Skip to main content
Back to news homepage

New report reveals improvement of local investigations into baby deaths and brain injuries which happened during childbirth

News 13 November 2018

The latest report from the RCOG’s Each Baby Counts clinical initiative shows there was an increase in the number completed local investigations into stillbirths, neonatal deaths and severe brain injuries that occurred from incidents during term labour in 2016 across the UK, when compared to 2015.

In 2016, 89% of completed local investigation reports contained more sufficient information for review which is necessary to drive clinical improvements to reduce the number of deaths and injuries.

The findings also show that different care might have led to a different outcome in almost three quarters of stillbirths, neonatal deaths and severe brain injuries included in the review.

There was an average of seven contributory factors per incident and this shows the complex relationship between clinical and non-clinical factors.

In almost half (45%) of the affected babies, guidelines and best practice were not followed. Reasons for not following guidelines included gaps in training, lack of recognition of problems, communication issues, heavy workload, staffing levels and local guidelines not being based on best available evidence.

There was also an increase in the number of parents who were invited to take part in reviews in 2016 – up to 41% from 34% in 2015. But in almost a quarter of instances parents were not involved, or even made aware, of reviews taking place.

Each Baby Counts is a clinical quality improvement programme that aims to halve the number of stillbirths and babies who die or are left severely disabled due to incidents during term labour by 2020. 

Every year in the UK over 1,000 babies die or are left with a brain injury during term labour. These are investigated at a local level by a hospital or maternity unit. The Each Baby Counts team is bringing together the results of these local investigations to make recommendations to improve future care on a national level.

Now the RCOG is calling for a national centre of excellence for maternity care in the UK.

Of the nearly 700,000 babies born in 2016, 1,123 babies fulfilled the Each Baby Counts criteria. There were 124 stillbirths, 145 babies who died early and 854 babies who sustained severe brain injuries during labour at term (babies born after 37 completed weeks of gestation).

The main areas of care in which improvements might have led to a different outcome for the babies affected included a failure of health professionals to identify or act upon relevant risk factors, issues related to monitoring of fetal wellbeing with cardiotocography (CTG) and blood sampling and individual education or training issues.

The report makes a number of recommendations including addressing workload issues, an individualised management plan for women during antenatal, labour and postnatal care, and ensuring local guidelines are updated in line with national guidance.

The RCOG continues to call for improvements to local investigations to ensure these are of the highest possible quality to drive improvements in maternity care and that all parents are invited to take part in reviews.

In a bid to take recommendations forward, the RCOG, in partnership with the Royal College of Midwives and the Department of Health and Social Care are establishing a four-year programme of work with a number of maternity teams. The aim is to support multi-professional learning and team working; the translation and delivery of services against national strategy; and to develop sustainable improvements in maternity services by disseminating best practice and learning locally and across the NHS.

Mr Edward Morris, Co-Investigator of Each Baby Counts and Vice President of the Royal College of Obstetricians and Gynaecologists, said:

“Sadly this latest report from Each Baby Counts shows that different care might have made a difference to the outcome for almost three-quarters of affected babies. This highlights that much work is still needed to ensure healthcare professionals are supported to implement recommendations. We are committed improving maternity safety and want to do everything possible to prevent these tragedies that can have a life-long and devastating impact on families.”

Professor Lesley Regan, President of the Royal College of Obstetricians and Gynaecologists, said:

“The stillbirth, death of a newborn baby or the birth of a baby with brain injuries are life-changing events that profoundly affect women and their families. It is absolutely vital that we sustain the momentum and progress to date to ensure we really make a difference to maternity care in the UK.

“Now is the time to establish a national centre dedicated to making sure that the UK is the safest place in the world for women and their babies. By bringing together the shared expertise and experience of women and families, frontline maternity teams, academics and policymakers would be a significant step forward in driving improvement across the country.”

Health Minister, Jackie Doyle-Price, said:

“Whilst this report acknowledges that important progress has been made, there is still more to do to ensure every mother and child receives the world-class care they deserve as part of our ambition to halve the rates of stillbirths, neonatal deaths and brain injuries caused during and after birth by 2025.

“We are giving staff the support they need to continue to improve maternity safety and have made the largest every investment in midwifery training to ensure the NHS has the skills it needs.”

Nicky Lyon, a parent representative on the Each Baby Counts Advisory Group and co-founder of the Campaign for Safer Births, said: 

“I feel the pain and sadness of the loss of my son, Harry, every day.  Since its launch four years ago the RCOG Each Baby Counts project has gained incredibly valuable insight and information – information we did not previously have.  This ground breaking project is now allowing us to understand the reasons why these tragedies occur and this report gives further recommendations for action.  Nothing will change my situation or that of the families who have suffered loss like me, however we now have the knowledge and power to ensure others do not suffer.”

Note 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 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, but the fact that 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 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 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. For more information, visit:

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. For more information, visit:

Case study

Nicky, mother of Harry

“My son, Harry, was born with profound brain damage due to lack of oxygen at birth after what should have been a ‘normal’ hospital labour. I was ‘low risk’, had no problems during pregnancy and did everything I could to be healthy and protect my baby. I went into labour at 10 days overdue, rang the hospital and went in when advised.

“When Harry was born, he was resuscitated and put on a ventilator. When Harry was 4 weeks old, we were told he had profound brain damage due to the lack of oxygen at birth and were given the devastating news that he would never walk, talk or be able to feed normally.

“An investigation concluded that the CTG (heart trace) had not been read correctly and NICE guidelines for care in labour had not been followed.

“After a difficult life of tube feeding, constant sickness, fits and discomfort, our son died of a chest infection aged 18 months. As a family we have been left devastated at the loss of our beautiful boy.

“I’m so pleased that the RCOG has decided to take action on this issue with the Each Baby Counts project. Success of this project will mean hundreds of babies’ lives will be saved and families will not have to experience the terrible pain and heartache that we have suffered.”