I wrote the first version of this post back in 2020 as the Each Baby Counts program ended. The perinatal mortality data set for 2022 was published this month, so it seems like an appropriate time to update the progress of efforts in the UK to reduce perinatal deaths.

Back in 2015, the Royal College of Obstetricians and Gynaecologists (based in the UK) launched their “Each Baby Counts” program. The program set an ambitious target to reduce perinatal mortality and severe brain injury in term babies by 50% by the year 2020. Several of the recommendations that were aimed at achieving this related to fetal monitoring in labour – like making sure CTGs were offered to women with risk factors and that staff who worked with CTG monitoring being required to attend annual CTG training, so it caught my attention. The program closed in 2020.

What was the starting point?

Perinatal mortality is the total number of stillbirths (fetal deaths in the second half of pregnancy) plus deaths of the newborn in the first few days or weeks. The Each Baby Counts program also counted babies born with brain injury. In 2015, the perinatal mortality rate PLUS the rate of babies with brain injury for term pregnancies (37 to 42 weeks) in the UK was 1.57 per 1000 births. A 50% reduction (meaning the Each Baby counts program was a success) would have meant a reduction to 0.79 per 1000 births.

Where did things get to in 2020?

In 2020, deaths and brain injury occurred at a rate of 1.52 per 1000 term births. 12% of the babies included in this outcome were lost to stillbirth, 13% experienced early neonatal death (first seven days after birth), and 75% had severe brain injury. In 72% of cases, at least one reviewer had the opinion that the outcome might have been prevented had care been different. There was also no change in this rate, having been 76% in 2015. It is fair to say then that not only had there been no change to the outcome of interest, there also appears to have been little improvement in the rate of poor care provision.

Where did things get to in 2022?

I need to change counting systems here as the best place to now go to when tracking perinatal outcomes is the Mothers and Babies: Reducing Risk through Audits and Confidential Enquires or MBRRACE-UK, report. The latest report was published this month and provides outcomes for the year of 2022. They use different definitions as they have a slightly different focus, so I need to take you back to 2015 once again, but using the MBBRACE-UK data instead. The numbers are higher as they are also counting babies prior to term.

In 2015, the rate of stillbirths was 3.87 per 1000 births and for neonatal death (now measured out to 4 weeks of life rather than one) the rate was 1.74 per 1000 births. The total perinatal mortality rate in 2015 was therefore 5.61 per 1000 births. MBRRACE-UK don’t provide information on brain injury, so I can’t track how that changed over time.

By 2020, the rates were 3.33 per 1000 for stillbirth and 1.53 for neonatal death, a perinatal mortality rate of 4.86 per 1000 births. This small reduction was bigger than what was seen in the Each Baby Counts program over the same time period. Why? Quite probably because much of the improvement has happened for preterm pregnancy, rather than at term. This is when the risk of death is higher, so it is easier to shift the dial by changing care earlier in pregnancy (though it is still not an easy thing to shift).

In this month’s 2022 report, there was a slight reversal of the previous progress. The stillbirth rate was 3.35 per 1000, and neonatal mortality was 1.69 per 1000, giving an overall perinatal mortality of 5.04 per 1000. Why has it gone back up again?

Looking at the graphs showing rates over time (you can find them here), 2020 was a bit of an outlier with a greater fall in neonatal death than was the case over the previous 7 years. Both 2021 and 2022 have seen a rise back to rates seen in the pre-pandemic years. Stillbirth rates didn’t drop in 2020, but they did rise in 2021 and then settled back to the same rate as in 2019.

There is no doubt that the pandemic changed the structure and delivery of healthcare, not to mention the daily lives of women. Research confirms little change in stillbirth rates during lockdowns around the world (Calvert et al, 2023), but a more consistent reduction in preterm birth rates – which are in turn strongly linked to neonatal deaths. This matches what we can see in the changes around 2020. The cause for the fall in preterm birth seems more likely to have been due to the big changes in women’s lives rather than changes in healthcare provision (though it could be both).

Why is it so hard to reduce mortality rates?

The Each Baby Counts goal was wildly over optimistic. Yes – change happens, but changes to perinatal mortality have always been slow, incremental, and with some set backs. Public health programs aiming to reduce perinatal mortality are effectively forms of research. You make a guess informed by current knowledge about what you think will work, you try it out, and you look to see what happened. Good researchers understand that they also need to examine closely the assumptions they make and consider the impact these assumptions have on their findings. I’m not convinced that people who make decisions about maternity system changes aimed at preventing perinatal death do this, or do this well.

MBRRACE-UK seeks to generate new knowledge by reviewing data from health services about poor outcomes. MMBRACE-UK then assumes that sharing this knowledge will lead to a permanent change in practice and an improvement in outcomes. I’m going to call this assumption the quality improvement assumption. This is a common assumption in healthcare services, and is a feature of a managerial approach that has been called New Public Management (Siltala, 2013). There is actually little hard evidence to show that quality improvement processes robustly achieve improvements in quality or safety in healthcare.

The other important assumptions that shape this body of knowledge are the framework through which data were examined and the tools used to generate knowledge. When the MBRRACE team review cases, the framework used is strongly aligned with an obstetric world view. The assumptions built in to that framework are that women’s bodies are a site of risk for the fetus, it is the role of the clinician (particularly the midwife) to detect this risk and to initiate additional monitoring, and that midwives must detect abnormalities in this monitoring (generally based on obstetrical standardised understandings of how women’s bodies function). Having detected the problem, the midwife is expected to communicate this with an obstetric staff member, who is meant to take a course of action designed to prevent the anticipated risk. The decision to use these particular frameworks excludes other possible ways to frame up what went on and why things happened the way they did. In making this choice, the focus is predominantly on the role played by individual clinicians within the healthcare system, ignoring the birthing woman or person as an active agent, the role of the healthcare system, and the impact of the social world outside healthcare.

There is the distinct possibility then that findings generated by these quality improvement processes don’t adequately explain the reasons for the poor outcomes. Given that the recommendations then stem from these reviews, there is the possibility that they might have little impact on perinatal outcomes as the don’t address the actual problem, or they are unable to address the problem effectively. At worst, there may be perverse consequences where other harms occur but are under-measured (like maternal traumatic stress).

Work to improve maternity care processes and outcomes is important. It is also important that it is done well. We should perhaps question whether current quality improvement processes are the best way to do this given the cognitive biases that the obstetric worldview brings to maternity care. The solutions to improving perinatal outcomes are likely to be found in social change and health system reform which are principally aimed at improving the social welfare of reproductive age women.

References

Calvert, C., Brockway, M., Zoega, H. et al. (2023). Changes in preterm birth and stillbirth during COVID-19 lockdowns in 26 countries. Nature: Human Behaviour, 7, 529–544. https://doi.org/10.1038/s41562-023-01522-y

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