RCOG launch new Each Baby Counts Report

Today marks the launch of the new Each Baby Counts report, by the Royal College of Obstetricians and Gynaecologists.

It states three in every four of the babies may have had a different outcome had they received different care.

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.”

Heidi Eldridge, CEO of MAMA Academy, said the report needs to be read amongst ALL maternity staff and an urgent call to action is desperately required. Despite the increased awareness that the majority of stillbirths can be prevented, there is clearly so much more work that needs to be done to improve consistency of care across the UK.

“We are currently working with the Royal College of Midwives on an I-leaning module to help save babies lives and we hope this will contribute to improving care for mothers and babies across the country.”

Health Secretary Jeremy Hunt said: “While maternal and neonatal deaths are falling, together we need to do even more to make sure fewer families suffer the heartache of losing a baby – and this vital work will help.”

Read the full Each Baby Counts report.

Image Source: Science Photo Library.