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Babies' deaths linked to suboptimal care

BMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6982.757 (Published 25 March 1995) Cite this as: BMJ 1995;310:757

Over 40% of the deaths in healthy babies in Britain that occur during birth are linked to suboptimal care, said a government report last week. The first investigation into the deaths of 388 babies by the confidential inquiry into stillbirths and deaths in infancy found that the main failures were “human beings and the particular circumstances in which they found themselves.” The report states, “This human factor included insufficient skills, inappropriate attitudes and apparent lack of senior accountability.”

Failure to react to abnormal cardiotocographs was the commonest reported problem, although induction procedures were criticised for lack of senior supervision, inadequate monitoring, and overdosage with prostaglandins or oxytocin. In 43 of the cases poor resuscitation technique contributed to the baby's death. In one case a junior paediatrician tried to intubate a baby four times. “This removed any chance the baby might have had,” said the report.

The inquiry was set up in 1992 to look at deaths in normal babies of between 20 weeks of gestation and one year of birth. Deaths are reported confidentially to regional centres and assessed by a panel of obstetricians, midwives, paediatricians, pathologists, general practitioners, and anaesthetists. Using anonymised case notes and postmortem reports the panel grades the care and feeds back its comments to the inquiry's national advisory board. The inquiry primarily focused on intrapartum deaths.

Nearly two thirds of the intrapartum and early neonatal deaths were attributed to asphyxia. Almost 40% of the cases were associated with serious complications such as antepartum haemorrhage, ruptured uterus, or shoulder dystocia. The commonest criticism of obstetricians was failure to act appropriately, whereas midwives and general practitioners were more likely to have failed to recognise problems. All professions are criticised for poor communication. “Difficulties with resuscitation were often compounded by communication problems…particularly between senior and junior staff and in identifying the need for paediatric attendance early enough for cover to be arranged,” says the report.

The report acknowledges that the subjective nature of the panel's grading system and the lack of denominators limits the accuracy of the inquiry's data. “The routine data, particularly from the maternity hospital episode system, which was needed as a source of denominator and comparative data on all births, was of poor quality,” said Alison Macfarlane, of the National Perinatal Epidemiology Unit and a member of the inquiry's national advisory board. “Without good data how can you find out about the more substantive things such as the quality of care?”

The report recommends the use of clinical guidelines for the management of complicated pregnancies and that hospitals provide multidisciplinary training sessions in risk management, communications, resuscitation, and the interpretation of cardiotocographs. The inquiry found an excess of maternal medical complications in their cases and recommends improvements in risk management in diabetes, post-term pregnancy, and infection.

David James, professor of fetomaternal medicine at the University of Nottingham and member of the Trent region confidential inquiry team, said that the report emphasised the importance of assessing risk. “All the regional reports reflect that there are well established practices that are not being followed, such as those for interpreting cardiotocographs. Cardiotocograph abnormalities are associated with fetal hypoxia—they do not identify every case, but where abnormalities are present they are associated with an increased risk to the baby,” he said.

“My hope is that this report will have the same effect as the confidential inquiries into maternal deaths. The idea is that the key recommendations are implemented into practice. From the maternal inquiry some lessons were quickly taken on board. There was an obvious risk associated with maternal anaesthesia and caesarean section, and the anaesthetic profession made sure that it tackled this area by ensuring the seniority of anaesthetic staff, the use of antacids, and crash inductions. There was a dramatic fall in deaths due to anaesthesia”.

The report also includes preliminary results from the inquiry's ongoing casecontrol study into sudden unexpected infant deaths. So far 101 deaths, each matched with four controls, have been classified as sudden unexpected infant deaths. The inquiry's findings confirm several of the known characteristics for such deaths such as being of lower birth weight or being born to younger mothers.

There was no association found between the type of mattress slept on by the baby and sudden death, but over half the mothers whose babies died had smoked during pregnancy compared with less than a quarter of controls. The report acknowledges that the numbers in the study are currently too low to analyse fully for confounding factors.–LUISA DILLNER, BMJ