Each Baby Counts 2019 Progress Report

Improving Outcomes for Hundreds of Babies – Recommendations from the latest Each Baby Counts report


Today, the Royal College of Obstetricians and Gynaecologists have published their latest Each Baby Counts 2019 progress report.

Although the UK is a safe place to give birth, term stillbirths, early neonatal deaths and severe brain injuries in the early neonatal period are still occurring; nearly three-quarters (72%) of which may have been avoided if care had been different. The impact of this on families is devastating and learning must come from the loss or harm of every baby.

The Each Baby Counts programme aims to reduce the number of term babies who die or sustain severe brain injuries during birth, which along with other national initiatives, plays an important role in working towards the aims laid out in the NHS Long Term Plan.

The report examines the data collected on the 1,130 cases of term babies who either suffered an intrapartum stillbirth (130), died in the 7 days following birth (150), or had a severe brain injury in the early neonatal period (850). The total number of cases remains relatively static compared with previous years.

Key Findings

Quality of local investigations/reviews

  • Parental Involvement:
    There was some improvement in the number of parents invited to participate in local reviews from the previous report (41%), but 50% of reviews still did not involve parents/families. The report notes that ‘supportive, parent-centred reporting brings the most important voices to the forefront of the review, and ought to be the norm…’
  • Quality of Reviews:
    The report found that the quality and consistency of local reviews had improved since the previous year, with 95% of the review reports containing enough information for the Each Baby Counts team to make an assessment of the quality of care. However, they emphasised the need for review panels to include individuals with the pertinent level of expertise and experience for the individual cases being reviewed.
  • External representation is a crucial element to gaining understanding in “what you don’t know that you don’t know” and a holistic clinical review; however, only 1% of review panel included an external representative.

Would different care have made a difference to the outcome?
Of all the cases where there was sufficient information to make a judgement about the quality of care, the report concludes that in 72% (714) cases at least one of the independent reviewers was of the opinion that different care might have made a difference to the outcome. This finding is similar to previous years.

An analysis of the contributory factors involved in each case found that in the majority of cases, multiple factors were identified.

The five most common themes were:

  • CTG and blood sampling
  • Risk recognition
  • Team communication issues
  • Individual human factors
  • Education/training

There were only 69 babies where reviewers did not identify any critical contributory factors falling under one of these themes.

The Each Baby Counts team analysed cases where one or more of the key factors identified concerned a breakdown in escalation and provision of timely care by senior members of the team.

From the eligible and fully reported babies born in 2017, the Each Baby Counts team identified 358 babies (36%) for whom ‘failure to escalate/act upon risk/transfer appropriately’ was selected by at least one reviewer as a critical contributory factor. The report contains a detailed thematic analysis of these cases.

Two distinctions in escalation were identified:

  • A lack of awareness of deterioration and the need to escalate
  • A breakdown in the process of attempted escalation. These could be categorised into the three themes below.

Theme 1 – Human factors and behaviour
1.1 Cognitive biases
1.2 Loss of situational awareness
1.3 Multidisciplinary team dynamics
1.4 Challenging a decision

Theme 2 – Workload and workforce challenges
2.1 High unit activity
2.2 Timely obstetric reviews

Theme 3 – Communication
3.1 Handover
3.2 Emergency communication protocols

Recommendations for Improving Care on the Frontline

The following are the recommendations for improvements to care made by the Each Baby Counts team:

  1. Involving Parents

The Each Baby Counts project team encourages all trusts and health boards to always inform the parents of any local reviews taking place and invite them to contribute in accordance with their wishes. This is an important process which should become the minimum standard for every trust and health board. 

  1. Review panel involvement

All local reviews of neonatal deaths or babies undergoing extensive resuscitation must involve a neonatologist.

  1. Use of the PMRT tool

All Each Baby Counts babies who are stillborn or babies who die within the first 28 days of life should be reviewed using the PMRT.

There remains an urgent need for a PMRT-style tool that includes morbidity to be commissioned by the UK healthcare system

  1. Human factors and behaviour

Each Baby Counts has demonstrated that human factors are recurrent themes that need to be urgently addressed at a systemic level. Research is required to establish how to operationalise learning from this report into practice with improved clinical outcomes. 

  1. Workload and workforce challenges

Develop and fund an appropriate tool to record current workload and anticipate the obstetric care required for the population. This tool should complement the midwifery acuity tools currently implemented nationally. Research is required to identify safe obstetric staffing standards for the workload and acuity, to guide policy-level changes for the workforce.

  1. Communication

All staff must be familiar with using their unit emergency communication and escalation protocols, in particular where emergency buzzers are located and how to activate a switchboard emergency call. This should be mandatory in departmental induction and included in simulated escalation calls during local multidisciplinary team training.

Other key learning points identified:

Cognitive biases
Escalation begins with correctly identifying an evolving pathology or a potentially critical situation. Mistakes evaluating and interpreting information may interfere with that assessment and result in missed opportunities to provide timely care.

Loss of situational awareness
Intrapartum care is a high-risk environment for loss of situational awareness. Understanding when it is lost and how to minimise risk is essential to maintaining safety.

Multidisciplinary team dynamics
Unbalanced skill sets within an unfamiliar team can result in problems identifying the need for escalation and a lack of assertiveness in executing the process.

Challenging a decision
All members of the multidisciplinary team must feel empowered to challenge a decision that they feel is incorrect. Where there is disagreement, a third party should be called to provide another opinion and fresh perspective.

Timely obstetric reviews
If an urgent medical review is needed and the on-site obstetric team is unable to deliver care in the required time frame, the consultant must be informed.

High-Quality Handover
Loss of escalation momentum can occur owing to incomplete transfer of information between staff. A high-quality handover is essential for continuity of care and for maintaining situational awareness of the unit as a whole.

Emergency escalation protocols
Incorrect methods of emergency escalation delay urgent assistance. All staff must be familiar with the location of local emergency buzzers and switchboard escalation protocols

In Conclusion

The Each Baby Counts work has again found that the majority of cases reported (72%) may have been avoided with different care, and so their recommendations for improvements to care need to be made a priority across all maternity teams.

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