The death of a baby is a devastating event for mothers, fathers and the wider family.
Penningtons Manches has represented numerous parents who have suffered the loss of a baby and members of the clinical negligence team know all too well how this loss can have a significant impact on both the parents of that baby and also the parents’ friends and families. It affects people in a psychological, social and economic way.
The prevention of stillbirth remains a challenge to UK maternity services. Currently, the UK ranks 24th out of 49 high income countries in terms of stillbirth rates, with around one in 250 pregnancies ending in stillbirth after 24 weeks of pregnancy.
Recent statistics gathered by Penningtons Manches from local hospital trusts including Frimley Health NHS Foundation Trust, University Hospital Southampton NHS Foundation Trust, Hampshire Hospitals NHS Foundation Trust and Portsmouth Hospitals NHS Trust, do indicate that the rates of stillbirth and neonatal deaths across these trusts have declined over the past four years, in line with the UK trend. However, between 2015 and 2018 they still had a combined total of 665 stillbirths and neonatal deaths, including 111 stillbirths and 35 neonatal deaths in 2018 alone.
It is therefore clear that there is still work to be done.
How can stillbirth rates be improved?
There are two strategies that can be taken to reduce the rate of stillbirths. Firstly, identifying women that are at an increased risk of stillbirth and, secondly, identifying aspects of the maternal lifestyle, such as personal habits, that may increase the risk of stillbirth.
Some risk factors are well established. These include maternal medical issues; smoking; fetal growth restriction; and reduced fetal movements.
In order to tackle the high stillbirth rates in the UK there needs to be a multifactorial approach.
Although not all of the information requested from the trusts was complete, Frimley identified that out of the term stillbirths that occurred at 37 weeks gestation or later within their Trust between 2014 and 2018, 18 per cent of these could have been avoided with alternate care.
The Saving Babies Lives Care Bundle (SBLCB) was launched by NHS England in 2015, in response to the Government’s ambition to halve the stillbirth rate by 2025. It focuses on the effective implementation of best practice care. An evaluation of the implementation of the SBLCB in early adopter trusts in England, between April 2015 and April 2017, was undertaken in November 2018 and this article considers that report’s findings.
The SLBCB sets out four different ways to potentially improve outcomes for babies and their parents:
- reducing smoking in pregnancy
- risk assessment and surveillance for fetal growth restriction
- raising awareness of reduced fetal movements
- promoting effective fetal monitoring in labour
Helen Hammond and Emma Beeson, senior associates in the clinical negligence team who often represent parents whose babies have been stillborn or pass away shortly after birth, comment: “It is the second, third and fourth issues 4 identified in the Saving Babies’ Lives Care Bundle that we see so often in the claims that we handle. A failure to properly identify and monitor fetal growth restriction, a failure of medical staff to heed a mother’s reports of reduced fetal movements and ineffective fetal monitoring during labour.”
The impact of the SBLCB
The trusts that indicated in the 2015 NHS England Tracker Survey that they were implementing SBLCB were deemed ‘early adopters’ and were eligible to take part in an evaluation of its implementation. The evaluation was conducted between May 2016 and December 2017 and took data from 19 NHS trusts (it should be noted that none of the trusts in the South contacted by Penningtons Manches for their statistics were included in this evaluation).
Over the five year period that the SBLCB was introduced, the total number of stillbirths across the 19 participating trusts declined from 4.2/1000 births to 3.4/1000 births. This equates to a 19.9 per cent reduction in the rate of stillbirths in the trusts that implemented SBLCB.
It is estimated, based on the stillbirth rate before and after the launch of the SBLCB, that there were potentially 156 fewer stillbirths across the participating trusts between April 2015 and April 2017 and if it were implemented across the whole of the country, there would be 1,119 fewer stillbirths across the UK in that timeframe.
The evaluation also highlighted that alongside the reduction in stillbirths, the rates of scans, inductions to labour and emergency caesarean sections have progressively increased over the past five years. Although the evaluation of the implementation of the SBLCB could not prove that the SBLCB was the direct cause of those increases, given the nature of some of the interventions recommended in SBLCB, it is plausible that the improvement in early detection was due to the implementation.
Risk assessment and surveillance for fetal growth restriction
It is incredibly important that babies that are small for their gestational age (SGA) are identified during pregnancy. There is a higher risk that an SGA baby will develop hypoglycaemia (low blood sugar) and other conditions that can negatively impact their health and chances of survival. They are also at a higher risk of stillbirth.
