, which is one reason the handover between maternity and neonatal teams so often appears in investigations.

Integrated care boards (ICBs) commission maternity care for their populations. The government has stated plainly that NHS England "does not commission or budget for maternity services - this is the responsibility of ICBs" (DHSC response to the Health and Social Care Committee). Local Maternity and Neonatal Systems bring the trusts, commissioners and service-user voice partnerships in each ICB area together to plan and oversee improvement.

The national layer is changing. The Health Bill, introduced in May 2026, would abolish NHS England and move its oversight functions to the Secretary of State, exercised through a restructured Department of Health and Social Care (DHSC), with ICBs as strategic commissioners for most local services (GOV.UK Health Bill fact sheet). It is still before Parliament, with its Lords second reading on 13 October 2026 (UK Parliament; Health Bill stages). On 1 April 2026, 12 ICBs were abolished, six new ones were created and one existing ICB was widened, with further changes planned for 2027 (NHS England). For maternity leaders, this means the people asking questions, and the routes for escalating concerns, are being redrawn at the same time as the reform agenda gets more demanding.

The work has also become clinically harder. In 2024/25, 45% of hospital deliveries were by caesarean section (NHS England Digital). Baroness Amos's investigation pointed to "the changing profile of women giving birth and the increase in medical interventions" as pressures that service planning has been too slow to absorb (National Maternity and Neonatal Investigation). Births are falling, down 1.5% in England in 2025 (ONS), but each birth is taking more care to deliver.

Who does the work

There were 25,457 full-time equivalent midwives in the NHS in England in July 2026, 31% more than in 2010 and slightly below the March 2026 peak of 25,638 (NHS England Digital). Leaver rates have fallen (DHSC evidence to the NHS Pay Review Body).

On its own, that number is close to useless to a board. Midwives are only one part of the team, alongside obstetricians, anaesthetists, neonatologists and maternity support workers, and a headcount says nothing about whether enough senior staff are on shift at 3am on a Sunday. In the 2025 NHS Staff Survey, only 17% of midwives said there were enough staff at their organisation to do their job properly, the lowest of any staff group (Nuffield Trust). Across all NHS staff the figure was 33% (NHS Staff Survey coordination centre).

There is also a strange mismatch at the entry point. In February 2026, a Royal College of Midwives survey found that around a third of newly qualified midwives had not secured a post (RCM). The government's response was to fund 1,000 temporary graduate roles with more than £10m (GOV.UK). A service that reports shortages while newly trained staff can't get jobs has a funding and workforce-planning problem, not simply a supply problem.

Where the money goes

There are three separate flows of money, and they rarely appear on the same page.

Care. The cost of providing maternity care rose from £4.72bn in 2022/23 to £5.17bn in 2023/24 and £5.79bn in 2024/25, an increase of 23% in two years. Figures for 2025/26 are not yet available (DHSC written answer, 23 February 2026). That works out at roughly £10,700 per hospital delivery, although the spending figure also covers antenatal and postnatal care that a per-delivery average can't separate out. Ring-fenced national maternity improvement funding was reduced from £95m to £2m in 2025/26 (Health and Social Care Committee). The government says the same money now sits inside general ICB allocations, without the ring-fence (DHSC response). Whether ICBs have kept spending it on maternity is not something the published data lets anyone check.

Indemnity. Trusts pay annual contributions into CNST, which NHS Resolution runs. NHS Resolution then handles and pays claims on their behalf. Each trust's maternity contribution reflects its births, claims history and staffing. On top of that, trusts pay an extra 10% of their maternity contribution into the Maternity (Perinatal) Incentive Scheme. Trusts that meet all of the scheme's safety actions get that 10% back, plus a share of any money left over (NHS Resolution). For Year 8 (April 2026 to March 2027), the scheme has been cut from ten safety actions to six, consolidating overlapping requirements and concentrating on the areas with the greatest impact on outcomes. Its own evaluation concedes that it "remains challenging to directly attribute improvements in maternity and neonatal safety to individual initiatives" (NHS Resolution evaluation summary).

Harm. In 2024/25, NHS Resolution paid £1.3bn on maternity claims and estimated the cost of that year's maternity incidents at £2.5bn. Obstetric claims accounted for 11% of clinical claims by number but 53% by value (NHS Resolution Annual Report 2024/25). The 2025/26 figures show payments steady at £1.3bn (40% of the total) and cost of harm down to £2.3bn. Maternity also accounts for £34.7bn of the provision NHS Resolution holds for future clinical negligence claims (NHS Resolution Annual Report 2025/26).

Put the 2024/25 figures side by side (the latest year for which both spending and NHS Resolution figures are published) and the scale becomes clearer. For every pound the NHS spent on providing maternity care, it paid out about 22p in compensation for harm from earlier years. It also took on about 43p of new liability for harm caused that year. This is a STRASYS calculation and the comparison has limits: payments relate to incidents from many years ago, and cost of harm is an actuarial estimate, not cash. Even so, the direction is not in doubt. A large part of what England spends on maternity goes on the consequences of failure. That money is held and managed away from the boards and commissioners who could reduce it.

