The challenge

Babies born before arrival at hospital (BBAs) – for example when a baby is born unexpectedly at home, in a car or in an ambulance often without the presence of a qualified midwife or obstetrician – are at risk of hypothermia and associated complications.

In a rural and coastal region like the South West, families face additional challenges such as restricted access to services and long transfer times to hospitals, leaving their vulnerable newborns at greater risk.

Initial research funded by Health Innovation South West in 2021 found that over a third of babies arriving at hospital following a BBA in the South West were hypothermic. It also highlighted inconsistencies in how newborn temperatures were recorded in the pre-hospital setting.

The study identified inequalities in outcomes, with higher risk of hypothermia among preterm babies and babies of women with safeguarding concerns, as well as among first-time mothers and women reporting disabilities.

The solution

In response to these findings, NHS Digital and the International Academies of Emergency Dispatch changed 999 call-handling processes for women giving birth before arriving at hospital.

The findings also drove South Western Ambulance Service NHS Foundation Trust (SWASFT) to implement changes including a new record page for newborns within their electronic patient care system, updated training, delayed cord clamping, and infant warming mattresses in all frontline vehicles. A poster campaign reminded paramedics to check and maintain newborn temperatures.

An audit by SWASFT after these changes were introduced in 2024 revealed they had improved recording and management of prehospital thermal care for BBA babies, leading to a decrease in neonatal hypothermia during the prehospital episode.

In 2025/26, Health Innovation South West funded a new evaluation. A reaudit of hospital data confirmed that this decrease in neonatal hypothermia among babies born before arrival at hospital is reflected in hospital admissions, along with increases in advanced care for hypothermic babies, since these changes were made. 

The project, led by Dr Laura Goodwin, Associate Professor in Emergency Care at the University of West of England, Bristol, used routinely collected hospital data from five NHS hospital trusts in the South West.

Our work in partnership

Health Innovation South West’s support over the years has enabled Dr Goodwin to develop a programme of work focused on improving care for babies born before arrival at hospital.

This has included identifying the scale of neonatal hypothermia in the South West and working closely with ambulance services and call-handling organisations to support changes in local, national and international practice.

The repeat audit demonstrates how simple, evidence-based changes to service delivery can transform care in a rural and coastal place like the South West, as well as opportunities to tackle resident health inequalities in maternal and neonatal care.    

Our impact 

Previous research drove changes to South West ambulance practice, guidance and 999-call handling processes.

A repeat audit we funded in 2025-26 showed: 

• 17% of babies born before hospital arrived at hospital hypothermic, compared with 35% in the previous evaluation, and none of these babies were severely hypothermic
• 33% more hypothermic babies received advanced care, possibly reflecting increased recognition and escalation of care.

This re-evaluation is important because it provides evidence on whether changes made in practice are being reflected in clinical indicators at hospital admission. While it is not possible to attribute changes to any single intervention, the findings are consistent with improvements in the recognition and management of neonatal hypothermia across the system.

It also highlights where further work is needed, particularly in addressing ongoing inequalities. Vulnerable pre-term babies are always likely to become colder quicker. But other inequalities, like those around safeguarding concerns, have the potential to be tackled.

Dr Laura Goodwin, Associate Professor in Emergency Care, University of West of England, Bristol

What’s next?

The latest evaluation provides important evidence to inform targeted quality improvement and service development for equitable care in the South West and beyond. 

The results have been shared with local and national stakeholders to inform policy, training and service planning.