Personal Injury, Serious Injury & Clinical Negligence

Report identifies Improvements in Maternal care needed to reduce stillbirths

Academics from the University of Leicester have led a team as part of the Maternal, Newborn and Infant Clinical Outcome Review Programme to investigate singleton stillbirths, born at term with no congenital abnormality.

The team (reporting for MBRRACE-UK) reviewed a sample of 133 stillbirths from 2013 and carried out a comprehensive review of the pregnancy notes, checking the care provided against national care guidelines.

Report findings

The findings show the following:

  • More than half of all the cases looked at showed at least one element of care requiring improvement which may have made a difference to the outcome
  • Where women presented with a risk factor for diabetes, two thirds were not offered testing
  • National guidance for screening and monitoring growth of the baby was not followed for two thirds of cases reviewed
  • Almost half of mothers had contacted their maternity units with concerns that there had been a change in fetal movement and there were missed opportunities for follow up with a lack of investigation, wrong advice given on the heart trace or a failure to respond to other factors.
  • Internal review documentation was available only in a quarter of cases with highly variable review quality

Although there were positive findings in respect of bereavement care, the above findings show opportunities missed and avoidable harm.


Recommendations include implementation of national guidance on the following:

  • Screening and identification of women who should be offered testing to detect those at risk of developing diabetes
  • Routine measurement of baby’s growth with symphysis fundal height measurement and detailed plotting of the growth at antenatal appointments from 24 weeks of pregnancy
  • Management of reduced fetal movements

This report comes a week after Jeremy Hunt, Secretary of State for Health announced a fund of £4 m to be used by trusts specifically to improve maternity care and to reduce stillbirth rates. (See our blog dated 17 November).

Health Minister, Ben Gummer said:

Last week we launched our ambition to halve stillbirths, neonatal deaths, maternal deaths and neonatal brain injuries, through cutting-edge technology and multi-disciplinary training. The MBRRACE-UK recommendations will help the NHS to further improve and shape future, safer care.

Dr David Richmond, President of the Royal College of Obstetricians and Gynaecologists (RCOG) said:

Although fewer babies in the UK are stillborn today, it’s desperately disappointing that the four recommendations from this report remain exactly the same as when the last confidential enquiry took place 15 years ago. Today’s report suggests six in ten of these stillbirths are potentially avoidable. We can and should do better by the 1,000 families affected by stillbirths that occur before a woman goes into labour each year in the UK.

If you or a family member has been affected by the issues in this article please contact our Clinical Negligence Team on 0800 316 8892 who will be able to advise you further.