Who is accountable

Accountability is shared between several bodies, and the arrangement is being rebuilt:

• Trust boards are accountable for the safety of the care they provide. Each year the chief executive makes the board declaration under the incentive scheme.
• ICBs commission services, oversee performance and, through Local Maternity and Neonatal Systems, lead local improvement.
• NHS England, then DHSC. NHS England still holds national oversight, standards and allocation functions. If the Health Bill passes, they move to the Secretary of State.
• The CQC inspects and rates services, and hosts Maternity and Newborn Safety Investigations.
• NHS Resolution manages claims and runs the incentive scheme.
• A Maternity and Neonatal Commissioner, announced on 30 June 2026, will co-chair the National Maternity and Neonatal Taskforce with the Secretary of State. The taskforce will publish a national action plan in December 2026 (GOV.UK). No one had been appointed at the time of writing. In September, ministers said the taskforce was still considering the full scope and role of the commissioner (written answer), and the government intends to put the role on a statutory footing (taskforce meeting note).

The commissioner is the first post with an explicit system-wide remit for maternity. Its effect will depend on whether it can see data from across the system and has the powers to act on it, and neither is yet settled.

What the reviews found, and why they keep finding it

England's maternity investigations now span more than a decade, and they describe the same failures.

The Ockenden review of Shrewsbury and Telford (March 2022) examined the care of 1,486 families. It found that 201 babies and nine mothers might have survived with better care. Dr Bill Kirkup's East Kent investigation (October 2022) found that the outcome could have been different in 45 of 65 baby deaths. It also found that the trust board had been given repeated signals of serious problems over a decade. The CQC's national inspection programme then showed these were not isolated cases: no hospital maternity service it inspected was rated outstanding for safety.

In June 2026 came two more reports. Donna Ockenden's Nottingham review, the largest in NHS history, drew on more than 2,500 families. It concluded that 162 deaths between 2012 and 2025 were potentially avoidable, and that the trust had known of serious problems since at least 2010. Six days later, Baroness Amos's national investigation reported on 12 trusts. It found that "structural and systemic issues mean that delivering kind and compassionate care is not always possible." Its eight recommendations cover national leadership, listening to women and families, responding properly when things go wrong, national service standards, racism and inequality, governance and regulation, culture and leadership, and estates and digital systems.

Taken together, the reviews have produced hundreds of recommendations. From data to trajectory counts 748 across a decade. The volume is part of the problem. When a board inherits that many actions, it tends to track whether each one has been completed. Whether care has actually changed gets less attention.

The STRASYS perspective

The pattern behind these reports is not a shortage of information. Maternity is one of the most heavily measured services in the NHS. Every trust submits data to the Maternity Services Data Set every month, MBRRACE-UK audits deaths, the CQC runs a maternity survey and NHS England's Maternity Outcomes Signal System flags unusual outcomes. The problem is that these signals arrive late, sit in separate places and reach boards as static red, amber and green ratings rather than as trends.

In From data to trajectory, Dr Nadeem Moghal and Mark Jennings argue that outcomes such as stillbirth and maternal death are verdicts on processes that have already run. By the time the outcome is recorded, the rota, the skill mix and the escalation decision that shaped it are months in the past. They propose that boards stop governing verdicts and start governing the trajectory: the staffing, training, escalation and experience measures that move earlier.

The way maternity is funded makes this harder. The financial cost of harm lands at NHS Resolution, years later. Assurance reaches the board as an annual declaration, and the commissioner's levers are contracts and allocations. None of those three is designed to show that a particular unit has been slowly deteriorating for 18 months.

The Strasys Maternity Index is our attempt to fill part of that gap. It brings clinical, safety, workforce and equity measures for every English trust into one comparative view and tracks their direction over 12 months. It doesn't replace national datasets or clinical judgement. As the paper notes, most of this can be started with data a trust already holds.

What leaders should consider

• Do you see maternity as a trend or as a status? If the board pack shows red, amber and green ratings rather than statistical process control charts, the board will usually find out about deterioration after it has happened.
• Can you connect your CNST contribution to your safety data? Your maternity contribution reflects your claims history and staffing. It is a financial reading of your risk, and it deserves a place in the quality committee's papers as well as the finance report.
• Has the maternity money survived the loss of the ring-fence? Commissioners and providers should be able to show what local maternity investment looks like now, compared with 2024/25.
• Who owns the handovers? Most of the failures above happened where responsibility passed between people or teams: triage to admission, midwife to obstetrician, maternity to neonatal, trust to ICB. Name an owner for each.
• Are you ready for the December action plan? The national plan and the new commissioner will set expectations. Boards that already have their own consolidated view of risk will find it easier to respond than those still working through inherited lists of actions.

Evidence, limitations and sources

This article covers England only. Spending comes from the NHS National Cost Collection, as reported in a DHSC written parliamentary answer. It excludes NHS Resolution payments, and its definition of maternity may differ from trusts' own reporting. Negligence figures come from NHS Resolution's annual reports and use cash payments, estimated cost of harm or provisions as stated; they are not interchangeable. The comparisons of pence per pound are STRASYS calculations from those published figures. The midwife figure (July 2026) is the latest published month of NHS England Digital's NHS Workforce Statistics, covering NHS trusts and core organisations. Annual hospital maternity statistics for 2025/26 are due on 24 November 2026, and this page will be updated when they are published. Facts are checked to 22 October 2026. Review findings are quoted from the published reports.

Related questions

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