New study exploring equitable outcomes for babies born out of hospital
Around 0.5% of all UK births happen out of hospital unexpectedly, whether at home, in a public place, or in a car or ambulance while the mother is on the way to hospital, without the presence of a qualified midwife or obstetrician.
These births, known as Birth Before Arrivals (BBA), are often associated with unfavourable outcomes for the newborn, including hypothermia.
As part of its new Perinatal Health Equity Programme, the South West Academic Health Science Network (South West AHSN) is delighted to launch a new project focused on BBAs, to understand which women are most at risk of giving birth before arriving at hospital and investigate the neonatal temperature management advice given to callers who ring 999 for the ambulance service about a BBA.
The project is being led by Dr Laura Goodwin, Senior Research Fellow in Emergency Care at University of West of England and part of the Research in Emergency Care, Avon Collaborative Hub (REACH). Dr Goodwin is an experienced researcher, with a background in both prehospital care and inequalities in maternal and perinatal outcomes.
Our South West AHSN Maternal and Neonatal Programme Manager, Sally Hedge, interviewed Dr Goodwin, as the project begins, to understand more.
Sally Hedge (SH): Hi Laura, can you tell me more about births of babies before arrival at hospital? How is it different to a home birth?
Laura Goodwin (LG): Home births are usually planned by the parents-to-be, and support will be in place in advance.
In contrast, BBAs are, by their nature, unexpected, and often the mother, father or another bystander is talked through the birth process by a 999 call-handler, with paramedics arriving either just before, or sometimes after, the baby has arrived. It is estimated that 3,700 BBAs are attended by the UK ambulance service each year.
In my previous research , 1,582 individual births were identified as BBA between February 2017 – February 2020 in the region serviced by the South Western Ambulance Service NHS Foundation Trust (SWASFT). This region covers the entire South West, from Bath and Gloucestershire, south to Wiltshire, and west to Cornwall and the Isles of Scilly. This is approximately 530 babies born before arrival at hospital per year, on average.
SH: Why are BBAs an issue? Are there increased risks involved?
LG: Yes – and one of the primary risks, for the baby, is hypothermia. This occurs when the baby’s temperature drops below 36.5°C. Newborns lose body heat quickly; for every minute that a newborn is exposed, their temperature can drop by approximately 0.1°C – 0.3°C.  This isn’t usually an issue in a hospital setting or homebirth, as the environment will be controlled (i.e. by putting the heating on, preparing warm blankets etc.). However, in a BBA, the birth is usually unexpected and people often don’t have time to make these preparations. BBAs can also occur in the car or outside, where it isn’t possible to create any kind of warm environment for the baby to be born into. The risk of hypothermia for babies born before arrival at hospital is recognised by the Joint Royal Colleges Ambulance Liaison Committee, and noted in their guidance to paramedics  for that situation.
SH: The South West AHSN is interested in helping to close the gaps in inequalities in the health and wellbeing of mothers and families. Can you give more detail on why BBA is potentially a health equity issue, Laura?
LG: The literature suggests there are some contributing risk factors for BBA, including ethnic group, age, parity (meaning the number of previous births a mother has had), antenatal care, etc. Some of these risk factors are the same things that increase the risk of poor outcomes for babies in general. So we think it is important to try to understand which women are most at risk of BBA, which babies are most likely to be cold on arrival, and how this interacts with outcomes such as mortality, length of hospital stay, and the need for special care/interventions.
Previous reports around inequalities in maternal and perinatal outcomes suggest increased risk of poor outcomes for women who do not engage with, or who have had little engagement with, maternity services. This includes concealed or teenage pregnancies, as well as women from migrant or minority ethnic backgrounds, who might not speak English well and therefore not fully understand instructions from 999 call handlers. We will be looking at all the demographic data to establish whether these hypotheses are correct, and whether there are more groups that are also at risk.
SH: What is the project aiming to achieve, other than investigating the demographics of BBAs?
LG: We know that often the most vulnerable women are those who do not engage with services until the time of the emergency call, so a change to the way that the emergency episode is managed is therefore more likely to have direct impact than carrying out a public health campaign. We will be investigating (and potentially improving on) the advice given to women regarding neonatal temperature management during 999 calls relating to BBA.
The Healthcare Safety Investigation Branch produced a report in Feb 2022  which looked at the advice being given by call handlers during pre-hospital births. Some of the information that was being given to those on a 999 call around a labouring mother was conflicting and potentially poor or problematic, but the scope of the report was not around ensuring that good advice was given. Instead it called for investigations to be done on this. Happily, we were planning this already!
