Stillbirth Certification

Wednesday 31st October 2012 Westminster Hall

16:30

[Chris Heaton-Harris (Daventry) (Con)]

It is a pleasure to serve under your chairmanship for the first time, Mr Owen. I hope that you will be as gentle with me as are the other Chairmen whom I have served under in Westminster Hall. I thank the House for giving me the opportunity to talk about stillbirth certification.

On 18 May 2011, I led a Westminster Hall debate on the sensitive and emotive subject of stillbirth. I explained back then that I had wanted to raise the subject ever since a couple of my best friends had a stillborn child. The way in which they and other parents of stillborn children are treated is simply not good enough for a modern developed country.

Seventeen babies are stillborn or die shortly after birth every single day in the United Kingdom, and the stillbirth rate has not changed in a decade. That number is way too high. I have been told that approximately 30% of stillbirths remain completely unexplained and that lots of different factors play into the deaths of the remaining 70%. I know that the Minister who will reply to the debate is concerned that the UK is slipping down the league table of developed nations in this regard. According to a study published last year in The Lancet, the UK has one of the worst records for stillbirths, ranking 33rd out of 35 high-income nations. Although it is important to acknowledge that all women are vulnerable, we need to work out why women in our nation may be at a higher risk of stillbirth and what we can do to change that fact.

There are some troubling regional differences in the percentage rates of stillbirth across the United Kingdom. How can we explain the 33% difference between the incidence of stillbirth in the south-west, which has the lowest rates, and the east midlands, of which my constituency is a part, which has the highest?

I have had discussions with people who point out that in recent years, Britain has become one of the unhealthiest nations in Europe. We are the most obese nation in Europe and we have the heaviest drinkers. As life expectancy has increased, more British women are also waiting until later in life to become first-time mothers. All those could be contributing factors to the horrid statistic that I read out earlier.

I could not let this occasion go by without asking the Minister what research is being done into the reasons behind our high stillbirth rate. Why is there so much regional variation? More than anything, I want the Minister to assure me and those in the Chamber that the Government have an ongoing commitment to reduce the number of stillborn children throughout the United Kingdom, to talk about this subject more and to spread best practice. What will the Minister do to ensure the spread of best practice? There are many hospitals across the United Kingdom that have fantastic practice in this area, but, equally, there are those where best practice is desperately needed. Eventually, I hope that fewer parents will suffer this terrible fate. I was personally delighted by the announcement by the Department of Health, on 16 May, of the Government’s maternity pledges, which include the pledge to provide more NHS support to women who have suffered a stillbirth.

I do not intend to go over much of the territory that we covered in the debate last year, but wish instead to concentrate on one particular area—the certification of stillborn children. Without a doubt the passing of the Still-Birth (Definition) Act 1992 was a breakthrough and had huge significance for parents. From the passing of that Act, a baby who was born dead at or after 24 completed weeks of pregnancy was recognised in law as an individual. It required that the baby’s death be registered in person by one or both parents at a register office within six weeks of the baby’s birth and it stated that a stillbirth certificate be issued.

Since I raised this subject in May 2011, I have been contacted by hundreds of families who have suffered the terrible anguish of stillbirth. Many of them have shared their stories with me, and I am in awe of how some of those parents have dealt with the worst of all possible situations.

A number of themes have started to fall together around the whole subject of stillbirth. Indeed, many parents had issues that were individual in their nature. If they had complaints about their treatment, they tended to sort them out for themselves. However, there was one very distinguishable theme that came out of my many conversations and e-mails—how to help parents grieve and eventually to move on. I believe that something simple can and should be done in that regard.

[Jim Shannon (Strangford) (DUP)]

I thank the hon. Gentleman for bringing this matter to Westminster Hall. It is something that affects many people across all the constituencies in the United Kingdom. Does he agree that as things stand, the parents are not able to get the closure that they so desperately need? Although nothing can ease the pain, even to acknowledge that there was life in the first place would give a sense of closure to the family. It is a small thing but it could be of great comfort to a grieving family.

[Chris Heaton-Harris]

Yes, I do agree, and I shall come on to that point in the next couple of minutes. Certainly, that applies to a number of the parents to whom I have been speaking. Although no one will ever be able to give them back their baby, they almost feel as though the state is cheating them. It is as if their baby was never in existence. Having a birth and death certificate might help them get over that point in their grief so that they can move on.

[Jim Shannon]

The issue for parents is coming to terms with the emotional trauma that they have been through. Having a certificate will mean a terrible lot to those people, and that is what we are trying to achieve.

[Chris Heaton-Harris]

That is my intention in raising this debate today. However, this is about not just the certification element, which I hope the Minister will answer, but the need for more awareness of all the issues around stillbirth and neo-natal care.

