A health board's maternity services were previously called 'dysfunctional' by an independent review.
The concerns 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.
An 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 19 reviews of maternal care revealed at least one factor where "different management would reasonably have been expected to alter the outcome".
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