Some of the key benefits described by participants were raising the profile of harm during labour, and of maternity safety more globally, and shining a light on the cohort of babies included in Each Baby Counts, which previously had not been investigated in this way.
“It’s been incredible to raise the profile [...] from a parent point of view, it was incredibly important at that time because there wasn’t anything like this and it felt like we were finally being listened to [...] we were so hopeful that these babies were being looked at.” (Parent representative – Campaign for Safer Births)
In particular, the inclusion of babies in Each Baby Counts who have had a brain injury was seen to be a vital part of the programme and one that gave voice to this cohort that previously was not being heard. For many participants, the aspect of morbidity being included in this programme as well as the mortality of babies was seen as a real strength.
“There is a requirement to review the care of all babies that’ve died, but until EBC, there was no requirement to look at babies who’ve had brain injuries – that is a definite impact.” (Researcher)
“it’s incredibly important [...] whilst brain injuries in babies are rare events and it’s important to get the learning from those, they’re catastrophic for the families. We have a moral duty to do anything we possibly can to reduce them [these events].” (Director of Safety and Learning, NHS Resolution)
The definitions applied to collate the cohort of babies included in Each Baby Counts has been widely shared and used by other organisations, which is seen as a huge testament to the external impact of the programme. While Each Baby Counts is reported to have been the first programme to utilise these criteria, subsequent groups have aligned themselves for their respective work, including NHS Resolution, the Scottish Stillbirth Group and HSIB.
A further strength and impact of the programme relates to the quality of the local reviews. While the aim of the programme was to externally review the local investigations of care, it was clear to many interviewees that the quality of the local investigation reports was highly variable.
“The local reviews are extremely heterogeneous; people use widely different processes to review a particular incident [...] there are some examples of reviews that are extremely thorough and really commendable [...] and how open they have been at identifying lessons and setting in [place] action plans for an incident and at the other extreme I have seen uploads which [are] essentially five slides from a perinatal mortality/morbidity meeting presentation and that’s what they call a review and that’s it, there is nothing else.” (Consultant in Neonatal Medicine)
For many, highlighting the issues in the quality of local reviews has enabled services to improve, and for those working as lead reporters and reviewers for the programme, being part of Each Baby Counts and being held to account in some way for the investigations carried out has impacted their own professional work.
“For me, it’s made me a lot more aware of my own practice, my own environment, and even the way I document things [...] only by reviewing and reflecting can you improve your own practice.” (Advanced Neonatal Nurse Practitioner)
A further impact identified by many of those interviewed is the increase in parental involvement in local reviews across the duration of the Each Baby Counts programme. This element is deemed vitally important as a way of ensuring parents and families are included in the trust’s maternity care practices, and ultimately learning, after such a tragic event.
“One of the key things for us is involving the parents. It was something that we didn’t probably do very well at all [...] we now encourage them to contribute, they have a named contact, and we share the review with them, and that’s definitely really come from a recommendation of EBC.” (Intrapartum Lead Midwife)
There was a real sense that learning from the investigations themselves and the thematic analysis provided by Each Baby Counts was a key impact of the programme. While some of the findings reported are not viewed as being new, the reporting of factors such as situational awareness and human factors has really enhanced the understanding of how maternity teams work and how incidents can arise. Giving a voice to these issues has enabled professionals to begin conversations around how and why incidents occur and how things can be changed to improve these outcomes.
“EBC has opened up the conversation about the bigger picture of why things go wrong, and it has used the thematic analysis to understand the system better.” (Executive Director – Midwife)
2.3 Systems approach
It has also highlighted the multifaceted nature of these incidents – there is not one solitary factor that leads to a negative outcome. Each Baby Counts has been seen by many as the first programme to report this complexity within maternity care, and this has been extremely valuable to those working on the front line, and in the wider maternity safety sphere. The shift from looking at individuals to a more systems approach has been viewed as a real success.
“There is not one silver bullet; there is not just one thing that we can do that is going to reduce the number of brain injury cases that result in clinical negligence – it’s a wider piece involving human beings and all their foibles. The more recent EBC reports [have] given us the evidence.” (Head of Maternity and Neonatal, Department of Health and Social Care)
The contribution of this multifactorial system to these incidents has meant that the findings of Each Baby Counts have been able to support some discussion points for clinicians and policymakers, but it has also meant a necessary acknowledgement that there is no ‘quick fix’ or solution for immediately improving outcomes. This and some other limitations of the programme are discussed in the next section.