Policy paper

Government response to the House of Lords inquiry into preterm birth: reducing risks and improving lives

Published 14 January 2025

Applies to England and Wales

Presented to Parliament by the Secretary of State for Health and Social Care by Command of His Majesty

14 January 2025

CP 1244

ISBN: 978-1-5286-5391-6

Introduction

The government welcomes the report of the House of Lords Preterm Birth Committee, Preterm birth: reducing risks and improving lives. We thank all the individuals and organisations that gave evidence to the inquiry and to the committee members for their detailed examination of the issues and evidence in drawing their conclusions. We share the inquiry’s view that current and future action will not only improve outcomes for babies but the experiences of families as they embark on this unexpected start of parenthood.

Preterm birth is the single biggest cause of neonatal death and illness in the UK. In England in 2023, 8.1% of all births were preterm (between 24 and 36 weeks completed gestation). The average global rate is around 10%, and while England’s preterm birth rate is lower than in some comparable countries (for example, the USA), it is higher than in others (for example, France and the Scandinavian countries)^{[footnote 1]}. There are also inequalities in outcomes, with Black and Asian women being more likely to give birth prematurely compared to their White counterparts (8.5% and 8.3% respectively are live preterm births compared to 7.7% of White women’s live preterm births).

As acknowledged in the report, the prediction and prevention of preterm birth is challenging due to the wide range of factors that contribute to a woman’s individual risk, and many women who have preterm births do not have apparent risk factors. While most babies born prematurely go on to do well, we know that reducing the incidence of preterm birth and improving outcomes for babies and their families would lead to significant health benefits and cost savings across healthcare, education and wider public sector.  

The challenges ahead

Public service performance is at historic lows. To fix the foundations and turn the page, the government is taking a different approach, taking tough decisions on tax, spending and welfare to restore Britain’s economic stability so the government can deliver on the commitment to not increase taxes on working people. We will need to consider any changes in this context and make choices that are transparent and responsible rather than easy.

This report further reiterates that we have inherited a broken NHS, and this government recognises that there are serious issues within maternity and neonatal services. This includes the findings from several high-profile independent reviews into maternity and neonatal services including Morecambe Bay, Shrewsbury and Telford, and East Kent. There is currently an ongoing independent review into maternity services at Nottingham University Hospital (NUH) led by Donna Ockenden, and the Thirlwall Inquiry looking at neonatal services. These reviews have identified significant issues which we now recognise are not isolated to individual trusts but systemic and nationwide.

These have, however, led to multiple recommendations for the maternity and neonatal system to implement. We also recognise that the maternity and neonatal workforce are experiencing multiple and complex challenges. For example, increasingly complex births and the increase in rate of deliveries by caesarean section has led to new and different demands on the whole maternity workforce. In this context, we will consider whether a more unified and streamlined approach is appropriate to ensure the NHS is delivering the best care possible. We have already invested in several initiatives focused on improving national-level support in maternity and neonatal services, in the context of increasing complexity of care required.

While change will not happen overnight, we are determined to make improvements to ensure everyone receives the care that they deserve.

What we are doing to reduce the rate of preterm births and negative outcomes

We are committed to working collaboratively and transparently as we build an NHS that is fit for the future. There are several key initiatives in place to prevent or reduce negative outcomes of preterm births. These include the updated version of the Saving Babies’ Lives Care Bundle (care bundle), maternal medicine networks and local equity and equality action plans.

The care bundle provides evidence-based guidance for maternity care providers and commissioners to help reduce preterm birth rates and optimise care in cases where preterm birth cannot be avoided. The guidance was co-developed by clinical experts including frontline clinicians, royal colleges and professional societies, with the aims to reduce variation in care. All trusts are implementing version 3 of the care bundle which was released in 2023.  

NHS England has created 14 maternal medicine networks in England for women with high-risk medical conditions, such as diabetes, heart disease, renal disease, hypertension and epilepsy. These networks offer specialist care and advice before, during and after pregnancy, including access to specialist management. They also co-ordinate out-of-area care for women. Obstetric physicians are being provided across all 17 specialist maternal medicine centres in these networks, and a training strategy is being developed. The networks are also establishing local pathways for pre-pregnancy counselling, typically through referral from a GP or managing physician.

NHS England has provided more than £20 million to local systems each year to support work to reduce inequalities in maternity and neonatal care, including implementing local equity and equality action plans. These action plans aim to tackle disparities in outcomes and experiences of maternity care at a local level, setting out tailored interventions to tackle inequalities for women and babies from ethnic backgrounds and those living in the most deprived areas. 

