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.

We need better postnatal care – and Mumsnet is on the case

I’ve been delighted to see the mighty Mumsnet launch a campaign to improve postnatal care in hospitals. Women with postnatal PTSD often mention poor postnatal care as a contributing factor.

After a traumatic birth in which you have nearly died, or your baby has nearly died, or you have lost several pints of blood, or been in pain for hours but denied drugs, or experienced a violent forceps delivery, or had multiple painful stitches, or had a retained placenta, or an emergency c-section after the baby’s heartrate has dipped – or, as is often the case, a combination of several of those things – then it’s not unreasonable to imagine that you will be treated gently, with some kindness and consideration.

In practice, this is far from the case. When Mumsnet asked women to recount their experiences of postnatal care, they offered depressingly similar stories of being left for hours and hours unattended, often on a noisy postnatal ward, or refused help with breastfeeding, or not being given food and drink despite being too ill to get out of bed.

Some of this can be put down to staff being overworked, but the dismissive, unkind attitude that accompanies it cannot. In an article for the Independent last year, I wrote about Rachael, who after a deeply traumatic emergency c-section resulting from placental abruption, was told by a midwife: “Don’t go thinking you’re anything special – we see bigger abruptions than you had.”

A new blogpost describes an experience that is all too typical. The writer, who blogs under the name IslandLiving, recounts an immensely difficult labour ending in c-section. Left alone with her baby afterwards, she felt petrified. She goes on:

“I stayed in a side room for two days. In those two days I struggled. I felt overwhelmed and scared. I was petrified. I was told to ring the bell, that I was not to pick up my baby myself. Yet every time I rang the bell no one came. Every time I cried for help no one came. I struggled out of bed because that was my job. I struggled to feed her because that was my job. I struggled to change her because that was my job. Yet, I didn’t know if I was doing my job properly. I didn’t know if she was getting any milk. I needed help and it didn’t come. The nights were the worse as I would feel alone, like I was ringing a bell into the great abyss. No one ever came.”

IslandLiving says, generously, that she doesn’t blame the nurses or the midwives because the unit was understaffed. But it depends whether you see caring for a woman after she’s given birth as a fundamental part of the job or not. If it’s not – if adequate postnatal care is simply a “nice to have” rather than an absolutely essential part of the midwife role – why expect women to stay in hospital at all? Why not send them straight home?

Apart from being inhumane, skimping on postnatal care makes no sense economically, because it so often leads to physical or mental health problems that need treatment. One of the women quoted by Mumsnet wrote that she asked for help cleaning round her episiotomy scar, but was told not to worry because “it’s a dirty part of the body anyway”. She ended up with a major infection.

Poor care isn’t inevitable: a few Mumsnetters gave examples of excellent care. It’s high time that other maternity units followed suit.

How can we stop so many babies dying at birth?

An investigation by the HSJ’s Shaun Lintern, also reported in the Nursing Times, has found that many babies are dying at birth as the result of a simple mistake: a failure to correctly read the CTG trace, which monitors the baby’s heart rate:

“Data from NHS Resolution – formally the NHS Litigation Authority – shows there were almost 300 clinical negligence claims between 2011 and 2016 where the primary cause of the injury was a failure to respond to an abnormal foetal heart rate.”

Lintern points out that this problem has been known about for a long time: reports by the NHS Litigation Authority in 2009 and 2012 made similar findings.

There have been recent well-publicised cases, he notes, where a failure to read the trace correctly resulted in tragedy: in February, for example, coroner David Hinchliffe said of baby Maxim Karpovich, who died in 2015:

“It was apparent that the midwives involved with Maxim’s birth and the junior obstetrician appeared not to understand that the CTG trace was abnormal on several occasions.

“This inquest and many previously have caused me to note that midwives and obstetricians lack the core skills to interpret CTG tracings.”

It’s easy at this point to blame the shortage of midwives, which is putting a lot of midwives under pressure – and indeed the Royal College of Midwives (RCM) spokesperson quoted in the piece does just that. She also blames outdated equipment and the increasing complexity of birth.

The Royal College of Obstetricians and Gynaecologists (RCOG) spokesperson, on the other hand, says that errors could be reduced with a focus on multidisciplinary training:

“There shouldn’t be a brick wall around obstetrics and a brick wall around midwifery.”

In hospitals, safety is paramount. The death of a baby should be an exceptional circumstance, and when it happens, staff should work together to review why it happened and what can be done to stop it happening again. This is what happens in organisations that have a culture of safety. The fact that in so many NHS hospitals this doesn’t happen is shocking.

Lintern goes on to mention Barking, Havering and Redbridge University Hospitals NHS Trust, which set out to tackle its rate of CTG errors. It had found that 75% of maternity “incidents” included some form of CTG error in 2015-16, but the trust had invested in staff training, equipment and an improvement in culture. In the past 11 months the trust hasn’t had a single CTG error.

According to the trust’s director of midwifery, Wendy Matthews:

“We have put in place quite a rigorous process. We’ve developed a culture of quality and safety and learning from errors which is very much about the multi-disciplinary team.”

