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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Why do so many babies die – and why aren’t we doing something about it?

Why, asks an article in the Telegraph, do 2,000 babies die needlessly during childbirth every year?

It’s a question that ought to bring us up short. Two thousand deaths is a huge number: compare it to, say, the number of people killed in road accidents in the UK, which is now down to about 1,700 a year.

The article’s writer, Mary Riddell, is talking about needless deaths: in total, there are 3,600 stillbirths a year in the UK, representing one in every 200 births. Some deaths can’t be avoided. So why aren’t we doing more about the ones that can?

It’s curious how complacent we are as a society about the problem of medical negligence. In the US, a study has estimated that medical errors are the third leading cause of death, behind heart disease and cancer. Somewhere between 210,000 and 440,000 patients who go to hospital in the US each year “suffer some type of preventable harm that contributes to their death”. As far as I know, however, no similar study has been carried out in the UK.

Childbirth injuries and deaths can be avoided

We do know that NHS doctors and midwives make mistakes during birth. According to the Telegraph article, compensation claims for childbirth errors have tripled in 10 years. It compares figures for England with those for Sweden:

“In the last five years, Sweden has reduced the number of serious birth injuries from 20 per 100,000 babies to five, compared with the English rate of 30 in every 100,000 babies.”

The Swedish figures show that many injuries and deaths relating to childbirth are avoidable. The Telegraph article goes on to look at a hospital that has got it right: Southmead Hospital in Bristol, which it describes as “probably the safest place in the world to give birth”. Fifteen years ago, Southmead introduced Practical Obstetric Multi-Professional Training, or PROMPT – a method of collaborative working and learning from mistakes. During that time, there has been a 50-70% reduction in common birth injuries.

How the PROMPT approach works

What PROMPT does is to make sure that all members of a team – obstetricians, midwives, anaesthetists – are on the same page when it comes to responding to a medical emergency. A representative group of professionals receive the training together and then take it back and train other staff in their own hospital. It means that if, for example, a baby’s shoulder becomes stuck, everyone knows what to do.

The only extraordinary thing about this is that it’s not already universally applied: you’d hope health professionals would all know exactly how to respond to any likely childbirth emergency. But in the less effective maternity units, that doesn’t seem to be the case – the Kirkup Review into failings at the maternity unit of Furness General Hospital exposed an apparently casual attitude towards safety. In James Titcombe’s account of his son Joshua’s death at Furness, it was striking that none of those involved seemed interested in understanding why he had died or putting measures in place to stop anything similar happening again.

A fundamental change in approach is needed. Everyone makes mistakes, but human error can be minimised if agreed best procedures are in place; and a culture of openness where people are encouraged to own up to, and reflect on, their mistakes enables everyone to learn and improve their practice in future. This is how the aviation industry treats mistakes, and it works well.

The government’s proposed rapid resolution and redress scheme, in which litigation claims could be settled quickly without recourse to the courts may help to end the culture of secrecy and cover-up and bring about a more open approach. The proposals are not without their flaws (safeguards need to be in place to make sure that rapid redress is also accompanied by a desire to learn from mistakes – which isn’t a given), but they are surely a step in the right direction. Certainly many families will be grateful for not having to wait years for compensation while litigation drags on.

It could be that we are finally on the cusp of a change that campaigners have been fighting for over many years. If so, we may look back on those 2,000 baby deaths every year and wonder why we ever tolerated it.

Maternity outcomes matter

Some good news at the Birth Trauma Association (BTA): my colleague Maureen Treadwell is leading a collaborative project called Maternity Outcomes Matter, or MOM. The idea is to reduce the incidence of stillbirth and neonatal death (both very high in this country), and also, importantly, to reduce the number of maternal injuries – a more neglected area. Several other maternity groups are involved, and we’re delighted that James Titcombe, whose baby son Joshua died as the result of a simple but catastrophic error at Furness General Hospital, has joined the group. With the help of an initial grant of £5,000, the project will produce a report to identify some of the key mistakes that are made in labour and birth and how they can be prevented in future.

