In 2016 NHS England released the Saving Babies’ Lives Care Bundle (SBLCB)¹ as part of the national ambition to reduce the rates of stillbirth. This first version appears to have contributed to the stillbirth rate in England falling to a historical low of 4.1 per 1,000.² An evaluation of the impact of the bundle has shown that in 19 trusts where work was carried out to implement these recommendations, rates of stillbirth fell by 20%.³ However there is more work to be done and in March 2019 NHS England launched the publication of the second version of the SBLCB,⁴ building on the achievements of version one and aiming to address the findings from the evaluation. Version two brings together five elements of care that are widely recognised as evidence-based and/or best practice; the new fifth element focuses on reducing preterm birth and improving outcomes when preterm birth is unavoidable to further decrease perinatal mortality.

Background

In November 2015, the Secretary of State for Health announced a national ambition to halve the rates of stillbirths, neonatal and maternal deaths and intrapartum brain injuries by 2030.⁵ The government now hopes to achieve this target by 2025, with a 20% reduction by 2020.⁶

Despite falling to its lowest rate in 20 years, one in every 200 babies is stillborn in the UK; this is more than double the rate of nations with the lowest rates. There are currently around 665,000 babies born in England each year and the SBLCB is part of a drive to halve the rate of stillbirths to 2.3 per 1,000 by 2025, potentially avoiding the tragedy of stillbirth for more than 1,500 families every year.

Independent evaluation of SBLCB Version 1

The care bundle approach is now a recognised and familiar method for improvement across the NHS. The SBLCB has been in operation in certain maternity units since 2015. NHS England commissioned an independent evaluation led by Professor Alex Heazell, Clinical Director of the Tommy’s Stillbirth Research Centre in Manchester. The detailed report shows that stillbirths fell by a fifth at the maternity units where implementation of the care bundle was evaluated over the two years to April 2017. The evaluation found that all trusts involved were implementing all elements of the care bundle to some degree and some of the key findings of the report were as follows:

• Stillbirth rates declined by 20% in the participating trusts during the period in which the care bundle was implemented.
• The proportion of women recorded as smoking at delivery reduced from 14.3% to 11.8%.
• Detection of small for gestational age (SGA) babies during the antenatal period increased by 59% in participating trusts during the implementation period.
• Units were more effective at monitoring the rates of babies’ growth in the womb and identifying when they were growing too slowly. However, this resulted in a number of other important changes in outcomes for women and their babies including an increase in the number of ultrasound scans (by 25.7%), increases in induction of labour (by 19.4%) and birth by emergency caesarean section (by 9.5%).

The evaluation concluded that neither the 20% reduction in stillbirth rates nor the increased intervention can be unequivocally attributed to implementation of SBLCB Version 1 but it is likely that these were related. Version 2 has been developed taking into consideration the recommendations published in the evaluation report, building upon the successful aspects identified and addressing increased interventions. The evaluation report is available to download from The University of Manchester website.⁷

SBLCB Version 2

The second version of the care bundle brings together five elements of care that are widely recognised as evidence-based and/or best practice setting out further improvements to reduce smoking in pregnancy, monitor reduced fetal movements, identify SGA babies and promote more effective cardiotocography monitoring in labour (TABLE 1).

TABLE 1 SBLCB Version 2: the five elements of care that are widely recognised as evidence-based and/or best practice.

The new version includes a greater emphasis on continuous improvement with a reduced number of process and outcome measures. It includes information about what women can do for themselves in preparation for a healthy pregnancy and provides a section on safe and healthy pregnancy messages to help women reduce the risks to their baby.

One of the key interventions in elements two and three of the new version is offering early births for women at risk of stillbirth. It is important that this intervention is not extended to pregnancies not at risk. The Atain (avoiding term admissions into neonatal units) programme⁹ has identified that babies born a 37-38 weeks’ gestation are twice as likely to be admitted to a neonatal unit as babies born at later gestations.

MBRRACE-UK surveillance data show that 70% of all stillbirths and neonatal deaths occur in babies born before term and nearly 40% are extremely preterm, being born before 28 weeks’ gestation.⁸ The new element is focused on reducing preterm birth, recommending the development of specialist preterm birth clinics across England and clinically appropriate use of magnesium sulphate. This is an additional element to the care bundle developed in response to the Department of Health and Social Care’s Safer Maternity Care report,⁶ which extended the maternity safety ambition⁵ to include reducing preterm births from 8% to 6%. The bundle tackles this by focusing on three areas:

1. prediction of mothers and babies most at risk of preterm birth
2. prevention of preterm birth through evidence-based intervention
3. adequate preparation when preterm birth is unavoidable despite this support, to ensure the best possible outcome.

To reduce differences in care across England the care bundle recommends implementation of new guidelines, Reducing Preterm Birt (2019),¹⁰ which have been developed by the UK Preterm Clinical Network.

Implementation of SBLCB Version 2

In 2019, NHS England released the NHS Long Term Plan¹¹ that includes much-needed plans to support every maternity unit in the country to implement the life-saving interventions of the care bundle.

It is important that SBLCB Version 2 should not be implemented in isolation but as one of a series of important interventions to help reduce perinatal mortality and preterm birth, including National Institute for Health and Care Excellence guidance and continuity of carer models, which are particularly important in improving outcomes for women and babies from black, Asian and minority ethnic backgrounds and economically disadvantaged groups.

The success of SBLCB Version 2 depends, of course, on successful implementation across England and it is heartening to see that the NHS Long Term Plan supports the government’s ambition and commitment to halve the number of stillbirths, maternal mortality, neonatal mortality and serious brain injury, and a reduction in preterm birth rate, from 8% to 6% by 2025.