This is a remarkable achievement. Yet it doesn’t sound as if there was a magic solution to the problem – simply that the trust approached the problem sensibly by training staff to read the CTG correctly, buying more effective equipment and working together to learn from mistakes.

In an ideal world, what would happen next is that every other maternity unit in the country would look at what Barking, Havering and Redbridge did and copy its example. This would save the NHS hundreds of millions of pounds a year in litigation – and more importantly, save the lives of hundreds of babies who die needlessly at birth.

When childbirth goes badly wrong: one woman’s account

Nilufer Atik has written a striking account of her experience of PTSD after childbirth. Atik was in labour for 53 hours, after which she was given an emergency caesarean.

But it shouldn’t have happened like that. Atik’s labour started with contractions that were “sharp and hard, beginning four minutes apart and lasting between 50 to 90 seconds each time.” The hospital – St George’s in Tooting – told her not to come in because she wasn’t in active labour. She stayed at home in increasing pain for 19 hours until eventually she could stand it no longer. At hospital:

“I was taken to a pre-delivery bay and more torturous hours passed with the contractions increasing in intensity and frequency. I cried out for pain relief and was given the powerful painkiller pethidine four times (most women are only allowed two injections) but it did little to help. With no sleep, food or water, and feeling so exhausted I could barely speak, I became fearful that, if the baby did come, I wouldn’t have the energy to push him out.”

She was eventually given an epidural, followed by a caesarean section when the baby appeared in distress. But the most remarkable part of her story is this:

“Poor Milo was in a bad birthing position with his back against mine and his head hyperextended. It meant not only that my labour was much more painful than it should have been, but I would never have been able to deliver him vaginally. His head was blocking my cervix from dilating, which was why I was having contractions for so long with no progress.”

The time that Atik spent in labour was wasted – physiologically, she wasn’t able to give birth. Why staff at St George’s didn’t realise this is an interesting question, but it may have been to do with the fact that when Atik arrived at the hospital in labour, the maternity ward was extremely busy.

Two weeks ago an NCT survey found that, in the Guardian’s words, “A chronic shortage of midwives across the UK means women in labour are left feeling unsafe and frightened or as if they are being treated ‘like cattle’ or ‘on a conveyor belt’.” It’s not just lack of midwives, it’s a lack of space: one woman even described giving birth on the antenatal ward, because there was no room on the delivery ward.

It’s been said so often that NHS services are at breaking point that perhaps nobody takes it seriously any more. But cases like Atik’s show that the seriousness and the urgency of the problem. When midwives are overworked, the quality of care for women is never going to be good enough. Women will suffer unnecessarily, as Atik did, and may as a result experience physical trauma or psychological trauma that will need treatment later on. Sometimes, babies will die.

 

 

Severe tearing in childbirth – not just a physical problem

NB I’ve edited this post to clarify that Liz Skinner’s research focuses primarily on women with damage to the levator ani muscle rather than with obstetric tearing.

A traumatic vaginal birth in which the levator ani and external anal sphincter muscles are damaged can cause mental health problems, including post-traumatic stress disorder (PTSD), according to a new study from Liz Skinner. About half the women also had severe tearing.

About 90% of women experience tearing during childbirth, but most are first or second degree tears, which are relatively mild and heal quickly. Approximately six percent of women have third or fourth degree tears that can damage the anal sphincter. Skinner and Hans Peter Dietz have also pioneered research into damage to the levator ani muscle (LAM), which can be devastating for women. The argue that the problems of a difficult vaginal birth tend to be overlooked in the drive to reduce caesarean sections, which are usually perceived as more risky for both mother and baby.

The study identified 40 first-time mothers with major pelvic floor trauma and interviewed them one-to-four years after they gave birth. Just over half (22) of the women had “major obstetric anal sphincter tears.”

Of the 40 women, 35 had “Multiple symptoms of pelvic floor dysfunction” causing lifestyle alteration. These symptoms included “urinary or fecal incontinence, prolapse, chronic pain, dyspareunia [painful intercourse]”.

It’s hardly surprising, then, that 27 experienced PTSD symptoms, including “poor baby bonding, flashbacks during sex, dissociation, avoidance, anxiety”.

Probably the most worrying themes to emerge from the study were the lack of awareness or communication from health professionals:

  • 36 women said there was no information provided by clinicians on potential postnatal pelvic floor morbidities
  • 36 said that there was no postnatal assessment of their injuries
  • 26 said that they experienced “dismissive reactions from poorly informed clinicians to maternal injuries. One woman said: “The midwife said that this was OK… but I knew that it was not normal… The doctors really did not understand the situation… I was in shock – devastated and unable to get any health professional to understand.”

Although the study was carried out in Australia, I’d be surprised if a UK study didn’t find something similar. I’ve now heard numerous stories about obstetric tears not being treated properly or women having their concerns dismissed as unimportant. One of the problems is that midwives often don’t see the consequences of tearing in childbirth – women are only under midwife care for 10 days after birth, so if a tear has failed to heal properly weeks, months or even, shockingly, years after birth, they’ll be dealt with by another group of health professionals entirely. So midwives may well assume, wrongly, that a tear during childbirth has healed without problems.  That may lead to an unjustified confidence that obstetric tearing isn’t a significant problem. And because LAM damage is impossible to detect without ultrasound, LAM problems are generally undiagnosed and therefore untreated.