It’s a small project, but an important one. One of the things the NHS lacks is a straightforward, simple way of sharing good practice and knowledge. Mistakes are often covered up (sometimes for understandable reasons) rather than shared so that lessons can be learnt. Medical practice isn’t always based on good evidence. Among members of the BTA’s Facebook group, we hear story after story of women experiencing unnecessarily traumatic births.

Recently, as part of the Royal College of Obstetricians and Gynaecologists’ campaign to reduce third- and fourth-degree tearing in childbirth, I’ve been in touch with women whose lives have been ruined by severe tearing that has left them in severe pain and in some cases incontinent. Some injuries are so severe that they have left the woman unable to work.

In 2016, this shouldn’t be happening. So this project represents is one step on the road to making childbirth safer for both women and their babies.

To find out more, contact enquiries@ birthtraumaassociation.org.uk.

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.

Maternity Review: the good, the bad and the not quite sure yet…

Today saw the publication of Julia Cumberlege’s Maternity Review, Better Births. Commissioned in the wake of the Kirkup investigation into the deaths of babies at Morecambe Bay, its remit was to improve the outcomes of maternity services in England.

I’ve had a look and there’s some good stuff in there. The personal maternity care budgets have been grabbing the headlines, but there are some recommendations that have been overlooked. These include:

  • Thorough, open, multi-team investigations when something goes wrong, such as a baby dying
  • A national, standardised process for investigating mistakes
  • Collection of data on the quality and outcomes of maternity services, so that maternity teams can measure their own performance and compare it against other maternity teams
  • Multi-professional working, with teams of midwives and obstetricians working together in the best interests of mother and baby

These all represent a huge step forward. One of the big problems at Morecambe Bay was the lack of communication between midwives and obstetricians, and an apparent “them” and “us” mentality. There was also an unwillingness to investigate when things went wrong, so that the same things kept going wrong, time and time again.

It’s very important that people are able to learn from their mistakes. The aviation industry was able to slash the number of air accidents by adopting an open approach to errors: encouraging staff to report their own mistakes without fear of being blamed and to come up with suggestions for improvements. But there has long been a culture of blame and cover-up in the NHS – time and again I’ve heard stories from women of trusts that failed to acknowledge their mistakes and sought to put the blame elsewhere. A remarkable number of trusts manage to “lose” a woman’s maternity notes as soon as a complaint is made. So a move towards acknowledging mistakes and putting steps in place to rectify them is long overdue.

On the other hand…

There are other elements of the maternity review I’m less sure of.

The recommended change to payment systems needs to be treated with caution. The review wants to “shape the payment system to reflect the different cost structures of different models of providing care” and also to “incentivise community deliveries where clinically appropriate”.

It suggests “working with providers to undertake a bottom-up costing exercise and proposing adjustments to the existing tariff in light of this so as to more accurately reflect relative costs. This could include potentially introducing different prices for home births, freestanding midwifery units, alongside midwifery units and obstetric units.”

Obviously it’s important that women have the choice to give birth at home or in a midwife-led unit if they prefer. But there is a danger that trusts will try to save money by encouraging women towards those options when they’re not clinically appropriate. As soon as you offer financial incentives, you also offer an incentive to cast clinical judgement aside in favour of saving money.

Personal budgets – too many unanswered questions

Finally, we’ll have to wait and see what happens with personal budgets, but it’s difficult to see how they will work in practice. Personal budgets have been used successfully for people with long-term conditions, but giving birth is unpredictable: if you use your budget up on antenatal classes and hypnotherapy, what happens if you suddenly need an expensive emergency caesarean? Or if you want to sue your private provider, paid for by a personal budget, who pays – the provider, or the NHS?

More fundamentally, women need good quality care, and the opportunity to choose between a number of poor options is not really a choice at all. So, while I’m not totally against personal budgets, I’d really need to see a lot more detail before I’m convinced they’re the route to delivering the best outcomes for women and their babies.

Joshua’s story, by James Titcombe: a review

A few weeks ago, Joshua Titcombe should have celebrated his seventh birthday. Instead, Joshua died at just nine days old, as a result of some very basic medical errors by midwives at Furness General Hospital.

