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‘Encouraging’ results from use of new NHS care bundle aimed at reducing stillbirths

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Maternity experts have given a cautious thumbs up to best practice guidance on reducing stillbirths, after a major independent evaluation found it probably helped to prevent baby deaths.

The evaluation of the Saving Babies’ Lives Care Bundle (SBLCB) by the University of Manchester found a 20% reduction in the number of stillbirths at 19 “early adopter” trusts.

“The care bundle appears to work to reduce stillbirth rates but the evaluation suggests there is room for improvement”

Matthew Jolly

While researchers stressed the drop in stillbirths could not be specifically linked to use of the SBLCB, they concluded that the guidance was likely to have had an impact.

Meanwhile, they found an increase in the identification and monitoring of small babies and greater awareness of foetal movement among expectant mothers, with a high number raising concerns and an increase in scans and obstetric intervention as a result.

Overall, the report by the Tommy’s Centre for Stillbirth Research – based at the university – suggested that 161 stillbirths may have been prevented at trusts involved in the trial, with 1,106 fewer stillbirths across the whole of England between April 2015 and April 2017.

First launched by NHS England in March 2015, the SBLCB focuses on four key measures aimed at reducing stillbirths – reducing smoking in pregnancy, improved identification and monitoring of small babies, boosting awareness of foetal movements and effective monitoring during labour.

It was devised as part of a goal to halve the number of stillbirths, neonatal and maternal deaths in the UK by 2025.

The researchers found all elements of SBLCB were implemented to some extent in the 19 trusts who took part in the evaluation, which saw an increase in the use of structured screening for small gestational age and almost all women being screened for smoking using carbon monoxide monitors.

The majority of women were both given and read information regarding reduced foetal movements, with almost all going on to monitor their unborn child’s movements.

“This project shows the importance of continually developing and evaluating the care we give to women and babies”

Alexander Heazell

Meanwhile, a “buddy system” to improve interpretation of foetal heart rate traces in labour was in place in almost all maternity units.

Researchers found the stillbirth rate across the trusts who took part decreased from 3.31 to 4.14 per 1,000 live births, with an estimated 161 stillbirths avoided. There was also a reduction in term stillbirths.

However, the evaluators made it clear “we cannot specifically relate these changes to the SBLCB interventions”, partly because trusts had other maternity initiatives in place at the same time and may have embarked on the trial because they were already committed to making improvements.

“It was not possible to determine whether implementation of the SBLCB or any of its individual components per se reduces stillbirths or affects any of the associated clinical and service outcomes,” said the report.

“However, due to the nature of the interventions it is highly plausible that SBLCB contributed to the continued improvement in stillbirth rates in the early adopter trusts,” it said.

Detection of babies who were small for their gestational age increased by nearly 59%. In addition, mothers’ awareness of foetal movements was found to be “good” and was reflected in the high number of women – 36.5% – attending hospital due to concerns about reduced fetal movement.

“The findings from the evaluation give me cause for cautious optimism that we are now on the right track”

Jennifer Kurinczuk

The researchers found the number of ultrasound scans performed increased by more than a quarter – 25.7% – while interventions at or around the time of birth, such as inducing labour, increased by 19.4% and emergency Caesareans by 9.5%. There were also more pre-term births.

In all, they estimated the costs of implementing the care bundle across all trusts in England was £94m – with much of that made up of ongoing extra costs from more ultrasounds, inductions of labour and an increased number of costly deliveries.

While the results were encouraging in key areas, the evaluation found no evidence the care bundle had an impact on smoking rates and referral to stop smoking services described as “poor”.

The proportion of women smoking at the time they gave birth dropped from 14.3% before the trial to 11.8% afterwards. However, researchers concluded this was probably down to other factors, such as the fact that fewer people generally and smoking during pregnancy is now largely seen as less acceptable.

“There was no evidence for an increase in smoking cessation rates; rather this likely reflects a societal change as fewer women were recorded as smoking at booking,” said the report.

“Carbon monoxide monitoring was almost universal with high acceptance rates yet referral to smoking cessation services as poor and even when referred many women did not attend their appointments,” it said.

“It is highly plausible that SBLCB contributed to the continued improvement in stillbirth rates in the early adopter trusts”

Evaluation report

Meanwhile, a key recommendation to come out of the report was the need for robust staff training on the SLBCB itself and regular training on specifics such as interpretation of cardiotocography (CTG) – as set out in the guidelines.

A significant proportion of staff involved in the trial – 42% – said they were unaware of SLBCB, although they were implementing all or some of it as part of daily practice. “Awareness was lowest among frontline staff and highest in managers,” noted the report.

A need to improve the recording and monitoring of training was also identified. In all, 18 out of the 19 trusts said they trained most or all staff annually in CTG interpretation and auscultation, with one reporting they did not provide annual training in CTG.

But “very few trusts were able to provide records for staff training in CTG interpretation and auscultation and competency assessment for the whole five year evaluation period”, said the report.

Overall, the report’s findings were given a cautious welcome by experts who said they showed progress was being made.

NHS England

Matthew Jolly

Matthew Jolly

“Neither the 20% reduction in stillbirth rates nor the increased obstetric intervention with associated costs can be unequivocally attributed to the implementation of the care bundle, but it is highly likely that these are related,” said Dr Matthew Jolly, national clinical director for maternity and women’s health at NHS England.

But he added there was “room for improvement” in the resource and other guidance. “The care bundle appears to work to reduce stillbirth rates but the evaluation suggests there is room for improvement in both the care bundle and the guidelines the care bundle signposts,” he said.

He added: “The introduction of any new pathway carries a risk of ‘intervention creep’ and the increases of induction of labour and Caesarean section suggest there is an opportunity to better target obstetric intervention.”

Commenting on the launch of the report today, Dr Jolly went on to praise the “dedicated maternity staff” who had helped develop and implement the guidance.

“We know more can be done to avoid the tragedy of stillbirth and as we develop the 10-year plan for the NHS, we want to build on the progress we’ve made to make maternity services in England among the safest in the world,” he said in a foreword to the report.

University of Manchester

Alexander Heazell

Alex Heazell

Professor Alexander Heazell, professor of obstetrics at the University of Manchester, said the findings from the SLBCB were promising.

Importantly, this project has also highlighted areas which need further work – to reduce preterm birth and ensure that intervention is focused on women and babies who require it,” he said.

“This project shows the importance of continually developing and evaluating the care we give to women and babies,” he added.

Jennifer Kurinczuk, national programme lead for MBBRACE-UK, which publishes regular updates on quality of care linked to stillbirths and neonatal deaths, said it was still early days but described the results as “very encouraging”.

“The findings from the evaluation give me cause for cautious optimism that we are now on the right track,” she wrote in a foreword to the report.

“One further important consequence of the care bundle has been to raise the profile of stillbirths in trusts as deaths they should be concerned to prevent,” said Ms Kurinczuk, who is also director of the National Perinatal Epidemiology Unit at Oxford University.

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