Science

Still

I had both of my babies at home, the first in a small two up two down terraced house, the second in the slightly larger house that we still live in, just a couple of streets away. Both are within 5 minutes drive of a major teaching hospital.

My girls were born safe and healthy, with no problems or complications. I was lucky.

Bad things happen.

In my first delivery, the midwife arrived early, which is to say, she set out after the second phone call because, she’d had a bad experience the night before (the cord caught around the baby’s neck as it was being pushed out, and she had struggled to keep the baby alive). Since it turns out that I’m the kind of woman who has 3 hour labours (the average is closer to 12 hours)  if she’d left it much later she’d have arrived too late.

The second midwife (one attends for the mother, one attends for the baby) failed to arrive in time. Since she’s the one who brings the pain relief (air and gas) it was a short but painful birth, with a first degree tear (not stitched – should have been stitched, never rely on nature to fix a raggedy labial tear).

But in conversation about the Vicky Foxcroft article afterwords, I took exception with one commentator who suggested that planned home births were the reason for the high still birth rate in the UK. It’s just not factually correct.
Babies are classed as stillborn if they die at any point after 28 weeks of pregnancy, up to the birthing process itself which is when half occur. Over 98% of stillbirths happen in low and middle-income countries. Pakistan has a rate of 43.1 for every 1,000 children born – that’s one in every 23 mothers finding out their baby is dead.

But bad things happen everywhere.

For every 1,000 babies born in Britain, 2.9 are stillborn (based on at least 28 weeks of gestation) – more than twice the rate of 1.4 in Iceland. Britain is now 21 out of 35 of the world’s wealthy countries according to the Lancet Stillbirth Series (2016). Croatia, Poland and Czech Republic have better stillbirth rates than the UK.

Equally worrying is the UK’s annual rate of reduction, which is now just 1.4% – placing us 114th globally for progress on stillbirths.

So what aren’t we doing as well as we might?

The Netherlands, which has cut its rates by almost 7%, hasn’t just improved care during the birth, but focused on women’s health while they are pregnant and even before that too. In particular, it has had a huge programme to reduce maternal smoking, as well as structured investment in analysis and understanding of each stillbirth.

Here in the UK, underlying the overall rate of 2.9 per 1000, the survey found mothers in the most deprived areas were up to twice as likely to experience a stillbirth as the country’s most affluent mums – although that research only covered the years up to 2005. Poorer mothers are more likely to smoke and more likely to be either significantly overweight or underweight, all risk factors for stillbirth.

And this is why I think I was so offended by the references to home birth in the context of still birth. In order to reduce the rate of stillbirth in the UK, it’s important to understand the risks, where they arise and what can be done to mitigate them.

Both the UK and Iceland have tiny levels of home births, both around 2% of annual births. Stillbirth, like most birth, is a hospital phenomena in the main (98%) of cases. If we want to improve our rates of stillbirth, we need to tackle the real causes.

  • 10 babies are stillborn every day in the UK.
  • In women with a BMI over 30, the risk rises to 1 in 100 (from 2.9 per thousand). An increasing BMI is associated with an increased incidence of pre-eclampsia, gestational hypertension, macrosomia, induction of labour and caesarean deliveries.
  • Underweight mothers also have an enhanced risk of stillbirth where being underweight (a BMI of < 19.9 kg / m2) has been shown to be associated with an increased risk of preterm deliveries, low birth weight and anaemia and a decreased risk of pre-eclampsia, gestational diabetes, obstetric intervention and post-partum haemorrhage
  • Women who smoke have an enhanced risk of stillbirth. In meta-analysis research carried out by BMC Public Health smoking during pregnancy was significantly associated with a 47% increase in the odds of stillbirth.
  • Around half of all stillbirths are linked to placental complications.
  • Other causes include bleeding before or during labour, placental abruption, pre-eclampsia, a problem with the umbilical cord, obstetric cholestasis, a genetic physical defect in the baby, pre-existing diabetes, and infection in the mother that also affects the baby.
  • Reduced fetal movement is a good indicator of stillbirth, with slowing down of movement noticed by the mother in two out of three stillbirths.

Still, Dr David Richmond, consultant gynaecologist and president of the Royal College of Obstetricians and Gynaecologists, describes the survey as a “wake-up call”.

In the UK, there is still much to be done to ensure our rate of progress is as good as the best in Europe.

Through the Each Baby Counts initiative, we are this year beginning to undertake a structured review of each and every stillbirth that occurs during labour in term pregnancies to help identify common risk factors, learn from what went wrong and apply the lessons in maternity units across the country.

– DR DAVID RICHMOND
A recent report by the NHS Saving Babies’ Lives – NHS England gives recommendations that aim to reduce the rates of stillbirth by half by 2030.

One of the most striking observations is how often poor fetal growth corresponds with stillbirth, consistent with a recent Panorama programme that suggested regular scans could halve the UK rate of still birth by tracking growth and highlighting failure to thrive. The latter can often be addressed by inducing early births.

The four key recommendations are based on extending best practice around the country and include:
  • Reducing smoking in pregnancy
  • Risk assessment and surveillance for fetal growth restriction
  • Raising awareness of reduced fetal movement
  • Effective fetal monitoring during labour

None of these relate to home births. All of the recommendations require joined up, consistent maternal care with time to be spent monitoring, managing, helping women to manage their lives and their pregnancies.