Britain's maternity crisis: A crying shame

Too few trained staff, a massive shortage of midwives, and poor resources mean that hundreds of babies are dying needlessly each year and that death rates in childbirth are showing no signs of declining, despite medical advances. Jonathan Owen reports

Up to 1,000 babies that are born dead each year could be saved if doctors and midwives were better trained to spot vital warning signs, according to one of the UK's leading experts on stillbirths. Health experts say the numbers of stillbirths in the UK are alarmingly high – 10 times the level of cot deaths – and most are unexplained.

New research to be presented at an international conference in Birmingham next week will hear that "sub-optimal care" is a key factor in many of the deaths. In many cases, midwives are having to deal with too many births.

The conference will hear important new evidence of a vital link between foetal growth restriction and stillbirths that can provide doctors with an early warning system that could save countless lives and spare families the loss of a child.

Almost 4,000 babies were stillborn in Britain last year according to the latest government figures. Despite falling since the 1960s, the rate of stillbirths has remained stubbornly unchanged for more than a decade and the rate (per 1,000 births) actually went up from 5.3 in 2001 to 5.7 in 2003. Figures show significant regional variations across the UK with London (6.3) and the East Midlands (5.7) showing the highest rates in England.

Research by the Perinatal Institute indicates that women living in the most deprived areas are twice as likely to have a stillbirth as those living in the least deprived areas, with babies of poorer women twice as likely to die before they are a month old. Black and Asian women are at increased risk of having a stillbirth compared with their white counterparts.

Stillbirth rates in Britain have fallen dramatically since 1960, when 30 out of every 1,000 newborn babies were stillborn or died soon after delivery. During recent years maternity care has been transformed beyond all recognition, with continuing advances in knowledge and technology, even prompting concerns in some quarters about the medicalisation of childbirth. But stillbirths have not gone down as one might have expected, staying at about the same level for more than a decade. Britain lags behind many European countries and is near the bottom of the table for Western European countries, with Italy, Sweden and Switzerland having rates of just 3 per cent. Only Andorra, Ireland, Portugal and Luxembourg have a higher stillbirth rate than Britain.

Professor Jason Gardosi, director of the Perinatal Institute in Birmingham, was careful to point out that many stillbirths are not avoidable, and that fetal growth restriction is not an actual "cause" of death, but an important warning sign.

"Our research has shown the largest percentage of stillbirths were associated with the baby not having grown well in the womb. It found that the majority of these stillbirths were potentially avoidable," said Professor Cardosi. "This reflects previous confidential inquiries that have been done nationally. Increasingly, we are starting to identify that there is also an issue about resources, in terms of midwifery caseload and in terms of providing ultrasound to check for foetal growth for high-risk pregnancies."

"Between 10 and 20 per cent of all pregnancies are affected by foetal growth restriction and are therefore have a five- or tenfold increased risk of stillbirth, but we only recognise around a third of these at the moment," said Professor Gardosi, adding that the importance of foetal growth restriction has been underestimated. "Distinction has always been muddled because we've been using the same charts for all pregnancies. We have developed customised growth charts that will give us a more accurate idea of growth rate and help us identify those babies that are smaller than they should be."

At the conference, organised by the Perinatal Institute and the Stillbirth and Neonatal Death Society (Sands), he will present the results of a 10-year study. These indicate that approximately 40 per cent of all stillbirths are growth restricted. Of those, maybe two-thirds are of a maturity where they could survive birth, so there are up to 1,000 stillbirths that might be avoided. "We are excited about these findings. If we can recognise that babies are not growing as they should then they can be further investigated and, if necessary, delivered at the right time, and in good condition, rather than being left in the womb and at continued risk of dying," he said.

Although almost two-thirds of stillbirths are categorised as " unexplained", a new system for classifying stillbirths, to include foetal growth restriction, will bring this figure down to about 15 per cent.

