1. Stillbirths in Scotland: Inequalities Lessening? Leslie Marr Manager, Reproductive Health Programme

2. 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)

3. Numbers Associations Causes Conclusions SCOTLAND’S STILLBIRTHS

4. NUMBERS

5. BIRTHS IN SCOTLAND 1974-2012

6. MORTALITY RATES 1974 - 2012

7. Scottish Daily Mail 21 st January 2011

8. 1974 - 900 stillbirths, 12.5/1000 1994 - 450 stillbirths, 7.2/1000 2012 - 274 stillbirths, 4.7/1000 SCOTTISH NUMBERS AND RATES

9. MORTALITY RATES 1993-2012 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 19931994199519961997199819992000200120022003200420052006200720082009201020112012 Year Rates Stillbirths Neonatal deaths Post-neonatal deaths

10. ASSOCIATIONS

11. MULTIPLE PREGNANCY

12. 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 1975 19771979198119831985198719891991199319951997199920012003 2005 Year Rate

13. SINGLETON AND MULTIPLE STILLBIRTH RATES 1993-2012 0 5 10 15 20 25 1993/951994/961995/971996/981997/991998/001999/012000/022001/032002/042003/052004/062005/072006/082007/092008/102009/112010/12 Years Rates Singleton Multiple

14. DEPRIVATION AND SMOKING

15. 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 1993-951994-961995-971996-981997-991998-001999-012000-022001-032002-042003-052004-062005-072006-082007-09 2008-102009-112010-12 Years Rate per 1000 births Dep 1 - least deprived Dep 2 Dep 3 Dep 4 Dep 5 - most deprived

16. PERCENTAGE OF WOMEN WHO SMOKED 2011-12

17. SMOKING AT BOOKING AND DEPRIVATION, 1997 - 2006

18. AGE AND OBESITY

19. MORTALITY RATES BY MATERNAL AGE 2008-12

20. Singleton births by maternal age group 1985-2006

21. SINGLETON STILLBIRTH RATES BY MATERNAL AGE 1985-2012 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 1985-871986-881987-891988-901989-911990-921991-931992-94 1993-951994-961995-971996-981997-991998-001999-012000-022001-032002-042003-052004-06 2005-072006-08 2007-092008-102009-112010-12 Years Stillbirth rate <20 20-24 25-29 30-34 35-39 40 +

22. PERCENTAGE OF OVERWEIGHT AND OBESE WOMEN 2011-12

23. 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

24. CAUSES

25. CAUSES OF STILLBIRTHS 2012

26. 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

27. 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

28. CONCLUSIONS

29. 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

30. “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

31. 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?

32. Rising obesity Smoking persists High rate of multiple births Assisted conception CHALLENGES

33. Socioeconomic deprivation Smoking Obesity Antenatal recognition of placental dysfunction Intrapartum hypoxia Individual root cause analysis WHERE SHOULD THE FOCUS BE?

34. Multiple pregnancies (assisted conception) The placenta OBSTETRIC CAUSES AND CHALLENGES

35. Deprivation Smoking Age Obesity SOCIETAL CAUSES AND CHALLENGES

36. 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