References
Maternity standards
1. Kirkup B. Reading the signals. Maternity and neonatal services in East Kent – the Report of the Independent Investigation. 2022 [2026 Mar 23]. Available from: https://assets.publishing.service.gov.uk/media/634fb083e90e0731a5423408/reading-the-signals-maternity-and-neonatal-services-in-east-kent_the-report-of-the-independent-investigation_print-ready.pdf.
2. MBRRACE-UK. Saving Lives, Improving Mothers’ Care. Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2020-22. 2024 [2026 Mar 23]. Available from: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2024/MBRRACE-UK%20Maternal%20MAIN%20Report%202024%20V2.0%20ONLINE.pdf.
3. Renfrew M. Enabling Safe Quality Midwifery Services and Care in Northern Ireland 2024 [2026 Mar 23]. Available from: https://www.health-ni.gov.uk/ga/publications/enabling-safe-quality-midwifery-services-and-care-northern-ireland.
4. Ockenden D. Final findings, conclusions and essential actions from the Ockenden review of maternity services at Shrewsbury and Telford Hospital NHS Trust. 2022 [2026 Mar 23]. Available from: https://assets.publishing.service.gov.uk/media/624332fe8fa8f527744f0615/Final-Ockenden-Report-web-accessible.pdf
5. Thomson K, Moffat M, Arisa O, Jesurasa A, Richmond C, Odeniyi A, et al. Socioeconomic inequalities and adverse pregnancy outcomes in the UK and Republic of Ireland: a systematic review and meta-analysis. BMJ Open. 2021;11(3):e042753.
6. Cheyne H, Elders A, Hill D, Milburn E. Is maternity care in Scotland equitable? Results of a national maternity care survey. BMJ Open. 2019;9(2):e023282.
7. Adesina M, MacDonald M, McKelvin G, Abayomi J. Maternal health inequalities: focusing on Black pregnant women. British Journal of Midwifery. 2025;33(4).
8. Hollinshead R, Gavin M, Byram A. Guidance: Tackling Maternal Health Inequalities in Gypsy, Roma and Traveller Communities. 2023 [2026 Mar 23]. Available from: https://www.gypsy-traveller.org/wp-content/uploads/2023/07/Extended-Maternal-Health-Inequalities-Guidance.pdf
9. McDonald H, Moren C, Scarlett J. Health inequalities in timely antenatal care: audit of pre- and post-referral delays in antenatal bookings in London 2015-16. J Public Health (Oxf). 2020;42(4):801-15.
10. Sudhakar V, Siddiqui F, Lim JNW, Pillay T. Can benchmarking uncover the disparities in the perinatal dashboard and improve the quality of care that pregnant women of diverse ethnic backgrounds receive? A retrospective cross-sectional study. BMJ Open Quality. 2025;14(3):e003431.
11. World Health Organization. Essential newborn care. 2025 [2026 Mar 23]. Available from: https://www.who.int/teams/maternal-newborn-child-adolescent-health-and-ageing/newborn-health/essential-newborn-care.
12. Sandall J FTC, Devane D, Soltani H, Gillespie P, Gates S, Jones LV, Shennan AH,Rayment-Jones H,. Midwife continuity of care models versus other models of care for childbearing women (Review). Cochrane Database of Systematic Reviews; 2024 [2026 Mar 23]. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004667.pub6/epdf/abstract.
13. UK Parliament. Black maternal health. 2023 [2026 Mar 23]. Available from: https://committees.parliament.uk/work/9110/black-maternal-health/publications/.
14. National Maternity and Perinatal Audit. Ethnic and socio-economic inequalities in NHS maternity and perinatal care for women and their babies. 2021 [2026 Mar 23]. Available from: https://maternityaudit.org.uk/pages/sprintpub.
15. Rayment-Jones H, Harris J, Harden A, Turienzo CF, Sandall J. Project20: Maternity care mechanisms that improve (or exacerbate) health inequalities. A realist evaluation. Women and Birth. 2023;36(3):e314-e27.