As I’ve already reported, the RCOG is now campaigning for better understanding of obstetric tearing in childbirth, and better care for the women who experience it. But we still have a long way to go – and In the meantime, a lot of women are suffering in silence.

At last: the NHS acts on maternal mental health

Good news: in the next five years, NHS England will create 20 new specialist treatment centres for women who suffer from mental health problems during pregnancy or after birth.

This has been a long time coming. For years the government has promised to address the poor quality of mental health care for new mothers, and finally it’s putting its money where its mouth is. Admittedly it’s not very much money – the centres will be funded to the tune of £40m, which is unlikely to cope with the scale of the problem: an estimated one in five new mothers (about 120,000 women a year) experience mental health problems.

The majority of these women suffer from postnatal depression, but a substantial minority will have post-traumatic stress disorder (PTSD). The most conservative estimate for PTSD after childbirth is 1.5% (about 10,000 women a year in England and Wales), but researchers now think that the true figure is probably double that. PTSD can’t be cured with a pill: treatment, usually trauma-focused CBT or eye movement desensitisation and reprocessing (EMDR) takes several weeks, and is expensive.

Having spoken to many women suffering from postnatal PTSD, I know that it can be hard to find specialist help. It’s not unusual for women to have to wait months for treatment, during which time they suffer the stress of flashbacks, nightmares, anxiety and terror. They are often frightened to leave the house and avoid contact with other new babies, making them isolated on top of everything else. All of these things have an impact on their relationship with their baby and with their partner. It’s not surprising that ­– according to the Guardian report of the NHS’s plans – perinatal mental health problems cost the UK £8.1bn a year.

So while I welcome the new centres as a step in the right direction, much more needs to be done to make sure that women with PTSD and other mental health problems receive the support they require. Even more importantly, I would love the NHS work towards preventing these mental health problems from arising in the first place. Most women with postnatal PTSD believe that it was caused, not solely by a traumatic birth, but by the feelings of helplessness and lack of control during the experience, and by the casual and sometimes even cruel attitude of healthcare professionals looking after them.

Some of this can be addressed by better recruitment and better staff training. But the NHS also needs to adopt rigorous standards of care that hold health professionals accountable: making sure that procedures aren’t carried out on women without their consent, for example, or that women are denied necessary pain relief. In a 21st century health service, in a wealthy democracy these things shouldn’t be difficult, but the stories I hear from traumatised women about poor care show we still have a very long way to go.

Half of maternity units putting mothers and babies at risk

A story in today’s Mail makes for grim reading.

The paper has analysed inspection reports of the maternity services in 150 hospital trusts. Of those, the

Care Quality Commission (CQC) rated the safety aspect of 65 of those as “requiring improvement” and of 13 as “inadequate”. (The Mail’s report focuses on the safety ratings – the figures for the overall ratings are slightly different, with only eight rated inadequate.)

At those 13 hospitals, women and their babies are receiving poor care that may be putting their lives at risk.

Here’s an excerpt from the CQC’s report on the Addenbrookes maternity unit, carried out in September 2015:

“We found serious concerns regarding the safety arrangements in the maternity services which were not replicated in the gynaecology service. These related to the environment, equipment, lack of recording of risk assessments and substantial midwife shortages. There were continued thematic incidents reported, relating to fetal heart rate (FHR) monitoring, with limited evidence of changes in practice to improve safety. We found that the suitability, safety and maintenance of many types of equipment throughout maternity services were unsuitable.”

It goes on, alarmingly:

“In the birthing unit, the environment was also found to be unsafe owing to poor ventilation whereby high Nitrous Oxide (gas and air) levels exceeded the safe “Work Exposure Level” (WEL) which the trust had known about since 2013. In maternity, numerous and essential patient risk assessments including venous thromboembolism (VTE) and early warning score (EWS) assessments were not being completed. Staff raised concerns to us that the maternity record system was potentially unsafe due to a combination of electronic and paper records being in use and being used inconsistently.”

Most of these problems could be put right with proper staffing: the NHS urgently needs more midwives and obstetricians. But we also need to look at the cultural attitudes towards safety in the NHS. There is no good reason for not acting on the poor ventilation at Addenbrooke’s, or for the failure, reported by the CQC, to log incidents correctly at Wexham Park Hospital: “Incidents were not always being reported and there were accusations of improper downgrading of their severity alongside suggestions of defensive practice.”

The recent Cumberlege Review made important recommendations on safety. But this has happened before (not least in the RCOG’s Safer Childbirth report in 2007), and nothing has changed. At Morecambe Bay, 11 babies, and one mother, died unnecessarily over a nine-year period. Judging from the evidence of the CQC, we may be seeing yet more tragedies like Morecambe Bay.