Stillbirths and Infant Mortality

Jane Ellison Excerpts

Wednesday 26th March 2014 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Jane Ellison)]

It is a pleasure to serve under your chairmanship, Mr Davies. Like others who have spoken today, I congratulate my hon. Friend the Member for Chatham and Aylesford (Tracey Crouch) on securing a debate on a sensitive issue that it is incredibly vital that our nation makes more progress on. I apologise that the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich (Dr Poulter), whose portfolio covers this policy, is not here to respond, but I undertake to report back to him and to refer him to colleagues if I am unable to respond to anything today.

The death of a baby, whether during pregnancy or following birth, is of course a tragedy. Colleagues have eloquently described the devastating impact on families of losing a baby to stillbirth or during the first year of life. Although stillbirth is now at its lowest recorded rate in England since the definition changed in 1993, a study published in The Lancet in 2011 ranked the UK 33rd worldwide on stillbirths, below a great many other high-income countries. As has been said, being in that place in the league table is not a record we can be proud of. We are making progress, which I will describe, but as everyone accepts we clearly need to do more and to be in a better place. Similarly, infant mortality rates are at historic low levels, but still higher than the European Union average.

Although the stillbirth rate has decreased dramatically over the past 50 years, until recently it had not declined significantly since the 1990s. My hon. Friend referred to that sense of stalled progress. Thus, the rate for England and Wales in 1993, when the current definition was introduced, was 5.7 stillbirths per 1,000 total births. By 1999 the rate had fallen to 5.3, but 12 years later, in 2011, it had not really changed, at 5.2. It is encouraging that the rate has now started to fall. The rate for 2012 was 4.8 stillbirths per 1,000 total births, which is the lowest rate recorded in England since the definition changed. Although that is a statistically significant fall, which we all welcome, we recognise that the decline in stillbirths in the UK has not kept pace with that in other comparable countries. My hon. Friend also demonstrated that across the UK we do not necessarily have even rates of progress. The decline in the infant mortality rate has been more encouraging, that in England falling from 5.2 to four deaths per 1,000 live births between 2002 and 2012, although that remains higher than the EU average, as I said.

Such reductions are welcome, but the rates in England are still high and there is considerable scope for future reduction. That is why we have a wide range of initiatives in place that will help to reduce stillbirth and infant mortality rates, and tackle health inequalities. The shadow Minister, the hon. Member for Denton and Reddish (Andrew Gwynne), and others, were right to refer to the relevance of this issue. It remains a source of concern that we sit where we do in international league tables.

What can be done to reduce the number of stillbirths? As colleagues have said, stillbirth has many causes, some of which are known and some not. That is one of the challenges: we are so used to identifying exactly what a problem is, what we need to do and the resources necessary to tackle it; but here we are in slightly strange terrain, in that we know some things but not enough. The known causes include lifestyle issues such as smoking and obesity; medical causes affecting the woman, baby or placenta; demographics; and the safety and effectiveness of the maternity care given.

On reducing the risk of stillbirth, an important first step is to raise the issue’s profile, so that people are aware that it needs to be dealt with and is not simply one of those things to be accepted and about which little can be done. It is not acceptable to have one of the worst stillbirth rates in comparison with similar countries. We have therefore included stillbirth and neonatal mortality as an area of improvement for the NHS in its outcomes framework. We have identified it as an area in which we need to do much better.

A range of research has been conducted that demonstrates that women who access antenatal care late have poorer outcomes. Early access to antenatal care is therefore pivotal to improving health and well-being outcomes for women and their babies. In line with the guidelines of the National Institute for Health and Care Excellence, women should have an assessment of their health and social care needs, risks and choices as early as possible in pregnancy. That enables midwives to provide pregnant women with important lifestyle messages —for example, about diet, exercise, smoking and drinking —and to identify any pre-existing conditions that might require additional support. I will say more about public health later, but I can only share in the alarm expressed by Members at some rates of drinking—quite heavy drinking—during pregnancy, for example. According to the national statistics on that, there is great variation between local authorities. I will touch later on one of the reasons why we think public health sits so well within local authorities, which are in a position to tackle that regional variation.

