Almost 80% of all cases of baby death could have been prevented through improvements in care, according to a Healthcare Quality Improvement Partnership report.
The study by MBRRACE-UK, which is a collaboration between academics at Oxford and Leicester universities, revealed that around 180 babies died in 2015 out of a total of 225 stillbirths and deaths during labour, because of a lack of appropriate care – meaning 80% of all cases could have been avoided.
The report said: ‘The panel consensus was that in nearly 80% of deaths improvements in care were identified which may have made a difference to the outcome of the baby.’
‘The main issues identified were: care before labour was established, including induction; monitoring during labour; delay in expediting birth; heavy workloads of the units; a lack of joint obstetric and neonatal inputs into bereavement care; and a lack of rigour in the local review of the deaths,’ said Elizabeth Draper, a professor at Leicester University and one of the reports editors.
The report highlighted how staffing pressures were affecting care through an ‘overstretched and under-resourced maternity and neonatal workforce’. It added, ‘heavy workload and staff capacity issues can affect the care provided’.
The Health Secretary, Jeremy Hunt, conceded that there were ‘not enough staff across the whole NHS’ and NHS England must do better at learning from its mistakes in order to reduce the number of baby deaths and injuries during birth. He added that from now on all unexplained cases would be independently investigated by the Healthcare Safety Investigations Branch.
There are roughly 1,000 cases of unexpected baby death or sever brain injury per year in the UK out of a total of 700,000 total births – which, Mr Hunt said, meant the NHS provided safe care in the vast majority of cases.
For the authors of the report: ‘Policy-makers, commissioners and health service providers should likewise note where system – or organisation – level change is needed to ensure front-line staff have the support and resources they need.’
Elizabeth Duff, of the National Childbirth Trust, said: ‘It’s shocking and heartbreaking that in nearly 80% of cases, improvements in care may have made a difference to the outcome for the baby. Staffing shortages mean midwives are under enormous pressure which can lead to situations that have a devastating impact on families.’
Gill Walton, General Secretary of the Royal College of Midwives, welcomed Mr Hunt’s independent investigation process, but said: ‘We must ensure we have enough midwives and obstetricians to provide safe care throughout the maternity pathway and adequate facilities in all birth settings.’