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Each Baby Counts report recommends new measures to reduce stillbirths, baby deaths and brain injuries

News 18 March 2020


  • There are still too many avoidable stillbirths, baby deaths and brain injuries that occur during term labour in the UK, finds the latest report from Each Baby Counts
  • New recommendations include how maternity care can be improved, and how to support maternity teams to escalate critical situations
  • The number of parents being involved in investigations, and the quality of reviews is increasing, and therefore improving understanding of how to prevent future deaths and injuries

Launched in 2014 by the Royal College of Obstetricians and Gynaecologists, Each Baby Counts is a national quality improvement programme that aims to reduce the number of babies who die or are left severely disabled as a result of incidents that happen during term labour.

The programme brings together the results of local maternity investigations into stillbirths, neonatal deaths and brain injuries to understand the bigger picture and share the lessons learned to prevent future cases.

The latest report, published today, analysed 1,130 cases of babies who met the eligibility criteria, out of around 677,192 babies born at term in the UK in 2017.

The findings show there were:

  • 130 (12%) stillbirths
  • 150 (13%) babies born alive following labour but died within the first 7 days after birth
  • 850 (75%) babies who had severe brain injury*

These figures remain similar to the number of cases reported in 2015 and 2016.

Other key findings include:

  • The number of babies reviewed where different care might have led to a different outcome – this was slightly lower at 72% of babies (714 cases) in 2017, compared to 76% in 2015.
  • Parents being invited to contribute to the local review rose to 493 (50%) of cases in 2017, compared with 34% in 2015.
  • The number of local reviews that contained sufficient information for analysis has grown year on year, 95% in 2017 from 75% in 2015.

A further analysis found that of the babies for whom different care might have led to a different outcome, there was an average of nine contributory factors.

The most commonly identified factors included a lack of timely recognition of women and babies at risk, communication problems, training and education issues, human factors and inadequacies related to the monitoring of the baby’s well-being during labour.

Detailed analysis of 986 fully completed local reviews revealed 358 (36%) cases of a failure to identify a high risk situation, escalate appropriately and transfer a woman and/or baby in a timely way.

Successful clinical escalation of a woman and baby at risk of harm is essential. With the right medical intervention, at the right time, maternity care can ensure the safest possible outcome for a mother and her baby.

Recommendations from the report focus on complex clinical and non-clinical factors that need to be improved, including better team working and behaviour, addressing workload and workforce challenges, and improving communication among maternity teams.

Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists, said:

“There are still too many avoidable baby deaths and brain injuries occurring during term birth in the UK – even one preventable case is one too many. We owe it to each and every one affected to find out why these deaths and harms occur, in order to prevent future cases where possible.

"Even though the majority of babies are born healthy and well, we are absolutely determined to reduce any harm, in line with the Government’s national ambition and the NHS Long Term Plan.

“National initiatives to improve maternity care are underway across the health system to make the NHS the safest place to give birth in the world.

“All maternity units across the country want to provide the highest quality of care for women and their babies, and we urge them to take forward the important recommendations in this report.”

Michelle Hemmington, Each Baby Counts Advisory Group Parent Representative and Co-founder of Campaign for Safer Births, wrote: 

“The loss of our son, Louie, in 2011 has deeply impacted our lives forever. His death, and knowing that it was avoidable, leaves an underlying sadness in everything I do that will always be present.

“Since Each Baby Counts began reporting, the key theme of low parental involvement in investigations has been highlighted. It has been made clear that parents should be made aware of the investigation, invited to participate and supported to do so if they choose.

“I urge everyone who reads this report to not just look at this from a professional point of view but from the perspective of parents who have been devastated by avoidable incidents. Errors in care are life changing and life damaging and we must do all we can to improve.”


Notes to Editors

For media enquiries and copies of the report as well as case studies, please contact the RCOG press office on 020 7772 6773 or email

The report is published on the RCOG Each Baby Counts website.

*The Each Baby Counts definition of severe brain injury is based on information available within the first 7 days after birth.

It is not yet known how many of these babies will have a significant long-term disability as a result of the injuries sustained during birth. The majority of these infants require active therapeutic cooling – an intensive intervention requiring sedation and admission to the neonatal unit – reflects the serious clinical condition of these babies.

Each Baby Counts report 2018. News story. Report.

Each Baby Counts report 2017. News story. Report.

About Each Baby Counts
Each Baby Counts is the RCOG’s national quality improvement initiative to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. The project has a 100% participation rate with UK NHS Hospital Trusts. The development of the Each Baby Counts programme was supported by a grant from the Department of Health and a generous legacy donation from Dr Lindsay Stewart to the Royal College of Obstetricians and Gynaecologists. 

Each Baby Counts: Learn & Support is a three-year partnership between the RCOG and the Royal College of Midwives (RCM), supported and funded by the Department of Health and Social Care, that will work with a number of local maternity units to support multi-professional learning and clinical leadership, improve joint working and drive innovation from within the NHS.

About the RCOG
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.