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.