The research looks in detail at events leading up to these deaths, 1 in 4 of which are the result of inadequate resources and staffing levels. It also reports that national guidelines are not being followed for many aspects of care.

The research found that many of these cases are the result of inadequate funding and support for healthcare staff. It also reports a lack of resources, meaning National guidelines during antenatal care are not always followed.

For too long, parents have not been consulted and lessons have not been learned despite research repeatedly finding that many deaths are potentially preventable and are related to the quality of care mothers and babies receive

Key findings include:

• Deaths of 8 out of 10 babies in the enquiry might have been prevented with better care.
• In at least 1 in 4 cases inadequate staffing or resources was a factor
• National guidelines during antenatal care were not followed for half of women, meaning opportunities were missed to care for them.
• In 7 out of 10 deaths there were problems in how labour or birth were managed.
• Although 74 of the 78 deaths were reviewed by the local hospital team, the quality of most reviews was poor and didn’t follow national standards.
• For 1 in 2 bereaved mothers, care after her baby had died was considered poor enough to have affected her psychosocial wellbeing and any plans she might have had for a future baby

In light of these findings both MBRRACE-UK and Sands are calling for a number of actions to prevent future labour-related deaths.

Read the full report, summary and lay summary on the MBRRACE-UK website.