Intrapartum stillbirths that occurred during the pandemic

Published on: 16/09/2021

MAMA Academy welcomes the publication today of the Healthcare Safety Investigation Branch (HSIB)’s National Learning Report – Intrapartum Stillbirth: learning from maternity investigations that occurred during the Covid-19 pandemic, 1 April to 30 June 2020.

As the UK’s Safer Pregnancy Charity, we believe that it is essential that healthcare services critically appraise incidents where adverse outcomes occurred to ensure that appropriate learning is gained. As a team of bereaved parents, we believe that learning from experience is the best way to seek to safeguard against tragic circumstances being repeated. Learning is not about apportioning blame, but about developing systems to better support both families and maternity professionals.

We are heartened to read that HSIB found no connection between Covid-19 infection and stillbirth in this group, and we reiterate the consistent public health advice that the evidence clearly shows pregnant women and birthing people should be supported to receive Covid-19 vaccinations.

MAMA Academy draws attention to HSIB’s findings that many of the factors identified in this report relate to “risks [that] are well recognised as existing in maternity care, and how some risks may have been exacerbated…by the Covid-19 pandemic”, and believe that this should encourage maternity services to redouble their efforts and their focus on ensuring that the UK is as safe a place as possible in which to give birth.

We particularly welcome HSIB’s recommendation that clarity and consensus with regards to reported changes in fetal movements during the third trimester and how that is managed are needed. Reduced fetal movement is clearly associated with increased risk of stillbirth, so appropriate management of, and communication with parents about, this issue is of vital importance. MAMA Academy always encourages women to contact their maternity unit immediately if they notice their baby’s movements have slowed down or stopped after 28 weeks’ gestation.

We also particularly welcome the HSIB call for a review to improve the reliability of existing assessment tools for fetal growth and fetal heart rate to minimise the risk for babies. Growth restriction and placental complications are a leading cause of stillbirth (shown again in these examples), so improving methods of identifying babies affected by this and taking appropriate action will support everyone’s key objective of saving babies’ lives.

We support the call for minimum standards for maternity triage services to ensure reliable identification of risk – maternity triage acts as an A&E for women’s health, and should be seen as such by senior Trust management teams everywhere. It is evident that staffing is also an important factor in this.

It was also clear from this report that – as already well-documented – stillbirth continues to disproportionately impact ethnic minority and marginalised groups, and implementation of the recommendation for minimum operating standards for interpretation services in maternity care is urgently needed.

Many of the recommendations in this report echo or align with similar points made in other reports including the Ockenden interim Report (2020) and the Saving Babies’ Lives Care Bundle v2 (2019), building a critical mass of reviews highlighting the urgent key factors in improving maternity safety.

Heidi Eldridge, Chief Executive of MAMA Academy, said:

“At MAMA Academy, we are grateful for the thorough review conducted by HSIB of these cases to further inform the learning and improvement work that is ongoing in maternity services. Whilst there are many difficult challenges affecting maternity services currently, helping more babies arrive safely must always be a top priority. Many of the points made in this report are the same as points we’ve heard before, so require urgent implementation.

MAMA Academy will continue to strive to support the NHS in meeting its targets of reducing stillbirth and neonatal death by 50% by 2025, but we urge everyone reading this report to also take a moment to look beyond the data and statistics quoted in the report and consider the 37 families whose experiences form the basis of this report who did not get to take their babies home. Putting families at the centre of their care is paramount to improving outcomes.”

Read the full report here.

For further information about MAMA Academy and our work, please see

For comment or input into media reports of this or any other issue relating to maternity safety, please contact us on or 07427 851670.