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Foreword

 

Lesley ReganAn introduction to Each Baby Counts by Professor Lesley Regan, RCOG President

 

While the UK remains one of the safest places to give birth, serious incidents do occur and can result in stillbirths, neonatal deaths and brain injuries. The likelihood of these events happening is thankfully rare; however, this does not reduce the devastating impact for the families affected, the healthcare professionals involved and the organisations where such events occur. And, when subsequent investigations suggest that the outcome might have been different if the care provided had been different, the impact on families is exacerbated still further, while the ensuing litigation costs divert much needed resources away from improving front-line care for women and their babies.

 

The Royal College of Obstetricians and Gynaecologists (RCOG) is committed to improving this situation and in 2014 we launched a dedicated programme of work, Each Baby Counts, to address this important issue. Each Baby Counts aims to halve the number of babies who die or are left severely disabled as a result of preventable incidents occurring during term labour by 2020, and we are proud that 100% of trusts and health boards across the UK are engaging with the programme and committed to improving care. By collating all local investigations carried out by each maternity unit, and analysing them at a national level, we are able to identify common themes and key actions that can be taken to improve the quality of clinical care.

 

In June this year we published a summary report based on the complete set of baseline data relating to all stillbirths, neonatal deaths and brain injuries occurring during term labour in 2015. We then held a Clinical Engagement Forum with over 300 midwives, obstetricians and neonatologists to discuss the data and identify how to support healthcare professionals to implement the recommendations. This full and final report presents the detailed data behind our recommendations as well as resources to support improved clinical practice.

 

The key finding – that for many of the babies reported to Each Baby Counts, different care might have resulted in a different outcome – makes a powerful case for the need to improve care. However, the data also demonstrate the complex nature of maternity care. Through analysis of the reviews submitted to Each Baby Counts, we identified over 3,800 critical contributory factors, with an average of 6 contributory factors for each baby. The image below demonstrates the intricate relationship between the various contributory factors, which also suggests the need for complex and nuanced solutions. For example, while improving fetal monitoring skills is clearly important, alongside this maternity teams need to be confident in their ability to work as a team, maintain oversight of the full clinical picture and communicate effectively.

 

This network graphic aims to portray the thematic analysis that affected each case with over 6 contributing factors, and should be taken as a visual aid to comprehend the extent of the complexity. This network analysis is created by compiling each case by all of the individual contributing factors, and then aggregating them by both case and thematic analysis areas.

 

The average number of critical contributory factors identified was 6 and there were no babies where a single identifiable critical contributory factor could be conclusively identified. The reviewers found that are multiple and complex interactions between clinical and non-clinical factors which can often be inter-related. This network graphic aims to portray the thematic analysis that affected each case with over 6 contributing factors, and should be taken as a visual aid to comprehend the extent of the complexity.

 

This network analysis is created by compiling each case by all of the individual contributing factors, and then aggregating them by both case and thematic analysis areas.

 

This report identifies common issues, and makes recommendations on how to improve care, in 3 areas: fetal monitoring, human factors and neonatal care. The report also includes suggestions for implementation and links to resources to help translate our findings into practical improvements to care. At our Clinical Engagement Forum in June, doctors and midwives told us that their priorities for implementation were improving human factors, or the way teams work together in maternity. For this reason we have focused our efforts on developing tools and training materials to support this area, and have developed a package of resources to support implementation of the human factors recommendations, which maternity units can use to help their staff develop situational awareness. We have published these on the RCOG website and encourage you to share them widely.

 

We have also collated information about a number of existing resources designed to support the development of fetal monitoring skills. Throughout each chapter you will also see sections titled "things you can do", which provide practical advice for everyday clinical practice.

 

So, where next for Each Baby Counts? The programme was intended as a long-term commitment focused on tackling safety, quality and care in maternity services, and we do not waver from this challenge. We are committed to regularly reporting and monitoring progress over time on stillbirth, neonatal deaths and brain injuries, and will continue to work with all maternity units to support the improvement of the quality of local reports. 

 

We also expect that this full report, alongside the growing learning from related work such as the Perinatal Mortality Review Tool, will provide the tools for teams to deliver safer maternity care for women and their babies.

 

We are aware that our findings come at a time when there is national attention on maternity services. The Maternity Transformation Programme provides a strong opportunity to improve maternity services and we welcome the commitments already made to address safety. We thank all the individual maternity teams working to improve care and ask them to apply the findings in this report into their local priorities.

 

At a national level we will continue to work with the many committed partners and organisations to ensure the findings are used to inform and support national priorities, and we welcome new opportunities for greater collaboration.

 

Finally, I would like to take this opportunity to personally thank all involved for their efforts in working together to make this a success.

 

Professor Lesley Regan signature 

Professor Lesley Regan
President, Royal College of Obstetricians and Gynaecologists