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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A forced episiotomy – why a woman is suing the hospital where she gave birth

A woman named Kelly (not her real name) is suing a California hospital for performing an episiotomy on her during labour without permission.

You can read an account of Kelly’s story here. In short, however, Kelly, a young woman, was a rape victim who had asked her healthcare providers to be gentle with her as she gave birth to her first baby. (For victims of rape and sexual abuse, giving birth can be particularly traumatic, often reigniting memories of the assault.)

Kelly, who had had an epidural and was giving lying birth on her back, had not succeeded in pushing the baby out. The doctor said he was going to perform an episiotomy. She asked him not to. He went ahead and did it anyway.

He seems to have made a particularly bad job of it, using scissors to make 12 cuts before pulling the baby out.

We know all this because the baby’s grandmother was videoing the birth. (I strongly recommend that you don’t view the video if you suffer from birth trauma.)

A doctor describing the scene in the video writes:

“The physician here applied a medio-lateral episiotomy unnecessarily early through thick tissue, but rather than making a single definitive cut, he makes a series of short cuts that cause unnecessary bleeding and will interfere with healing. The episiotomy was done so early that the perineal tissues did not have time to stretch, so that the tissues were thick and bloody, a situation that would not have pertained if the professionals had waited…Having decided in advance to do an episiotomy, the doctor apparently does not even know how to do one – how to time it to minimize trauma. This behavior makes it more likely that severe trauma will occur.”

So far, so shocking.

But it gets worse. Kelly will represent herself in court because she has been unable to find legal representation. This is because, in the US – as in the UK – litigation for malpractice during labour or birth generally takes place when either the mother or the baby has died or has been left severely physically damaged as a result of poor medical decisions. Improving Birth, the organisation supporting Kelly, writes that lawyers she approached “were unable to see the value in a case where there were no permanent damages or deaths.”

At the heart of it all is the issue of consent. In California, a health professional needs the patient’s consent to carry out a medical procedure (except in cases of emergency). A similar law applies in the UK.

Yet there is plenty of anecdotal evidence of, for example, women having their waters broken during labour, to show that the issue of consent is often ignored, both in the UK and the US.

It seems extraordinary that this breach of a fundamental principle has not hitherto been tested in court. The outcome will be of interest to any woman whose wishes have been ignored during labour.

If you want to contribute towards Kelly’s expenses, you can do so here.