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Publication of the latest MBRRACE-UK Perinatal Mortality Surveillance Report and Learning from Standardised Reviews when Babies Die; the first year of Perinatal Mortality Review Tool (PMRT) data

By James Titcombe

 

This month has seen the publication of 2 important reports: the fifth MBRRACE-UK Perinatal Mortality Surveillance Report [1] looking at perinatal mortality in the UK in 2017, and the first report examining themes from the first 1,500 reviews completed using the Perinatal Mortality Review Tool (PMRT) in the first year of its implementation; Learning from Standardised Reviews When Babies Die [2].

A national focus on reducing perinatal mortality

The Government in England have committed to a target to reduce perinatal mortality in the NHS by 50% by 2025 and 20% by 2020 [3]. This target is supported by a comprehensive strategy overseen by the national maternity transformation programme.

The reports published this month offer a useful insight into progress as well as highlighting areas that need further focus and improvement.

Positive progress… but more to do

In 2017, there were 2,840 stillbirths and 1,267 neonatal deaths in the UK. Overall, the extended perinatal mortality rate decreased compared with 2016. This was largely due to a fall in the stillbirth rate and, more particularly, in the rate of stillbirths of babies who had reached term. Compared with the first MBRRACE-UK perinatal mortality surveillance report in 2013, this represents around 500 fewer deaths in 2017.

Over the last 7 years (2010-2017) the stillbirth rate in the UK has reduced by 18.5% and neonatal deaths by 6.8%. Whilst this is positive progress, if the government’s 2025 target is to be met, stillbirth and neonatal mortality rates in the UK will need to further reduce each year by 4% and 5.4% respectively. In order to achieve this, MBRRACE state that ‘…renewed efforts need to be focused on implementing existing national initiatives…’ and that ‘…particular emphasis should be placed on reducing preterm birth.’

 

Themes found by MBRRACE-UK

Preterm births
The largest reduction in stillbirth and neonatal deaths was in babies that died at term (37 – 41 weeks), which accounted for half of the reduction reported in the report. The number of babies that were stillborn between 24-27 weeks gestation increased in 2017 when compared to previous years (2014-2016).

Variation
Despite positive progress overall, the MBRARACE report found variation in perinatal mortality across the UK, even when the rates are adjusted for socioeconomic factors. In around a quarter of Trusts, stillbirth and neonatal mortality rates were more than 5% higher than the overall UK average.

There was significant variation in neonatal mortality rates for Trusts and Health Boards which care for the most complex pregnancies and births, with rates between 0.98 and 1.79 per 1,000 births in those with Level 3 Neonatal Intensive Care Units (NICUs) and surgical provision (after exclusion of congenital abnormalities).

Ethnicity
Mortality rates remain high for Black or Black British and Asian or Asian British babies. Whilst stillbirth rates for these groups have reduced over the period 2015 to 2017 from 8.17 to 7.46, neonatal mortality rates have increased over the same period from 2.45 to 2.77. There is an urgent need to do more to address this disparity.

Birthweight
Most neonatal deaths and stillbirths occur in babies born with a weight below 1500g, although there has been an overall reduction in mortality for this group (555 babies in 2016 to 524 babies in 2017). The largest reduction in mortality when looking at birthweight was for babies born at 2,500 – 3,499g.

Twin Pregnancies
The reduction in both the stillbirth and neonatal death rate ratios associated with twin pregnancies (relative to singletons) over the period 2014 to 2016 has not been sustained, with small increases in risk seen in 2017 for stillbirths from 1.60 (95% CI, 1.36 to 1.88) to 1.93 (95% CI, 1.65 to 2.25) and for neonatal deaths from 3.33 (95% CI, 2.80 to 3.98) to 3.53 (95% CI, 2.97 to 4.21).

Intrapartum Care Improvements
There has been a substantial reduction in stillbirths recorded as having an intrapartum cause in the CODAC classification of cause of death from 189 (5.8%) stillbirths in 2014 to 51 (1.8%) stillbirths in 2017.

Improvements in Reporting
Carbon Monoxide monitoring data has increased from 36.4% (2015) to 48.3% (2017), which will likely have been impacted by guidance within the Saving Babies’ Lives Care Bundle (2016). In addition, the proportion of stillbirths reported as having an unknown cause of death was reduced from nearly half (46%) in 2014 to around a third in 2017 (35%).

