The UK is one of the safest places in the world to give birth so it is heartbreaking when a poor outcome turns a happy event into family tragedy. In a major new initiative, the Royal College of Obstetricians and Gynaecologists (RCOG) is collecting data about perinatal deaths and severe brain injuries caused by incidents during labour so that lessons can be learned and shared. Project team member, Dr Edward Prosser-Snelling, calls the Each Baby Counts initiative ‘one of the RCOG’s biggest but most worthwhile challenges’.
Between 500 and 800 babies each year in the UK die or are left with serious disabilities as a result of incidents in intrapartum care, according to the RCOG.
If these numbers seem vague, it is because there has, until now, been no central source of information about intrapartum-related perinatal deaths and injuries. And without a national picture, there has been no opportunity to identify common risk factors, learn from what went wrong and apply the lessons in maternity units across the country.
As Dr Edward Prosser-Snelling, recalls: “We didn’t know the scale of the problem but there was a sense within the College that numbers of intrapartum-related stillbirths and perinatal deaths were higher than we would like and we weren’t doing as well as other regions, especially Scandinavia, something the current maternity review is picking up on too. The President and the two principal investigators, Zarko Alfirevic and Alan Cameron, felt that there was an opportunity to make a difference.”
“The ambitious target of the Each Baby Counts project is a 50% reduction by 2020 in incidents during term labour which lead to stillbirth, neo-natal death and severe brain injury.”
The ambitious target of the Each Baby Counts project is a 50% reduction by 2020 in incidents during term labour which lead to stillbirth, neo-natal death and severe brain injury diagnosed in babies in their first week of life. To achieve its goal, the RCOG is pooling the anonymised results of local investigations across the UK, carrying out thematic data analysis and making evidence-based recommendations to reduce avoidable harm.
A broader perspective is of critical importance and echoes the principles established by An Organisation with a Memory, the ground-breaking investigation into patient safety in the NHS1. Dr Prosser-Snelling says: “An individual maternity unit might carry out a root cause analysis or make risk recommendations and people will remember for six months but then inevitably they will move on. We want to capture this information at a higher level and make lasting cultural changes.”
Every NHS and private maternity service in the UK has nominated a Lead Reporter for Each Baby Counts. They are responsible for reporting eligible cases when they occur via an online data collection system, and will be the main contact point in case of queries from the project team. Dr Prosser-Snelling and his colleagues have already started to analyse more than 100 cases which have been reported since the collection process began in January 2015.
They hope to make a preliminary report in the next few months and there will be an annual report summarising the main themes which emerge from the analysis, as well as shorter and more frequent safety bulletins and newsletters. The team is also carrying out a review of existing literature and guidance to inform its reports and help ensure future research is focused where it is most needed.