Campaigners are now calling for urgent action to drive down stillbirths. Despite the fact that 10 babies are stillborn every day in Britain and a further seven die within the first four weeks of life, there is no national strategy for reducing these deaths. Neale Long, director of Sands, said: "We have long felt that stillbirth rates in the UK are just too high. The charity is calling for changes in practice that could help reduce the loss of life.

"There is growing concern that overstretched maternity resources are resulting in a reduction in quality of care and leading to unnecessary deaths. We are determined to raise awareness of the human impact of stillbirth and ensure that the task of reducing stillbirths is given the national priority it deserves."

Professor Andrew Shennan from the baby charity Tommy's said stillbirths are more common than many realise. "For us it's a weekly problem in our hospital," he said. "We see it all the time and it's devastating, particularly when it's unexpected." He acknowledged that the ways in which pregnant women are monitored need to improve.

Research into stillbirths has been a neglected area, according to Professor Shennan. "I think we need research to look very carefully at the reasons why these babies are dying as a first step to solving the problem," he said. "This area is very neglected and dead babies have traditionally not been a high priority.

"Babies still die unexpectedly, even during labour, at a rate that I think would shock people. The shocking thing really is that they are so often unexplained and my own feeling is that with a little bit of resource we could probably answer a lot of questions."

Recent months have seen rising concern within the medical profession about the persistent levels of unexplained stillbirths. The Confidential Enquiry into Maternal and Child Health (CEMACH) warned that "the lack of progress in reducing the stillbirth rate is a matter of considerable public health concern".

And Sir Liam Donaldson, the chief medical officer, has declared the current level of stillbirths involving apparently healthy babies as " unacceptable", adding that "many could have been avoidable". In a report released earlier this year, he called on the Government to research and review infant deaths. The concerns are echoed by the Royal College of Gynaecologists, which also said a lack of information on causes of death is impeding attempts to reduce stillbirths.

But research has been hampered by the Alder Hey body-parts scandal of the 1990s, with the majority of parents now declining post-mortems.

A Department of Health spokesperson said: "Research has not yet pinpointed a specific cause for this phenomenon, which is why it is essential that vital work into this area continues. Current government research funding specifically into premature births stands at around £3.7m per year."

Sue MacDonald, spokeswomen for Royal College of Midwives, agreed that the current level of stillbirths is a cause for concern. "We want to carry on reducing the rate of stillbirths and neonatal deaths. For a family, the loss of a baby is a tragedy and we need to reduce that as soon as possible. Stillbirths are very traumatic; being there for the birth is painful for everyone concerned. Not all are preventable, but we want to make sure that the ones that can be prevented are."

Stillbirths can no longer be ignored, according to Mr Long, director of Sands. "There has been a taboo around stillbirths for far too long but these deaths should no longer be swept under the carpet. This does nothing to help the thousands of people whose lives are changed for ever when their babies are born dead each year."

Campaigners are now calling on the Government to develop a national strategy for stillbirth prevention and address the chronic shortages that remain in maternity care.

Bereaved parents: 'When Thomas was born, it was the worst kind of silence you can imagine'

For Samantha Springall, 27, who lives with her partner Wayne, 40, in Crawley, Sussex, the news that she was pregnant after two miscarriages filled her with hope. "After I got past 12 weeks it didn't even occur to me that something could go wrong."

But after a "low-risk" pregnancy with normal scan results, Ms Springall discovered that her son Thomas had died in the womb. He was stillborn on 15 August 2006. "When Thomas was born, it was the worst kind of silence you can imagine," she said. "You expect your baby is going to cry, but when you give birth to someone that's dead and see them being taken away you just think this isn't the way it's supposed to be."

Doctors had failed to spot signs of foetal growth restriction, one of the main factors in full-term stillbirth. "At the time you're not really sure what it means but I began to realise and then the anger kicked in. The inconsistency of antenatal care was definitely a factor.

"With a stillbirth you're mourning for what could have been. All the time, all the milestones, like his birthday, we mark them."

Jonathan Owen

Further reading: 'When a Baby Dies: The Experience of Late Miscarriage, Stillbirth and Neonatal Death' by Nancy Kohner and Alix Henley

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