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Next steps


This report sets out a number of recommendations about what is needed to drive quality improvement within UK maternity services. To make the recommendations a reality, engagement and support are needed from all stakeholders.


Healthcare professionals


Doctors, midwives and other healthcare professionals should ensure this report’s recommendations for clinical practice are followed at all times.


Healthcare professionals involved in local reviews should ensure good practice is followed, based on this report’s recommendations for the conduct of future reviews.


All healthcare professionals should support the dissemination of learning and, where it is needed, culture change within their unit.

Trusts and health boards


The RCOG asks all trusts and health boards for their continued commitment to Each Baby Counts, which is vital for the programme’s continuing success and impact.


Trusts and health boards should support their staff to implement the recommendations set out in this report, ensuring staff tasked with CTG interpretation receive annual training, promoting the development of nonclinical skills such as situational awareness and providing multidisciplinary training to support good team working.


Trusts and health boards should ensure the necessary protocols are in place to ensure all local reviews are of high quality, incorporating the key points highlighted in this report.


Policy makers and governments


As an urgent priority, maternity units need to be adequately resourced. Without this trusts, health boards and healthcare professionals will struggle to implement the recommendations from the Each Baby Counts project.


Each Baby Counts should be supported to fulfil its maximum potential as part of the continuing commitment to maternity safety.