Too many babies are dying at birth

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.

How can we stop so many babies dying at birth?

An investigation by the HSJ’s Shaun Lintern, also reported in the Nursing Times, has found that many babies are dying at birth as the result of a simple mistake: a failure to correctly read the CTG trace, which monitors the baby’s heart rate:

“Data from NHS Resolution – formally the NHS Litigation Authority – shows there were almost 300 clinical negligence claims between 2011 and 2016 where the primary cause of the injury was a failure to respond to an abnormal foetal heart rate.”

Lintern points out that this problem has been known about for a long time: reports by the NHS Litigation Authority in 2009 and 2012 made similar findings.

There have been recent well-publicised cases, he notes, where a failure to read the trace correctly resulted in tragedy: in February, for example, coroner David Hinchliffe said of baby Maxim Karpovich, who died in 2015:

“It was apparent that the midwives involved with Maxim’s birth and the junior obstetrician appeared not to understand that the CTG trace was abnormal on several occasions.

“This inquest and many previously have caused me to note that midwives and obstetricians lack the core skills to interpret CTG tracings.”

It’s easy at this point to blame the shortage of midwives, which is putting a lot of midwives under pressure – and indeed the Royal College of Midwives (RCM) spokesperson quoted in the piece does just that. She also blames outdated equipment and the increasing complexity of birth.

The Royal College of Obstetricians and Gynaecologists (RCOG) spokesperson, on the other hand, says that errors could be reduced with a focus on multidisciplinary training:

“There shouldn’t be a brick wall around obstetrics and a brick wall around midwifery.”

In hospitals, safety is paramount. The death of a baby should be an exceptional circumstance, and when it happens, staff should work together to review why it happened and what can be done to stop it happening again. This is what happens in organisations that have a culture of safety. The fact that in so many NHS hospitals this doesn’t happen is shocking.

Lintern goes on to mention Barking, Havering and Redbridge University Hospitals NHS Trust, which set out to tackle its rate of CTG errors. It had found that 75% of maternity “incidents” included some form of CTG error in 2015-16, but the trust had invested in staff training, equipment and an improvement in culture. In the past 11 months the trust hasn’t had a single CTG error.

According to the trust’s director of midwifery, Wendy Matthews:

“We have put in place quite a rigorous process. We’ve developed a culture of quality and safety and learning from errors which is very much about the multi-disciplinary team.”

This is a remarkable achievement. Yet it doesn’t sound as if there was a magic solution to the problem – simply that the trust approached the problem sensibly by training staff to read the CTG correctly, buying more effective equipment and working together to learn from mistakes.

In an ideal world, what would happen next is that every other maternity unit in the country would look at what Barking, Havering and Redbridge did and copy its example. This would save the NHS hundreds of millions of pounds a year in litigation – and more importantly, save the lives of hundreds of babies who die needlessly at birth.

Severe tearing in childbirth – not just a physical problem

NB I’ve edited this post in response to a comment.

A traumatic vaginal birth involving severe tearing can cause mental health problems, including post-traumatic stress disorder (PTSD), according to a new study from Hans Peter Dietz and Liz Skinner.

About 90% of women experience tearing during childbirth, but most are first or second degree tears, which are relatively mild and heal quickly. Approximately six percent of women have third or fourth degree tears that can damage the anal sphincter.

Dietz and Skinner have done a lot of work in this area, which I’ve written about before. They both feel that the problems of a difficult vaginal birth tend to be overlooked in the drive to reduce caesarean sections, which are usually perceived as more risky for both mother and baby.

The study identified 40 first-time mothers with major pelvic floor trauma and interviewed them one-to-four years after they gave birth. Just over half (22) of the women had “major obstetric anal sphincter tears.”

Of the 40 women, 35 had “Multiple symptoms of pelvic floor dysfunction” causing lifestyle alteration. These symptoms included “urinary or fecal incontinence, prolapse, chronic pain, dyspareunia [painful intercourse]”.

It’s hardly surprising, then, that 27 experienced PTSD symptoms, including “poor baby bonding, flashbacks during sex, dissociation, avoidance, anxiety”.

Probably the most worrying themes to emerge from the study were the lack of awareness or communication from health professionals:

  • 36 women said there was no information provided by clinicians on potential postnatal pelvic floor morbidities
  • 36 said that there was no postnatal assessment of their injuries
  • 26 said that they experienced “dismissive reactions from poorly informed clinicians to maternal injuries. One woman said: “The midwife said that this was OK… but I knew that it was not normal… The doctors really did not understand the situation… I was in shock – devastated and unable to get any health professional to understand.”

Although the study was carried out in Australia, I’d be surprised if a UK study didn’t find something similar. I’ve now heard numerous stories about obstetric tears not being treated properly or women having their concerns dismissed as unimportant. One of the problems is that midwives often don’t see the consequences of tearing in childbirth – women are only under midwife care for 10 days after birth, so if a tear has failed to heal properly weeks, months or even, shockingly, years after birth, they’ll be dealt with by another group of health professionals entirely. So midwives may well assume, wrongly, that a tear during childbirth has healed without problems. And that may lead to an unjustified confidence that obstetric tearing isn’t a significant problem.

As I’ve already reported, the RCOG is now campaigning for better understanding of obstetric tearing in childbirth, and better care for the women who experience it. But we still have a long way to go – and In the meantime, a lot of women are suffering in silence.