Results of study on prehospital births driving improvements to urgent neonatal care

The findings of a South West Academic Health Science Network funded study exploring outcomes for babies born outside of hospital are driving improvements to urgent care for newborns. 

Births Before Arrival at hospital (BBAs) – where a baby is unexpectedly born at home, or in a car or ambulance, often without the presence of a qualified midwife or obstetrician – account for around 0.5% of UK births. ¹  A key concern for babies born outside the hospital environment is hypothermia.  

In 2022, the South West AHSN launched a project to examine the circumstances around BBAs, specifically which women were most at risk of giving birth before arriving at hospital (Phase A) and the type of neonatal temperature management advice given to callers who ring 999 for the ambulance service about a BBA (Phase B). 

The project was part of the South West AHSN’s Perinatal Health Equity Programme and led by Laura Goodwin, Associate Professor in Emergency Care at University of West of England, Bristol.  

The study, now complete, has yielded learning in neonatal temperature management for UK emergency care that is already being implemented in the South West and taught to paramedics across England. The research has also highlighted potential barriers in inequalities research. 

Managing neonatal temperature outside of hospital  

Newborns can become cold quickly in the prehospital setting. For every 1oC below 36.5⁰C, the relative risk of death rises by at least 28%. ²   

Associate Professor Goodwin’s previous work suggests that paramedics do not consistently record newborn temperatures following BBA in the South West. ³ When neonatal temperatures are recorded by paramedics, the majority (72%) of babies are hypothermic. ^2,3

However, because temperatures were recorded so infrequently (less than 3%) it wasn’t clear whether most newborns were becoming hypothermic in the prehospital setting, or if paramedics were just measuring temperatures of babies they thought might be cold.  

By effectively managing hypothermia in the prehospital setting, it is thought better outcomes for BBAs can be achieved. 

Understanding risk factors for BBA 

In Phase A of the study, the temperatures of babies arriving at hospital from the ambulance service were analysed to establish how many were hypothermic on arrival across six trusts in the South West. The data were also used to explore possible inequalities, by looking at who might be most likely to have a BBA, and which babies were most likely to be hypothermic on arrival.  

184 babies featured in the study, of whom 35% were hypothermic when they arrived at hospital. Most (75%) were classed as having ‘cold stress’ (having a body temperature between 36⁰C and 36.4⁰C  ⁴) but 25% were classed as either ‘moderately’ or ‘severely’ hypothermic, where warming was needed urgently to prevent poor outcomes.  

Due to the low number of babies in the study and the difficulties assessing ethnicity data, the findings did not strongly indicate that any one factor posed a high risk for BBA. Despite these limitations, there were some interesting correlations: 

• Safeguarding concerns were present in 22% of BBA cases, compared to 3% in the general population of those giving birth in the South West 
• Women and birthing people who had a BBA were generally first booked in with a medical professional regarding their pregnancy at a later stage than the rest of the birthing population in the South West. 

Findings linked to hypothermia 

Pre-term babies were much more likely to be hypothermic on arrival than term babies (82% vs 32%). All of the pre-term and term babies with hypothermia were more likely to: 

• Need advanced care and/or admission to a Neonatal Intensive Care Unit (NICU). 
• Stay in hospital for seven days or more and require treatment such as glucose, radiant heat and an incubator. 
• Be the birthing person’s first child. 

Furthermore, the birthing people whose babies were hypothermic were more likely to report disabilities at their booking appointment (9%, as opposed to 2% for normothermic babies). 

Relationships in the data vs causality 

As these findings are only correlations, causality cannot be assumed. For example, an infant with health difficulties is likely to arrive unexpectedly, requiring a longer stay in hospital even if they had not been hypothermic.  

From a health equity perspective, it was hoped that the study would be able to uncover whether ethnicity had a role to play in BBAs, perhaps due to relationships with medical professionals, or a lack of appropriate language resources.  

Unfortunately, the data could not be compared to national or local maternity data sets because of differences in the way that ethnicity is recorded in trusts and at a national level. The South West AHSN is working with local trusts to try and resolve this issue. Crucially this finding has brought to light the potential barriers in inequalities research that need to be addressed moving forward. 

Neonatal temperature management advice  

Phase B analysed 999 calls relating to imminent birth and looked specifically at the advice given by call handlers around neonatal temperature management. This involved analysing redacted transcripts from 28 calls taken from South Western Ambulance Service NHS Foundation Trust (SWASFT) and North East Ambulance Service NHS Foundation Trust (NEAS), which both use algorithms to direct call handlers. SWASFT uses Advanced Medical Priority Dispatch System (AMPDS) whereas NEAS uses NHS Pathways. 

The next step involved two sets of focus groups. The first set comprised NHS staff, including midwives, paramedics, neonatal nurses and doctors, learning development officers and call handlers, and looked at what advice was given around keeping the baby warm, how that advice was delivered, and how it compared to the clinicians’ ideas of best practice. 

