Halving the stillbirth rate by 2025: ambitious, but doable

Some good news: parents of babies who are stillborn, or have suffered a severe brain injury, will be offered the option of an independent review of their care. Currently reviews are carried out, to a varying standard, by individual hospitals. Health secretary Jeremy Hunt is to announce that a new Healthcare Safety Investigation Branch (HSIB) will, from next April, take over investigation of the 1,000 deaths of new babies and mothers and unexplained serious injuries.

This will, it is hoped, achieve two things: one is to have a greater culture of openness, with a quick resolution after a terrible mistake. This is important because currently some hospitals lie and obfuscate about their role in a baby’s death or injury – the Joshua Titcombe case was a particularly egregious example, but the urge to cover up is widespread. More significantly, the existence of an independent review body could, Jeremy Hunt hopes, halve the numbers of stillbirths, neonatal deaths and severe birth-related brain injuries by 2025.

Hunt’s announcement comes the day after the publication of a MBRRACE report, which revealed that the rate of intrapartum death had halved since 1993. Back then, there were 0.62 deaths for every 1,000 births; now that figure is down to 0.28. This is particularly worth celebrating because during that time, the age of women giving birth has been rising, and more women have conditions relating to being overweight. Both of those factors increase the risk of stillbirth.

(“Intrapartum death” refers to deaths of “normally formed babies of 2.5 kg or more who were stillborn or died within the first week of life where the death was related to problems during labour”. This isn’t the same as stillbirths in general: the overall stillbirth rate has dropped by just over a fifth, and neonatal death by a third, in the same time frame.)

Most intrapartum deaths could be prevented by better care

But it was shocking to read that, of the 78 deaths the MBRRACE team looked at, 80% could have been prevented by better care in labour. The biggest single cause was an issue with capacity – in other words, not having enough staff. We’ve known for some time that the NHS doesn’t have enough midwives and obstetricians, and that the government needs to address this immediately.

Other important findings included a delay in inducing babies who were due to be induced, staff failing to recognise that a woman had moved to the second stage of labour, a lack of urgency in offering a caesarean section when needed, and a failure to monitor the baby’s heartrate correctly.

We know, from women’s own stories, and from NHS litigation records, that these are complaints that come up time and time again. An inability to read the CTG trace that monitors the heartrate appears frequently in litigation. But this – along with the ability to identify the change to second stage labour – could be improved with better training. Even more importantly, it could be improved by an independent review of what went wrong.

No-one is perfect; everyone makes mistakes. But when the same mistake is repeatedly leading to babies dying, then something is wrong. Reviewing the deaths of babies, and identifying the causes, can lead to better training and better practice. The launch of the HSIB offers real hope that we can bring about an end to babies dying unnecessarily in labour.

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Too many babies are dying at birth

Last week saw the publication of two reports on the deaths of newborn babies. Each Baby Counts, published by the Royal College of Obstetricians and Gynaecologists (RCOG), found that three-quarters of the babies who die or are brain damaged during childbirth in the UK might have been saved by better medical care.

The MBRRACE report found that between 2013 and 2015, the stillbirth rate fell from 4.2 to 3.87 per 1,000 births. That’s good news, though the report noted that the stillbirth rate is still higher than many similar European countries and that there is “significant variation” across the UK – variation that can’t be explained simply by factors such as poverty or maternal age. In other words, the difference is likely to be the result of different practices in different hospitals.

Each Baby Counts investigated the cases of 1136 cases of babies born in the UK in 2015 who either suffered brain damage during birth, or died during delivery or in the next week. Of those, the report estimates that 550 babies could have been saved. Shockingly, in 409 cases, the Each Baby Counts team wasn’t able to determine whether the babies could have been saved because the information provided wasn’t good enough.

And that’s the real scandal. The best way to improve medical care and prevent unnecessary deaths is through the collection and analysis of evidence so that we can determine best practice that can then be followed by every hospital in the country.

Childbirth is a complicated business because it can involve countless small decisions that women have to make in conjunction with their caregivers. Each one of those decisions has the potential to increase or decrease the risk of harm to the mother and baby. Decisions are rarely easy to make because every intervention (induction, foetal monitoring, epidural, episiotomy, forceps…) can increase some risks while decreasing others. This is why evidence is so important.

Doctors don’t always know best

Ben Goldacre illustrates the importance of evidence through the example of head injuries. In a blogpost, he writes:

“For many years, it was common to treat everyone who had a serious head injury with steroids. This made perfect sense on paper: head injuries cause the brain to swell up, which can cause important structures to be crushed inside our rigid skulls; but steroids reduce swelling (this is why you have steroid injections for a swollen knee), so they should improve survival. Nobody ran a trial on this for many years. In fact, it was widely argued that randomising unconscious patients in A&E to have steroids or not would be unethical and unfair, so trials were actively blocked. When a trial was finally conducted, it turned out that steroids actually increased the chances of dying, after a head injury.”

It may be that some midwives and obstetricians have instinctive beliefs about reducing the harm to mother and baby that turn out to be completely wrong. It’s hard to know until we collect the evidence. Yet we do know that some trusts, such as Southmead Hospital in Bristol, and Barking, Havering and Redbridge University Hospitals, have adopted good practice that has led to the reduction of birth injuries in the first case, and of errors relating to the CTG trace in the second (errors caused by misreading the CTG trace are a common cause of injury and death in newborn babies).

Other countries manage to have far fewer babies die at birth than we do. It’s not an impossible dream. But if we are serious about saving the lives of newborn babies, then we have to start with the absolute basics: collecting the data to find out why they are dying.