The Department and NHS England are working with a number of key partners, including the stillbirth charity Sands, Public Health England, the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, to take forward a stillbirth prevention work programme. The programme covers a range of initiatives, including raising awareness of the known risk factors among pregnant women and health professionals. That will ensure that women receive consistent advice on how to minimise the risk of stillbirth—including the importance of healthy eating and the other lifestyle issues that have been raised—are aware of foetal movement and what is normal for their baby, and know where to go for help if they suspect there is a problem. It is important that each stillbirth is investigated and lessons are learned. We are therefore working with NHS England to explore how standardised perinatal death reviews could be introduced.

Growth-restricted babies are up to eight times more likely to be stillborn than non-growth-restricted babies. My hon. Friend the Member for Chatham and Aylesford is aware of the encouraging results we have achieved in reducing the stillbirth rate in the three regions where uptake of the Perinatal Institute’s growth assessment protocol training package—the GAP programme—was most prevalent. Following discussions with the Perinatal Institute, NHS England is encouraging uptake of the programme across the NHS in England. More than 75% of trusts in England have already signed up for that training.

[Tracey Crouch]

Will the Minister elaborate slightly on that training? Given the example of my constituent whose son, Henry, was stillborn at 38 weeks but had not grown for 16 weeks, the measurement tools currently available to midwives are clearly simplistic and some more sophisticated technology for measurement could well be of use. Will she elaborate on whether the new system is using more sophisticated technology? That is one reason why having an extra scan could help with early intervention, by identifying any growth problems sooner.

[Jane Ellison]

My hon. Friend has asked an extremely good question. I hope she will allow me to reply after the debate—I do not have an answer readily to hand, as the subject is not in my policy portfolio. I will come back to her on that, because it is a good question.

Although we know some of the risk factors for stillbirths, other causes are unknown, and it is important that we gain a greater understanding of those. The NHS National Institute for Health Research funds a range of research relating to causes, risk factors and prevention of stillbirth and neonatal death. Both the NIHR Cambridge and the NIHR Imperial biomedical research centres have ongoing research programmes on women’s health, including research relevant to the prevention of stillbirth and neonatal death.

In addition, the NIHR health technology assessment is funding three significant trials. The first is a £6 million trial of an intelligent system to support decision making in the management of labour using the cardiotocogram, or CTG. The second is a £1.4 million trial of nicotine replacement therapy in pregnancy, led by the university of Nottingham. The third is a £1.2 million trial of physical activity as an aid to smoking cessation during pregnancy, led by St George’s, university of London.

My hon. Friend referred to the Tommy’s stillbirth research centre at the university of Manchester, which is conducting innovative research that focuses on the unborn baby’s life support machine—the placenta. It has opened the Manchester placenta clinic, which combines specialised antenatal care for pregnancies affected by foetal growth restriction with front-line research into why the condition occurs and how it might be treated. The Government also fund MBRRACE-UK, or Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom, which is continuing the national Confidential Enquiry into Maternal Deaths and national surveillance of late foetal losses, stillbirths and infant deaths.

I turn now to bereavement support and counselling, which were quite rightly raised during the debate. It is obviously important that women who have suffered a miscarriage, stillbirth or neonatal death receive evidence-based care, in an appropriate location, which supports both their physical health and their emotional well-being. In December 2012, NICE published clinical guidance that offers evidence-based advice on the diagnosis and management of ectopic pregnancy and miscarriage in early pregnancy—that is, up to 13 completed weeks of pregnancy.

We expect maternity care providers and commissioners to give due regard to NICE guidance and to ensure that there are comprehensive, culturally sensitive services and facilities for the management and support of families who have experienced a miscarriage, stillbirth or neonatal death. Skilled staff should of course be available to support parents. I take on board entirely the point that that picture might sometimes be inconsistent. Clearly, we have to work towards greater consistency. As I often say when we have debates such as this, it can only be a good thing that Parliament continues to demonstrate its great interest in this area, as we can demonstrate to those who provide and plan our health services in which Parliament has shown a particular interest. Today’s debate provides another opportunity for us to do that.

