MBRRACE-UK has published a confidential enquiry report into term antepartum stillbirths. The report was based on a detailed review of 85 cases against national care guidelines by a panel of clinicians, including midwives, obstetricians and pathologists who considered every aspect of the care.

The most concerning findings from the review were:

  • Half of all term, singleton, normally-formed, antepartum stillbirths had at least one element of care that required improvement which might have made a difference to the outcome.
  • Two thirds of women with a risk factor for developing diabetes in pregnancy were not offered testing – a missed opportunity for closer monitoring.
  • National guidance for screening and monitoring growth of the baby was not followed for two thirds of the stillbirths reviewed.
  • Almost half of the women had contacted their maternity units concerned that their baby’s movements had slowed, changed or stopped. In half of these there were missed opportunities to potentially save the baby including a lack of investigation, misinterpretation of the baby’s heart trace or a failure to respond appropriately to other factors.
  • Documentation indicating that an internal review had taken place was only present in one quarter of cases and the quality of these reviews was highly variable.
  • Only half of the stillbirths selected for confidential enquiry had a post mortem carried out.

You can read the full report or a lay summary on the MBRRACE-UK website. The key findings are also summarised in the infographic below.


Stop Still Comment: The findings of the review are absolutely shocking. But they will come as no surprise whatsoever to many parents whose babies have died, who will recognise the common themes – these failings are happening every single day, up and down the country. The report makes a number of important recommendations, targeted at different groups of people from policymakers down to individual hospitals. Acting on these recommendations will be crucial in ending preventable stillbirths.