In addition, the National Institute for Health and Care Research (NIHR) launched a £50 million NIHR challenge fund in March 2024, to task researchers and policymakers with finding new ways to tackle maternity disparities and poor pregnancy outcomes, such as preterm birth.  

While these achievements are noteworthy, the inquiry has rightly highlighted that families and services are still struggling. We understand that implementation of guidelines, good practice and access to services are inconsistent across the healthcare system, and this is a driving force behind disparities experienced by babies and their loved ones. The issues experienced by the workforce are significant, as are those relating to the suitability of maternity and neonatal estates. We recognise the impact this has when delivering the right level of care to meet a baby’s needs.

In summary, we agree with the overarching aims of the findings and recommendations, including the importance of research in optimising care and outcomes for all.

This report will support the government in its future work to ensure everyone receives the safe and compassionate care they deserve so they can thrive. 

Government response to recommendations

Recommendation 1

The government should set out its plans to revise the current national maternity safety ambition, focusing particularly on targets that will support efforts to reduce the incidence and impact of preterm birth.

Government response

The previous government’s national maternity safety ambition was set to 2025. We are currently considering what actions are needed to tackle issues related to maternity and neonatal care and, as part of that, will consider what future metrics, targets or ambitions should be set. Crucially, this will include a focus on tackling the stark and unacceptable inequalities, including the rate of preterm births that exist for Black and Asian women and babies, and women and babies from the most deprived backgrounds. We are committed to ensuring all women and babies receive safe, personalised and compassionate care, regardless of their background or ethnicity.

We remain committed to ensuring these decisions are woman and baby centred. Within the context of this, we must consider the balance needed between reducing avoidable preterm births, with the acknowledgment that in some cases preterm birth is medically appropriate and safer for the mother and baby. For example, this may include where a woman develops pre-eclampsia (high blood pressure during pregnancy) and the condition worsens, or when a woman develops an infection inside the womb, then an early delivery may be required for the health of both the mother and the baby.

We will closely examine the latest research and evidence and work closely with NHS England and our partners as this work progresses.

Recommendation 2

The government should set out how, as part of its strategy for women’s health, it will ensure that all women have access to information and advice on pregnancy planning and preconception health at an appropriate time.

Government response

We agree that all women and their partners should have timely access to information and advice regarding pregnancy planning and preconception health. This is particularly crucial to address inequalities in maternity and neonatal outcomes and involves taking action before women come into contact with maternity care and addressing wider health inequalities. As part of our work to address maternal and neonatal inequalities for women and babies, we will consider how to ensure targeted advice and support is available to women who are at higher risk of adverse maternal and perinatal outcomes, such as preterm birth, including Black and Asian women, and women from the most deprived backgrounds.

Contraception plays a crucial role in helping women manage whether and when they get pregnant and ensures they can effectively plan for any pregnancies. Contraception advice is integrated into a range of different health encounters that women are likely to have. This advice is delivered in sexual health clinics, general practice, some pharmacies, abortion services, maternity services and online.

Additionally, to further support women post-birth, NHS England has collaborated with the Royal College of General Practitioners to publish guidance on the 6 to 8 week postnatal check-up. This check-up provides an important opportunity for GPs to listen to women in a confidential and supportive environment. It provides personalised postnatal care for their physical and mental health, as well as supporting them with family planning and any future pregnancies.

In terms of pre-conception advice focusing on fitness for pregnancy, the NHS website provides women and families with information and advice on pregnancy planning. In 2023, the department and NHS England created a women’s health section on the NHS website, bringing together over 100 health topics for women seeking health information. This includes a range of pages on pregnancy, such as ‘trying for a baby’, ‘planning your pregnancy’, ‘keeping well in pregnancy’ and ‘pregnancy care’. The ‘planning your pregnancy’ page contains advice on steps women can take to improve their chances of getting pregnant and having a healthy pregnancy, including advice on potential risk factors for preterm birth (such as smoking and obesity). We will consider if any additional information resources or approaches could further help women in preparing for a healthy pregnancy.

We introduced new legislation on 14 November 2024 to require the fortification of non-wholemeal wheat flour with folic acid from the end of 2026. The fortification of flour is a simple and effective way to help to reduce cases of neural tube defects, which can cause a large number of serious and debilitating conditions to babies in the womb, including spina bifida. Although it is important that women who are pregnant or intending to become pregnant continue to take folic acid supplements before and during the first 12 weeks of pregnancy, this is another step forward in supporting women by giving them greater peace of mind throughout their pregnancy.

