Each Baby Counts - The Royal College of Obstetricians and Gynaecologists reports on its findings

The Royal College of Obstetricians and Gynaecologists (RCOG) – the professional association which works to improve women’s healthcare by publishing clinical guidelines and advising government – has published its report, Each Baby Counts. The report details the findings of the RCOG’s inquiry into the causes of all stillbirths, early neonatal deaths and severe brain injuries caused to babies born at term in the UK in 2015.

RCOG launched Each Baby Counts in 2014, describing it as a long-term, quality improvement programme designed to improve the standard of maternity and neonatal care. Its aim was to halve the numbers of babies who die or are left severely disabled as a result of preventable accidents during term labour by 2020. In a foreword to the report which makes no apology for their ambitious target, RCOG reiterate their intention that Each Baby Counts shall serve as a ground-breaking, long term inquiry that will deliver improvements to maternity care over time.

In recent months I have expressed my concerns about various initiatives which purport to address the rising problem of birth injury in the NHS. Designed from the Department of Health’s perspective, each has approached the issue with financial cost as its foremost concern. Litigation is expensive but as we have constantly maintained, compensation is a by-product of the problem not the cause. Taken from the perspective of limiting cost, the cultural and economic shift needed to transform the NHS into a learning organisation capable of dramatic change seems impossible to achieve. In contrast, the report from Each Baby Counts has the feeling of something workable and that comes from both the focus and fearlessness of its approach.

Here, at last, we see clinical advisors to the profession taking a care-based stance which asserts that if maternity standards are to improve so that every baby born in the UK has the best chance of being born unharmed, a fearless approach to examining the common causes of avoidable harm must be taken. Only by being willing to face up to deficiencies in practice by “rapidly and robustly” investigating the care provided, will measures be taken to prevent further avoidable mistakes.

For the first time, and with 100% buy-in from NHS trusts, health boards and the profession, the RCOG have collected and analysed data from every stillbirth, neonatal death and brain injured baby born in the UK in one year. This complete analysis of each of the individual tragedies of 2015 and the local investigations which followed each event provides an in-depth yet also nationwide view of what is going wrong. Based on the common areas of concern arising from these cases, RCOG have made recommendations which they require all healthcare individuals to follow and government and NHS organisations to support, culturally, procedurally and economically. If these key areas of concern are addressed, RCOG believe rapid improvement in maternity care can be achieved across the NHS. Without talk of blame, budget or liability, recommendations are laid down for future practice, which “address critical factors in the care of many of the Each Baby Counts babies, that may have prevented their death or injury.” Each Baby Counts has taken its first steps towards safer maternity care by distilling the lessons from its analysis of 2015 and offering them up to anyone with a willingness to learn.

Findings and Recommendations

Of 720,000 term babies born in the UK in 2015:

• 126 were intrapartum stillborn
• 156 suffered early neonatal death
• 854 had severe brain injury evident by 7 days of birth.

RCOG regarded 25% of the local investigation reports which followed these events as inadequate. As the introduction from the Campaign for Safer Births comments: “The Each Baby Counts report shines a spotlight on how too many hospitals are failing to examine and admit, even to themselves, how things go wrong and where care might improve.”  In 76% of the 727 reports which provided sufficient information to enable the care to be analysed, at least one Each Baby Counts panel reviewer concluded that the baby might have had a different outcome with different care.

The RCOG’s clinical recommendations included:

• Formal fetal risk assessments to be carried out on admission in labour of women who are apparently at low risk to determine the most appropriate method of fetal monitoring. IT tools which bring together data from across the trust’s systems to support easy, accurate risk assessment should be developed as a priority.
• Regular reassessment of risk should take place during labour and NICE guidance followed on when to switch from intermittent auscultation to continuous cardiotocography (CTG).
• Staff tasked with CTG interpretation must have documented evidence of annual training
• Key decisions on the management of labour should not be based on CTG interpretation alone but should take into account the history, progress in labour, antenatal and other relevant factors
• The paediatric or neonatal team must be informed promptly of relevant risk factors for a compromised baby

The Each Baby Counts report has highlighted the unacceptable number of stillbirths, neonatal deaths and brain injured babies whose outcomes might have been better with different care. The figures are upsetting but the RCOG’s message is clear. Each baby counts. It’s time to stop the harm and that begins with better care.