Each Baby Counts

Colleagues have already blogged on investigations into tragic events that have occurred in the maternity units at The Countess of Chester and Shrewsbury & Telford Hospitals.

Second worst for maternity care

Now it appears that the problems are nationwide. Although still one of the safest places to give birth, the UK is second only to Malta in having the worst record for maternity care in Western Europe. 

The Royal College of Gynaecologists (RCOG) launched a programme in 2015 called ‘Each Baby Counts’ aiming to reduce the number of babies who die or are left severely disabled as a result of incidents. Now a detailed report has been published.


The RCOG report looked at 1136 stillbirths, neonatal deaths and brain injuries that occurred on UK maternity units during 2015:

  • 126 babies were stillborn

  • 156 died within the first seven days after birth

  • 854 babies had severe brain injuries (reported within seven days of birth, it is not known how many have long term disabilities)

The report found that three in every four babies may have had a different outcome if they had received different care.

Interpreting baby's heart beat

In many of the reviewed cases, problems with accurate assessment of the baby during labour and consistent issues with staff understanding and processing complex situations, including interpreting recording of the baby’s heart beat (CTG tracing) were identified. 

Many of the cases investigated at local level were not thought thorough enough to allow the report authors to do a full assessment of what went wrong.

Prof Lesley Regan, president of the RCOG, said: "The fact that a quarter of reports are still of such poor quality that we are unable to draw conclusions about the quality of the care provided is unacceptable and must be improved as a matter of urgency."

Annual training

The RCOG aim to achieve a 50% reduction by 2020 in incidents during term labour that lead to stillbirth, early neonatal death or severe brain injury. The Each Baby Counts report has recommended:

  • All low risk women are assessed on admission in labour and checked to see what foetal monitoring is required.

  • Annual training for staff on interpreting CTG traces.

  • A senior member of staff must maintain oversight of the delivery suite.

  • All Trust Boards should inform parents of any local reviews and invite them to take part.

Let us hope that everyone working in maternity care will ensure the reports recommendations are followed and outcomes are improved for all mothers and babies in the UK.

More information at https://www.rcog.org.uk/eachbabycounts