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.

Advertisements

Reading CTG traces: the tragic consequences of getting it wrong

A CTG trace showing a baby's heart rate.
A CTG trace showing a baby’s heart rate.

Earlier this month a court made the highest ever award for clinical negligence.

James Robshaw, 12, is to receive £14.6m for injuries he received as a result of mistakes made during his birth in December 2002. Because James was deprived of oxygen during his birth, he now suffers from cerebral palsy. He can’t speak or control the use of his limbs, and he communicates using a machine that he controls with his eyes.

Although £14.6m seems like a lot of money, it is the amount needed to provide care for James 24 hours a day, seven days a week for the rest of his life.

The NHS spends about £1bn a year settling medical negligence claims. About a third of this is spent on compensation for mistakes in maternity care, equivalent to £700 per baby born. The reason it is so costly is not because obstetricians and midwives are especially negligent, but because the consequences of birth injury are long-term and catastrophic: as in James’s case, the NHS has to pay for a lifetime of care.

Earlier today, I heard James Robshaw’s mother Suzanne interviewed on the Radio 4 programme You and Yours. She talked about her long labour and the decision by doctors to allow her carry on labouring rather than perform an emergency caesarean section. Her account included a detail that is all too common in birth injury stories: the failure of her midwife to read the cardiotocography (CTG) trace correctly.

The CTG trace shows the baby’s heart rate. If it is too high, or too low, it means there’s a problem and the baby could be at risk. According to Suzanne, her husband repeatedly pointed out to the midwife that the CTG trace was showing a low heart rate, but the midwife insisted that all was fine. She was wrong.

Reading a CTG trace accurately isn’t necessarily an easy thing to do – and doctors and midwives need training in how to do it well. This article from 2011 says that 200 babies die every year because of a failure to act on an abnormal CTG reading. Others, like James Robshaw, are left brain damaged through oxygen starvation.

Part of the problem is that midwives and obstetricians are overworked and often stressed: the shortage of health professionals means that those who remain are expected to do too much. It’s not surprising under those circumstances that mistakes get made.

But it’s also true that better training – and checks to make sure that the training has been understood and is being followed correctly – can help. When I was writing my book on birth trauma, I was startled to discover, in an interview with a litigation lawyer, that her firm was so horrified by the number of medical negligence claims arising from a failure to read the CTG correctly that it offered CTG training to midwives. (This is a firm that benefits from medical negligence errors, so this is no small thing.)

Most babies are born safely: the number of medical negligence claims as a proportion of the number of births is tiny. But the financial cost to the NHS – and, more importantly, the emotional cost to the victims and their families – is enormous. A simple thing like better and more effective training in reading CTG traces could do a lot to put that right.