Having the flexibility for parents to be able to choose to have a birth and death certificate for babies born after 24 completed weeks of pregnancy but showing no signs of life, would massively help a large number of parents in their grief and show that the state recognises that they had a wonderful child. As some parents would be distressed at the possibility of having to go down that route, I wonder whether we could have a more flexible system whereby parents have the choice of a formal birth certificate, a stillbirth certificate issued by the hospital or—if they so choose—nothing. In modern society, we have the ability and sensibility to deal with the matter of certification, which is important to most of the parents to whom I have spoken because it is a simple process of formally naming their deceased baby.

Over the course of my time in this place, I have raised the matter of stillbirth certification a number of times. However, on each occasion I have received a similar reply from the Department of Health. One reply said:

“The registration of stillbirths and live births serve different purposes.”

It helps Departments collect statistical data and

“enables us to monitor the causes of stillbirth.”

Another reply said:

“Different state benefits are available to parents depending on whether a child was live-born or stillborn, so it is important to be able to distinguish one certificate from another.”

I completely understand the need for the state and the Department to be able to collect these important data for use in research. In fact, I am keen to encourage the Department to do more. However, I simply cannot understand why in 2012, with all the modern technology that we have at our disposal, we cannot, in a sophisticated way, collect all the data that are required and issue birth and death certificates when they are requested by parents.

[Jonathan Lord (Woking) (Con)]

I am grateful to my hon. Friend for giving way and I commend him for pursuing this issue in Westminster Hall when I know that there is another debate very close to his heart going on in the main Chamber. Does he have any information that he could share with us about how other countries do things, which might help to nudge the Department of Health in the right direction on this matter?

[Chris Heaton-Harris]

There is actually quite a lot of information out there. There is a very good charity called Sands, which has brought me lots of examples of best practice from across Europe, and indeed from different states in the USA. I am not saying that those methods would all work if they were brought into the NHS. However, by looking at the research that has been going on in Denmark and in Australia, and at the best practice in France and in some states in the US, we might be able to form much better practice in the UK to spread throughout the NHS. There are examples of good practice out there, and although I cannot cite them “fact for fact” off the top of my head right now, the charity Sands has all that information on its website. Sands is a very good resource for information.

I want to go back to the issue of what the state can do when it comes to stillbirth certification. I am quite sure that a sensible and easy solution can be found that allows these certificates to be issued and at the same time enables the state to have all the right information that it might require about any situation around each stillbirth.

Knowing that this debate was coming up, I asked some parents to try to help me to express why this new flexibility—if we are able to have it—would help them. A mum in my local area called Michelle told me this:

“My son was 9 days past his due date when he died at the end of my labour in May 2011; he weighed 7 pounds and 7 ounces, had wavy fair hair and was perfect. I can still feel the weight of him in my arms and how soft his skin felt. To be told your child has died is the worst pain a parent can feel but to be told they will not be recognised as a person in their own right but a statistic is heart-breaking. My son looked like any other baby, I went through a labour like any other mother but I didn’t have the happy ending. Going to the registry office to register his death was made harder knowing that the parents waiting with us would be registering their baby’s birth yet we would only be allowed to register our son’s death, not given the dignity of having a birth certificate. I feel I am being punished for not having a child that was lucky enough to take a first breath or to hear his first cry. A birth certificate is incredibly important to me and unless you have lost a child who has had the misfortune of being labelled as stillborn it is difficult to understand the need for this recognition. I have been lucky enough to go on to have a daughter, I love both my son and daughter equally yet they are not treated equally in the eyes of the law.”

She went on to say:

“This cruel law needs to be changed, what sense does it make to only register the death when the baby has to be born first regardless if he will take a first breath.”

I know from previous conversations that I have had with the Minister that he completely understands all the issues that I have raised here today, and I very much look forward to hearing his comments. All I ask is that he returns to his Department, reflects on today’s debate and considers whether it is actually not too difficult to build into the system the flexibility that I and a large number of parents from across the country would like to see. It would mean a great deal to a lot of people, Michelle included.

16:43

[The Parliamentary Under-Secretary of State for Health (Dr Daniel Poulter)]

Thank you, Mr Owen, for calling me to speak. It is a great pleasure to serve under your chairmanship; like my hon. Friend the Member for Daventry (Chris Heaton-Harris), it is the first time that I have done so.

I pay particular tribute to my hon. Friend for raising this matter in Westminster Hall today. He and I have worked together in the past to raise awareness of the need to do more to support those families who have had the terrible experience of stillbirth. We have also worked together in the past to discuss the need for greater research in this area. He is absolutely right to highlight a number of the issues that he has raised today, and I will deal with the issues that he has raised in turn.

