How birthplace and outcomes are evolving in England & Wales
The office for National Statistics has released data on birth characteristics in England and Wales last week. The data, which reveals birthing trends and characteristics in 2020,show a promising trend in terms of place of birth and neonatal outcomes, however they also highlight the continued inequities in health outcomes associated with ethnicity.
The steady trend of yearly increasing maternal age seems to be halting, with the average maternal age staying at 30.7 years as reported in 2019. While the age of fathers or second partner, for same sex couples, has increased slightly to 33.7 years.
The stillbirth rate is at a record low of 3.8 per 1,000 births, which is heartening, particularly when we take into account the evidence from UKOSS data that indicate that women who become unwell with COVID are more likely to experience a stillbirth. However, there are substantial differences when stratifying for age and ethnicity. Women aged 40 years have the highest stillbirth rate (5.5 per 1,000 birth), followed by women aged 20-24 years (4.5 per 1,000 births).
The largest group of women having babies are aged 30-34 years and the stillbirth rate for this group remains unchanged (3.6 per 1,000 births). The decreasing trend is welcome, however the difference in stillbirth rate when adjusting for ethnicity is stark, with Black babies having the highest stillbirth rate at 6.3 per 1000 births, almost double their white counterparts (at 3.2 per 1,000), and Asian babies at the second highest with 5.2 per 1,000.
Similar differences applied to preterm live births, with Black babies experiencing the highest percentage of preterm birth rate at 8.8 per 1,000 compared to 7.5 in Asian babies and 7.3 in white babies. While preterm birth is generally on a downward trend for all ethnic groups, Black babies had a higher rate compared with the previous year. Such health inequalities are of serious concern and may be accentuated by the pandemic: as younger women and women from Black, Asian or minority ethnic groups were more likely to test positive for COVID at the time of birth (NMPA, 2021). The RCM Expert Clinical Advisory group has produced guidelines to address such disparities in outcomes by providing personalised assessment and has been encouraging vaccination uptake.
A positive story emerging from the ONS bulletin, is the reversal of the declining homebirth rate. For the first time in five years, there is a slight increase to 2.4 per cent of births taking place at home compared to 2.1 per cent in 2019. The variation in homebirth rate between geographical area is interesting, with areas with well-established midwifery continuity teams and community services, such as Powys in Wales having the highest homebirth rate (8.9%).
The increasing national trend may be linked to the impact of the pandemic on services, such as restrictions on birth partners and visiting, given that most births in 2020 took place during the first two waves. However, the increasing trend needs to also be considered in the context of midwifery led-settings closures and/or temporary suspension.
Data from UKMiDSS showed that most services have been affected mostly due to staffing changes and in some areas due to pressures on ambulance services causing delays. The RCM produced a joint guidance with the RCOG on provision of midwife-led settings and homebirth during the pandemic; and commissioned the RCM professional group to conduct a rapid scoping review on optimisation or maternity services in a pandemic. The RCM Expert Clinical Advisory Group (ECAG) produced clinical briefings for midwives attending women at home and caring for those who may be planning to give birth unassisted in the context of homebirth service suspension. It seems that despite all the challenges presented by the pandemic in 2020, midwives and services leads were nationally able to facilitate women’s choice in regards to place of birth.