Units that look after premature babies are being run without the recommended numbers of staff to monitor critical changes in their condition, new figures show, amid concern over an "alarming" spike in deaths.
Guidance states that the minimum nurse-to-baby ratio in neonatal wards should be 1:1 (nurse to baby) for babies receiving intensive care, 1:2 for high-dependency care and 1:4 for special care.
Around 4,400 babies are born prematurely (under 36 weeks) every year in Scotland.
Experts say that for babies to have the best chance of survival they must be cared for in a unit that is able to give them the right level of clinical care and by the right number of well-trained staff.
However, figures obtained by The Herald show that most Scottish health boards that have neonatal units are breaching 'safe' staffing guidelines.
NHS Lothian data shows that 62% of shifts met the standard set by the British Association of Perinatal Medicine (BAPM) from April 1 2022 to March 31 of this year but the health board said this exceeded the national average of 57.9%.
Borders said 184 shifts (out of 1460 ) over the past two years were "recognised as being below required level in neonatal units".
On a further 57 occasions information regarding staffing was not completed.
NHS Tayside said staff shortages in its neonatal unit were raised on 322 occasions over the past two years.
READ MORE: Third 'mystery' spike in baby deaths probed by public health experts
In one month, January 2022, levels fell below recommended levels 43 times at Ninewells Hospital's neonatal unit.
The figures show 116 shifts were red-flagged from January to October this year compared with 206 the previous year.
The health board insisted that the figures were based on the initial roster and prior to any mitigating actions being taken including staff being relocated from other areas.
A spokeswoman added: "Since the beginning of 2022, the escalation process to mitigate any unexpected gaps in nursing numbers in NICU has only been invoked on one occasion when it was quickly resolved using the measures outlined in the escalation process to ensure safe staffing levels."
NHS Greater Glasgow and Clyde said there were 28 occasions recorded in its three neonatal units where staffing did not meet the standard over the past two years.
The board said that only two of these incidents were identified as having a "moderate impact" on care.
Neonatal staffing was red-flagged on 20 days this year at Raigmore Hospital, until November 21, up from 17 days for the previous year.
NHS Lanarkshire said that providing the data would exceed charging thresholds contained in Freedom of Information legislation.
The board said Datix incident reporting system recorded 29 incidents where “staff shortages" were logged in the neonatal unit at Wishaw General from November 14 2021 to November 14 2023.
It comes as new figures show deaths of newborns in Scotland have hit a 15-year high.
Forty one neonatal deaths, defined as when a baby dies in the first 28 days of life, were recorded in the three months to the end of September.
The number equates to 3.4 neonatal deaths per 1,000 live births, the highest rate recorded since September 2008.
The figures come amid an expert review commissioned by the Scottish Government into unexplained spikes in neonatal mortality in September 2021 and March 2022, when 39 infants died.
Dr Sarah Stock, an expert in maternal medicine at Edinburgh University, told The Herald last year that maternity and neonatal services were "stretched".
READ MORE: NHS Tayside had UK's second highest rate of stillbirth during first year of pandemic
NHS Grampian said 84% of shifts were staffed as per BAPM recommendations from October 2021 – October 2023.
Where this was not possible the board said "safe staffing" was ensured daily through a combination of mitigating actions including the closure of beds, movement of staff or transfer of patients to other areas.
The Royal College of Nursing (RCN) in Scotland said The Herald's figures showed that staffing in neonatal units was "an ongoing challenge."
In NHS Dumfries and Galloway there were ten occasions in 2022 where staffing did not comply with recommended ratios and three instances this year.
READ MORE: Neonatal deaths investigated at Scottish health board
NHS Ayrshire and Arran said it does not record the data for 1:1, 1:2 and 1:4 care ratios but provided figures which showed that between January and October this year there were four months where all shifts did not meet the standard.
Eileen McKenna, Associate Director for Nursing, Policy and Professional Practice at the Royal College of Midwives (RCM) said: “Neonatal nursing staff are pivotal in providing parents, babies and their families with high-quality care, yet staffing remains an ongoing challenge in neonatal units across Scotland as these figures demonstrate.
“It is vital that appropriate numbers of qualified specialist nursing staff are trained and retained to ensure safe care and to meet the national standards, and the requirements of Scotland’s safe staffing Act which is due to be implemented next year.”
Beth McCleverty, policy manager at the charity Bliss, which campaigns for standards in neonatal care, added: “Evidence shows that there is a chronic understaffing of neonatal services, and workforce levels do not currently meet safe staffing standards set out by national bodies.
“Babies born premature and sick need to be cared for by a fully staffed, multidisciplinary team of healthcare professionals to have the best outcomes.
“For the safety and quality of neonatal services to be maintained and improved there must be continued investment to ensure that services are staffed in line with national standards, as well as investment in training and Allied Health Professional services.”
Some health boards including Orkney, Shetland and the Western Isles do not offer specialised neonatal care and are therefore not included in the analysis.
A report published in October found evidence of "unacceptable" variations in neonatal care between units in Scotland, England and Wales.
The National Neonatal Audit Programme (NNAP) report collects and analyses data relating to babies discharged from neonatal units in 2022.
Death rates varied between neonatal networks; from 4.8% to 8%.
The proportion of neonatal nurse shifts that met recommended staffing levels in 2022 fell for the second year in a row (from 78.6% in 2020 to 73.9% in 2021 and now to 71.1% in 2022).
Public Health Minister Jenni Munro said: “We are committed to ensuring that high quality maternity care is delivered in the safest possible way for mothers and babies.
“Neonatal cot capacity is monitored across Scotland daily to help identify emerging pressures on Neonatal Units, including pressures which may have resulted from staffing challenges.
“The Health and Care (Staffing) Act ensures high quality care and improved outcomes in both health and care services by helping to ensure appropriate cover.
”The Act will commence in April 2024.”
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