We know that smoking is the single biggest modifiable factor for preterm birth. Although the percentage of women smoking at the time of delivery is decreasing, in 2023 to 2024 around 7.4% (1 in 20) of women continue to smoke during pregnancy. There is significant work underway to accelerate progress, including the national smoke-free pregnancy incentive scheme to improve tobacco treatment for pregnant smokers and the care bundle which routinely tests for carbon monoxide during antenatal booking appointments to identify smokers (or those exposed to tobacco smoke) and refer them to stop smoking support on an opt-out basis. The Tobacco and Vapes Bill is a landmark step in creating a smoke-free UK that aims to introduce a progressive smoking ban by banning sale of tobacco products to those born on or after 1 January 2009, banning vape marketing to children and strengthening enforcement. 

Pre-pregnancy obesity increases the risks for gestational diabetes and pre-eclampsia, both of which are risk factors for preterm birth. We know that rates of maternal obesity are rising and approximately 28% of women were categorised as living with obesity (BMI greater than 30) in early pregnancy in March 2024, compared with 20% of women in March 2017.

The National Institute for Health and Care Excellence (NICE) provides clear guidance on weight management before, during and after pregnancy. It advises against weight loss programmes during pregnancy, as they can potentially harm the health of the unborn children. Instead, health professionals should use any opportunity, as appropriate, to help signpost women who are living with obesity about the health benefits of losing weight before becoming pregnant. This may involve a referral into one of the range of services provided by the NHS and local authorities to help people lose weight, including online tools like the NHS Weight Loss Plan app, behavioural programmes like local authority weight management services and the NHS Digital Weight Management Programme, or more specialist services including medicines and surgery.

The government is addressing obesity by focusing on population weight, and limiting junk food advertising, fast food access for school children and ensuring the effectiveness of the soft drinks industry levy. These measures aim to reduce obesity prevalence and potentially decrease the number of women becoming pregnant while living with obesity.

Recommendation 3

The government and NHS England must take further action to ensure the consistent implementation of clinical guidance relating to preterm birth, particularly the perinatal optimisation interventions set out in the Saving Babies’ Lives Care Bundle. Every region should have the resources to adopt the methodology of implementation programmes that have been shown to be effective and continue to strengthen maternal medicine and neonatal networks.

Government response

We agree that there is learning to be taken from the success of the rollout of maternal medicine and neonatal networks. We must ensure high quality care for everyone is delivered consistently across the country.  

At a national level, the NHS has taken action to reduce variation in maternal and neonatal care through the Maternity Incentive Scheme, which provides a financial incentive to trusts for implementing safety actions. The implementation of the latest version of the care bundle is one of the safety actions that trusts must comply with. NHS Resolution findings from April 2024 demonstrate that 87% (104 out of 120) of maternity providers in England were considered on track to fully implementing the care bundle. Trusts that are unable to deliver the safety actions are required to develop an improvement plan to ensure future compliance. NHS Resolution offers direct support to trusts to develop these plans and, if trusts are on the Maternity Safety Support Programme, it is recommended that they involve their maternity improvement advisor. Trusts can apply to NHS Resolution for discretionary funding to support the delivery of the improvement plan.

Additionally, NHS England expanded local quality improvement support for implementation of the care bundle through patient safety collaboratives. These now support implementation of the interventions set out in the care bundle to reduce preterm births and care for preterm babies. NHS England will assess if this approach can be extended further to support local implementation of all perinatal interventions.

At regional level, NHS England commissioning teams and neonatal operational delivery networks (ODNs) will continue to reduce regional variation through the development of local care pathways and implementation and monitoring of local quality plans.

Recommendation 4

It is imperative that the government and NHS England meet the commitments to develop the maternity and neonatal workforce set out in the NHS Long Term Workforce Plan.

Government response

We recognise the concerns around workforce. Bringing in the staff we need will take time, but this is an absolute priority for this government. We are committed to ensuring the NHS has the workforce to care for patients when and where they need it. It is our mission to train more midwives and health visitors, incentivise continuity of care, and make sure the NHS is squarely focused on tackling the stark inequalities. 

We have launched a 10 Year Health Plan to reform the NHS. The department has established 11 working groups to support the development of the plan. This includes a group focused on people which will carefully consider how to deliver the 3  shifts and how staff will increasingly work in the community. This will support our long-term plans for the health service, and we are clear that we must act now to address the challenges staff and families are experiencing.