In my own medical career as a doctor, I have never seen anything more tragic than either a very badly injured or ill child, or a dead baby. The death of a baby is probably the worst situation that I came across, and losing a child is the worst experience for family and friends; it lives with people for ever. For some families, there is no coming to terms with the death of a child. It is a very difficult thing to live with and we must continue to do all we can to support those families, working with Sands and the other organisations that do a very good job in supporting those families; we must continue to do more.

My hon. Friend quite rightly highlighted the unacceptable regional variation in stillbirths. From the figures for 2011, we know that the strategic health authority for the north-east of England reported 5.8 stillbirths per 1,000 live births, whereas the SHAs for the east of England and the south-west of England reported 4.7 stillbirths per 1,000 live births. As I say, that is an unacceptable variation. There is an acknowledgment by the Royal College of Obstetricians and Gynaecologists, by the Royal College of Midwives and by Sands and many organisations that we need to do more to reduce the rate of stillbirths in this country. We must continue to do more to research the factors that cause stillbirth. As my hon. Friend said, in many cases the cause of a stillbirth is still unclear. We also need to continue to crack down on this unacceptable regional variation, and learn where there is good practice in combating and reducing stillbirth rates and where the NHS is doing things better, so that that good practice can be rolled out across the country.

As I said, the death of a baby, whether during pregnancy or following birth, is probably the worst tragedy that anybody can face, and that is true both from the point of view of a health care professional and from a family’s perspective. Stillbirth is not only the loss of a child, but the loss of all the hopes and dreams that the family would have had about what that baby would have become and what it would have meant to them in the years ahead. That is why it is particularly important that this is an area that we continue to focus on, to reduce stillbirth rates and so that both the Department of Health and medical professionals take this issue increasingly seriously. As my hon. Friend rightly highlighted, our stillbirth rates are 33rd out of 35 high-income nations and as a country we need to do better than that and improve on those rates.

[Jonathan Lord]

I am glad to hear my hon. Friend the Minister and my hon. Friend the Member for Daventry (Chris Heaton-Harris) talk about the work of Sands. I myself have had constituents come to me with the help of Sands, and my hon. Friend the Minister speaks very well about that organisation and about the real hurt of those families who have suffered a stillbirth.

However, could my hon. Friend the Minister just give us a little bit more information as to why he thinks the stillbirth rates in this country are higher than they should be, and why they are higher than the rates in many other western countries? What are the reasons behind that? That is the crucial thing—to stop this terrible tragedy happening to other families.

[Dr Poulter]

I thank my hon. Friend for that question, and he makes a very good point. As we have said today, we have high stillbirth rates in this country. One factor that the Royal College of Obstetricians and Gynaecologists has picked up on is the fact that there are sometimes variations in clinical practice, including in picking up on early warning signs that we know are associated with stillbirth, for example reduced foetal movements during pregnancy. That sort of thing always concerned me as a front-line professional and it concerns many midwives.

However, we need to have in place across the NHS better systems so that professionals can work with women to identify those early warning signs that something may be wrong in a pregnancy and to ensure that women come in quickly and seek help, or hopefully, rather than seeking help because something is going wrong, in many cases they can seek reassurance. However, where things are not right for a baby, we must ensure that the medical help is on hand to intervene quickly and to support the pregnant woman and hopefully mum-to-be.

There are parallels that can be drawn between where we are now with stillbirths and the situation with cot deaths a number of years ago. Back in the 1980s, the cot death rate was very high, peaking at 2.3 deaths per 1,000 live births in 1988. Following the launch of the “Back to Sleep” campaign in the early 1990s, the rate declined dramatically, falling to 0.6 deaths per 1,000 live births in 1995. This reduction has continued as awareness of the key messages on reducing the risk of cot death has increased. By 2010, the rate was 0.22 per 1,000 live births. To put that in real life rather than statistical terms, we are actually talking about a reduction from some 3,000 cot deaths a year to 300 or 400, which is not perfect, because we still have babies dying of cot death, but raising awareness and targeting cot death has proved to be an effective way of reducing rates. That is something we can learn from in the discussion we are having today about stillbirth.

The point that all hon. Members have made today is that the decline in stillbirths in the United Kingdom has not kept pace with that of comparable countries. According to The Lancet, we rank 33rd in the world for stillbirths. We need to ensure that we do better and take this issue seriously.

Both my hon. Friends have spoken about Sands. It is worth highlighting what that organisation has done. It provides tremendous support for families who find themselves in very difficult situations. It has highlighted the vital importance of the Government and the medical profession—midwives are taking this issue on board and are taking it more seriously—supporting families to make sure that in future pregnant women and families do not have to suffer the problems associated with stillbirth.

