Prevention of stillbirth
in high income countries
Understanding risks, causes and rates
Dr Frances MacGuire SpR
Yorkshire and Humber School of Public Health Annual Conference
Gomersall Park Hotel 20-21 June 2012
Overview
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Why stillbirth matters
Outline of MPH research
Causes and risks for stillbirth
Bradford rates and the BiB cohort
Next steps
Stillbirth is not a rare event,
globally…nor in the UK
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~ 3 million babies stillborn every year, 98% LI/MI countries
WHO: “most stillbirths are avoidable”
2011 Lancet series: UK ranked 33/35 similar HI countries
UK: one in every 200 babies stillborn
Rate of stillbirth unchanged since 1990s – 5.2/1000 births in 2009
CMO: 500 intrapartum deaths/yr “major public health issue”
NHS Outcomes Framework
Impact on parents, clinicians, services
• Profound impact on parents and families
o Isolating form of bereavement – invisible, taboo
o Risk of severe psychological reactions
o 40% higher risk of relationship breakdown & reduced income
• Clinicians
o 1 in 10 obstetricians considered giving up practice (RCOG)
• Healthcare system
o Future pregnancies high risk – more intervention (us scans, CS)
o 50% of all negligence costs intrapartum-care related ~ NHSLA £328
million 2010/11, 1 billion over 5 years
MPH dissertation: Evidence base
Structured literature reviews of guidelines and
systematic reviews on prevention
• No systematic reviews or guidelines to specifically
prevent stillbirth
• Two Cochrane reviews underway on
interventions for:
– preventing stillbirth
– supporting parents decisions about post mortem
2011 Lancet series
“Each geographical area must understand the
local causes of and risk factors for stillbirth and
the contexts in which they occur…so that
appropriate prevention strategies can be
developed and implemented”
Cause of death – difficult to
determine but important
• For the parents:
– helps with grieving, understanding risks
• For clinicians:
– understanding risks, changing clinical practice.
• Efforts to identify cause of death “inadequate”
• Cause of death unexplained 50% cases
• Best practice: high-quality post-mortem
Major causes of death
Flenady et al., (2011) Retrospective 8 country cohort
study of stillbirths and neonatal deaths. The Lancet
•Placental pathologies
•Infection
•Cord incidents
•Pre-existing maternal conditions e.g. diabetes
•Congenital anomalies
•Intrapatrum complications e.g. breech
•Unexplained, most unexplored
25%
12%
9%
7%
6%
3%
30%
Risk factors for stillbirth
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Maternal age (under 20 and over 35)
First pregnancy (nulliparity)
Pre-existing conditions e.g. diabetes, hypertension
Placental abruption
Small size for gestational age
Use of IVF
Multiple pregnancy
Post-term pregnancy
Previous stillbirth or caesarian
Deprivation
Ethnicity
Obesity
Lifestyle – smoking, alcohol, drug use
Adequacy of antenatal and intrapartum care
Born in Bradford
• Stillbirth rates higher than E&W average 7.5/1000
• Retrospective case series of babies stillborn in
the Born in Bradford cohort
• Exploration of local rates, causes and risks to
inform prevention strategies at a local level
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Rate per 1000 live + stillbirths
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8
7
6
5
4
3
2
1
0
19931995
19941996
19951997
19961998
19971999
19982000
Bradford
19992001
20002002
20012003
20022004
20032005
20042006
20052007
20062008
20072009
England & Wales
Calendar Years
StillBirth
1993-1995 1994-1996 1995-1997 1996-1998 1997-1999 1998-2000 1999-2001 2000-2002 2001-2003 2002-2004 2003-2005 2004-2006 2005-2007 2006-2008 2007-2009
Bradford No. deaths
151
153
144
129
135
142
163
158
162
169
192
192
198
178
187
Bradford Rate
6.8
7.0
6.7
6.1
6.3
6.6
7.6
7.3
7.3
7.5
8.2
8.0
8.0
7.1
7.3
Eng & Wales Rate
5.6
5.6
5.4
5.4
5.3
5.3
5.3
5.4
5.6
5.7
5.6
5.5
5.3
5.2
5.1
Source: NHS Bradford and Airedale
Figure 1. Stillbirth rate in 3 year rolling periods
Bradford’s stillbirth rate is consistently higher and more variable than the England
and Wales (E&W) average, which declined slightly from 1993-2009. Bradford’s
rates were higher in 2009 than during the early 1990s.
