An in-depth investigation into stillbirths and neonatal deaths showed that in the large majority of cases different care during labor and directly after birth could have led to a better outcome. In more than a quarter of the cases, issues relating to capacity regarding staffing and health resources were identified as having been a problem. The Foreword to the report states that “Every midwife, obstetrician, neonatologist and neonatal nurse should read this report and ensure that, where changes are needed to their practice, these are put in place.”
The study was part of the ongoing national collaborative surveillance and investigation by MBRRACE (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) into the causes of maternal deaths, stillbirths and infant deaths – and the third investigation into intrapartum stillbirths and intrapartum-related neonatal deaths in full-term, single birth pregnancies.
The panel, which reviewed detailed data collected from a sample of 78 eligible deaths in 2015, found that in 80% there had been significant or major issues in the quality of care provided during labor which could have affected the outcome for the baby. In any one case, there might have been one single incident affecting the result, but there could also have been some issues along the care pathway. Some of the key issues identified included lack of identification of the urgency of situations and delays in speeding up births, delays in transferring the mother, not recognizing all the implications of the whole situation, failure in communication between members of the health team, as well as lack of supervision and leadership.
In more than a quarter of the cases, staff shortages and other capacity issues were identified as a contributing problem, mostly in the delivery suite. In some cases, transfers of mothers or delays in induction of labor were caused by high workloads in the units and a lack of beds and staff. From individual case files, it was difficult to determine how workloads could have affected appropriate decision making and recognition of critical problems, but the panel reported that it appeared to be an important issue. To a lesser extent, there were also problems related to the provision of care for the neonate, for example, the neonatal resuscitation team not being available when needed.
For this investigation a checklist, based on national standards and guidelines of care, was developed to collect information on all aspects for care – with emphasis on labor, delivery and resuscitation. Detailed information on the sample was compiled from the medical case notes, where notes were incomplete, further information was collected. The care provided to the mothers and babies was then subjected to collaborative quantitative and qualitative review by a panel of expert clinicians including medical practitioners from various specialties, midwives and neonatal nurses.
Compared to 1993 figures, the number of cases of intrapartum stillbirths and neonatal deaths related to the delivery process had more than halved. These deaths were however still a cause for concern, particularly because in most cases the mother was under direct maternity care. A further significant factor highlighted in the report was that the average age of first-time mothers stood at 30.2 years in 2014, with around one-fifth of mothers giving birth at 35 years of age or older. This implies that there are more women than in the past with high-risk factors that require more advanced care and monitoring during pregnancy and delivery.