So strongly did the author of the report, Sir Ian Kennedy, feel about his findings that he took the unusual step of making known his concern ahead of publication. Giving birth, he acknowledged, was probably safer now, in overall terms, than it had ever been, and he had found plenty of examples of good practice. But he said there was growing evidence that in some places maternity services were not as good or as safe as they should be. There was "too much poor practice", and this needed to be eliminated.
The commission found long-term shortages of staff and equipment, poor organisation of wards, uncommunicative doctors, and shockingly dirty bathrooms and toilets. Little of this will come as news to the many women who have given birth in such unwelcoming and insanitary conditions. And the proliferation of published accounts by new mothers about their unsatisfactory experiences of giving birth in hospital have exposed multiple failings in individual cases. Before Sir Ian's findings, however, ministers and NHS managers could dismiss such complaints as isolated instances or - shamefully - as a reflection of unrealistic expectations on the part of certain highly educated middle-class mothers. Now, there are no excuses for not acting. At 5.3 deaths per 1,000 births, Britain has one of the highest infant mortality rates in Europe - only Poland and Slovakia have a worse record - and the number of women who die in childbirth has been rising.
Sir Ian concludes that many failings result not from lack of money - that bane of NHS life - but from bad organisation, poor training or weak management. In other words, the problem is less one of resources than how they are used. In that respect, it should be soluble. In two of three hospitals reviewed, the commission judged that lives could have been saved with better care, while in the third, standards were imperilled by rows among consultants.
Ministers must now use the momentum created by this report to raise maternity care higher up the pecking order of health service priorities. There is no reason why the excellent practice Sir Ian notes in some hospitals should not be reproduced in all.