The falling stillbirth rate and what it tells us
This week the Office for National Statistics (ONS) published the rates of child and infant mortality in England and Wales, covering 2020 in full.
While many of us have been concerned that the major disruption to maternity services during the pandemic would lead to a significant increase in stillbirths, this has fortunately not been borne out in the figures. Instead, the stillbirth rate in England and Wales remained stable at 1 in 263 births. Following a very short term increase in the stillbirth rate in Scotland after the first lockdown, the rate in Scotland also appears to have remained quite stable.
When I first qualified as a midwife in 1995, the stillbirth rate hovered between 1 in 150-180 births, a huge improvement on the rate of 1 in 50-66 in the 1960s. It was commonly believed then that it was possibly as low as it could be expected to go. Advances in neonatal care in the early 2000s highlighted the difference that changes in practice could make to death rates: in Scotland the neonatal death rate fell dramatically from 2000 – 2010, from 4.0 per 1000 to 2.6 per 1000. With governments, NHS bodies and maternity services in all parts of the UK focussing their efforts on reducing stillbirths , the rates have all fallen significantly from 2010-2019.
We all wish that there could be one, simple answer to reducing stillbirths in the UK. But the solutions need to match the complexity of the causes.
Reflecting this complexity, our approaches have aimed to put together ‘bundles’, using a number of different approaches to tackle some of the key problems. Smoking in pregnancy has been identified as the leading modifiable cause of stillbirth, and so, in all four countries, there has been a focus on reducing the number of women who smoke during pregnancy, . leading to significant reductions. In 10 years, the number of women who smoked at the time of birth in England in Wales fell from nearly 14% to 9.6% in 2020. More and more women and their partners have taken up support to give up smoking during pregnancy and the number of women in Scotland who successfully quit during pregnancy almost doubled from 17% to 33% in that same period.
Ensuring more women access antenatal care early in their pregnancy so they can receive the support, advice and care they need has been another area of focus. Again, the efforts of midwives have paid off, including a staggering threefold increase in Scotland from 23% of women booked with their midwife before 10 weeks in 2010 to 69.2% in 2021. These improvements are also reflected in the other UK countries.
The Saving babies lives initiative in England and the Scottish Maternity and neonatal quality improvement collaborative (MCQIC) have helped to drive the implementation of these improvements – with a greater focus on identifying babies at risk of being small for gestational age, being born preterm and ithose who are struggling with the additional strain that the labour process places on them. The RCM is working hard with others to continue to improve safety and reduce the risk of a poor outcome.
Health inequalities are a key factor in stillbirth and the solutions lie not just in maternity services, but in tackling the social inequality of our society. Women who are Black, Asian or from another ethnic minority background are far more likely to experience a stillbirth than their white counterparts. Women who live with deprivation are also much more likely to have poor outcomes. More must be done to focus on the impact of inequality in our society on the stillbirth rates across the UK. It is unacceptable that some babies are more likely to die due to their ethnicity or the wealth of their parents.
The solutions to these embedded inequalities are not simple, but we know from the success in reducing stillbirth rates that, when we work together and focus our efforts on tackling these difficult and complex problems, we can make a change. Over the coming year the RCM will work with others – and our members - to reduce inequity in experience, provision and outcomes for all pregnant women.
I take my hat off to everyone working tirelessly throughout the pandemic in maternity services to keep things safe for women and their babies. It has been a hugely challenging period, but these ONS data published this week, show that, through the huge efforts of midwives, obstetricians and all the maternity team, we have managed to keep maternity services running and as safe as possible.