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Review of baby deaths highlights shortcomings in care

Posted on 24th November 2015

A report launched on 19 November 2015 by Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries across the UK (MBRRACE-UK) has highlighted fundamental failings in antenatal monitoring and care that may have contributed to the deaths of babies, undermining the belief that stillbirth is not possible to predict or prevent.

The MBRRACE-UK report can be found here with the findings summarised as:

  • Half of all term, singleton, normally-formed, antepartum stillbirths had at least one element of care that required improvement which might have made a difference to the outcome.
  • Two thirds of women with a risk factor for developing diabetes in pregnancy were not offered testing – a missed opportunity for closer monitoring.
  • National guidance for screening and monitoring growth of the baby was not followed for two thirds of the stillbirths reviewed.
  • Almost half of the women had contacted their maternity units concerned that their baby’s movements had slowed, changed or stopped. In half of these there were missed opportunities to potentially save the baby including a lack of investigation, misinterpretation of the baby’s heart trace or a failure to respond appropriately to other factors.
  • Documentation indicating that an internal review had taken place was only present in one quarter of cases and the quality of these reviews was highly variable.
  • Only half of the stillbirths selected for confidential enquiry had a post mortem carried out; the majority of post mortems were of satisfactory or good quality.
  • A good standard of bereavement care was provided for parents immediately following birth including the offer of an opportunity to create memories of their baby.

Clear pointers for improving services and care by individual practitioners were identified and these are discussed in detail alongside the findings in the full report on the reports page.

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