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 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.