Stillbirths in Scotland: Inequalities Lessening? Leslie Marr Manager, 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

MORTALITY RATES

Scottish Daily Mail 21 st January 2011

stillbirths, 12.5/ stillbirths, 7.2/ stillbirths, 4.7/1000 SCOTTISH NUMBERS AND RATES

MORTALITY RATES Year Rates Stillbirths Neonatal deaths Post-neonatal deaths

ASSOCIATIONS

MULTIPLE PREGNANCY

Twin births per 1000 maternities Year Rate

SINGLETON AND MULTIPLE STILLBIRTH RATES /951994/961995/971996/981997/991998/001999/012000/022001/032002/042003/052004/062005/072006/082007/092008/102009/112010/12 Years Rates Singleton Multiple

DEPRIVATION AND SMOKING

STILLBIRTH RATES BY DEPRIVATION Years Rate per 1000 births Dep 1 - least deprived Dep 2 Dep 3 Dep 4 Dep 5 - most deprived

PERCENTAGE OF WOMEN WHO SMOKED

SMOKING AT BOOKING AND DEPRIVATION,

AGE AND OBESITY

MORTALITY RATES BY MATERNAL AGE

Singleton births by maternal age group

SINGLETON STILLBIRTH RATES BY MATERNAL AGE Years Stillbirth rate <

PERCENTAGE OF OVERWEIGHT AND OBESE WOMEN

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 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

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