Joshua’s Story: Uncovering the Morecambe Bay NHS Scandal is James Titcombe’s account of Joshua’s life and death, his long battle to find the truth about why his son died and his determination to make sure that the same mistakes couldn’t happen again.

James’s wife Hoa gave birth to Joshua at 37 weeks. Hoa had a sore throat and headache at the time, but midwives declined the opportunity to give her antibiotics as a precautionary measure. When both Hoa and Joshua became ill shortly after birth, Hoa was administered antibiotics, but Joshua was not – despite James’s repeated requests.

After that, the tragedy unfolds with a horrifying inevitability: Titcombe describes how his son became very ill and had to be taken to hospital in Newcastle to receive a treatment called Extra Corporeal Membrane Oxygenation. The treatment was unsuccessful, and Joshua died.

Joshua’s life could almost certainly have been saved if he had been given antibiotics in time. The key indication was a drop in his body temperature: James and Hua didn’t know this then, but in babies, a low temperature is a sign of infection. The response of midwives, however, was to keep Joshua warm by putting him in a heated cot with an overhead heater.

It took six years from Joshua’s death to the publication of the Kirkup report, a damning investigation into the maternity unit at Furness General.

Dogged determination

James Titcombe’s account of those six years is mesmerising. Determined to find out why his son hadn’t been properly treated, he took his complaint to every authority that might be able to help – the trust chief executive, the Care Quality Commission (CQC), the Nursing and Midwifery Council (NMC), the parliamentary and health service ombudsman, his MP and the police. He also wrote to both the Newcastle coroner and his local coroner asking for an inquest.

At every turn, he was blocked. A report by the Local Supervising Authority (which has statutory responsibility for governing midwives) was a whitewash. Both the coroner and the ombudsman initially refused to investigate. The trust chief executive admitted that errors had been made but said that lessons had been learnt and refused to investigate further.

What is extraordinary is that James Titcombe kept going. He wrote endless letters and emails and had numerous meetings with people from the relevant organisations. While the authorities appeared determined to shut him up, he was equally determined not to be fobbed off. The scandalous fact that a key piece of evidence (an observation chart recording Joshua’s low temperature) had gone missing was given as a reason not to investigate, on the basis that, without this evidence, it would be impossible to determine what exactly had happened. Yet, as Titcombe points out, the suspicious fact that a crucial document is missing is surely a reason why you should investigate.

Eventually, Titcombe’s sheer dogged determination led both to an inquest and an investigation by the ombudsman, and those in turn led to the Kirkup report. But why was it so difficult? It becomes clear early on in the book that crucial facts were covered up (for example, Titcombe only later became aware that other babies had died at the unit, both before and after Joshua, as a result of medical negligence). Even at the inquest, three midwives categorically denied that they knew that a low temperature could be a sign of infection – presumably on the basis that it is better, as a health professional, to appear ignorant of basic medical facts, than it is to admit that one is aware of the facts but has decided not to act on them.

Failure to work together

Even now, it’s not clear to me why the midwives refused to give Joshua antibiotics. The Kirkup report talks of an “extremely poor” working relationship between midwives and doctors at the unit, and a determination by midwives to push normal birth at all costs. But Joshua didn’t die as a result of an over-zealous adherence to normal birth (though other babies did): he died because of a refusal to administer antibiotics. Astonishing as it may appear, this seems to have been down to a reluctance on the part of midwives to consult paediatricians. (At the inquest, midwives claimed that they bleeped a paediatrician for advice about Joshua, and the paediatrician had advised them simply to keep an eye on him; all the paediatricians on duty at the time denied having received such a call.)