We will refresh the NHS workforce plan to fit the transformed health service we will build over the next decade, so the NHS has the staff it needs to treat patients on time again.

While we continue to develop a plan for the future of the NHS more widely, there is targeted work to improve the maternity and neonatal workforce, which encompasses a wide range of professionals such as midwives, obstetricians, neonatologists and allied health professionals. NHS England has invested £45 million in enhancing capacity, developing the neonatal workforce and improving family experiences, following recommendations from the Neonatal Critical Care Review (2019). This includes spending £39 million on 550 neonatal nurses and network-level roles. Additionally, neonatal nurses can undertake quality in specialty (QIS) training for neonatal care. This enables them to provide a higher level of care to critically ill or premature babies and offer crucial support to other nurses in the daily care of these babies.

The 3 Year Delivery Plan (financial year 2023 to 2024 to financial year 2025 to 2026) outlines tailored interventions for professional groups, such as midwives, career stages and local requirements. NHS England has a range of programmes in places to boost the midwifery workforce through undergraduate training, apprenticeships, postgraduate conversion and return to midwifery programmes. The maternity international recruitment programme ensures the ethical and long-term recruitment of internationally educated midwives. While training more midwives and wider staff is important, we must retain the experience and skills we already have. This is a key objective of the work underway to improve organisational culture and working conditions for nurses and midwives, such as flexible working arrangements.

A retention midwife is funded in every maternity unit, to focus on retention and providing pastoral support to midwives as they consider their future options in and outside of the NHS. Additionally, ODNs, which are responsible for commissioning neonatal services, have dedicated workforce leads that are focused on delivering a range of retention initiatives within their regional areas.

Recommendation 5

NHS England should publish the findings of its maternity and neonatal estates survey, setting out what proportion of neonatal units are currently able to provide sufficient accommodation for all families, as per the updated service specification for neonatal critical care.

Government response

NHS England will publish the findings of the NHS maternity and neonatal estates survey, which examined compliances against the current estates’ standards, including the requirements of neonatal parental accommodation, early next year.

Recommendation 6

The government and NHS England should set out their plans for future investment in parental accommodation on neonatal units, to support improved provision of family integrated care.

Government response

It is important for families to feel they are properly involved in their babies’ care alongside healthcare professionals.

The provision of neonatal care is set out in the neonatal critical care service specification. This requires providers to ensure that facilities are available to support family-centred care including access to parent accommodation (including co-bedding, where appropriate) for all families.   

There is a network level care co-ordinator in each ODN who supports neonatal units across the region. This serves to develop and implement family-centred and integrated care initiatives, and support initiatives to improve the parent and family experience (including parental accommodation). 

The findings of NHS England’s maternity and neonatal estates survey will provide important evidence when considering the future investment needed to support services that meets babies’ needs and enables parents to be properly involved in their baby’s care.

Significant extension and improvement of parental accommodation on neonatal units would require additional investment, and any further actions will therefore need to be considered in the round in the context of the 10 Year Health Plan and phase 2 of the spending review. 

In addition to the existing estate, we must consider how new hospitals will meet the needs of babies and their loved ones. The New Hospital Programme is working closely with maternity and neonatal clinical leaders to ensure that these needs are addressed before hospitals are built.

Recommendation 7

The government and NHS England should detail the steps they are taking to ensure equitable access to neonatal outreach and perinatal mental health services for all families that experience preterm birth.

Government response

The 3 Year Delivery Plan for maternity and neonatal services sets out a plan to make care safer, more personalised and more equitable for women, babies and families.

Neonatal outreach services 

Neonatal community outreach services provide nursing care and support at home for preterm and term babies with ongoing additional medical needs. This increases the availability of cots for babies who still require care in hospitals while also improving experiences for loved ones.

We recognise neonatal outreach services are not available consistently across England. The national report for neonatology by Getting It Right First Time (GIRFT) outlines only 57% of services having some form of outreach service.

Outreach services have been developed by individual services but supported by a national commissioning for quality and innovation (CQUIN) framework. NHS England is delegating responsibility for commissioning and implementing the national service specification to integrated care boards from April 2025, allowing them to make investment and pathway decisions, ensure compliance with the national specification and consider the role of local outreach pathways.

We will monitor progress on reducing variation and standardising the implementation of neonatal outreach across England.

