A new report published from the Each Baby Counts (EBC) project shows, shockingly, that 3 out of 4 babies at the end of pregnancy who died or suffered harm in labour, might have had a different outcome with different care.

For any one maternity unit a labour-related death may seem rare but every day across the UK, 3 babies who reach the end of pregnancy, start labour alive but die or suffer a brain injury.

The EBC report on 2016 data shows little improvement compared to 2015, with the level of potentially avoidable harm remaining unacceptably high.

EBC found that in cases where the harm was potentially avoidable an average of seven different things had gone wrong, showing the complexity of factors.

More encouragingly, EBC found that for 9 out of 10 babies, the events around the death or harm were reviewed locally, which is a vital first step to understanding what has gone wrong and providing clear answers to parents about what happened to their baby.

But for over 100 cases there was still insufficient information to draw any conclusions. 

While a higher proportion of families in 2016 were invited to contribute to a review of their baby’s care, over half were not.

We have long called for parents’ stories about their care to be an integral part of mortality reviews.

Our chief executive, Clea Harmer, said: “The report shows that systematic problems such as excessive workloads and under-staffing in maternity units are making sub-standard care more likely, leading to catastrophic consequences for families.  When mistakes do happen lessons must be learned.

“Parents are the only ones there throughout their maternity journey, and they frequently have crystal clear recollections of when things went wrong. Yet in many cases, this vital perspective is still not taken into account.”

The report adds to the calls for all baby deaths to be investigated using the new Perinatal Mortality Review Tool, which has been developed by a team that includes Sands.

However resources must be made available by Trusts and Health Boards to release staff time in order to carry out high quality reviews that actually lead to change.

The Royal College of Obstetrics and Gynaecology-led EBC project aims to reduce labour-related deaths and harm by 50% by 2020.

We fully support this ambition and the high-quality work of the EBC team in analysing what needs to change.

If it is to be achieved, and every mother and baby is to receive maternity care according to national guidance as a minimum, the complex factors which include staffing and resourcing of maternity care must urgently be addressed. 

It is vital that the recommendations of the report are prioritised and acted on by all Trusts and Health Boards.

To read the full EBC report click here.