Mortality rates for premature and full term births, 1996-2009
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Mortality rate per 1000 births
5
4
Neonatal
Postneonatal
3
Infant
Still birth
2
1
0
1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 20052000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Premature
1996- 1997- 1998- 1999- 2000- 2001- 2002- 2003- 2004- 20052000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Full term
Source: NHS Bradford and Airedale
Figure 2. Neonatal, postneonatal, infant and stillbirth mortality rates in Bradford
District, 1996-2009
Born in Bradford
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Cohort – 13,776 total births
68 babies stillborn, 30 male, 36 female
28 (41.2%) premature, 40 (58.8%) term
Of term babies
• 28 between 37 and 39+6 weeks
• 5 at 40+0
• 7 at 41+0 and over
Higher proportion of term babies reflects District findings, contrasts with
national data – 1/3 stillbirths at term
Cause of death:
P95 – “fetal death of unspecified cause”
• 187 stillbirths Jan 07 to Dec 09
• Primary COD P95 for 96 records - 70% cases
• Of 55 cases with a primary diagnosis
• 5 cases premature separation of placenta
• <5 cases each for hypertension, slow fetal growth,
anencephaly
• 14 cases – congenital anomalies and trisomies
Cause of death
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Available for only 32 out of 68 cases (47.1%)
Data only available to 2009
25 cases, 78% coded P95
Of 19 term cases, 18 coded P95
Next steps
In discussions with BRI about:
– how to reduce rates
– use of CTG and ultrasound amniotic fluid
measurement in monitoring of pregnancies over
41+0 weeks
– investigation for thrombophilia where stillbirth
remains unexplained following core investigations
Acknowledgements
Professor Mary Renfrew, Dr Alison McFadden,
Dr Stephen Oliver, Professor Hilary Graham,
Dr Shirley Brierley, Dr Helen Brown, Teresa
Keegan and Simon Chappell, Dr John Wright,
Professor Neil Small, Professor Derek Tufnall,
Dr Sam Oddie, Dr Pauline Raynor, Shaeen
Ahktar, Dawn Jankowicz, Neil Garside.
References
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Bahtiyar, M.O., Funai, E.F., Rosenberg, V., Norwitz, E., Lipkind, H., Buhimschi, C. and Copel, J.A. (2008).
Stillbirth at term in women of advanced maternal age in the United States: when could the antenatal
testing be initiated. American Journal of perinataology 25 (5), 301-4.
Balchin, I., Whittaker, J.C., Patel, R.R., Lamont, R.F. and Steer, P. (2007). Racial variation in the association
between gestational age and perinatal mortality: prospective study. BMJ 334.
Flenady, V. and Wilson, T. (2011). Support for mothers, fathers and families after perinatal death. Cochrane
Database of Systematic Reviews 2008, (1). Cochrane Database of Systematic Reviews 2008, Issue 1. Art.
No.: CD000452. DOI: 10.1002/14651858.CD000452.pub2.
Flenady, V., Middleton, P., Smith G.C., Duke W., Erwich, J.J., Yee Khong, T., Neilson, J., Ezzati, M., Koopmans,
L., Ellwood, D., Fretts, R., and Frøen, J.F. (2011b). Stillbirths: the way forward in high-income countries.
Lancet 377, (9774).
Gordon, A. and Jeffrey, H.E. (2008). Classification and description of stillbirths in NSW, 2002-2004. The
Medical Journal of Australia 118 (11), 645-648. Available at:
http://www.mja.com.au/public/issues/188_11_020608/gor10947_fm.html. [Accessed 24 May, 2011].
Perinatal Society of Australia and New Zealand (PSANZ) (2009). Clinical Practice Guideline for Perinatal
Mortality. Available at: http://psanz.com.au/special-interest-groups/pnm.aspx. [Accessed 7 September,
2009].
Royal College of Obstetricians and Gynaecologists (2011). Obstetric choleostasis. Green-top Guideline
No.43. London: RCOG.