 

The Perinatal Mortality Review Tool (PMRT) report

The national Perinatal Mortality Review Tool (PMRT) was launched in early 2018 with the fundamental aim of supporting objective, robust and standardised review to provide answers for bereaved parents about why their baby died. The tool is also designed to better enable local and national learning to improve care and ultimately prevent future deaths.

In England, Scotland and Wales, where the PMRT is currently being used, more than 5,000 families are bereaved every year when their baby dies. The recently published report presents data from the first 1,500 reviews conducted.

Themes from the PMRT report

Issues with care
Over 90% of all reviews identified at least one issue with care, with an an average of four issues per death reviewed. Around 1 in 10 reviews identified issues with care that may have made a difference to the outcome. Overall, a third of cases identified a need for improvement.

Parental Awareness and Involvement
Parents were told that a review of was taking place in 84% of cases. ‘Parent Engagement’ [4] materials have recently been developed by a multi-disciplinary group within the MBRRACE-UK/PMRT collaboration, to help improve parent involvement going forward.

Around 42% of parents who made comments about the review had no concerns over the care they were given, and over a quarter of comments were about care in labour.

The quality of reviews
The report found that only 9% of reviews involved an external panel member and only 16% of the reviews undertaken included the minimum recommended review composition and 41% of reviews did not involve a neonatologist. Among all neonatal death reviews (346), only 1 involved the minimum number of panel members

Changing Practice
In total, 3010 issues that required action were identified and incorporated into action plans. However, of these only 10% were system-level focussed, half of all actions plans were graded as ‘weak’ and only 10% considered ‘strong’.

Conclusion

The reports published this month suggest that the national initiatives to reduce perinatal mortality across the UK are starting to make a real impact on outcomes. However, to meet the governments 2025 ambition, the rate of perinatal mortality reduction over the next few years will need to increase. A particular focus is needed on making further progress with the initiates already in progress, including the implementation of the second Saving Babies Live Care Bundle [5], launched in March this year.

Whilst the overall direction of change is encouraging, the analysis shows that there is still considerable variation in perinatal outcomes (even when the rates are adjusted for socioeconomic factors) across different Trusts. It is particularly alarming that perinatal mortality rates amongst Black or Black British and Asian or Asian British babies are significantly higher than other groups and addressing this disparity must be an urgent priority.

The introduction of the Perinatal Mortality Review Tool (PMRT) is a welcome initiative set to play an important role in both improving how parents are involved in the review process after their baby dies and also improving local and national learning to ensure changes are made to improve care in the future. However, it is clear that the effectiveness of this tool is currently limited by the capacity for local organisations to carry out reviews to the required standards, with full input from multidisciplinary panels and external representation. It is also crucial that action plans are developed that address the systemic factors that contribute to poor outcomes and that lessons are shared across the system

Baby Lifeline is committed to supporting safer maternity care, including through provision of high quality, expert-led, multi-professional training courses. The newly developed, 2-day, Learning from Adverse Events course has been specifically designed to provide local organisations with the skills needed to carry out effective local reviews. The full catalogue of Baby Lifeline’s training is available here.

References

1. Draper, ES., Gallimore, ID., Smith, LK., Kurinczuk, JJ., Smith, PW., Boby, T., Fenton, AC. And Manktelow, BN. on behalf of the MBRRACE-UK Collaboration. (2019). MBRRACE-UK Perinatal Mortality Surveillance Report, UK Perinatal Deaths for Births from January to December 2017. Leicester: The Infant Mortality and Morbidity Studies, Department of Health Sciences, University of Leicester.

2. Chepkin, S., Prince, S., Johnston, T., Boby, T., Neves, M., Smith, P., Bevan, C., Bidwell, P., Brocklehurst, P., Draper, ES., Fenton, A., Heazell, A., Kenyon, S., Knight, H., Knight, M., Luyt, K., Manktelow, B., Siassakos, D., Smith, L., Storey, C., Tuffnell, D. and Kurinczuk, J. (2019). Learning from Standardised Reviews When Babies Die, National Perinatal Mortality Review Tool: First Annual Report. Oxford: National Perinatal Epidemiology Unit.

3. Maternity Safety Programme Team, Department of Health. (2017). Safer Maternity Care. Retrieved 22nd October 2019.

4. National Perinatal Epidemiology Unit. (2019). Parent Engagement Materials | PMRT | NPEU. Retrieved 22nd October 2019.

5. NHS England. (2019). Saving Babies’ Lives Version Two: A Care Bundle for Reducing Perinatal Mortality. Retrieved 22nd October 2019.

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