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Parent foreword

Foreword by bereaved parents and members of the Each Baby Counts Advisory Group

Back in 2013, the two of us were bereaved mothers not only trying to understand why our sons had died but also trying to investigate how many other babies across the country were injured or dying following term labour. No one could tell us and there was little focus or recognition of potentially avoidable harm. This led to us starting our Campaign for Safer Births, with the main aims being to highlight the issue and campaign for improvements.

In April 2014, we read an article in The Guardian that quoted David Richmond, the then President of the RCOG. David was raising this issue of avoidable baby death and brain damage. We wrote to him immediately. He responded telling us the amazing news that the college had secured funding for a new project and he asked us to consider being involved as parent representatives. It was soon named Each Baby Counts (EBC) and we attended the first Advisory Group meeting in late 2014.

"Britain's leading obstetrician says it is legitimate to ask whether understaffing of maternity care and labour wards is contributing to Britain's stubbornly high rates of baby death and brain damage.

"Dr David Richmond, president of the Royal College of Obstetricians and Gynaecologists, has voiced alarm that nearly 300 babies a year are dying during or soon after birth with a further 1,200 ending up with brain damage or other serious health problems."

Extract from the Guardian article "NHS understaffing may have effect on baby mortality rate, says top doctor" 6 April 2014

Each Baby Counts published its inaugural report in June 2017 and, for the first time, the number of babies affected by potential brain injury or death in term labour was published. At last a voice was being given to these babies and families.

Many parents have been involved with the EBC project over the years. Some have bravely documented their story for the EBC website and newsletters, whilst others have spoken at the annual report launches. We, along with the RCOG, would like to thank all parents who have been involved in, followed and supported the project.

So many powerful stories were shared, like that of the Dalhaug family who tragically lost one of their twin sons:

“The loss of Thor has devastated our lives, and we count ourselves amongst the lucky ones as we still have Harrison – we live for him. Every day, every birthday, every Christmas, every first has been a great joy tainted by deep sadness. We will carry the scars of Thor’s loss and the circumstances of his death for the rest of our lives.

Every mother, every father and every family who has to suffer, and live with the consequences of a preventable loss share one thing, a simple thing, a deep and powerful wish that things could have been different – through Each Baby Counts, you have the power to make things different!”

Much has been learnt in the years since 2014 and there is now, rightly, huge focus on maternity safety. It is fantastic that this focus and activity has resulted in a significant reduction in overall stillbirth and neonatal death rates. Sadly, the EBC rates published today for 2018 remain static. However, we feel the focus on these cases has definitely been of value.

We now know many of the reasons for harm occurring and recommendations have been developed to overcome these; however, there are still many recommendations to be fully implemented by trusts and there are areas where national work and outputs are needed. We urge that adequate resource and funding is given to ensure that all recommendations are implemented and sustained.

An area of major concern for us is that, with the end of Each Baby Counts and uncertainty on the future of the HSIB maternity investigation programme, this group of baby deaths and injuries may become invisible again. Parents deserve to know why their baby died through thorough independent investigations. The numbers of these cases must be published for public record. Learning must be turned into local and national action.

These babies must not be forgotten again.

Nicky Lyon and Michelle Hemmington
Bereaved parents

Co-founders, Campaign for Safer Births
Parent representatives, Each Baby Counts Advisory Group