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RCOG responds to latest HSIB report

16 Sept 2021

The RCOG has responded to the Health and Safety Investigation Branch (HSIB)'s latest report setting out findings from their review into intrapartum stillbirths during the first wave of the COVID-19 pandemic. 

HSIB says the review was prompted by an increase in referrals of intrapartum stillbirths to HSIB that fitted their specific criteria between April and June 2020 (45 compared to 24 in the same period in 2019). They analysed 37 maternity investigation reports focused on intrapartum stillbirths, from the April to June time period to understand what learning could be drawn from these cases.

Findings in the report suggest that many safety risks that were identified in the review were already known to maternity services and these were further exacerbated by the pandemic, for example, the sustainability of staffing levels in maternity units. It also highlighted that COVID-19 created specific safety risks including the impact of limiting face to face interactions and increasing remote consultations.

Commenting on the report, Dr Edward Morris, President at the Royal College of Obstetricians and Gynaecologists, said:

“This report by HSIB shines a light on the challenging circumstances in which the maternity services have been operating in during the COVID-19 pandemic. The pandemic has put huge pressure on all healthcare services but despite this maternity staff have maintained a high standard of care to pregnant women and their babies.

“We are aware that during the first peak of the pandemic, some pregnant women had difficulty accessing maternity services or presented late with reduced fetal movements - which can be a sign their baby is unwell, and of women missing antenatal appointments. This may have been due to confusion around whether these appointments were essential, fear of attending a hospital or not wanting to burden the NHS.

“Ahead of the second wave, we issued clear advice to NHS services to ensure women were encouraged to attend day assessment and triage services if they had concerns about their wellbeing or that of their babies. We also recommended a full schedule of antenatal care be offered wherever possible, with appointments offered in-person especially for those from Black, Asian or minority ethnic communities and women living with medical, social or psychological issues. 

“Antenatal care is essential and face-to-face appointments are necessary to support a healthy pregnancy. We understand during the pandemic more remote appointments have been taking place and would welcome further investigation to see the impact of remote consultations during pregnancy.

“Anyone who has concerns or worries about their or their baby’s health – including the baby's movements - should seek medical advice immediately."


To contact the RCOG press office call +44 (0) 7986 183167 or email .

About 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. For more information, visit:

  • Policy and governance
  • Pregnancy and birth