Babies' deaths linked to suboptimal careBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6993.1536b (Published 10 June 1995) Cite this as: BMJ 1995;310:1536
- Charles D A Wolfe
- Clinical director of obstetrics nd gynaecology Guy's and St Thomas's Hospitals Trust, London SE1 7EH
EDITOR,—When a government report states that over 40% of deaths during birth are linked to substandard care both those managing labour and those purchasing maternity care wish to know how practice can be changed to reduce the number of such deaths.1 Changes to practice should be based on firm, scientifically based evidence.
The confidential inquiry into stillbirths and deaths in infancy has not set standards for care, “substandard” being decided at a regional level on the basis of individual cases. In contrast, the inquiry into maternal deaths has produced guidelines for good practice.2 3 Therefore, how valid are these estimates of substandard care, and how does one interpet differences among regions as the inquiry has not published interobserver studies? Until criteria for substandard care are set and interregional variation has been assessed it is misleading to publish these data without expressing considerble caution.
The inquiry examines only deaths, and the denominator of intrapartum care that does not result in death is ignored. There can therefore be only a speculative association between substandard care, however defined, and outcome. Before investigating certain factors further one would wish to establish that the level of substandard care in normal labours is different. Case-control studies may overcome such problems, but with the increasing use of obstetric computer databases in maternity care it should be possible to assess the risk associated with substandard care by multivariate analysis, using data from all intrapartum events.
Confidential inquiries may be useful audit tools, although there is no firm evidence of their effectiveness. Inquiries such as the confidential inquiry into stillbirths and deaths in infancy will not improve our knowledge of the antecedents to death unless rigorous epidemiological and clinical research methodologies are used to answer specific objectives.