The main issues from these conversations were then taken to the second set of focus groups comprising people who had lived experience of BBAs either as a parent or someone who had made a 999 call about an imminent birth. They looked at the current advice that is given around temperature management, considered the ideas put forward by NHS staff, and discussed the accessibility of the advice given. 

Five main themes were identified as impacting on neonatal temperature management during 999 calls. These included:  

• The importance placed on neonatal temperature. 
• Advice on where the baby should be placed following birth. 
• Advice on how to keep the baby warm. 
• The timing of temperature management advice. 

• The clarity and priority of instructions. 

Within these themes, participants noted some potential barriers to good quality neonatal thermal care in the advice currently scripted in UK emergency service algorithms. Suggested changes, supported by NHS staff and members of the public include: 

• Highlighting the importance of neonatal temperature to callers. 
• Encouraging skin-to-skin contact and removing advice that ends with babies being put on the floor/bed. 
• Offering specific warming measures rather than general advice to ‘keep the baby warm’. 

• Using long gaps in conversation (i.e., while waiting for an ambulance) to promote warming and check advice has been followed. 
• Reviewing the order of advice currently given to ensure actions are correctly prioritised. 

Staff also noted that the cost-of-living crisis may have had an impact on being able to keep babies warm, where in some cases a birthing person and their baby could be waiting hours for paramedics in a cold house due to concerns about heating costs. 

Driving real care improvements for families  

The South West AHSN provided the University of the West of England with additional funding to support conversations with key stakeholders to turn the projects findings into real improvements for families in the South West and beyond. 

SWASFT has also applied the learning from the research to improve neonatal temperature measurement and management. This includes: 

• A staff-facing ‘winter campaign’ around neonatal hypothermia with a poster displayed at ambulance stations. 
• Carrying out an audit of axillary thermometers, with a view to replacing lost or broken equipment. 
• Creating a new record page for newborns within the electronic patient care system which highlights the need for neonatal temperature measurement and management.  

At the University of the West of England, Nick Miller, who is also part of the study team and a senior lecturer in Paramedic Science, has been supporting the real-life impact of the BBA work by integrating temperature management as a key learning outcome for Paramedic Science students in their Year 3 maternity simulations. This change in the curriculum took place in 2021.   

The research team has also worked closely with Róisín McKeon-Carter, who is a neonatal nurse consultant and safety champion in Neonatal Services at University Hospitals Plymouth, and Chair of the Neonatal Nursing Association. With Roisin’s support Associate Professor Goodwin has presented at the British Association of Perinatal Medicine Spring Conference 2023, the 999EMS Research Forum Conference, where she won an award for ‘Research most likely to affect practice’, and at the Bristol Patient Safety Conference, winning second place in the poster competition. Associate Professor Goodwin will also be presenting this work at the Wales and South West Maternity and Midwifery Festival 2023 in Cardiff in September. 

Future work 

Associate Professor Goodwin’s team has used additional funding from the South West AHSN to support conversations with stakeholders such as NHS Pathways and AMPDS to consider ways in which they might be able to improve the neonatal warming advice given during emergency calls regarding prehospital birth. If successful, these improvements could then be rolled out at a national level. 

Summarising the next steps for the project, Associate Professor Goodwin said: 

 “We know there are pockets of good practice across the country, which we’ve been coming across as our research has progressed. We’d love to bring them all together and create a standardised list of evidence-based interventions for prehospital neonatal hypothermia, to ensure babies born before arrival are kept warm, and given the best opportunities to thrive. We’re grateful to the South West AHSN for allowing this opportunity!” 

The impact from the second part of the study will be published by early 2024. However, one of the initial outcomes is an agreement in principle from both NHS Pathways and AMPDS to make changes to their call handler advice on neonatal temperature management with support from Associate Professor Goodwin.

If you have any questions, please contact Associate Professor Laura Goodwin at Laura.goodwin@uwe.ac.uk or via Twitter @laurakgoodwin.

References

¹ Loughney A, Collis R, Dastgir S. Birth before arrival at delivery suite: Associations and consequences. British Journal of Midwifery. 2006;14(4):204-208

² Adamsons K, Towell ME. Thermal homeostasis in the fetus and newborn. The Journal of the American Society of Anesthesiologists. 1965;26(4):531-548

³ Goodwin L, Voss S, McClelland G et al. Temperature measurement of babies born in the pre-hospital setting: analysis of ambulance service data and qualitative interviews with paramedics. Emerg Med J. 2022;39(11):826–832 

⁴ WHO. Thermal Control of the Newborn: a practical guide
https://apps.who.int/iris/bitstream/handle/10665/60042/WHO_FHE_MSM_93.2.pdf?sequen