In May 2012, the then Secretary of State, my right hon. Friend the Member for South Cambridgeshire (Mr Lansley), pledged that women who have suffered a miscarriage would get more support from the NHS. Over the past two years, the Department has awarded £35 million in capital funding to improve NHS birthing environments, including facilities for bereaved parents.

My hon. Friend the Member for Chatham and Aylesford raised the issue of scans. There are currently no plans to introduce routine scans in the third trimester of pregnancy to monitor foetal growth and development. I recognise that there is a challenge to that policy. The UK national screening committee advises Ministers and the NHS in all four countries of the UK about all aspects of screening policy, and supports implementation. It uses evidence based on research, pilot programmes and economic evaluation, and assesses the evidence for programmes against a set of internationally recognised criteria. If stakeholder organisations, individuals or Members feel that there is enough evidence published in peer-reviewed journals to consider screening for a condition in the third trimester of pregnancy, they can submit a policy proposal to the national screening committee. That might well be something that my hon. Friend wishes to consider.

I turn briefly to the subject of the registration of stillbirths. I say briefly, because I know that the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich, is meeting my hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) in early April to discuss his ten-minute rule Bill on the registration of stillbirth. That Bill aims to amend the Births and Deaths Registration Act 1953 to provide that parents may register the death of a child stillborn before the threshold of 24 weeks’ gestation. That Act, as amended by the Still-birth (Definition) Act 1992, provides for the registration of all babies stillborn after 24 weeks’ gestation. When a baby is stillborn, the doctor or midwife who attended the delivery or who examined the baby’s body after birth gives the parents a medical certificate certifying the stillbirth.

Although some parents are very distressed that they cannot legally register the birth of a baby born before 24 weeks who did not breathe or show any signs of life, others would be distressed at the possibility of having to do so. Getting the right balance between those conflicting wishes is challenging, but the existing system, whereby hospitals can issue local commemorative certificates—my hon. Friend the Member for East Worthing and Shoreham alluded to those in his remarks—for those parents who want them goes some way to addressing the issue. I know that he will have more questions and challenges for my hon. Friend the Member for Central Suffolk and North Ipswich, and will want to discuss those at that meeting in April. I recognise that he has signalled his intention to take the matter forward.

Although infant mortality rates are at an historically low level, health inequalities remain and often reflect inequalities by socio-economic group, ethnicity, geographical area and age. There is a threefold difference in infant deaths rates between professional groups and manual groups. Mothers born in the Caribbean, west Africa, Pakistan and Bangladesh have rates between one and a half times and twice the national average. The greatest numbers of infant deaths and the highest rates are to be found in the most deprived parts of big cities such as Birmingham and Bradford. Young mothers under 20 have the highest risk of infant mortality—almost 60% higher than that for mothers aged 20 to 39, with young lone mothers at even greater risk. That is a terrible catalogue of loss, for the families concerned, for their communities and for the nation as a whole.

There has, however, been some progress in reducing those inequalities in recent years. The difference in the infant mortality rate between the routine and manual group, for example, and the population as a whole has narrowed from 18% in 2002-04 to 9% in 2009-11. We are looking to build on that progress, and that is why we have made reducing these inequalities a priority for the whole of the new health system, working with PHE and NHS England, and backed that up with new legal duties on access to and outcomes from services.

Professor Sir Michael Marmot has been referred to during the debate. He said in his post-2010 health inequalities review that there is a social gradient in health, whereby the lower a person’s social position is, the worse his or her health will be. He recommended that action should be proportionate to the level of disadvantage, including on his first priority of giving every child the best start in life, with which none of us would disagree.

On a practical note, we are strengthening the health visitor service, which Members were right to highlight. We are conscious that it is an important pledge and crucial to infant health and early child development. We are increasing the number of health visitors by 50%—4,200—by 2015. We are also doubling—by 1,600—the number of places on the family nurse partnership programme, which supports vulnerable young mothers over the same time scale. Sure Start children’s services also have a role to play.

