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Each Baby Counts report finds solutions to tackle baby deaths and brain injuries

News 12 October 2017

The Royal College of Obstetricians and Gynecologists (RCOG) has today published the first full Each Baby Counts report into all stillbirths, neonatal deaths and brain injuries that occurred during childbirth in 2015. Each Baby Counts is a UK quality improvement programme, launched in October 2014, aiming to halve the number of babies who die or are left severely disabled as a result of preventable incidents occurring during term labour (after 37 weeks) by 2020.

In June the College published a summary report based on the data and the key finding was that for many of the babies reported to Each Baby Counts, different care might have resulted in a different outcome. The summary report included recommendations highlighting critical factors in the care of many of the Each Baby Counts babies that may prevent these incidents in the future.  These recommendations are aimed at doctors and midwives working in maternity units across the UK and centre around fetal monitoring, neonatal care and human factors – the way teams work together in maternity.

The full report published today presents the detailed data behind these recommendations as well as resources and proposed actions to support improved clinical practice. These were developed following a Clinical Engagement Forum in June with over 300 midwives, obstetricians and neonatologists who discussed the data and identified how to support healthcare professionals to implement the recommendations. The full data also demonstrate the complex nature of maternity care. Through analysis of the reviews submitted to Each Baby Counts, the project team identified over 3,800 critical contributory factors, with an average of six contributory factors for each baby.

Professor Lesley Regan, President of the RCOG, said: “The key finding that different care might have resulted in a different outcome for many of these babies makes a powerful case for the need to improve care, while the intricate relationship between the various contributory factors suggests the need for complex and nuanced solutions. We are pleased that our final report includes suggestions for implementation and links to resources to help translate our findings into practical improvements to care.

“The RCOG is committed to regularly reporting and monitoring progress over time on stillbirth, neonatal deaths and brain injuries, and will continue to work with all maternity units to support the improvement of the quality of local reports.We also expect that this full report, alongside the growing learning from related work such as the Perinatal Mortality Review Tool, will provide the tools for teams to deliver safer maternity care for women and their babies.

“We are aware that our findings come at a time when there is national attention on maternity services. The Maternity Transformation Programme provides a strong opportunity to improve maternity services and we welcome the commitments already made to address safety. We thank all the individual maternity teams working to improve care and ask them to apply the findings in this report into their local priorities.

“At a national level we will continue to work with the many committed partners and organisations to ensure the findings are used to inform and support national priorities, and we welcome new opportunities for greater collaboration.“


For media enquiries, please contact the RCOG press office on 020 7045 6773 or email

Notes to editors

Read the 2015 summary report and press release (published June 2017).

Read the 2015 interim report and press release (published June 2016).

Each Baby Counts is the RCOG’s national quality improvement initiative to reduce by 50% the number of babies who die or are left severely disabled as a result of incidents occurring during term labour by 2020. The project has had a 100% participation rate with UK NHS Hospital Trusts.

The Royal College of Obstetricians and Gynaecologists (RCOG) is a medical charity that champions the provision of high quality women’s healthcare in the UK and beyond. It is dedicated to encouraging the study and advancing the science and practice of obstetrics and gynaecology. It does this through postgraduate medical education and training and the publication of clinical guidelines and reports on aspects of the specialty and service provision. Visit our website or follow us on Twitter @RCObsGyn