Each Baby Counts is a UK-wide quality improvement programme led by the Royal College of Obstetricians and Gynaecologists (RCOG). Its aim is to reduce the incidence of intrapartum stillbirth, early neonatal death and severe brain injury as a result of events in labour by 50% between 2015 and 2020.
The Each Baby Counts team is made up of:
Lead Reporters were nominated by the clinical director of each trust/board. Trusts/boards are able to nominate more than one Lead Reporter to help identify and report every eligible baby.
Each Baby Counts reviewers were recruited via the relevant professional bodies and were trained to carry out a structured review using the Each Baby Counts pro forma. It included:
- 25 obstetricians
- 24 midwives
- 8 neonatologists
- 3 anaesthetists
The RCOG wishes to stress that the Each Baby Counts project would not function without the expertise and support of the reviewers and Lead Reporters, and the College is indebted to them for all their hard work in providing the information on which this report is based.
By April 2015, all (100%) NHS trusts/boards in the UK had agreed to participate in the Each Baby Count project and nominated Lead Reporter(s) to report all eligible babies born in their trust/board since 1 January 2015. Private maternity hospitals and independent midwives were also invited to participate in the project to ensure improvements in all aspects of intrapartum care can be identified.
Eligible babies include all term babies (at least 37+0 completed weeks of gestation) born following labour who have one of the following outcomes:
- Intrapartum stillbirth: when the baby was thought to be alive at the start of labour but was born with no signs of life.
- Early neonatal death: when the baby died within the first week of life (i.e. days 0–6) of any cause.
- Severe brain injury diagnosed in the first 7 days of life, when the baby:
- was diagnosed with grade III hypoxic ischaemic encephalopathy (HIE) OR
- was therapeutically cooled (active cooling only) OR
- had decreased central tone AND was comatose AND had seizures of any kind.
Babies whose outcome was the result of congenital anomalies were excluded centrally by the project team.
The definition of labour for Each Baby Counts includes:
- any labour diagnosed by a health professional, including the latent phase of labour at less than 4 cm cervical dilatation
- when the woman called the unit to report any concerns of being in labour, for example (but not limited to) abdominal pains, contractions or suspected ruptured membranes
- induction of labour
- when the baby was thought to be alive following suspected or confirmed pre-labour rupture of membranes.
The rationale for this is to have an inclusive definition of labour to include as many babies as possible and to identify babies who are affected in the latent phase of labour.
The severe brain injury definition is a pragmatic definition which is a composite of defined populations such as those entering the TOBY (Total Body HYpothermia) trial[i] as well as data that can be captured from neonatal information systems. It is not yet known how many of these babies will have a significant long-term disability as a result of the injuries sustained during birth, but the fact that the majority of these infants require active therapeutic cooling – an intensive intervention requiring sedation and admission to the neonatal unit – reflects the serious clinical condition of these babies.
Lead Reporters are requested to complete basic information within 5 working days of the baby’s birth or death via a secure online platform.[ii] This is used to confirm that the baby is eligible for Each Baby Counts. If a baby is confirmed as eligible, the Lead Reporter is required to upload an anonymised copy of the local review and complete a short form capturing details about the review process. The data include professionals involved in the review process, involvement of the parents and the specific review tool(s) used. Lead Reporters are requested to remove all patient identifiers from local investigation report files before these are uploaded.
The anonymised report from the local review is then sent to two independent Each Baby Counts reviewers, a midwife and an obstetrician. The reviewers do not have access to the case notes or statements from the staff involved; therefore the process is reliant upon the quality of the local reviews. The reviewers are required to answer the following questions:
- In your opinion, taking into account the information presented, is this review of sufficient quality to make a judgement about the care provided?
- According to the information presented, might different clinical care have resulted in a different outcome?
- What were the critical contributory factors that, if done differently, could have changed the outcome?[iii]
If there is a discrepancy between the reviewers’ answers to the first question, the report is read by a member of the Each Baby Counts team and the consensus opinion is upheld. A report that contains insufficient information for a judgement about the care to be made is flagged as such and the Lead Reporter from the reporting unit is informed.
If the report is considered to contain sufficient information and it is felt that different care might have prevented the outcome, the reviewer is asked to identify the factors that contributed to the outcome. The list of contributory factors was adapted from the framework previously used by the National Patient Safety Agency augmented by an analysis of the contributory factors that emerged from the review of the first 100 Each Baby Counts reports received in early 2015.
The reviewers are asked to indicate if they feel that the report requires the review of a neonatologist or anaesthetist. Reviewers are not asked to assess the care of babies who were born in their own or neighbouring regions to protect the confidentiality of both patients and staff involved.
[i] The TOBY Xe Study. Study Handbook. Version 2; 2012 [https://www.npeu.ox.ac.uk/downloads/files/toby-xe/protocol/TOBY-Xe-Study-Handbook-Version-2.pdf]
[ii] Each Baby Counts online reporting platform [www.medscinet.net/eachbabycounts].
[iii] Royal College of Obstetricians and Gynaecologists. Each Baby Counts Training Manual for Reviewers. London: RCOG; 2016.