Presentation on theme: "Prevention of stillbirth in high income countries Understanding risks, causes and rates Dr Frances MacGuire SpR Yorkshire and Humber School of Public Health."— Presentation transcript:
Prevention of stillbirth in high income countries Understanding risks, causes and rates Dr Frances MacGuire SpR Yorkshire and Humber School of Public Health Annual Conference Gomersall Park Hotel 20-21 June 2012
Overview Why stillbirth matters Outline of MPH research Causes and risks for stillbirth Bradford rates and the BiB cohort Next steps
Stillbirth is not a rare event, globally…nor in the UK ~ 3 million babies stillborn every year, 98% LI/MI countries WHO: “most stillbirths are avoidable” 2011 Lancet series: UK ranked 33/35 similar HI countries UK: one in every 200 babies stillborn Rate of stillbirth unchanged since 1990s – 5.2/1000 births in 2009 CMO: 500 intrapartum deaths/yr “major public health issue” NHS Outcomes Framework
Impact on parents, clinicians, services Profound impact on parents and families oIsolating form of bereavement – invisible, taboo oRisk of severe psychological reactions o40% higher risk of relationship breakdown & reduced income Clinicians o1 in 10 obstetricians considered giving up practice (RCOG) Healthcare system oFuture pregnancies high risk – more intervention (us scans, CS) o50% of all negligence costs intrapartum-care related ~ NHSLA £328 million 2010/11, 1 billion over 5 years
MPH dissertation: Evidence base Structured literature reviews of guidelines and systematic reviews on prevention No systematic reviews or guidelines to specifically prevent stillbirth Two Cochrane reviews underway on interventions for: – preventing stillbirth – supporting parents decisions about post mortem
2011 Lancet series “Each geographical area must understand the local causes of and risk factors for stillbirth and the contexts in which they occur…so that appropriate prevention strategies can be developed and implemented”
Cause of death – difficult to determine but important For the parents: – helps with grieving, understanding risks For clinicians: – understanding risks, changing clinical practice. Efforts to identify cause of death “inadequate” Cause of death unexplained 50% cases Best practice: high-quality post-mortem
Major causes of death Flenady et al., (2011) Retrospective 8 country cohort study of stillbirths and neonatal deaths. The Lancet Placental pathologies 25% Infection 12% Cord incidents 9% Pre-existing maternal conditions e.g. diabetes 7% Congenital anomalies 6% Intrapatrum complications e.g. breech 3% Unexplained, most unexplored 30%
Risk factors for stillbirth Maternal age (under 20 and over 35) First pregnancy (nulliparity) Pre-existing conditions e.g. diabetes, hypertension Placental abruption Small size for gestational age Use of IVF Multiple pregnancy Post-term pregnancy Previous stillbirth or caesarian Deprivation Ethnicity Obesity Lifestyle – smoking, alcohol, drug use Adequacy of antenatal and intrapartum care
Born in Bradford Stillbirth rates higher than E&W average 7.5/1000 Retrospective case series of babies stillborn in the Born in Bradford cohort Exploration of local rates, causes and risks to inform prevention strategies at a local level
Source: NHS Bradford and Airedale Figure 1. Stillbirth rate in 3 year rolling periods Bradford’s stillbirth rate is consistently higher and more variable than the England and Wales (E&W) average, which declined slightly from 1993-2009. Bradford’s rates were higher in 2009 than during the early 1990s.
Source: NHS Bradford and Airedale Figure 2. Neonatal, postneonatal, infant and stillbirth mortality rates in Bradford District, 1996-2009
Born in Bradford Cohort – 13,776 total births 68 babies stillborn, 30 male, 36 female 28 (41.2%) premature, 40 (58.8%) term Of term babies 28 between 37 and 39 +6 weeks 5 at 40 +0 7 at 41 +0 and over Higher proportion of term babies reflects District findings, contrasts with national data – 1/3 stillbirths at term
Cause of death: P95 – “fetal death of unspecified cause” 187 stillbirths Jan 07 to Dec 09 Primary COD P95 for 96 records - 70% cases Of 55 cases with a primary diagnosis 5 cases premature separation of placenta <5 cases each for hypertension, slow fetal growth, anencephaly 14 cases – congenital anomalies and trisomies
Cause of death Available for only 32 out of 68 cases (47.1%) Data only available to 2009 25 cases, 78% coded P95 Of 19 term cases, 18 coded P95
Next steps In discussions with BRI about: – how to reduce rates – use of CTG and ultrasound amniotic fluid measurement in monitoring of pregnancies over 41 +0 weeks – investigation for thrombophilia where stillbirth remains unexplained following core investigations
Acknowledgements Professor Mary Renfrew, Dr Alison McFadden, Dr Stephen Oliver, Professor Hilary Graham, Dr Shirley Brierley, Dr Helen Brown, Teresa Keegan and Simon Chappell, Dr John Wright, Professor Neil Small, Professor Derek Tufnall, Dr Sam Oddie, Dr Pauline Raynor, Shaeen Ahktar, Dawn Jankowicz, Neil Garside.
References Bahtiyar, M.O., Funai, E.F., Rosenberg, V., Norwitz, E., Lipkind, H., Buhimschi, C. and Copel, J.A. (2008). Stillbirth at term in women of advanced maternal age in the United States: when could the antenatal testing be initiated. American Journal of perinataology 25 (5), 301-4. Balchin, I., Whittaker, J.C., Patel, R.R., Lamont, R.F. and Steer, P. (2007). Racial variation in the association between gestational age and perinatal mortality: prospective study. BMJ 334. Flenady, V. and Wilson, T. (2011). Support for mothers, fathers and families after perinatal death. Cochrane Database of Systematic Reviews 2008, (1). Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD000452. DOI: 10.1002/14651858.CD000452.pub2. Flenady, V., Middleton, P., Smith G.C., Duke W., Erwich, J.J., Yee Khong, T., Neilson, J., Ezzati, M., Koopmans, L., Ellwood, D., Fretts, R., and Frøen, J.F. (2011b). Stillbirths: the way forward in high-income countries. Lancet 377, (9774). Gordon, A. and Jeffrey, H.E. (2008). Classification and description of stillbirths in NSW, 2002-2004. The Medical Journal of Australia 118 (11), 645-648. Available at: http://www.mja.com.au/public/issues/188_11_020608/gor10947_fm.html. [Accessed 24 May, 2011]. http://www.mja.com.au/public/issues/188_11_020608/gor10947_fm.html Perinatal Society of Australia and New Zealand (PSANZ) (2009). Clinical Practice Guideline for Perinatal Mortality. Available at: http://psanz.com.au/special-interest-groups/pnm.aspx. [Accessed 7 September, 2009].http://psanz.com.au/special-interest-groups/pnm.aspx Royal College of Obstetricians and Gynaecologists (2011). Obstetric choleostasis. Green-top Guideline No.43. London: RCOG.