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To assess implementation of the Saving Babies Lives (SBL) Care Bundle, a collection of practice recommendations in four key areas, to reduce stillbirth in England. A retrospective cohort study of 463,630 births in 19 NHS Trusts in England using routinely collected electronic data supplemented with case note audit (n = 1,658), and surveys of service users (n = 2,085) and health care professionals (n = 1,064). The primary outcome was stillbirth rate. Outcome rates two years before and after the nominal SBL implementation date were derived as a measure of change over the implementation period. Data were collected on secondary outcomes and process outcomes which reflected implementation of the SBL care bundle. The total stillbirth rate, declined from 4.2 to 3.4 per 1,000 births between the two time points (adjusted Relative Risk (aRR) 0.80, 95% Confidence Interval (95% CI) 0.70 to 0.91, P<0.001). There was a contemporaneous increase in induction of labour (aRR 1.20 (95%CI 1.18-1.21), p<0.001) and emergency Caesarean section (aRR 1.10 (95%CI 1.07-1.12), p<0.001). The number of ultrasound scans performed (aRR 1.25 (95%CI 1.21-1.28), p<0.001) and the proportion of small for gestational age infants detected (aRR 1.59 (95%CI 1.32-1.92), p<0.001) also increased. Organisations reporting higher levels of implementation had improvements in process measures in all elements of the care bundle. An economic analysis estimated the cost of implementing the care bundle at ~£140 per birth. However, neither the costs nor changes in outcomes could be definitively attributed to implementation of the SBL care bundle. Implementation of the SBL care bundle increased over time in the majority of sites. Implementation was associated with improvements in process outcomes. The reduction in stillbirth rates in participating sites exceeded that reported nationally in the same timeframe. The intervention should be refined to identify women who are most likely to benefit and minimise unwarranted intervention. The study was registered on (NCT03231007); www.clinicaltrials.gov.

Background Reducing stillbirth and early neonatal death is a national priority in the UK. Current evidence indicates this is potentially achievable through application of four key interventions within routine maternity care delivered as the National Health Service (NHS) England’s Saving Babies’ Lives care bundle. However, there is significant variation in the degree of implementation of the care bundle between and within maternity units and the effectiveness in reducing stillbirth and improving service delivery has not yet been evaluated. This study aims to evaluate the impact of implementing the care bundle on UK maternity services and perinatal outcomes. Methods The Saving Babies’ Lives Project Impact and Results Evaluation (SPiRE) study is a multicentre evaluation of maternity care delivered through the Saving Babies’ Lives care bundle using both quantitative and qualitative methodologies. The study will be conducted in twenty NHS Hospital Trusts and will include approximately 100,000 births. It involves participation by both service users and care providers. To determine the impact of the care bundle on pregnancy outcomes, birth data and other clinical measures will be extracted from maternity databases and case-note audit from before and after implementation. Additionally, this study will employ questionnaires with organisational leads and review clinical guidelines to assess how resources, leadership and governance may affect implementation in diverse hospital settings. The cost of implementing the care bundle, and the cost per stillbirth avoided, will also be estimated as part of a health economic analysis. The views and experiences of service users and service providers towards maternity care in relation to the care bundle will be also be sought using questionnaires. Discussion This protocol describes a pragmatic study design which is necessarily limited by the availability of data and limitations of timescales and funding. In particular there was no opportunity to prospectively gather pre-intervention data or design a phased implementation such as a stepped-wedge study. Nevertheless this study will provide useful practice-based evidence which will advance knowledge about the processes that underpin successful implementation of the care bundle so that it can be further developed and refined. Trial registration www.clinicaltrials.gov NCT03231007 (26th July 2017)

