Each Baby Counts
How Each Baby Counts will achieve its aims
Currently, stillbirths, neonatal deaths and brain injuries occurring due to incidents in labour are investigated at a local level. The Each Baby Counts project team will, for the first time, bring together the results of these local investigations to understand the bigger picture and share the lessons learned.
From 2015, the RCOG began collecting and analysing data from all UK units to identify lessons learned to improve future care. Recommendations on how to improve practice at a national level can then be made.
The detailed report outlines how to prevent such tragedies in future.
“Although the UK remains one of the safest places to give birth, serious incidents do occur, some of which could be prevented if different care were given,” says the report.
The report looked at all 1,136 stillbirths, neonatal deaths and brain injuries that occurred on UK maternity units during 2015:
126 babies were stillborn
156 died within the first seven days after birth
854 babies had severe brain injury (based on information available within the first seven days after birth. It is not known how many might have significant long-term disability)
Local investigations into a quarter of the cases were not thorough enough to allow the report authors to do a full assessment of what might have gone wrong.
In many of the 727 cases that could be reviewed in-depth, problems with accurate assessment of foetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting baby heart-rate patterns (on traces from CTG machines), were cited as significant factors.
Parents were invited to be involved in only a third of the local reviews, the report found.
The Each Baby Counts report recommends:
- All low-risk women are assessed on admission in labour to see what foetal monitoring is needed.
- Staff get annual training on interpreting baby heart-rate traces (CTGs).
- A senior member of staff must maintain oversight of the activity on the delivery suite.
- All trusts and health boards should inform the parents of any local review taking place and invite them to contribute.
Co-principal investigator, Prof Zarko Alfirevic, consultant obstetrician at Liverpool Women’s Hospital, said: “We urge everyone working in maternity care to ensure the report’s recommendations are followed at all times.”
Prof Lesley Regan, president of the RCOG, added: “The fact that a quarter of reports are still of such poor quality that we are unable to draw conclusions about the quality of the care provided is unacceptable and must be improved as a matter of urgency.”
Visit the RCOG project governance page for more information about who is involved in the project.
If you have any questions about the Each Baby Counts project, please email [email protected] or call +44 20 7772 6498.