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We are indebted to the many healthcare professionals and other organisations who were involved in the notification of Each Baby Counts babies and the provision of other information. Without the generous contribution of their time and expertise it would not have been possible to produce this report.


This report has been prepared by the Each Baby Counts Project Team:

  • Zarko Alfirevic; Co-Principal Investigator
  • Alan Cameron; Co-Principal Investigator
  • Becky Dumbrill; Administrator
  • Alison Elderfield; Head of the Lindsay Stewart Centre for Audit and Clinical Informatics
  • Hannah Knight; Co-Investigator
  • Marian Knight; Senior Project Advisor
  • Edward Morris; Co-Investigator
  • Emily Petch; Project Manager
  • Edward Prosser-Snelling; Quality Improvement Lead
  • Louise Robertson; Clinical Fellow


The development of the Each Baby Counts programme was supported by a grant from the Department of Health and a generous legacy donation from Dr Lindsay Stewart OBE CA FRCOG(hon) FRCSEd FRCSI to the Royal College of Obstetricians and Gynaecologists (RCOG), for which we are very grateful. We are also thankful to the March of Dimes for sponsoring the Each Baby Counts launch event in October 2014, the Clinical Engagement Forum in 2016 and the Clinical Engagement Forum at which this report was launched.


We would particularly like to thank all of the Each Baby Counts Lead Reporters and Reviewers whose contribution has made it possible to carry out this surveillance and analysis.


We would also like to express our gratitude to the members of our Independent Advisory Group for supervision, strategic direction and governance of the activities of the programme, to our Independent Data Surveillance Panel, who are responsible for careful scrutiny of the national surveillance and Serious Incident (SI) data submitted to Each Baby Counts, and to the MBRRACE-UK team for providing data to check case ascertainment.


Finally, we are grateful to members of the RCOG committees, who have provided useful thoughts and valuable feedback on draft versions of this report, particularly the Lindsay Stewart Committee for Audit and Clinical Informatics and the Clinical Quality Board.


Authorship is attributed as follows:

  • Overall findings for 2015: Emily Petch, Hannah Knight
  • Methodology for the Each Baby Counts project: Emily Petch, Edward Prosser-Snelling, Louise Robertson, Hannah Knight
  • Can all Each Baby Counts outcomes be avoided?: Louise Robertson, Zarko Alfirevic
  • Fetal monitoring: Louise Robertson, Zarko Alfirevic
  • Human factors and lack of nontechnical skills: Edward Prosser-Snelling, Marian Knight
  • Neonatal care: Emily Petch, Marian Knight. Specialist Neonatologist Reviewer Authors: Dr Sean
  • Ainsworth, Consultant Neonatologist*; Dr Mallinath Chakraborty, Consultant in Neonatal Medicine*;
  • Dr Lesley Jackson, Consultant Neonatal Medicine*; Professor Minesh Khashu, Consultant
  • Neonatologist and Professor of Perinatal Health*; Dr Ghada Ramadan, Consultant Neonatologist*
  • With thanks to Dr Gary Hartnoll, Consultant Neonatologist; Dr Jane Hawdon, Consultant Neonatologist and Responsible Officer and Dr Robert Ironton, Consultant Neonatologist, who also undertook additional reviews in order for the information in this chapter to be compiled.
  • Implementation: Edward Prosser-Snelling
  • Improvement opportunities in fetal monitoring: Edward Morris, Sarah Prince

* denotes an equal contribution to this chapter