The SBLCB recommended five interventions to identify SGA babies, including:
- using the SBLCB algorithm for risk classification
- for high risk women, using serial ultrasounds to assess fetal growth and plotting the estimated fetal weight on a chart
- for low-risk women, assessing fetal growth using symphysis fundal height
- an ongoing audit of SGA birth rates and antenatal detection rates
- an ongoing audit of ‘missed’ SGA cases
The evaluation found following the implementation of the SBLCB that antenatal detection of SGA babies increased significantly. This in turn has reduced the number of stillbirths as action can be taken to ensure that the baby is delivered at the right time to be born safely.
Raising awareness of reduced fetal movements
A large proportion of women who experience a stillbirth report recognising reduced fetal movement (RFM) prior to the birth. RFM can be a key warning sign that a baby is in distress. If the baby is being deprived of oxygen, their movements will slow to conserve energy, but this has to be recognised and action taken to ensure a baby is born before it is too late.
Various studies, such as Confidential Enquiry into Term Antepartum Stillbirth, published in 2017, have found that the lack of prompt management of RFM was a contributing factor to stillbirths that could be avoided.
From the local trusts that Penningtons Manches contacted when conducting investigations, Frimley’s statistics alone demonstrated that of the neonatal deaths that occurred there between 2014 and 2018, 17 per cent of those delivered at 37 weeks gestation or later reported a maternal appreciation of reduced fetal movement during pregnancy.
The SBLCB focused on raising awareness among pregnant women of the importance of detecting and reporting RFM during pregnancy, and ensuring that healthcare providers have protocols in place to manage RFM.
Raising awareness about the importance of monitoring fetal movements and recognising RFM is a very high profile initiative, with charities such as Kicks Count and Tommy’s focusing significantly on this and the impact that raising awareness may have on reducing stillbirths.
The recommendations on tackling RFM by the SBLCB were relatively low cost and included providing women with an information leaflet on RFM and discussing the importance of reporting RFM at every antenatal appointment.
Following the implementation of the SBLCB, virtually all women reported monitoring their baby’s movements. A large proportion of women who experienced RFM attended their maternity unit and, of those women, 74 per cent received fetal heart monitoring and 65 per cent received an ultrasound scan. In addition, around 55 per cent of women reporting RFM were induced.
This demonstrates that there is still room for improvement, but taking the necessary steps to raise awareness and having protocols in place to react to women reporting RFM can have a significant impact on stillbirth rates.
Promoting effective fetal monitoring during labour
Monitoring the baby during labour is one way of checking on the baby’s wellbeing. Recording the baby’s heartbeat can help to identify distress and shortage of oxygen, thereby reducing the chances of stillbirth.
Monitoring can ensure that if a baby becomes distressed, a mother can be offered an assisted instrumental delivery (usually a ventouse or forceps) or a caesarean section so that the baby is delivered safely.
The SBLCB recommended specific actions to help improve effective fetal monitoring during labour. These recommendations included annual training for all staff and a buddy system for reviewing cardiotocography (CTG) results, with protocols for escalation if concerns are raised about the baby’s wellbeing.
Unfortunately, the report on the SBLCB stated that CTG training for staff across trusts was poor and there was not adequate data for analysis. Nonetheless, the buddy system was utilised quite highly, and even through trusts were not completely compliant with the system, escalation protocols were well utilised.
What are the challenges of implementing these initiatives?
The initiatives recommended by the SBLCB come with increased costs. It is estimated that the cost of implementing the SBLCB between April 2015 and April 2017 in the early adopter trusts was £26 million. This figure includes purchasing new equipment, the increase in the number of scans conducted, investment in training and the increase in intervention such as induction of labour and caesarean sections.
There may also be other costs associated with implementing the SBLCB which are more difficult to monitor, for example, the impact on staff, as they would be required to complete additional tasks within the same appointment time.
Although these costs may seem high, it is possible that by investing in the recommendations made by the SBLCB, there will be a reduction in expenditure elsewhere. An example of this would be that costs will be saved on testing and post-mortem examinations conducted as a result of a stillbirth, something which may become more significant with the implementation of inquests for stillbirths at term. Additionally, a reduction in the rate of stillbirths that are easily preventable will lead to less money being spent on litigation, which can be incredibly expensive for the NHS. In 2016/17 obstetric claims made up 50 per cent of all claims that the NHS Litigation Authority handled and cost around £4,370 million Furthermore, intangible costs that are incurred as a result of parents suffering a stillbirth, such as unemployment, adverse psychological consequences and social isolation will be prevented and reduced, which is invaluable.
When evaluating the implementation of the SBLCB in early adopter trusts, it is clear that there have been significant changes in outcomes for women and their babies. There is a national aim to reduce the amount of stillbirths in England and the results from this study are in line with what would be required to achieve those targets.
By following the fairly simple, yet effective, recommendations made in the SBLCB in the future, ensuring that SGA babies are identified and monitored, that women are made aware of RFM and that there is effective fetal monitoring during labour, there could be a drastic reduction in the high level of stillbirths.