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Executive summary

Each Baby Counts is the RCOG's national quality improvement programme to reduce the number of babies who die, or are left with severe disability, as a result of incidents occurring during term labour.


Each Baby Counts has an ambitious aim to reduce by 50% the incidence of stillbirth, neonatal death and severe brain injury as a result of incidents during term labour by 2020. 


Stillbirths, neonatal deaths and brain injuries occurring due to incidents in labour are initially investigated at a local level. The Each Baby Counts programme brings together the results of these local investigations to understand the bigger picture and share the lessons learned. The results presented are based on analysis of the data submitted along with in-depth thematic analysis of several key topics.


This report builds on the Each Baby Counts interim report published in 2016 and it reports complete data relating to the care of babies born during 2015. A summary report based on the findings of this report was published in June 2017. This report, relating to 2015, will be used as a benchmark for subsequent annual reports. Future reports may focus their in-depth analysis on different topics, depending on the findings of local investigations.


The aim of this report is to share the lessons from the care of Each Baby Counts babies born in 2015. In each maternity unit, these incidents are rare and it is difficult to see the clear patterns or best ways to avoid them. The Each Baby Counts programme utilises a multidisciplinary approach which provides us with a unique opportunity to learn from parents, midwives and doctors. Together we will continue to work hard to ensure that each baby receives the safest possible care during labour.


A parent’s perspective


"When something goes wrong during labour at the end of a healthy pregnancy, and a baby dies or experiences a serious brain injury, what should be one of life’s happiest events turns to devastating tragedy.


As parents, we have to go through something for which we had no preparation. We are in a blur of distress and shock. We cannot believe this could happen to our baby, carried with care and love for 9 months … But it has. And in 2015, it happened to 1136 babies.


The vast majority of parents want desperately to know what happened, even when the truth is difficult. After all we’ve already experienced the worst. But too many of us are left with poor explanations and unanswered questions.


We want our babies' lives to matter and to see hospitals determined to learn from these grave mistakes that have changed our lives.


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.


We want to know that things will be better for the next parents whose labour and birth are like ours.


To make this happen, there have to be thorough reviews of every baby’s case that involve us, the parents … the only ones to be present at every stage. And there needs to be learning, and a commitment to change, at every level.


Each Baby Counts is starting to show the areas that need urgent attention. This must not be another report that sits on a shelf; it is vital that it is acted upon and these levels of avoidable harm are confronted."


Laura Price and Janet Scott from Sands, and Michelle Hemmington and Nicky Lyon from Campaign for Safer Births