Two-thirds of women at the heart of a review into maternity services at a Welsh health board could have had very different outcomes if they had received better care, a report has found.
The Independent Maternity Services Oversight Panel (Imsop) focused on the experiences of pregnant women at Cwm Taf Morgannwg health board.
Its maternity services have been in special measures since "serious failings" were found two years ago.
Concerns emerged in late 2018 that women and babies may have come to harm because of staff shortages and failures to report serious incidents. This sparked a major independent review, which gave a damning verdict on maternity services in Cwm Taf Morgannwg health board.
Published on Monday, the Imsop report focuses on the care of mothers between January 2016 and September 2018. It found that 19 reviews of maternal care (68%) revealed at least one factor where "different management would reasonably have been expected to alter the outcome".
The panel's chairman, Mick Giannasi, said: "These findings will be concerning and potentially distressing for the women and families involved, and it will be difficult for staff."
"Of the 28 episodes of care, we concluded that in 27 of them, our independent teams who reviewed the care would have done something differently. Put simply, what went wrong, might not have gone wrong if things had been done differently."
Source: BBC News, 25 January 2021