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.
The health board noted the findings.
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 the health board area that covers about 450,000 people living in Rhondda Cynon Taf, Bridgend and Merthyr Tydfil.
Published on Monday, the Imsop report focuses on the care of 27 women, most of whom were admitted to an intensive care unit during 28 "episodes of care" 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."
Two further reviews of stillbirths and neonatal mortality and morbidity will follow later this year. In total, all three independent reviews will looks at 160 cases.
Imsop's findings reinforce those of the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.
The royal colleges' 2019 investigation found mothers faced "distressing experiences and poor care" at the Royal Glamorgan Hospital in Llantrisant and Prince Charles Hospital in Merthyr Tydfil, with maternity services deemed "dysfunctional".
Four key areas have been identified by Imsop as factors which contributed to poor care. These are:
- A "failure to listen to women"
- A "failure to identify and escalate risk"
- "Inadequate leadership"
- And "inappropriate treatment leading to adverse outcomes"
Wales' Health Minister Vaughan Gething said the latest report recognises things are moving in the right direction for the health board, but more needs to be done.
"The report highlights that women weren't always at the centre of their care and that women weren't always listened to, and that led to harm that could have been avoided," Mr Gething told reporters at the latest Welsh Government press briefing.
"Nothing will be able to change what these women and their families experienced at these two hospitals or the outcome for those families whose babies died or came to harm.
"I am deeply sorry for everything that happened."
He said he hoped "families can take some comfort" from the reviews that have provided answers to questions they were asking.
"My thoughts are with everyone affected by this report today and those who are still awaiting the outcome of their reviews," Mr Gething added.
Cwm Taf Morgannwg health board said it has been "working with the panel and families" to put in place a "comprehensive maternity and neonatal improvement programme".
"It has been a period of reflection during which we have examined the regrettable failings in maternity services of the former Cwm Taf University Health Board and we acknowledge the fact that we still have some way to go," said Greg Dix, the health board's executive director of nursing and midwifery.
"We will never forget the tragedies suffered by women, their families and our staff, and the learning from these cases is a key corner stone on which we are building our improvement plans."