Each Baby Counts (EBC) final report says no reduction in brain damaged babies, stillbirths or early neonatal deaths

Each Baby Counts (EBC), the RCOG’s maternity improvement programme which hoped to halve the number of term babies who die or suffer brain injury during birth, has published its final report.

The Each Baby Counts 2020 Final Progress Report gathers together information from local investigations into stillbirths, neonatal (newborn) deaths and brain injuries suffered during the births of babies at term in 2018 in the UK. It concludes that the numbers of babies harmed during the four years of the programme have remained ‘stubbornly static’. Despite EBC’s specific recommendations for improvements in key areas of maternity care, babies born in 2018 had the same chance of suffering these injuries as those born in 2015, when Each Baby Counts began.

How many babies suffered brain injury, stillbirth or early neonatal death in the UK in 2018?

According to Each Baby Counts (EBC), in the UK in 2018:

• 651,587 babies were born at term (at least 37 weeks of pregnancy);
• 1145 (or 1 in every 569 term babies, or 1.76 per 1000 term births) met EBC eligibility for brain injury, stillbirth or neonatal death;
• 121 babies (11% of those reported) were intrapartum stillborn (alive at start of labour but born without signs of life);
• 165 babies (14%) suffered early neonatal death (died within the first week of life);
• 859 babies (75%) met the following EBC criteria for babies born with severe brain injury, diagnosed within 7 days of life:
  • they were diagnosed with grade III hypoxic-ischaemic encephalopathy (HIE); or
  • they were treated with therapeutic cooling; or
  • they had decreased central tone and were comatose and had seizures (fits or convulsions) of any kind.
• 81% of the liveborn babies reported to Each Baby Counts received therapeutic cooling.

EBC states that it is not known how many of the reported brain-injured babies will have significant long-term disability as only live babies with a diagnosis of brain injury at seven days of life are included in these figures. Where a baby suffered a brain injury which resulted in their death in the first week of life, they have been classified as a neonatal death.

Better care might have changed the outcome for 74% of term babies who suffered brain injury, stillbirth or neonatal death

EBC reviewers found that 508 babies (74%) might have had a different outcome with better care. In cases where neonatal treatment was reviewed, EBC neonatologists believed that better neonatal care might have improved the outcome for 123 (39%) babies.

As with other maternity reviews and past EBC reports, the failings which almost always contributed to the babies’ harm were within the following themes:

• fetal heart monitoring (CTG) and blood sampling;
• recognising and managing risk;
• teamwork and communication;
• individual human factors;
• education and training.

EBC pointed out that these top five themes have not changed over previous reports, despite EBC’s previous recommendations which were specifically designed to address them.

The one significant improvement in the investigations reviewed from 2018, was that 70% of parents had been invited to contribute to the review following their baby’s injury, compared with 50% in 2017.

What has the NHS learned from Each Baby Counts?

Sadly, the Each Baby Counts 2020 Final Progress Report concludes that, on the 2018 figures, EBC’s efforts to help NHS maternity services learn from mistakes has had little impact on reducing the incidence of harm. Far from reducing the number of babies injured, the injury rates appear to have increased slightly year on year.

At Boyes Turner, we welcomed the EBC programme and the RCOG’s openness and willingness to expose the true causes and count the human cost of failings in maternity care. Each Baby Counts shone a spotlight on the suffering of those babies and families who have suffered devastating harm, calling for change where it mattered most, and putting maternity safety firmly on the agenda. As the report points out, EBC’s definitions and criteria have been adopted by many improvement agencies, including NHS Resolution and HSIB.

Given the importance of maternity care improvements, above all to babies and their families, the now commonly recognised causes of failings in care, and the government’s stated ambition to reduce this type of harm, EBC’s finding that “little demonstrable action has been taken in widely implementing recommendations to change practice” is an insult to those who have suffered and, frankly, shocking.

Whilst issues relating to leadership, toxic culture, technical competence, teamwork, lack of staffing and resourcing are allowed to threaten the safety of NHS maternity care, babies will continue to suffer devastating harm and families mourn the needless loss of their child’s life. We wholeheartedly agree with President of the RCOG, Edward Morris, who in the foreword to the report calls for the entire health system to recommit itself to challenging safety issues head on at what he describes as a ‘watershed moment’ for maternity services. What remains unclear is whether the NHS is capable of learning from their mistakes.

How Boyes Turner help families who have suffered harm caused by negligent maternity care

For over 30 years, Boyes Turner’s birth injury specialists have helped families affected by negligent maternity and neonatal care recover compensation to meet the needs of their disabled child and provide financial security for their future. We focus on achieving early admissions of liability (fault) and securing early, substantial interim payments to meet our clients’ urgent needs for care, essential equipment, therapies and suitable accommodation whilst we work towards settlement of the claim. Final settlements are carefully valued, negotiated and structured to make the best provision for our client’s lifelong needs.

We also help families suffering as a result of maternal injury, death or severe psychological injury arising from failings in maternity care.

If you or a member of your family have suffered severe injury as a result of negligent maternity or neonatal care and you would like to find out more about making a claim, contact us by email at cerebralpalsy@boyesturner.com.