Stillbirths in Scotland:Inequalities Lessening? Leslie MarrManager, Reproductive Health Programme

• Registration in Scotland since 1855

• Information on stillbirths and neonatal deaths collected and reported since 1974

• Increasing detail in recent years and modern classification of causes since 2011

SCOTTISH STILLBIRTH AND INFANT DEATH SURVEY (SSBIDS)

• Numbers

• Associations

• Causes

• Conclusions

SCOTLAND’S STILLBIRTHS

NUMBERS

BIRTHS IN SCOTLAND 1974-2012

0

10000

20000

30000

40000

50000

60000

70000

80000

197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012

Year

Nu

mb

er o

f bir

ths

MORTALITY RATES 1974 - 2012

0

2

4

6

8

10

12

14

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Year

Rat

es

Stillbirths

Neonatal deaths

Post-neonatal deaths

*Change in stillbirthdefinition

Scottish Daily Mail 21st January 2011

• 1974 - 900 stillbirths, 12.5/1000

• 1994 - 450 stillbirths, 7.2/1000

• 2012 - 274 stillbirths, 4.7/1000

SCOTTISH NUMBERS AND RATES

MORTALITY RATES 1993-2012

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Year

Rat

es

Stillbirths

Neonatal deaths

Post-neonatal deaths

ASSOCIATIONS

MULTIPLE PREGNANCY

Twin births per 1000 maternities

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

19

75

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

20

05

Year

Rat

e

SINGLETON AND MULTIPLE STILLBIRTH RATES 1993-2012

0

5

10

15

20

25

1993/95

1994/96

1995/97

1996/98

1997/99

1998/00

1999/01

2000/02

2001/03

2002/04

2003/05

2004/06

2005/07

2006/08

2007/09

2008/10

2009/11

2010/12

Years

Rat

es

Singleton

Multiple

DEPRIVATION AND SMOKING

STILLBIRTH RATES BY DEPRIVATION 1993-2012

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

19

93

-95

19

94

-96

19

95

-97

19

96

-98

19

97

-99

19

98

-00

19

99

-01

20

00

-02

20

01

-03

20

02

-04

20

03

-05

20

04

-06

20

05

-07

20

06

-08

20

07

-09

20

08

-10

20

09

-11

20

10

-12

Years

Ra

te p

er

10

00

bir

ths

Dep 1 - least deprived

Dep 2

Dep 3

Dep 4

Dep 5 - most deprived

PERCENTAGE OF WOMEN WHO SMOKED 2011-

12

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

All births Stillbirths Neonatal deaths

Pe

rce

nta

ge

SMOKING AT BOOKING AND DEPRIVATION,

1997 - 2006

AGE AND OBESITY

MORTALITY RATES BY MATERNAL AGE 2008-12

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

<20 20-24 25-29 30-34 35-39 40+

Age

Ra

te

SB (1496)

NND (771)

PNND (325)

Singleton births by maternal age group 1985-2006

SINGLETON STILLBIRTH RATES BY MATERNAL AGE 1985-2012

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.019

85-8

7

1986

-88

1987

-89

1988

-90

1989

-91

1990

-92

1991

-93

1992

-94

1993

-95

1994

-96

1995

-97

1996

-98

1997

-99

1998

-00

1999

-01

2000

-02

2001

-03

2002

-04

2003

-05

2004

-06

2005

-07

2006

-08

2007

-09

2008

-10

2009

-11

2010

-12

Years

Sti

llbir

th r

ate

<20

20-24

25-29

30-34

35-39

40 +

PERCENTAGE OF OVERWEIGHT AND OBESE WOMEN

2011-12

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

All births Stillbirths Neonatal deaths

Pe

rce

nta

ge

• Decline in stillbirth rate (p=0.004)

• Decline in stillbirth rate among most deprived women (p=0.001)

• Stillbirth rate among women ≥ 40 years higher than those 25-34 years (p<0.001)

• Proportion of smokers among women with stillbirths compared to all births (p<0.001)

• Proportion of overweight/obese women with stillbirths compared to all births (p<0.001)

STATISTICAL SIGNIFICANCE IN PAST 10 YEARS

CAUSES

CAUSES OF STILLBIRTHS 2012

Associated obstetric factors (0.8%)

No antecedent or associated obstetric

factors (11.4%)

Unable to classify (1.6%)

Maternal disorder (4.7%)

Intra-uterine growth restriction (0.8%)Specific placental

conditions (40%)

Antepartum or intrapartum

haemorrhage (15.7%)

Major congenital anomaly (11%)

Infection (6.7%)

Mechanical (3.1%)

Hypertensive disorders of

pregnancy (2%)

Specific fetal conditions (2.4%)

• Post mortem offered for 99% of stillbirths

• Post mortem authorised for 65% of stillbirths

• Placenta examined histologically for 97% of stillbirths

ASSIGNING A CAUSE OF DEATH 2012

The relationship between FGR, SGA and placental abnormality is not straightforward!

• 33% of stillbirths with FGR were SGA

• 54% of stillbirths with FGR had placental abnormality

• 36% of stillbirths without FGR had placental abnormality

FETAL GROWTH RESTRICTION, PLACENTAL

ABNORMALITY AND SMALL FOR GESTATIONAL AGE 2012

CONCLUSIONS

STRENGTHS

• Identify trends in specific groups

• Monitor investigations (eg post mortems)

• Test appropriateness of categories of cause of death

WEAKNESSES

• Unhelpful for individual deaths

• May not help perinatal reviews

SOME STRENGTHS AND WEAKNESSES OF

STUDYING THE EPIDEMIOLOGY OF STILLBIRTHS

“Intrapartum deaths”

In 2012, 11 deaths reported as “intrapartum” but 19 reported as “alive at the onset of professional care in labour”

Perinatal reviews

85% of stillbirths reviewed at a local perinatal mortality forum but detailed root cause analysis carried out for 15% of stillbirths

DIFFICULT AREAS

• Stillbirth rate is declining significantly

• Particular improvement in stillbirth rate among multiple pregnancies

• Stillbirth rate among older women is declining more than younger women

• Stillbirth rate among the most deprived women is approaching that of less deprived women

WHAT HAS IMPROVED?

• Rising obesity

• Smoking persists

• High rate of multiple births

• Assisted conception

CHALLENGES

• Socioeconomic deprivation

• Smoking

• Obesity

• Antenatal recognition of placental dysfunction

• Intrapartum hypoxia

• Individual root cause analysis

WHERE SHOULD THE FOCUS BE?

Multiple pregnancies (assisted conception)

The placenta

OBSTETRIC CAUSES AND CHALLENGES

•Deprivation

•Smoking

•Age

•Obesity

SOCIETAL CAUSES AND CHALLENGES

• Chris Lennox, Clinical advisor, Reproductive Health Programme (RHP) Healthcare Improvement Scotland

• Naomi Fearns, Audit co-ordinator, RHP

• Kenny Gifford, Administrator, RHP

• Jim Chalmers, Public Health Consultant, Information Services Division, ISD

• Celina Davies, Kirsten Monteith and Samantha Clarke, Analysts, ISD

• All maternity unit coordinators

ACKNOWLEDGEMENTS