The family nurse partnership has an exceptional record of successful intervention, particularly in the lives of young and vulnerable mothers. It has supported many thousands of them throughout the country through pregnancy and birth, and sustained the life chances of the child and the mother. I will quote a nice comment from one of the young women who were helped by this service. She said of her family nurse:

“Margaret doesn’t tell me what to do but helps me make good decisions about my baby, my life and how to be a great mum. I’m excited about my future and seeing my baby grow up. My partner and I became engaged last October and next year I start university”.

That is typical of a young life that has been turned round by effective intervention at a critical moment—not just the mother’s life but, critically, the life of her child also. We are delighted to support the family nurse partnership and to see it grow.

As expected, reference was made to midwives. It is vital to have the appropriate number of trained midwives available in the NHS. Since May 2010, the number has increased at twice the rate of the number of births. There are now 1,500 more midwives than in May 2010, and more than 5,000 in training who are due to qualify in the next three years. Obviously, Health Education England has been given a mandate by the Government in this area, but I completely accept the point about consistency of midwife care and support. That very good point was well made, and I will ensure that it is made to the NHS.

[Tracey Crouch]

I am delighted to hear that there are 5,000 midwives in the training programme. Are they receiving dedicated bereavement training?

[Jane Ellison]

Again, if my hon. Friend will forgive me, I will respond to that question after the debate. I would not want to get the answer wrong.

We have touched throughout the debate on public health, which sits within my portfolio. National action must be complemented by local action. I mentioned the extraordinary range of indicators that I see regularly on issues such as drinking in pregnancy. It makes the case for why the transfer of responsibility for public health from the NHS to local government is sensible. We have backed that with £5.4 billion over two years, and a public health outcomes framework that focuses on health inequalities and key indicators in infant mortality such as low birth weight, which is associated with prematurity and is a significant cause of infant mortality and poor infant and child health.

Some of that local action is already being taken. My home city of Bradford has an excellent record in addressing infant mortality, despite having some of the worst outcomes. It established the Born in Bradford project, a long-term cohort study of 14,000 pregnant women and their children to improve understanding of health and sickness in babies and children, tracking their health throughout pregnancy and childhood into adult life.

In Salford, which is closer to home for the shadow Minister, the city council’s health improvement service offers activities to support new mums and children, including breastfeeding, weaning, exercise and socialising, and it is working to improve MMR vaccine uptake among black and minority ethnic and other groups, where uptake remains low despite our good national statistics.

In Birmingham, pregnancy outreach workers employed by the social enterprise, Gateway family services, tackle health inequalities in infant mortality by bridging the gap between women who need support and the agencies that provide it. Those are three illustrations of some of the imaginative projects that are under way. I hope we will see more and more local government adopting best national practice and responding to the particular challenges in their areas. Some of the contrasts are stark, and local government, which knows its communities well, is well placed to respond to them.

My hon. Friend the Member for Chatham and Aylesford referred to cot deaths. We have made reducing infant mortality an area of improvement for the NHS. Comprehensive advice to parents about reducing the risk of cot death is available on the NHS Choices website, which includes a wealth of other advice. In 2012, the NHS launched the Start4Life information service for parents. They can receive regular e-mails, videos and texts about pregnancy and the first eight months of their baby’s life. It is a free digital service to provide quality-assured advice at the right moments for parents, who can sign up online for it.

The Department has also included advice about the risk of sudden infant death in the Healthy Child Programme, which is the universal programme for all children from the start of life and includes preventive services for children with additional risks. Obviously, anything more we can do to highlight the available advice and support would be valuable, and Parliament has a great role to play in that regard, as do MPs in their constituencies, and local government. The advice is there, but the challenge is always to ensure that it gets to vulnerable groups, and accessing advice across a whole range of health information is difficult.

I thank my hon. Friend for securing this debate, and other Members for their contributions. It further raises the profile of this vital issue of stillbirth and infant death. I assure the House that the Department is working collaboratively with partners, including charities such as Sands and Bliss, the royal colleges and others on a range of initiatives to help to reduce the number of tragic deaths. The Department is always open to new ideas and to working with partners throughout the health sector. We welcome these debates and the opportunity to engage further in any way that Members believe will help us to move forward in this vital area of policy for all our constituents.