We also want to investigate ways to support better temperature management of babies in the prehospital setting, and will be using the data from this report to feed into a funding bid to look at that in the future.
SH: Tell me about how the project will be carried out.
LG: Phase A is a data-gathering exercise, looking at the number of BBAs in Somerset, Devon, Cornwall and the Isles of Scilly, and the proportion of those babies who are below the lower temperature limit (36.5°C) on admission. We want to look at the babies’ outcomes, (i.e. need for special care, length of hospital stay, interventions/treatment needed, and mortality). We’re also going to be examining the demographic information around the mothers/parents of these babies (i.e. ethnicity/migrant status of parents, age of mother, geographical location, deprivation index, and more) in order to understand more about potential risk factors for BBA and/or poor outcomes.
We are delighted that all seven local NHS trusts have signed up to participate in this research.
Phase B will look at transcripts from real-life 999 calls regarding BBA and analyse the advice that is given around managing the baby’s temperature.
Phase C will discuss the findings of Phase B with focus groups comprising NHS staff in relevant disciplines and members of the public who have experience of prehospital birth, either as the mother or the person who called 999. We will be looking for volunteers for these groups in early summer 2022.
SH: What’s the timescale you’re working with, Laura?
LG: Phase A and Phase B are now up and running. We will start recruiting for Phase C in May or June 2022, with our report due to be published in November 2022.
SH: The South West AHSN has been involved from the beginning, providing funding and project management, and facilitating links with local NHS Trusts and other key individuals and organisations. How are you finding working with us so far?
LG: It’s been great! There is a lot of involvement and great support in finding the right people. I’ve noticed more volunteers and enthusiasm than previous work. Being part of the wider Maternal and Neonatal Safety Improvement Programme community is also really helpful.
SH: What impact are you hoping your research will have?
LG: Primarily, we want to improve outcomes for babies born unexpectedly outside of a hospital setting. This work is focused on the babies, but it’s also the case that better outcomes for them lead to better outcomes for their parents too. Our route to doing this is by improving the call handlers’ scripts, or algorithms, for prehospital delivery situations, to enable good temperature management advice to be given.
We are also hoping to do future work to support paramedics and ambulance staff to manage temperature of newborns more effectively. We have already had brilliant engagement from SWASFT and other ambulance services in taking this forward.
SH: Thank you for your time Laura, we look forward to working with you this year, and seeing your results in the winter.
If you would like to find out more about the Birth Before Arrival project, including becoming involved, please contact Dr Laura Goodwin (firstname.lastname@example.org).
The South West AHSN’s Perinatal Health Equity Programme has been set up to identify and spread innovative practice that can help to close gaps in perinatal health and care in South West England. Learn more about our Perinatal Health Equity Programme on our webpage.
The Birth Before Arrival project builds on previous work by the South West AHSN’s Maternal and Neonatal Safety Improvement Programme. Place of birth and thermoregulation are also elements of PERIPrem (Perinatal Excellence to Reduce Injury in Premature Birth), a bundle of 11 interventions designed to reduce brain injury and death caused in premature birth. The South West AHSN and West of England Academic Health Science Network are driving adoption of PERIPrem throughout the South West.
 Loughney A, Collis R, Dastgir S. Birth before arrival at delivery suite: Associations and consequences. British Journal of Midwifery. 2006;14(4):204-208.
 Office for National Statistics Dataset: Vital statistics in the UK: births, deaths and marriages, 2020 https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/vitalstatisticspopulationandhealthreferencetables. Accessed 20 October 2020.
 Goodwin L, Voss S, McClelland G, Beach E, Bedson A, Black S, Deave T, Miller N, Taylor H, Benger J. Temperature measurement of babies born in the pre-hospital setting: analysis of ambulance service data and qualitative interviews with paramedics. Manuscript submitted for publication.
 Adamsons K, Towell ME. Thermal homeostasis in the fetus and newborn. The Journal of the American Society of Anesthesiologists. 1965;26(4):531-548.
 Joint Royal Colleges Ambulance Liaison Committee, Association of Ambulance Chief Executives. JRCALC Clinical Guidelines 2019. Somerset: Class Professional Publishing; 2019.
 Maternity pre-arrival instructions by 999 call handlers, Healthcare Safety Investigation Branch, 2022. https://hsib-kqcco125-media.s3.amazonaws.com/assets/documents/hsib-report-maternity-pre-arrival-instructions-by-999-call-handlers.pdf
Image: Solen Feyissa