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RCOG release: UK maternity services encouraged to review serious clinical incidents occurring in labour

News 4 February 2015

The Royal College of Obstetricians and Gynaecologists (RCOG) is calling upon UK maternity services to report all cases of intrapartum stillbirth, early neonatal death and severe neonatal brain injury occurring as a result of incidents during term labour as part of its Each Baby Counts project.

Each Baby Counts is a five-year quality improvement initiative which aims to reduce the number of these tragic events by 50% by 2020.

The project was launched in October 2014 and data collection will begin this week. A crucial part of the project involves bringing together the lessons learned from local investigations in order to improve the quality of care in labour at a national level.

Stillbirth rates in the UK remain high and current estimates suggest that 500 and 800 babies a year die or are left severely disabled because of potentially avoidable harm in labour. The emotional cost of these events is immeasurable and each case of disability costs the NHS in excess of £1.5million in compensation to pay for the complex, lifelong support these children need.

Rigorous investigations into such cases should already be carried out as a matter of course in every maternity unit, following guidance issued by the RCOG in 2009, but should now be submitted via the RCOG’s secure, online platform. Affected parents and families have also called to be actively involved in the investigations.

The results of these reviews will be analysed in order to identify avoidable factors and develop action plans suitable for local implementation. By identifying common themes across the country which relate to these events, the RCOG will also be able to advocate for national change, where appropriate, as well as encourage local service improvements.

The majority of NHS Trusts and Health Boards in the UK have now nominated a lead reporter and have received training on how to report eligible cases.

Professor Alan Cameron, RCOG Vice President for Clinical Quality and co-Principal Investigator for Each Baby Counts said:

“We hope that all maternity providers will show their support for this project and engage in reporting and learning from these tragic incidents, so that in time we can make it as safe for a baby to be born as it is for a mother to deliver.

“There can be little justification for neglecting to undertake reviews when the outcome for parents is as devastating as the loss of a child, or a child born with a severe disability.

“The collection of data is a key part of the project and its success depends on high quality information being submitted for national analysis. The aim of Each Baby Counts is to focus resources, both at the RCOG and locally, to ensure that these investigations are conducted thoroughly and that lessons are both acted upon and shared.”

Charlotte Bevan, Senior Research and Prevention Adviser at Sands, the stillbirth and neonatal death charity and a bereaved parent herself said:

“Each Baby Counts is an important project seeking to understand events leading to the tragic death or serious illness of a baby as a result of events in labour at term, that moment in pregnancy when a mother least expects to lose her child.

“Standards of care can vary considerably across the country and frustratingly not all deaths are reviewed rigorously to ensure lessons are learned when mistakes do happen. It’s time to ensure that every mother receives the best quality care available and avoidable deaths are prevented.

“The death of a baby has a lifelong impact on families. Sands is dedicated to preventing such devastating and potentially avoidable tragedies and the Each Baby Counts project is a vital contribution to this work.”


For further information, please contact the RCOG Media and PR team on +44 20 7772 6300 or email


Read more about the Each Baby Counts project.

Read RCOG’s guidance Improving Patient Safety: Risk Management for Maternity and Gynaecology (Clinical Governance Advice No. 2).