The Each Baby Counts 2018 progress report has now been published. This is the second annual report for the programme. Each Baby Counts was launched in 2014 with the aim of reducing the number of babies who die or are left with severe disabilities as a result of problems in labour when the baby is born at term (in other words, when the pregnancy has progressed to 37 weeks or more.)
Around 700,000 babies were born in the UK in 2016 and of these, 1,123 fulfilled the Each Baby Counts criteria. The figure encompasses 124 stillbirths, 145 babies who passed away in the first seven days of life and 854 babies who suffered severe brain injury during term labour.
It is sobering to read, in the forward to the report, that ‘[s]adly, once again this year’s report finds that different care might have made a difference to the outcome for almost three-quarters’ of babies reported to the project. Out of 955 incidents, where sufficient information had been provided for the project to draw conclusions about the quality of care, 674 babies might have had a different outcome.
The report found that there is rarely one single cause for a term pregnancy ending in stillbirth, early neonatal death or severe brain injury. Instead, on average, seven ‘critical contributory factors’ were at work and there was a ‘complex interaction between interrelated clinical and non-clinical factors’.
This year’s report looked, in depth, at two clinical areas: adherence to guidelines and anaesthetic care. It found that in 45% of the births that met the Each Baby Counts criteria, best practice and guidelines were not followed. A number of reasons were identified for this including heavy workload, staffing levels, lack of recognition of problems, gaps in training and incidents where local guidelines were not based on the best available evidence. The report highlights the need to update local guidelines so that they are in line with national guidance: ‘In order to improve the care provided to women and their babies, it is vital that reviews go beyond simply identifying that a guideline was not followed. The reviews must also look at why this occurred’.
Anaesthetists were not involved in maternity care reviews even where anaesthesia was a core aspect of the care provided. The report highlights the importance of anaesthetic care in achieving safety in maternity care. Gaps and delays in handover between shifts and variations in the level of participation of anaesthetists in labour ward reviews are identified. A core theme of the report is a commitment to supporting multidisciplinary working and collaboration.
On a positive note, the quality of reporting of the type of incidents covered by Each Baby Counts has improved by 14% since 2015. The project puts this down to the support it now offers to maternity units when they report incidents. The number of parents invited to take part in reviews increased from 34% in 2015 to 41% in 2016. However, around one quarter of parents were not involved or had not been made aware that a review had taken place into their child’s serious injury or death.
Camilla Wonnacott, an associate in the clinical negligence team at Penningtons Manches, said: “The lack of available resources continues to be an important factor in the tragedy of stillbirth, neonatal birth and severe brain injury in children born at term. Many parents faced with such a catastrophe want to investigate the reasons why their son or daughter passed away or sustained a severe injury and ensure that the mistakes that led to their family’s tragedy are not repeated. The Every Baby Counts project is to be commended for its efforts to improve maternity care and reduce avoidable injury and death to babies during birth and in the very early neonatal period.”