Each Baby Counts and Mind the Gap Reports

Published on: 14/11/2018

In this article, we are going to cover two reports that have recently been released. 

Whilst it’s sobering reading, we would like to say how incredibly important these honest reports are, not just scratching at the surface reasons for lack of progress, but aiming to delve deeper into the whys. 

The Each baby Counts programme by the Royal College of Obstetricians and Gynaecologists collates the results of local investigations into stillbirths, neonatal deaths and brain injuries occurring during term labour to help to understand overall what lessons can be learned to help prevent babies from dying or sustaining brain injuries in the future. 

A summary of the report shows that of 955 babies in the review (that provided enough information in the investigation for a conclusion to be drawn), 71% could have had a different outcome with different care. The report states that there are so many factors and reasons for these outcomes, that it makes finding concrete overall solutions particularly hard. On average, there were 7 critical contributing factors in each case. The full report which can be found here goes into more detail with many examples cited that show the reasons for the recommendations that have been made as a result of the progress report.

Contributing factors in the report include:

> Guidelines and locally agreed “best practice” were not followed in 45% of the investigations reviewed.
> Problems not being recognised.
> Communication.
> Workloads.
> Staffing levels.
> Local guidelines not being based on best practice.
> Gaps in training.

The number of parents invited to take part in reviews had risen to 41% (from 34% in the previous year), however in nearly one quarter of cases, parents were not even made aware that a review was taking place. We strongly feel that it is vital that parents are involved (or offered involvement) 100% of the time. 

The report is clear that continued investment to improve care is needed to improve future outcomes. We must always remember with any reports that each of the figures stated represent a family who’s lives are changes forever.

The next report links in smoothly from the Each Baby Counts programme; as released just last week, the Mind The Gap report by the charity Baby Lifeline highlighted the urgent need for maternity training for frontline staff. The full report can be found here.

Over the last 2 decades, reports similar to the above, have made recommendations regarding training for frontline staff to help improve outcomes. Mind the Gap looked at the national response to the recommendations that have been previously made. A summary of their recent findings are shown below:

Only 38% of trusts recorded a training attendance rate of 90% and above for all staff groups

Fewer than 8% of trusts provided ALL of the training components of the Saving Babies’ Lives Care Bundle (note that in the SPiRE report 42% of mainly frontline staff were not even aware of the bundle, despite implementing all or parts of it). 

There was an average spend of £59k on training in trusts, however a huge variation existed between each one with one trust spending just £1k and another £372k

The main barriers to training were reported as staffing, sickness and finance.

Mind the Gap makes clear that there is still little/no standardisation in the way maternity training is prioritised, provided, funded, assessed or attended across the UK. The report calls for maternity training to be funded. We believe that this is absolutely key in putting a stop to preventable losses.

Baby Lifeline are a charity providing training on specific recommendations that have been made to save babies lives (find their courses here). A quote from one of their Tweets: “No healthcare professional goes to work to do harm. We need to better equip frontline professionals with up-to-date training in best practice.”

The SPiRE report recorded a 20% reduction in stillbirths since the implementation of the Saving Babies Lives Care Bundle. Mind the Gap reports that fewer than 8% of trusts provided all of the training for the bundle. Imagine what could be achieved and how many lives could be saved with sufficient and consistent training!

MAMA Academy has a big 2019 planned, with this training gap being one of the issues at the front of our agenda. We want to advocate for fabulous charities like Baby Lifeline, who are offering the training that is desperately needed to save lives and work together in pushing this issue up in the political agenda. 

We have some great plans to help give frontline staff a voice and platform for sharing best practice. Watch this space!