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Report structure

This report is comprised of five main sections:

  • Overall findings for 2015 (a quantitative summary of the number of eligible babies, the quality of local reviews and the proportion of babies for whom Each Baby Counts reviewers felt that different care might have made a difference to the clinical outcome)

  • Thematic analysis 1: Can all Each Baby Counts outcomes be avoided? (A thematic description of the babies for whom both Each Baby Counts reviewers felt that different care might not have changed the outcome)

  • Thematic analysis 2: Fetal monitoring

  • Thematic analysis 3: Human factors and lack of non-technical skills

  • Thematic analysis 4: Neonatal care


Quantitative summary

Data collection for eligible babies born in 2015 was closed on 1 May 2017. No further data will be collected for these babies. Most of the information presented in this report is based on the 727 babies whose reviews were assessed by Each Baby Counts reviewers as containing sufficient information to make a judgement about the quality of care provided.


Thematic analysis

The four main thematic analysis chapters for the 2015 report are:

  • babies for whom different care might not have made a difference to the outcome
  • fetal monitoring
  • individual human factors
  • neonatal care.


Babies for whom different care might not have made a difference to the outcome

The Each Baby Counts team identified a subset of babies for whom different care might not have made a difference to the clinical outcome. Agreement between the obstetric and midwifery Each Baby Counts reviewer on this pro forma question was taken to mean that, based on the information provided in the local review, it is unlikely that different care would have changed the outcome.


Although the reliance upon the content of the local report may not be viewed as the most robust way to assess the care provided, agreement between the two independent reviewers adds weight to the argument that different care was unlikely to have changed the outcome.


A member of the Each Baby Counts project team reviewed the reports to identify why and when these outcomes occurred. Vignettes and discussion surrounding the babies’ care have been included to illustrate these babies’ stories.


Fetal monitoring

Fetal monitoring was chosen for in-depth review because this was highlighted as a commonly recurring clinical contributory factor.


There were 409 babies for whom one or both Each Baby Counts reviewer(s) indicated that fetal monitoring was a key contributory factor in the outcome. These babies were further divided into three groups based on the identified contributory factors:

  • the conduct and interpretations of continuous cardiotocography (CTG)
  • intermittent auscultation
  • both of these factors.


In order to identify the main themes, all babies in the intermittent auscultation group and a random sample of 70 babies from the CTG group were reviewed in depth. Although data saturation for each group was reached after 30 reports were reviewed, all reports were read for completeness. Vignettes have been included as evidence for the themes identified. The themes along with support from national guidance and current literature have been used to formulate the key recommendations.


Individual human factors

Human factors were chosen as a nonclinical, commonly recurring and growing area of interest with potential for learning.


Human factors were considered to be a contributory factor in 352 babies.The human factors (both individual and team issues) considered were; poor intra or inter-professional communication, lack of team leadership, lack of situational awareness, stress, fatigue and “other” human factor issues.The Each Baby Counts team selected the most frequent individual human factors – lack of situational awareness and stress and fatigue – for thematic analysis. 


Situational awareness

To avoid overlap, the Each Baby Counts team selected reports that did not have CTG highlighted as a contributory factor. This produced a sample of 108 babies, from which 54 (50%) were randomly selected for further analysis.

NVivo (QRS International, Melbourne, Australia) was used to search the text of the local review reports for the words ‘situational awareness’. Eight reports were found which mentioned this directly, and the remaining 46 were then also coded. After a review of the care of a further eight babies, the team agreed that data saturation on this topic had been reached.


Stress and fatigue

For 25 individual babies, the Each Baby Counts reviewers highlighted stress or fatigue as significant factors leading to the adverse outcome.


Neonatal care

Neonatal care was identified as a significant contributory factor warranting in-depth analysis because over 80% of the babies reported to Each Baby Counts fall into one of two categories:

  • babies who die within the first 7 days of life and
  • those who sustain a severe brain injury.


As the majority of these babies will have received neonatal care, it was felt important to examine this aspect of care alongside the midwifery and obstetric care given in these instances.


Eight specialist neonatal reviewers were recruited and trained to complete Each Baby Counts reviews. By February 2017, each specialist neonatal reviewer had assessed the neonatal care provided to around 20 babies whose reports had been randomly assigned whilst allowing for geographical separation.


The Each Baby Counts team hosted a roundtable for the neonatal reviewers to facilitate a discussion and identification of the emergent themes based on their assessments. Five specialist neonatal reviewers attended, discussed the findings and formulated key recommendations for improvements in neonatal care.