Different care could have led to a different outcome in almost three quarters of stillbirths, neonatal deaths and severe brain injuries, according to the latest report by Royal College of Obstetricians and Gynaecologists out today.
The Each Baby Counts report reveals there was a 14% increase in the number of completed local investigations into stillbirths, neonatal deaths and severe brain injuries that occurred during term labour in 2016 across the UK, from 2015.
It also reveals that in 2016, 89% of completed local investigation reports contained sufficient information for review. There was an average of seven contributory factors per incident, showing the complex relationship between clinical and non-clinical factors, the researchers say.
RCOG has now called for a national centre of excellence for maternity care in the UK.
Edward Morris, co-investigator of Each Baby Counts and vice president of RCOG, said: “Sadly this latest report from Each Baby Counts shows that different care might have made a difference to the outcome for almost three-quarters of affected babies.
“This highlights that much work is still needed to ensure healthcare professionals are supported to implement recommendations.
“We are committed to improving maternity safety and want to do everything possible to prevent these tragedies that can have a life-long and devastating impact on families.”
The report says that in 45% of cases, guidelines and best practice were not followed for reasons including gaps in training, lack of recognition of problems, communication issues, heavy workload, staffing levels and local guidelines not being based on best available evidence.
There were nearly 700,000 babies born in 2016, of whom 1,123 fulfilled the Each Baby Counts criteria. There were 124 stillbirths, 145 babies who died early and a further 854 babies who sustained severe brain injuries during labour at term.
Among the recommendations in the report are addressing workload issues, putting in place an individualised management plan for women during antenatal, labour and postnatal care, and ensuring local guidelines are updated in line with national guidance.
Professor Lesley Regan, president of RCOG, said: “The stillbirth, death of a new-born baby or the birth of a baby with brain injuries are life-changing events that profoundly affect women and their families. It is absolutely vital that we sustain the momentum and progress to date to ensure we really make a difference to maternity care in the UK.
“Now is the time to establish a national centre dedicated to make sure the UK is the safest place in the world for women and their babies. By bringing together the shared expertise and experience of women and families, frontline maternity teams, academics and policymakers would be a significant step forward in driving improvement across the country.”
Health minister Jackie Doyle-Price said the government was investing in midwifery training with a view to tackling the problems identified in the report.
She said: “Whilst this report acknowledges that important progress has been made, there is still more to do to ensure every mother and child receives the world-class care they deserve as part of our ambition to halve the rates of stillbirths, neonatal deaths and brain injuries caused during and after birth by 2025.”
The report can be found at: https://www.rcog.org.uk/eachbabycounts
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