London School of Hygiene & Tropical Medicine

Over a quarter of investigations into stillbirths, neonatal deaths and severe brain injuries are not good enough, according to a report published by the Royal College of Obstetricians and Gynaecologists (RCOG).

Each Baby Counts is a national quality improvement programme launched by RCOG to reduce the numbers of the above events by 50% by 2020. It brings together reviews of all local investigations in order to improve the quality of care during labour. Data from 2015 shows 921 babies were referred to the programme and that 27% of these were classified as poor quality, as they did not contain sufficient information on the incidents.

Additionally, the report finds varying results in parental engagement in these investigations. In just under half the reviews, parents were made aware of an investigation and were informed of the outcomes. Furthermore, in a quarter of the reviews, parents were not even made aware an investigation was occurring.

So what impact could this report have on local review processes and maternity services? Dr David Cromwell, Reader in Health Services Research at the London School of Hygiene & Tropical Medicine, said:

"While women in this country have access to high-quality maternity care, complications can still arise during labour.  In some cases, this can lead to a baby either dying at birth or within the first week of life, or suffering a severe brain injury.  This is a profoundly sad event for the parents and it is the duty of health services to provide appropriate, sensitive support at this time. 

"Each Baby Counts was launched to help maternity services fulfil this expectation, and the initiative is to be welcomed. Only by looking at the different approaches adopted by services across the UK can examples of good practice be identified and shared.  Their first report offers maternity services valuable advice on improving how they investigate the severe injury or death of a baby.  It should help maternity services identify changes that will lead to the improved organisation of care and, as importantly, provide parents with respectful and compassionate support."

Related links

• Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH)

• Free online course - Improving the Health of Women, Children and Adolescents: from Evidence to Action