Blaming the messenger

One of the many dispiriting aspects of the book is the clear unwillingness of the hospital to investigate safety incidents properly. Titcombe rightly points out that in other industries, there is a culture of openness about safety errors. The aviation industry, for example, has vastly improved its safety record by requiring staff to report their own mistakes, with no blame attached: if there is a pattern of people admitting similar mistakes, it’s possible to change procedures or designs so that those mistakes aren’t made in future. At Furness General, the immediate response to mistakes was to cover them up. There was clearly also a strong culture of blaming the messenger: it’s obvious that staff and, sadly, even patients were angry at Titcombe for his persistence in trying to find the truth of what happened. At one point Titcombe sees an email from the head of midwifery in response to “good news” mentioned in another email. “Has Mr T moved to Thailand?” the midwife’s email speculates hopefully –­ a confused reference to the fact that Hua is Vietnamese.

By the end of the book, I could only marvel both at James Titcombe’s dedication to finding out the truth and at the authorities’ dedication (with the exceptions of a few principled individuals) to stopping him. But I’m glad that he gives over the appendix to another couple, the parents of Alex Davey-Brady, to give their account of how their baby son died as the result of yet another medical error at Furness General. Because their first baby had been large, they were concerned that their second baby would be too, and they wanted an early delivery. This didn’t happen: an induction finally took place at 39 weeks, followed by a difficult labour. Alex was stillborn, weighing nearly 12lb, and with the umbilical cord wrapped around his neck. Alex’s parents are less polished writers than Titcombe, but the account is all the more moving for that.

They speak of their frustration at others’ unwillingness to take their story seriously, and say: “I would like to think that as a parent, if we had received excellent care with Alex and he would be here today going to school and causing mayhem like most little boys, I would be open minded enough to read this story told by someone else and not turn a blind eye and say the truth has to come out so that the future can move on in a more positive and more importantly more trusting path.”

Amen to that.

Are women who give birth at home selfish?

Milli Hill has written a thoughtful piece on home birth. The piece is in response to comments by the president of the Australian Medical Association Western Australia, Michael Gannon, that women who choose to give birth at home when they are considered “high risk” are “selfish”. He was commenting in response to an inquest into the deaths of two babies who had died after home births.

Leaving aside the questionable tact of labelling two grieving mothers “selfish”, there are some bigger issues here. One is: why pick on mothers? The investigation into the deaths of babies at University Hospitals Morecambe Bay NHS Trust found that the babies died as a result of negligence by doctors and midwives.

There are many reasons why babies die, some of which are down to bad luck, but baby deaths that result from the “selfishness” of the mother are much fewer in number than those resulting from mistakes by health professionals. Yet I don’t see Gannon criticising his medical colleagues, even though Australia’s stillbirth rate is six times as high as that of Finland. Gannon isn’t alone, of course – if you don’t believe me, try googling “home birth selfish”.

Another question is: why do women choose to give birth at home? Wanting to have a positive experience, in the familiarity of your own home, isn’t selfish. Wanting a good experience as a mother also means wanting a good experience for your baby. As Hill writes: “I had experienced home birth with my second baby and knew how delicious and comforting it is to be in your own surroundings as you birth and get to know your newborn.” Women who choose a home birth want their baby to be born in a relaxed, warm, gentle atmosphere. This doesn’t make them bad people.

Of course safety is important. But as Hill argues, some women feel safer at home. And the reason for that is very often that they have had a bad experience of giving birth in hospital – an experience that has been traumatic for both them and their baby. At their worst, hospital maternity units can be places where women feel bullied, where poor decisions are made about their care, where their needs are neglected and, yes, as in Morecambe Bay, where babies die as a result.

Anecdotal evidence suggests that women who have had a very traumatic birth often opt, next time round, either for a home birth or a planned caesarean, because both allow a woman to regain some control over the experience. They are both choices that give the mother an active say in her baby’s birth, rather than being expected to passively wait while decisions are forced upon her.

One way to make this happen is to improve the quality of care offered to women in hospital so that they can give birth in comfortable, quiet, private surroundings, looked after by a midwife who isn’t overstretched or exhausted, while knowing that interventions such as caesareans or Ventouse delivery are available if they become necessary. It will be expensive, though, as Morecambe Bay found out when it paid £12.5m to bereaved parents, perhaps not as expensive as the cost when maternity care goes badly wrong.