Almost Three-Quarters of Baby Deaths 'Might Be Avoidable'

Peter Russell

November 13, 2018

Different levels of care might have led to different outcomes in almost three-quarters of stillbirths, neonatal deaths, and severe brain injuries, a review concluded.

The report by The Royal College of Obstetricians and Gynaecologists (RCOG) also identified an average of seven contributory factors for each incident.

The second Each Baby Counts annual report said there had been some improvements to local investigations into baby deaths and brain injuries that happened during childbirth but that more could be done to ensure these investigations were of the highest quality.

The RCOG initiated the annual review with the aim of reducing by 50% the number of babies who die or are left severely disabled as a result of incidents occurring during term labour by 2020.

Clinical Findings

Of the nearly 700,000 babies born in 2016, 1123 fulfilled the Each Baby Counts criteria. Of these:

  • 124 (11%) were intrapartum stillbirths

  • 145 (13%) were early neonatal deaths

  • 854 (76%) had severe brain injuries

Of 955 babies where there was enough information to draw conclusions about the quality of care, the review concluded that 674 babies (71%) might have had a different outcome with different care.

The analysis suggested that in cases where at least one reviewer felt that different care might have made a difference to the outcome, guidelines and locally agreed best practice were not followed in 304 (45%) cases. Reasons for not following guidelines included lack of recognition of problems, communication issues, heavy workload, staffing levels, local guidelines not being based on best available evidence, and gaps in training.

The main contributory themes identified were failure by health professionals to identify or act upon relevant risk factors, issues related to monitoring of foetal wellbeing with CTG and blood sampling, and education or training issues.

"This highlights that much work is still needed to ensure healthcare professionals are supported to implement recommendations," said Mr Edward Morris, vice president of the RCOG, and one of the investigators involved with the review. "We are committed [to] improving maternity safety and want to do everything possible to prevent these tragedies that can have a life-long and devastating impact on families."

A National Centre to Drive Up Standards

The RCOG called for a national centre of excellence dedicated to improving maternity care, "with the aim of making the UK the safest place in the world to have a baby".

Prof Lesley Regan, RCOG president, said: "Bringing together the shared expertise and experience of women and families, frontline maternity teams, academics and policymakers would be a significant step forward in driving improvement across the country."

Improvements to Local Investigations

Compared with 2015, the latest review showed a 14% increase in the overall quality of local investigations, with a total of 89% of completed reports in 2016 being assessed as containing sufficient information. There was insufficient information provided in 11% of cases.

The review said a significant improvement had been made, and commended the efforts of midwives and obstetricians who produced the reports.

Review Recommendations

A number of recommendations were made concerning guidelines and anaesthetic care. These were:

  • Workload: Labour ward co-ordinators should not be caring for women during the antenatal, intrapartum, or postnatal period

  • Escalating high activity: Ensuring a clear escalation policy was in place to manage difficult workloads, including a culture in which even the most junior of staff could inform senior midwives, consultants, and managers when labour ward activity was high

  • Cross-site communication: Ensuring that women receiving care from multiple units have an individual management plan that outlines the roles and responsibilities of each site to avoid any confusion

  • Local guidelines: Establishing a clear policy to ensure that local guidelines are updated in line with national guidance

  • Migration of boundaries: Teams should protect against migration of boundaries by ensuring that real practice reflects practice as described in guidelines

  • Anaesthesia: A decision about the purpose of transfer to theatre and urgency of any birth should be made together with the anaesthetist before transfer to theatre

In order to build on its recommendations, the RCOG said it would establish a 4-year programme, in partnership with the Royal College of Midwives (RCM), the Department of Health and Social Care, and a number of maternity teams, to develop "sustainable improvements in maternity services".

Responses to the Report

Responding to the review, Elizabeth Duff, senior policy adviser at the National Childbirth Trust (NCT), said: "Our own recent research showed a worrying 50% of women reported at least one 'red flag' event, as defined by NICE, during labour. 

"These are indicators of dangerously low staffing levels, such as women not receiving one-to-one care during labour or there being an undue delay in a time-critical activity."

Mandy Forrester, head of quality and standards at the RCM, said: "There are real improvements being made through this project to improve the safety and quality of care for mothers and their babies. This project is clearly making a difference and that is very welcome.

"However, as the report shows, there is clearly much more that needs to be done. I am concerned that there are still issues affecting care, such as staff capacity and training and failures to involve the parents. I am concerned also that in some cases guidelines and best practice were not followed. 

"We need to be doing everything we possibly [can] to prevent further tragedies happening, and that is why we support the RCOG's call for a UK national centre of excellence for maternity care."

Health Minister, Jackie Doyle-Price, said: "We are giving staff the support they need to continue to improve maternity safety and have made the largest ever investment in midwifery training to ensure the NHS has the skills it needs."


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