Care for premature babies in England is compromised by a shortage of nurses and overcrowded special units, the National Audit Office has found.

Huge regional variations mean that babies who need care after birth are more than twice as likely to die in the southwest Midlands than they are in Surrey and Sussex.

Although this is partly a result of the different social and ethnic mix, the audit office says that demography is not a complete explanation. Real differences in the quality of care cannot be ruled out.

The study found serious problems in the way that care is organised and provided, in spite of a Department of Health review in 2003 and some resulting improvements since.

There are “significant shortages” of trained nurses across England – an average of three whole-time nurses for each unit, a roughly 10 per cent shortfall – and baby units are often operating above capacity.

Units had to close their doors to new admissions an average of once a week during 2006-07, mainly because of a lack of nurses or cots, it said. The more demanding the nursing skills, the greater the shortages.

Only at the lowest level of care needed (special care) was the British Association of Perinatal Medicine (BAPM) guideline ratio of one nurse to every four babies being met.

Only half of units had the right staff-to-baby ratio for high-dependency care (one nurse to two babies) and less than a quarter did for intensive care (one nurse to one baby). A third of units were operating above the 70 per cent capacity recommended as a guideline by the BAPM.

Three units were operating above 100 per cent capacity, meaning that there were more babies in cots than trained staff to care for them.

“These high-occupancy rates could have consequences for patient safety, for example due to the increased risk of infection or inadequate levels of care,” the report said.

Demand for care for at-risk babies is rising, for a multitude of reasons. Birth-rates generally are rising, and many mothers delay having children until they are well into their thirties or even forties, which increases the risk. In addition, the proportion born to mothers of nonUK origin has risen sharply, from 12.8 per cent in 1996 to 21.9 per cent in 2006. Women from ethnic minority communities may be less likely to attend antenatal clinics, increasing the risk that dangers in pregnancy go undetected.

Services are struggling to keep up. The 2003 plan set up 23 regional networks, within which hospitals should cooperate so that the available units are used to best advantage.

The aim was to avoid lengthy cross-country transfers for newborns and to maximise the use of the available staff and hardware. The audit office report says that the plan has worked for the most part. Most vulnerable babies these days do not need to be sent by ambulance out of their region.

Death rates, at 3.5 per 1,000 live births, are comparable to those of European countries and have fallen. About one in ten babies born every year – 62,471 in 2006-07 – needs specialist neonatal care for reasons such as prematurity, low birthweight or conditions such as a heart defect.

Care is provided at three different levels of rising sophistication: special care, high-dependency care and intensive care. As babies grow, they should move seamlessly to the lower levels of care; or if they get worse, they should move to higher levels. In fact, more than half of units were caring for babies who were ready for transfer to less specialist care, but for whom cots were unavailable. And a third of units were caring for babies who needed a higher level of care, putting extra pressure on staff and “leading to a reduction of appropriate medical input for other babies on the unit”.

The wide variations in death rates remain largely unexplained. In 2005, the south west Midlands network had the highest death rate at 4.8 babies per 1,000, while the figure was only 1.8 in Surrey and Sussex. Deprivation cannot be the only cause. Some networks in areas with high levels of deprivation also had some of the lowest death rates.

The National Audit Office said that units had little idea what their services actually cost. Some hospital trusts believed they were making a profit from the service, while others thought they were losing money.

A spokeswoman for Bliss, a premature baby charity, said: “We strongly welcome the report. Particularly worrying is the finding that one third of all units reported having to care for a baby who should have been transferred to a higher level of care. More babies are being born each year and more of them are being admitted to neonatal units after birth. The report has found that there is no strategic plan in place to manage this.”

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