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Each Baby Counts report: Bliss' response

21 June 2017

A new report from the Royal College of Obstetricians and Gynaecologists (RCOG) has found wide variation in how instances of stillbirth, neonatal death and brain injury occurring during term labour are being reviewed. It has put forward a number of recommendations which must be implemented to improve both the quality of care and the quality of reviews when an incident occurs.

The Each Baby Counts report (PDF), which has been published today, looked at the cases of 1,136 babies born in 2015 who were stillborn, died within seven days after birth or who suffered a severe brain injury. The key findings are:

  • In 76 per cent of cases it was deemed that the baby might have had a different outcome with different care1
  • Parents were only asked to be involved in 34 per cent of reviews
  • While the majority of review teams were multi-disciplinary, a neonatologist or neonatal nurse was only involved in 68 per cent of reviews

Caroline Lee-Davey, Bliss Chief Executive, says "The stark findings of this report make for devastating reading. Every stillbirth, neonatal death and life-long injury is a tragedy for the family affected, whose hopes and dreams for their baby are changed in an instant. It is therefore deeply concerning that the Each Baby Counts researchers found that three quarters of babies may have had a different outcome if their care had been different.

"The report highlights that much more needs to be done to ensure staff across maternity and neonatal services are able to access the training they need to provide high-quality, safe care to every baby. However, we know from our own research that chronic staffing shortages make it harder for health professionals to maintain their skills.

"The report also highlights that more needs to be done to ensure that a neonatal expert is included on the local review team every time a baby is born alive who then sadly dies, or suffers severe brain injury. We would also echo the importance of the report recommendation to ensure all parents are given the opportunity to feed into the review process.

"It is crucial that all of the recommendations in this report are adopted as a matter of urgency in order to reduce the number of baby deaths and brain injuries during childbirth."

Each Baby Counts is a national quality improvement programme, launched in October 2014, aiming to halve the number of babies who die or are left severely disabled as a result of preventable incidents occurring during term labour (after 37 weeks) by 2020. This project will bring together the lessons learned from a review of all local investigations in order to improve the quality of care in labour across the UK.

Download a PDF version of the research


  1. Based on the 727 reviews which provided sufficient information.
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