Sands has raised a number of issues, including research, which we have talked about and which I will come on to in a moment, and the fact that action is required to raise awareness, as we saw with cot death in the past, of the known risk factors for stillbirth so that prospective parents can make better choices and understand what could go wrong in pregnancy and what the warning signs may be—for example, reduced foetal movements. We need to ensure that parents are informed and that health care professionals know how to support parents and pregnant mums to help them to recognise the warning signs. They need to provide reassurance and care where appropriate and need to intervene when very serious concerns are raised.

We have said that it is not acceptable that the UK has one of the worst stillbirth rates in the developed world. We have developed a stillbirth prevention work programme, which my hon. Friend the Member for Daventry alluded to earlier. The Government are taking this piece of work very seriously, in conjunction with the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists, and the NHS to help to iron out the unacceptable variations in practice and the unacceptable regional variations that we have talked about.

The development of this work programme has been informed by a workshop jointly hosted by Sands and the Department of Health, which took place on 1 March this year. Discussions focused on key areas such as raising awareness and improving identification of babies at risk and improving perinatal reviews. We are continuing with this work to ensure that we can put that into practice throughout the NHS so that we provide pregnant mums with the support that they deserve.

My hon. Friend rightly raised the issue of research. It is important that we fully understand stillbirths. We do not always know what the cause of a stillbirth was. It is important that we do research and look into what the unknown causes and reasons might be. What are the factors that cause stillbirths? We know some of the causes; we do not know all of them. Continuing to research and focus on that is important.

The Government have funded a number of research programmes. Most recently, the Department has funded research through the National Institute for Health Research and the policy research programme. An estimated spend relating to maternal and foetal health has increased from £4.4 million in 2006-07 to £12.7 million in 2010-11. The issue of improving foetal health, babies’ health and maternal health is something that we take very seriously.

Working with Sands, the Department’s policy research programme has funded a policy research unit in maternal health and care at the national perinatal epidemiology unit at Oxford university. Research themes focus particularly on pregnancy loss, perinatal morbidity, maternal morbidity and maternal mortality.

The National Institute for Health Research in Cambridge has an ongoing programme of research on women’s health. A major focus of that research is understanding the determinants of stillbirth risk and using that understanding to improve clinical care of pregnant women. Indeed, last week I visited Manchester where there is a very high quality of care for pregnant women and for newborn babies. The university of Manchester’s maternal and foetal health research centre is currently leading projects in understanding the reasons for stillbirth. I know it will be looking to feed that in nationally so that we can continue to reduce stillbirth rates.

Research on its own is not enough. When we have the research, we have to ensure that we get it out there to the professionals, sharing it and the information from that with parents, to help them to make informed choices about their care and to be aware of the risks and the possible warning signs of stillbirth. Raising awareness is so important. It is an issue highlighted in particular by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists. They have said that there is unacceptable variation, as we have accepted in this Chamber, in the rate of stillbirth and in how some health care professionals interact with families and pregnant women during pregnancy. Working up national guidelines that focus on professionals supporting families, as well as being aware of the other factors, is an important part of reducing stillbirth.

Another point made by my hon. Friend is that families who have suffered a stillbirth have not always received good bereavement support. We know that a lot of care and attention has been paid to ensure that more support and care is given to families—the royal colleges have taken that on board—and we are looking seriously at how we can provide more support. Many hospitals and trusts have invested in bereavement rooms and quiet areas for families when they have had early pregnancy loss or a stillbirth. That is right, because although maternity things generally go well and we have a good outcome, when things go badly we need to ensure that we are prepared and have a supportive environment to look after families in such circumstances.

Finally, it is important to focus on certification, an issue raised by my hon. Friend. I will look into the matter in more detail and get back to him in writing as well, rather than try to put together an answer in the two or three minutes available to me. He made the point that some mums who give birth have to go through the whole birthing process—they actually give birth to a dead baby—and that is an incredibly traumatic and difficult thing to do, because they know that their baby is not alive. Some mums, however, have to do that. In such situations, although the law, with such things as birth and death certificates, is there for good reason, the human reality is sometimes not recognised in the law as effectively as we might like. There will, though, sometimes be difficulties with law, however we have it. As best we can, we have tried to mitigate such situations by beginning to provide more supportive environments for parents after a stillbirth and by providing certificates recognising that there has been a stillbirth after 24 weeks. That goes some way towards recognising the difficult and tragic event—we recognise that a baby has been born, although the baby was not born alive. I will write to my hon. Friend in more detail in the next few weeks, because the issue deserves more than a few sentences at the end of the debate.

I thank my hon. Friend and pay tribute to his work on raising awareness of such an important issue. The Government are very much committed to taking forward our work with Sands and ensuring that we reduce stillbirth rates in this country, as well as providing more research to investigate the causes of stillbirth and better support for bereaved parents in what is perhaps the most difficult thing I have ever seen in my medical career.

Question put and agreed to.

16:59

Sitting adjourned.