Preventing deaths in the womb : Stillbirths inquiry

The UK currently has one of the worst stillbirth rates in Europe. In Wales – while the numbers of neo-natal deaths have fallen over the last few years - there are around four stillbirths every week (~150 per year).

That's shockingly high and a real eye-opener – probably because it's not a particularly nice thing to think about. I imagine it takes a terrible toll on prospective parents.

Last June, the Assembly's Health & Social Care Committee held a special one day inquiry into stillbirths, hearing evidence from medical professionals and charities like Sands (Stillbirth and Neonatal Death Society).

The committee reported back last week, making nine recommendations, summarised as :

• Improved public awareness of the risks associated with stillbirths, as well as improved/targeted training programmes for health professionals dealing with stillbirths and stillbirth post-mortems.
• The establishment of a "maternity network" to standardise care across Wales.
• The Welsh Government should investigate providing more specialist foetal medicine consultations in Wales, as costs of providing services outside Wales are now said to be exceeding the costs of providing an indigenous service.
• Improved clinical research into the causes of stillbirths.

Causes and risk factors

Stillbirths are deaths of a baby in the womb after 24 weeks. Deaths before 24 weeks are miscarriages. Babies that die shortly after birth are neonatal deaths. I touched on this in my post on abortion last year.

Most causes appear to be problems with the blood supply between mother and foetus, or problems with the placenta itself – including bleeding during labour. There are numerous medical conditions that could exacerbate this, like pre-eclampsia (high blood pressure during pregnancy).

There are also genetic and congenital abnormalities that can cause stillbirths. I'm familiar with them, but I needn't go into any details for reasons of taste. Some maternal infections are a cause too.

In terms of risk factors, having twins/multiple pregnancies is said to increase the chances of a stillbirth. There's a clear risk to older mothers, increasing above age 35 and doubling above age 40.

Overall lifestyle is another risk factor - as you might expect. Smoking more than 10 cigarettes a day during pregnancy doubles the risk. 16% of prospective Welsh mothers are said to smoke during pregnancy. Stillbirth rates are higher amongst obese mothers.

There's also a clear link with deprivation. Mothers living in deprived area are said to be 1.7 times more likely to have a stillbirth than one living in a less-deprived area.

Clinical & Public Awareness

Stillbirths are more common than cot deaths and conditions
like Down Syndrome, yet public (and clinical) awareness remains poor.
(Pic : ITV Wales)

Sands say that many parents who experience a stillbirth end up "shocked" at how common stillbirths actually are. Conditions like Down Syndrome and cot death are openly discussed, but awareness around stillbirths is quite low – simply because medical professionals don't have enough knowledge or training to deal with it.

There are said to be "warning signs" of a stillbirth, namely : reduced foetal movement and reduced foetal growth/weight gain.

Evidence from an obstetrics specialist suggests that clinical awareness is limited amongst medical professionals, and that medical schools are "reducing their obstetrics curricula rather than extending them."

The Chief Nursing Officer said prospective mothers need to be made more aware of risk factors, but "professionals have been reluctant to raise it." This is despite stillbirths being "ten times more common than cot deaths."

Bodies like the British Medical Association are keen to change this. A national Stillbirth Working Group has been set up to work with charities like Sands to oversee possible ways to raise public awareness.

Standards of care

The committee were "shocked" by the "failure of routine antenatal care to identify babies at risk of stillbirth." It's said that 1 in 3 stillbirths are simply down to poor standards of care. Specialists also said a third of stillbirths occur amongst babies "who are otherwise healthy" and would have survived if they were delivered before whatever complication caused their stillbirth.

It's been recommended that care be standardised across Wales through the creation of a clinical network (collaboration) - even via a "virtual" one. However, in an update about the Stillbirth Working Group, the Welsh Government said "there is no funding for an obstetric network." 

Identifying babies at risk


It's said high risk mothers are "readily identified", but identifying high risk babies in low risk mothers is an issue.

There's also an issue about delayed births/post-term delivery, which is another risk factor. Because of pressure on maternity services - from a number of different directions - some mothers might be delivering babies over two weeks past their due date. It's said that this may simply be because the mothers are reluctant for anyone to intervene. It's suggested delayed births should be closely monitored.

There's too much variance in monitoring reduced foetal movement and reduced foetal growth. Some medical professionals may have different ideas about what qualifies as either, or will have been trained differently. The Welsh Government say they're looking at successful practises in Scandinavia and are keen to introduce them across Welsh maternity units.

Staffing issues

There's a lack of specialist obstetricians. There's currently only two fully-trained foetal medicine consultants in Wales and both are based in Cardiff. Many patients have to travel to Liverpool or Bristol. However, contrary to popular belief regarding these things, it's said that providing a service in house would work out cheaper.

Although there was praise from Local Health Boards for how the Welsh Government determines staffing requirements, the number of midwives in Wales has fallen for three years in a row.

Equally important to this, but perhaps slightly unpleasant, is the issue of baby post-mortems. There's currently the equivalent of just one specialist "baby pathologist" in Wales. Parents are therefore reluctant to have babies undergo a post-mortem, as there's considerable delays and the body might have to travel across the country.

It's said that proper research into cot deaths reduced them by 70%. Post-mortems would provide a valuable opportunity to research causes of stillbirths, but medical professionals are said to be reluctant to "broach the subject" with parents – perhaps understandably.

Conclusions

Developmental biology is an interest of mine, that's why I decided to cover this in case you were wondering.

I think we conveniently forget how dangerous childbirth and pregnancy is - both to mothers and babies. Midwives and obstetricians aren't there for show, and they undergo intensive training to deal with all sorts of issues specific to pregnancy and childbirth.

You wouldn't want to get dental treatment from a GP, would you? Just as a shortage of dentists would impact oral health, shortages of midwives and obstetricians would affect childbirths. You might not think they're the most important members of NHS staff, but you'll appreciate them if you need them.

Pregnancy and childbirth have been romanticised into something "miraculous", as if played out on TV dramas as a few grunts, pushes and a baby appears. Nothing goes wrong, and it all ends with a mother cooing. Nope.

Neural tube defects - by themselves - are perhaps proof positive that a caring, infallible Creator doesn't exist. A foetus with anencephaly or harlequin icthyosis isn't a "miracle of life", it's a pretty big screw up. If deaths from things like that can be prevented by educating mothers or identifying mothers at risk – do it.

I was taken aback by some of the revelations in this inquiry, namely the lack of consistency in medical training – which is pretty serious! Some of the numbers involved were also unnerving, bordering on scandalous.

We're hardwired to want to protect babies, that's why moving things like neo-natal services and issues like stillbirths will tug at heartstrings. Increasingly, it feels as if maternity services are coming under strain in Wales as emphasis is shifted towards those nearing the end of their lives as we all live longer.

Well, those coming into the world are equally fragile. Hopefully this short, sharp, shocking committee inquiry will serve as the slap across the head that Lesley Griffiths and Local Health Boards need. The problem, as always, is the issue of where the resources are going to come from. It's probably worth it though.

I don't know how many "one day inquiries" have been held in the Assembly's history, but if they're as hard-hitting as this one, it should be done more often.