UK national guidance is not followed in most cases of stillbirth, according to the latest findings of a major inquiry.
Researchers said they found little evidence that improvements proposed by an inquiry 15 years ago had been implemented.
Last week the government announced a £4 million programme to tackle deaths in maternity departments after a series of scandals around the country.
The MBRACE-UK findings, published today, involved a study of 133 stillbirths in 2013.
Researchers from the Maternal, Newborn and Infant Clinical Outcome Review Programme found that in two thirds of cases national guidelines were not followed.
Two thirds of women with a risk factor for gestational diabetes were not offered testing, they report.
In more than 50% of cases, antepartum, full-term, singleton stillbirths there was wat least one element of care needing improvement, they say.
In nearly 50% of cases women had contacted maternity units to express concern about the baby’s movements. In half these cases (25% of the total) there were "missed opportunities" that might have saved the baby, they say.
In only 25% of cases was there documentation of an internal review – and these were of "highly variable" quality, they say.
The researchers praise the standard of bereavement care offered to mothers.
Professor Jenny Kurinczuk, Director of the National Perinatal Epidemiology Unit, said: “The findings from this enquiry are important because they provide clear pointers as to how care can be improved. The guidelines are clear and individual practitioners and maternity units need to ensure that the guidelines are implemented and every opportunity is taken to prevent a stillbirth occurring.
"There is no panacea in this situation; we have to prevent stillbirths one by one to ensure that as a nation we are able to reduce our stillbirth rate to those rates experienced by our European neighbours and avoid the terrible heartache experienced by three families every day across the UK.”
Researcher Professor Elizabeth Draper, from Leicester University, said: “The panel has identified a number of areas where improvements of care are required which, if implemented, could lead to an overall reduction in this type of stillbirth, representing missed opportunities in the provision of antenatal care."
The Royal College of Obstetricians and Gynaecologists said it was "desperately disappointing" that the inquiry had to make the same recommendations as the last one – 15 years ago.
President Dr David Richmond said: "Today’s report suggests six in ten of these stillbirths are potentially avoidable. We can and should do better by the 1,000 families affected each year in the UK."
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