Health and Social care Committee

Inquiry into stillbirths in Wales

SB 14 – Cwm Taf Health Board

TITLE OF OVERVIEW REPORT

Prevention of Stillbirths

SITUATION / PURPOSE OF REPORT

Response for the “Health and Social Care Committee” in relation to the Inquiry into Stillbirths in Wales

BACKGROUND / INTRODUCTION

Every stillbirth is a tragic event, and there are many causes associated with stillbirth such as younger mothers (less than 25 years), or older mothers (over 40 years), obesity (a Body Mass Index of over 35), multiple pregnancies, smoking in pregnancy, pregnancy complications such as pre-eclampsia, pre-existing medical conditions such as diabetes, placental conditions, congenital abnormalities and ethnicity.  However, in many stillbirths the cause remains unknown.  The reasons for the regional variations in stillbirth rates are also unclear, but women living in the most deprived areas are 1.7 times more likely to suffer a stillbirth compared to women in the least deprived areas. Cwm Taf Health Board has a high level of poor health indices across the population. In addition to the physical effects, stillbirth can have profound emotional, psychological and social impact on the parents and family.

All maternity services report stillbirths nationally, and the improved classification score has resulted in improved data collection which will help professionals detect emerging patterns in order to understand why stillbirths occur.  Maternity units also review and monitor their own rates so that processes and procedures can be put in place to improve services.

Providing maternity care for women who live in the Cwm Taf area presents challenges which are linked to the poor health of the population, and to the social deprivation within the area.  Cwm Taf Health Board has the highest percentage of births to mothers below 20 years of age within Wales (10.7%) (WIMD, 2008).  This, along with social deprivation, is associated with high levels of smoking, alcohol use, low birth weight babies and mental health illness, all of which are at high levels within the Cwm Taf area.  Maternal obesity in Wales is high, with many women in the Cwm Taf Health Board (CTHB) catchment area having a high body mass index (BMI). 

Obesity has been shown to increase the incidence of pre-eclampsia, antepartum haemorrhage, diabetes, which are factors related to stillbirths. 

The number of live births within Cwm Taf Health Board during 2011 was 4310, compared to 4345 live births in 2010. There were 16 stillbirths in 2011, compared to 17 stillbirths in 2010, this is 4% of the total births for both years, which is below the All Wales percentage. 

The latest National Statistics on births and infant mortality produced by the Welsh Government show there were 35,952 live births in Wales, the largest number in a year since 1993.  Although there has been a fall in the number of babies born to women under 20 years, there is an increase of 50 % of babies born to women over 40 years in Wales.  The national trend in the stillbirth rate since 2000 has decreased from 5.4 (2000) to 5.2 (2009) per 1,000 births.  The stillbirth rate for twin births has also fallen.

Current Situation within Cwm Taf Health Board

Cwm Taf Health Board provides both consultant and midwifery led care for pregnant women at two District General Hospitals.  Women who have specific risk factors are cared by a consultant obstetrician, and women with medical conditions have shared care which is provided by both an obstetrician and a specialist physician or surgeon.  Women with no risk factors are offered midwifery led care, and there are excellent links between the midwives and obstetricians to provide a robust holistic and integrated service.

Professionals within Cwm Taf Health Board are proactive in reducing risks for pregnant women, and are aware of the current guidance and recommendations with regards to stillbirth prevention.  The following actions are in place to reduce the stillbirth rate:

• All women receive maternity and obstetric care based on NICE Antenatal Care, Intrapartum Care and Postnatal Care guidelines

• There are many specific Health Board guidelines which include guidance for the care of pregnant women with the following conditions -  diabetes, obesity, pre-eclampsia and eclampsia

• There are also Health Board guidelines relating to multiple pregnancy and altered fetal movements 

• There is a Health Board Antenatal Care guideline which identifies specific criteria for booking women for midwifery led and consultant led care

• At booking and during the antenatal period, women are continually risk assessed, and a clear management plan is provided based on individual needs

• Combined specialist physician/surgeon and obstetric antenatal clinics for high risk women are in place and there is excellent liaison between the specialities.

• In addition, diabetic women have regular contact with the Diabetic Specialist Nurse throughout pregnancy and the initial post partum period

• Symphysis fundal measurement is carried out at all antenatal clinic visits

• Routine serial ultrasound scans are provided for women with specific risk factors e.g. measuring small for dates, history of previous small for dates baby, specific medical conditions

• Routine glucose tolerance tests are carried out for diabetic women or women presenting with a strong family history of diabetes

• Anaesthetic review is undertaken for women with a BMI over 40 in the antenatal period, and a clear management plan is developed for pregnancy and labour

• Women with specific risk factors are seen in the Maternity Day Assessment Unit, which provides individualised care and direct access to  consultant advice

• Support and advice with regards to smoking cessation is offered routinely.  Referral to the Smoking Cessation Midwife is offered, and individual cessation programmes are available across the Health Board.

• Midwives offer all women advice and support regarding diet, smoking, and keeping healthy throughout pregnancy and during the postnatal period

• Education and support is offered through regular parentcraft classes

• Continual cardiotocograph monitoring in labour is undertaken for women at high risk of obstetric complications

• Midwifery and obstetric training programmes are in place based on Confidential Enquiry into Maternal and Child Health recommendations.

The implementation and effectiveness of the above action is monitored in the following ways:

· Sharing of information and lessons learnt through multidisciplinary 

Meetings

· Clinical audit

· Clinical review and Root Cause Analysis.

· Comparisons and ongoing monitoring is applied utilising the midwifery dashboard

· The Obstetric, Gynaecology and Sexual Health Directorate Governance arrangements.

· Sentinel events (which can include stillbirths) result in a review by the Medical Director and the Director of Nursing and are reported through to the Welsh Government and to the Health Board.

ONGOING ACTIONS

Within Cwm Taff Health Board the following actions are currently being undertaken in order to further reduce the stillbirth rate:

• Re-evaluation of the content of parentcraft classes, to improve accessibility, relevance and to appeal to a wider group of pregnant women.  Greater emphasis on education and advice relating to healthy eating, smoking cessation and the importance of ensuring fetal movements are felt on a daily basis. 

• Reviewing whether local slimming classes will provide an alternative input into the parentcraft classes to broaden appeal.

• Actively prescribing nicotine replacement treatment to all pregnant women who smoke 

• Re-evaluation of the midwifery and obstetric training relating to the detection of intra-uterine growth retardation.

• Further development of the midwifery and obstetric training programmes to ensure greater emphasis on public health issues such as smoking cessation and healthy eating

• Developing new antenatal `fetal kick’ charts

• Development of proposals for an enhanced services for pre-conceptual care

• ongoing audit of stillbirths 2011 – 2012 to identify trends 

• audit of glucose tolerance testing.

The Health Board has maintained a lower percentage of stillbirths  compared to Wales, despite significant challenging health indices for the population. Continuous improvements are sought and there is close scrutiny and monitoring of the standards of treatment and care provided within obstetrics and midwifery services through the governance structures of the Health Board.

Allison Williams, Chief Executive.

Cwm Taf Health Board.

25^th May 2012.