IntroductionThe Saving Babies’ Lives Care Bundle (SBLCB) was introduced in England in 2015 and was updated in 2019 (SBLCBv2). This study aimed to describe the degree to which SBLCBv2 was implemented in practice and describe contemporary experiences of receiving and delivering antenatal and intrapartum care informed by the recommendations of SBLCBv2.MethodsThis cross-sectional questionnaire study was conducted in 28 National Health Service maternity units across England between October and December 2023. The study had two arms, one for maternity service users and one for healthcare professionals. Maternity service users aged ≥16 years who had given birth in the last 12 months were invited to participate in an online survey which contained closed questions about elements of the SBLCBv2, and two free-text questions about their experiences of receiving antenatal and intrapartum care. Maternity healthcare professionals from participating sites were invited to complete a separate questionnaire about delivering care. Responses were summarised by descriptive statistics.Results1140 women and 633 healthcare professionals participated. The majority of staff reported implementing all five elements of SBLCBv2, though this varied from 57% (prevention of preterm birth) to 99% (smoking cessation). Service users frequently reported receiving interventions that were part of SBLCBv2: 26% were offered Aspirin and 97% monitored fetal movement. Staff generally reported positive experiences of implementing the SBLCBv2, feeling that it supported clinical decision making. 89% and 86% of service users reported a positive experience in pregnancy and labour, respectively. This was underpinned by positive staff attitudes, behaviours and communication, and being listened to and involved in decisions about care.ConclusionsSBLCBv2 has been integrated into clinical practice, though some elements require additional focus to increase implementation (e.g., preterm birth). Maternity staff may benefit from additional training to discuss the reasons for and results of interventions to reduce the risk of pregnancy complications.

IntroductionThe UK Department of Health have targeted a reduction in stillbirth by 50% by 2025; to achieve this, the first version of the Saving Babies’ Lives Care Bundle (SBLCB) was developed by NHS England in 2016 to improve four key areas of antenatal and intrapartum care. Clinical practice guidelines are a key means by which quality improvement initiatives are disseminated to front-line staff.MethodsSeventy-five clinical practice guidelines covering the four areas of antenatal and intrapartum care in the first version of SBLCB were obtained from 19 maternity providers. The content and quality of guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Maternity health professionals in participating organisations were invited to participate in an anonymous survey to determine perceptions toward and experiences of the use of clinical practice guidelines using a series of Likert scales.ResultsUnit guidelines showed considerable variation in quality with median scores of 50%–58%. Only 4 (5.6%) guidelines were recommended for use in clinical practice without modifications, 54 (75.0%) were recommended for use subject to modifications and 12 (16.7%) were not recommended for use. The lowest scoring domains were ‘rigour of development’, ‘stakeholder involvement’ and ‘applicability’. A significant minority of unit guidelines omitted recommendations from national guidelines. The majority of staff believed that clinical practice guidelines standardised and improved the quality of care but over 30% had insufficient time to use them and 24% stated they were unable to implement recommendations.ConclusionTo successfully implement initiatives such as the SBLCB change is needed to local clinical practice guidelines to reduce variation in quality and to ensure they are consistent with national recommendations . In addition, to improve clinical practice, adequate time and resources need to be in place to deliver and evaluate care recommended in the SBLCB.

Human placental villi are covered by a layer of trophoblast epithelia in direct contact with maternal blood, which exist in a constant steady-state of turnover and renewal ensuring both maternal and fetal health. The process of trophoblast turnover involves proliferation, differentiation and fusion of cytotrophoblast cells to form a terminally differentiated outer syncytiotrophoblast layer which functions as the active transport compartment between mother and fetus. Alterations in the balance between these three processes are thought to diminish both the structural and functional integrity of the syncytiotrophoblast, potentially leading to placental insufficiency associated with severe complications of pregnancy such as pre-eclampsia (PET), intrauterine growth restriction (IUGR) and sudden infant death syndrome (SIDS). Placentas from early (<32 weeks) and late-onset (>33 weeks) pregnancies complicated by PET, IUGR, SIDS and gestational age-matched controls were systematically uniform randomly sampled to assess the morphological basis of placental villous structure and trophoblast turnover (villi, cytotrophoblast, syncytiotrophoblast, apoptotic syncytial knots) using unbiased stereological techniques (volumes and numbers). Villous cytotrophoblast proliferation was assessed using double immunohistochemistry for Ki67 and cytokeratin 7 (CK-7). Severe early-onset IUGR placentas (n=5) were smaller displaying significant reductions in the total number of CT cells, within which the density of proliferating CT was further reduced by 50%. Syncytiotrophoblast volume and number was significantly reduced with an increase in apoptotic syncytial knots. Late-onset IUGR placentas (n=4) also displayed significant reductions in the total number of CT and proliferating CT, but were not associated with changes in the density of proliferating CT. SCT numbers were significantly reduced with an increase in apoptotic knots. Placentas from severe early-onset PET (n=11) were similar to preterm controls, except for a significant increase in apoptotic syncytial knots. However, late-onset PET (n=6) displayed a significant decrease in total CT number, the percentage of which undergoing proliferation was significantly increased for structural villi. There were increased numbers of apoptotic syncytial knots in peripheral villi.