16. Liberati EG, Tarrant C, Willars J, Draycott T, Winter C, Kuberska K, et al. Seven features of safety in maternity units: A framework based on multisite ethnography and stakeholder consultation. BMJ Quality & Safety. 2021;30(6):444-56.
17. Braithwaite J, Herkes J, Ludlow K, Testa L, Lamprell G. Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open. 2017;7(11):e017708.
18. Rance S, McCourt C, Rayment J, Mackintosh N, Carter W, Watson K, et al. Women's safety alerts in maternity care: is speaking up enough? BMJ Quality & Safety. 2013;22(4):348-55.
19. Beecham E, Brady G, Iqbal S, Fatima Q, Arshad S, Bondaronek P, et al. Systematic review of patient safety incident reporting practices in maternity care. BMJ Open Quality. 2025;14(4):e003432.
20. McDonald P L FTJ, Verheij R, Braithwaite J, Rubin J, Harwood K et al, . Data to knowledge to improvement: creating the learning health system. BMJ. 2024;384.
21. Scottish Government. Maternity and neonatal care - Best Start five-year plan 2017–2024: report 2025 [2026 Mar 23]. Available from: https://www.gov.scot/publications/best-start-five-year-plan-maternity-neonatal-care-20172024-report/pages/1/.
22. World Health Organization. Standards for improving quality of maternal and newborn care in health facilities. 2016 [2026 Mar 23]. Available from: https://www.who.int/publications/i/item/9789241511216.
23. NHS Scotland. Workforce policies 2025 [2026 Mar 23]. Available from: https://workforce.nhs.scot/.
24. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience 2016 [2026 Mar 02]. Available from: https://www.who.int/publications/i/item/9789241549912.
25. Judiciary of Scotland. FAI Determination summaries: Leo Lamont, Ellie McCormick and Mira-Belle Bosch 2025 [2026 Mar 23]. Available from: https://judiciary.scot/home/sentences-judgments/fai-determination-summaries/2025/03/18/leo-lamont--ellie-mccormick-and-mira-belle-bosch.
26. Gerry S JB, Redfern OC, et al,. Development of a national maternity early warning score: centile based score development and Delphi informed escalation pathway. BMJ Medicine,. 2023;3(1).
27. Park LJ. Using the SBAR handover tool. British Journal of Nursing. 2020;29(14).
28. The Royal College of Midwives (RCM). Strengthening perinatal mental health. A roadmap to the right support at the right time. 2023 [2026 Mar 02]. Available from: https://rcm.org.uk/wp-content/uploads/2024/08/rcm-perinatal-mental-health-report-2023.pdf.
29. The Royal College of Midwives. Position statement: perinatal women in the criminal justice system. 2024 [2026 Mar 23]. Available from: https://rcm.org.uk/wp-content/uploads/2024/03/rcm-position-statement-perinatal-women-in-the-criminal-justice-system.pdf.
30. The Royal College of Midwives. Position statement: caring for migrant women 2022 [2026 Mar 23]. Available from: https://rcm.org.uk/wp-content/uploads/2024/03/rcm_position-statement_cfvmw.pdf.
31. Kirubarajan A, Barker LC, Leung S, Ross LE, Zaheer J, Park B, et al. LGBTQ2S+ childbearing individuals and perinatal mental health: A systematic review. BJOG. 2022;129(10).
32. Givrad S, Hartzell G, Scala M. Promoting infant mental health in the neonatal intensive care unit (NICU): A review of nurturing factors and interventions for NICU infant-parent relationships. Early Human Development. 2021;154:105281.
33. Burden C BS, Storey C, et al,. From grief, guilt pain and stigma to hope and pride – a systematic review and meta-analysis of mixed-method research of the psychosocial impact of stillbirth. BMC Pregnancy and Childbirth. 2016;16(9).
34. Quenby S. et al. Miscarriage matters: the epidemiological, physical, psychological, and economic costs of early pregnancy loss. The Lancet. 2021;397(10285):1658-67.
35. National Trauma Transformation Programme. Trauma Informed and Responsive Maternity Services. 2025 [2026 Mar 23]. Available from: https://www.traumatransformation.scot/tailored-support/maternity-services/.