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Conclusion

The very fact that so many people were happy to be interviewed about the project was indicative of the regard that the programme is held in.

The value and impact of the programme is not just in the Each Baby Counts criteria that underpin many safety initiatives across all nations, but the catalyst for change that Each Baby Counts delivered.

Participants cited Each Baby Counts as being the driving force behind involving parents in reviews, of driving improvement of local reporting and the realisation that each and every case was a combination of factors rather than perhaps a single cause.

It propelled human factors and teamworking in maternity care into the limelight and has consistently recognised key clinical challenges that have had resonance with the maternity and neonatal communities.

It has not been perfect and the data lag and data anonymity have been mentioned above. However, the key challenge is that not enough focus has been put on the implementation of the findings.

“As a parent, who’s lived through an experience like this, you want to know something is happening. You’re really fed up of hearing lessons will be learnt, and this will change, but every death in this area, you are looking at very similar failings over and over again, so really it’s ‘what are you going to do now, what is going to happen?’”

(Parent representative – Campaign for Safer Births)

From the quote above we hear the call for action – to move from counting to action, to move from recommending to delivering change. This is the Each Baby Counts programme’s last chance to directly influence the maternity landscape.

The numbers over the 4 years have remained stubbornly static, with the chance of a term baby fitting the Each Baby Counts criteria being the same in 2018 as in 2015. While we have tentatively suggested some explanations for this, we need to continue to learn from each and every case to see what factors are present, or absent, in the system that mean this situation persists, despite considerable investment. A notable exception to the lack of improvement is in parental involvement, which has increased year on year, driven by the awareness raising of both programmes like Each Baby Counts and the tireless campaigning of baby-loss charities and individuals.

Realising the ambitious Each Baby Counts aim of reducing by 50% the incidence of stillbirth, neonatal death and severe brain injury as a result of incidents during term labour by 2020 was always going to be a complex problem. It has to be recognised that the answers to these complex problems don’t lie solely in the healthcare domain. Colleagues in social sciences and engineering can bring novel and innovative methodologies to bear on change-resistant problems.

It is with this in mind that the RCOG has partnered with The Healthcare Improvement Studies (THIS) Institute, exploring practical changes that will improve interpretation of electronic fetal heart monitoring, using ethnography to understand what makes a safe maternity unit, and exploring, through the lens of behaviour change science, how to tackle escalation with the Each Baby Counts + Learn and Support team.

The next phase of Each Baby Counts is the application of the knowledge and learning gained from 4 years of considered and high-quality investigations of intrapartum care.  As a maternity community, we should reflect on what has gone before, building on what has worked and implement effective innovations. However, we can catalyse faster improvement using the new opportunities afforded by big data, digital technologies, broader academic collaborations and the skills and expertise of our clinical workforce, with families at the centre. Together, we can make the UK the safest and best place in the world to have a baby.

Box 1: An extract from ‘How to be a very safe maternity unit: an ethnographic study’

What we found

  • A very well-founded training programme is very important to achieving safety, but on its own doesn’t provide a full explanation of what makes a maternity unit safe.
  • At Southmead Hospital, safe maternity care was influenced by a training intervention (PROMPT) as well as broader social, organisational and cultural factors.
  • These factors include:
    • collective competence and agile professional boundaries
    • insistence on technical competence
    • systems to facilitate coordination and distributed cognition
    • clearly articulated and constantly reinforced standards of practice, behaviour, and ethics
    • monitoring multiple types of data about the unit’s state of safety
    • a highly intentional approach to safety
  • The mechanisms were also influenced by the unit’s structural conditions, such as staffing levels and physical environment.
  • The intervention (PROMPT) interacted constantly with these mechanisms. Though PROMPT was not a ‘magic bullet’ for safety, it both fostered and reinforced the conditions needed to achieve safety.
  • Improvement interventions and the context that enables their success should be considered in tandem.

Box 2: Each Baby Counts + Learn and Support (EBC L&S)

Emergence

Funded by the DHSC, the RCOG and the RCM established the EBC Learn and Support programme to address the findings from EBC reports which highlighted human factors such as situational awareness, stress, fatigue, clinical leadership and communication in multidisciplinary frontline teams as crucially important to safety and quality of care.

Aims

EBC L&S aims to build the capacity of 16 frontline health professionals in clinical leadership, safety thinking and quality improvement. They will be supported to prioritise, design and implement local practice changes using a structured approach based on behavioural science. This approach aims to increase the likelihood of recommendations being translated into practice that are sustainable, and replicable across settings.  Each of these components will be evaluated to provide an evidence base going forward.

Key focus

Given the salience of clinical escalation highlighted in EBC and maternity safety reports, this will be a key focus of the quality improvement component of the EBC L&S programme.