Perinatal mental health services 

Since 2014, significant progress has been made to ensure women experiencing moderate to severe and complex perinatal mental health problems, including as a result of preterm birth, can access specialist perinatal mental health services, such as mother and baby units, specialist perinatal mental health community teams and newly established maternal mental health services.  

As of November 2024, significant progress has been made, including:

• the commissioning of 159 beds across England in mother and baby units, providing inpatient care to women who experience severe mental health difficulties during and after pregnancy
• the setting up of 41 maternal mental health services to provide care for women with moderate, severe or complex mental health difficulties arising from birth trauma or loss in the maternity and/or neonatal context
• a record 60,637 women accessing a specialist community perinatal mental health service or maternal mental health services in the 12 months to September 2024. This is a 98% increase (30,625) from March 2020

Additionally, neonatal practitioner psychologists play a crucial role in supporting babies, loved ones and staff on neonatal units. We recognise that access to these services varies across the country and NHS England is working to strengthen existing pathways and improve consistency to ensure equitable access.

Recommendation 8

NHS England should work with training providers to embed opportunities to develop specialist knowledge of the needs of preterm babies and their families into health visitor training and continuous professional development, with protected training time.

Government response

We agree that all health visitors should receive training and be supported to access learning relevant to their practice as part of their required ongoing professional development. It is the responsibility of employers, who may be NHS providers, local authorities, charities or private providers, to identify gaps in knowledge and additional skills needed to meet the needs of the local population. 

The Nursing and Midwifery Council sets the standards for health visitor training that is delivered by higher education Institutes. These already include a requirement to assess the impact of complexity and comorbidity and their impact on people and loved ones, which would include prematurity. This training is important and enables health visitors to provide personalised care.

We also recognise the importance of health visitors working within multidisciplinary teams, such as specialist community nurse teams, to ensure babies and children with higher levels of need receive the appropriate support.

The refreshed workforce plan will focus on ensuring that we have the staff we need, so that babies, their carers and their families are cared for by the right professional, when and where they need it.

Recommendation 9

The government and NHS England must take swift action to determine why the follow-up assessments recommended by NICE are not being consistently delivered, in particular at age 4, and prioritise work to address this.

Government response

We agree that it is crucial for all children, especially those who are born preterm, receive the support they need in early childhood to promote optimal health and wellbeing. For children aged 2 to 4 years old who meet the criteria, enhanced developmental support and surveillance are an important opportunity for loved ones and healthcare professionals to identify any areas of concern and discuss how these can be improved.

NICE guidelines are not mandatory, but they do set out best practice standards that have been developed by experts after thorough evidence, assessment and stakeholder engagement. Integrated care systems and local providers are expected to work towards full implementation of guidelines over time. This is to recognise the complexity of the guidelines and capacity within the wider system to implement them.

It is encouraging that the number of follow up assessments at age 2 is improving, from 68.4% in 2020 to 77.0% in 2023^{[footnote 2]}. However, only one-third of neonatal units are achieving the National Neonatal Audit Programme standard of 90% of eligible babies having a 2-year follow-up, which is not acceptable.

We will consider what further investigation and action is required to ensure children are receiving follow-up assessments.

Research observation

Research is an essential component of optimising care and outcomes for mothers at risk of preterm birth and babies who are born prematurely. A greater focus on pregnancy and neonatal research is needed, alongside increased funding, to make progress in understanding the fundamental mechanisms of preterm labour, developing more effective interventions, and ensuring clinical guidance is implemented effectively.

Government response

The NIHR is working with the Medical Research Council and other research partners to drive a comprehensive preterm birth research portfolio across the translational research pathway. This will ensure progress is made to better understand the fundamental mechanisms of preterm labour.

The NIHR is developing more effective interventions to optimise the care and outcomes for women at risk of preterm birth and babies who are born prematurely. Where appropriate, and in collaboration with NHS partners, the NIHR is also working to understand how research can support the effective implementation of clinical guidance, while embedding considerations of individual need.

The NIHR will continue to monitor its portfolio of research in this area, including number of studies, funding awarded, successful study delivery, and impact of the awards for women and their babies, together with uptake of the findings into policy, practice and guidelines.

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1. O Ohuma, Eric, and others, National, regional, and global estimates of preterm birth in 2020, with trends from 2010: a systematic analysis, The Lancet: 2010. ↩

2. National Neonatal Audit Programme - Summary report on 2023 data, Royal College of Paediatrics and Child Health (RCPCH): 10 October 2024. ↩