Section B: Mortality Statistics in Wales – Stillbirths

  1. Stillbirths in Wales
  2. Risk factors for stillbirth
  3. Cause of stillbirth death in Wales
  4. Comment on behalf of the National Stillbirth Working Group
Stillbirths in Wales

 In the UK, stillbirth is defined as late fetal death from 24 weeks’ gestation. The stillbirth rate (including late terminations) to women usually resident in Wales in 2015 was 4.83 (95% CI 4.14, 5.63) per 1,000 registrable births, which is lower than the 2014 rate of 5.38 per 1,000 births and the rate for the combined three years 2012-2014 (5.04 per 1,000 births). The stillbirth rate in 2015 was 4.4 per 1,000 registrable births in England (ONS), 4.7 per 1,000 in Wales (ONS). These rates include late terminations. Overall ONS rates for stillbirths are very comparable to AWPS rates when late terminations are included (4.83 vs 4.73 per 1,000 registrable births).

The stillbirth rate in Wales excluding late terminations was 4.12 per 1,000 registrable births in 2015 (Table A10(2)), which is a decrease on the previous year (4.64 per 1,000 registrable births in 2014). The rate has declined this year (Figure 8). Similar trends were observed for stillbirth rates in some Health Boards and regions in Wales (Table A10) although there are variations in rates within regions.

Figure 8: Stillbirths (excluding late terminations): 3 year rolling rates in Wales (1995-1997 to 2013-2015)

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Source: NCCHD and AWPS/MBRRACE-UK

Figure 9 shows the stillbirth rate for individual Health Boards in a funnel plot. All Health Boards had rates that fall within or just on the 95% confidence limits.

Figure 9: Stillbirth mortality rate (excluding late terminations) by Health Board to mother’s resident in Wales: 2011-2015

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Source: NCCHD and AWPS/MBRRACE-UK

Risk factors for stillbirth

Within Wales, stillbirth rates have previously been persistently higher in the most deprived quintile of social deprivation measured using the Welsh Index of Multiple Deprivation (WIMD). Figure 10 shows the rates for deprivation quintiles of the population as given by the Welsh Index of Multiple Deprivation (WIMD) and shows a narrowing of the gap between highest and lowest quintiles since 2001-2005.

Figure 10: Stillbirth rate by deprivation quintile: five year rolling rates (1994-1998 to 2011-2015)

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Source: NCCHD and AWPS/MBRRACE-UK

Cause of death in stillbirths

Classification systems for stillbirths are used to give as much insight as possible into the underlying cause of death or events leading up to death, in order to explore any trends or variation in causes of death and to identify areas that can be potentially addressed. We present data on cause of death in stillbirths using CODAC classification (Figure 11). Between 2013 and 2015, for 52% of stillbirths the cause of death was unknown and the cause of death was missing in 9% of cases (Figure 11a). Where it was possible to identify a cause, intrapartum and placenta were leading causes of stillbirth. Screening and monitoring in pregnancy are used to identify high risk pregnancies so that appropriate clinical management can be provided.

Figure 11a: Single main cause of death in stillbirths using CODAC classification: 2013-2015

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In 2015, the cause of death was unknown for 62% of stillbirths and the cause of death was missing in 6% of cases.

Figure 11b: Single main cause of death in stillbirths using CODAC classification: 2015

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When the placenta category was broken down further, abruption or retro-placental hematoma were leading causes of death. The number of deaths in this category was small though.

Figure 11c: Placenta category broken down to level 2 of CODAC classifications: 2015

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When the intrapartum category was broken down further for stillbirths, cord and placenta complications were leading causes of death. The number of deaths in this category was small though.

Figure 11d: Intrapartum category broken down to level 2 of CODAC classifications: 2014

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Source: AWPS/MBRRACE-UK

Comment from Claire Roche (Maternity Network Manager) and Claire Francis (Clinical Lead: Maternity Network) on behalf of the National Stillbirth Working Group

On behalf of the National Stillbirth Working Group (NSWG), we welcome the publication of the All Wales Perinatal Survey Report for 2015. The AWPS team are valued members of the NSWG and their important work helps inform the work we are doing in Wales.

We are pleased to see that the stillbirth rate for 2015 has declined from the 2014 rate and is also lower than the combined three year rate of 2012-2014. However, we recognise that rates can vary year on year and that there is much more work to do to reduce rates akin to other European countries.

The National Stillbirth Working Group continues to work with a wide range of stakeholders from across Wales to progress a number of work-streams aiming to reduce the stillbirth rate. In July 2016, the all Wales Guideline for Fetal Movements in Pregnancy was launched which aims to ensure that from the first booking appointment to birth, the woman and her family are aware of the importance of monitoring fetal movements and of seeking immediate advice should they be concerned.

During June 2016, in partnership with all Health Boards in Wales, we facilitated three regional events hosted by the Perinatal Institute. These events aimed to address questions posed by clinicians to the Institute regarding the Growth Assessment Programme. All three events were very well attended by Midwives, Obstetricians and Sonographers and the days provided excellent opportunities for further knowledge to be developed.

The Bereavement Sub Group (previously known as the Perinatal Pathology Sub Group) are working hard to monitor the implementation of the All Wales Training Package for Obtaining Consent for Post Mortem and the introduction of the All Wales Standards for the Processes Associated with Post Mortem which have been in effect from the 1st January 2016. We are pleased to see that in 96.4% of stillbirth cases, an autopsy was requested by clinicians. However, we are aiming for this to be 100% and in particular are working towards histological examination of the placenta to be undertaken by a suitably trained paediatric pathologist. We are hoping that the work we are doing to evaluate compliance with the Standards will inform how we further improve the experience of those families who choose for their baby to have an autopsy.

This year we have agreed to take on another two work-streams: 1) Standardising bereavement care across Wales and 2) improve the detection and management of gestational diabetes. Therefore, the Perinatal Pathology Sub Group has become the Bereavement Sub Group and will progress this new work-stream and we have brought together a wide range of stakeholders to address how we progress improving the detection and management of GDM.

We continue to be committed in our aim to reduce stillbirth rates in Wales and working in partnership with AWPS.