Incidence

According to national statistics, the perinatal mortality rate in England and Wales is 7.6 per thousand live births and stillbirths in 2008 (latest available).¹ The neonatal mortality rate (deaths under 28 days) decreased to 3.2 per thousand live births in 2008.

• These rates are lower than the previous 3 years.
• In 2008 the West Midlands had the highest infant mortality rate in England at 6.5 deaths per thousand live births. The south east coast had the lowest at 3.8 deaths per thousand live births.

The perinatal mortality rate is indicative of perinatal and neonatal care, as well as living standards, maternal health, medical intervention and care.

Risk factors

• Low birthweight:
  • Stillbirth rates for the low birthweight (2500 g) group are 300 times higher than the normal birthweight group (above 2500 g).^2,3
  • Customised birthweight standards improve the prediction of adverse neonatal outcome.⁴
  • The association between small for gestational age (SGA) and adverse outcome is independent of the gestational age at delivery.
• Age of mother:
  • The stillbirth rates for women aged below 20 years (teenage mothers) or over 40 years tend to be higher than for women in the 25-35 age bracket.
• Maternal health:
  • Mother's BMI >30.
  • Chronic diseases, e.g. diabetes, renal failure, hypertension, haemoglobinopathy, rhesus disease, thrombophilias, antiphospholipid syndrome.
  • Infection, e.g. erythema infectiosum, varicella, measles.
  • Substance abuse, especially cocaine.
• Multiplicity of pregnancy:
  • The risk of stillbirth is approximately 3 times higher for multiple deliveries compared to singleton deliveries - 15.6 compared to 5.1.
  • Neonatal death is 7.6 times more common in multiple pregnancy - 21.9 compared to 2.9 per thousand live births.
• Region of maternal residence:
  • Most regions in the UK show fluctuations in stillbirth rates.
  • In 2008 there were 730 stillbirths registered in London, but only 179 in the north east of England.¹
• Social class:
  • This is reflected in regional differences; rates are higher among lower classes.
  • The influence of social, environmental, and behavioural factors on the risk of perinatal mortality is as important a risk factor as having had complications during a previous pregnancy.⁵
  • A combination of risk factors significantly increases risk.
• Marital status:
  • Between 1993 and 2002 for England and Wales, the stillbirth rates were higher among babies born outside marriage, with the rates for births with no details of the father on the birth certificate (sole registration) being the highest.
• Maternal country of birth:
  • Rates are 30% higher among ethnic minority mothers born outside the UK compared to UK-born mothers.
  • Increased rates are shown for non-UK born mothers of Bangladesh or West Indian origin.³
• Gestation/prematurity:
  • Risks increase with lower gestation (babies of low birthweight predominate).
• Pregnancies with a raised maternal serum human chorionic gonadotrophin (hCG) level:
  • These are associated with adverse obstetric outcomes.
  • Increased maternal and fetal surveillance is necessary in these pregnancies.⁶
• Sex:
  • Trends show that stillbirth rates are predominantly higher among males compared to females.
• Method of delivery/perinatal interventions:
  • Forceps and breech deliveries show highest risk of increasing perinatal mortality rates.
  • High-risk babies have improved outcomes with improved obstetric and paediatric care (staffing, departmental organisation, intrapartum intervention, neonatal intensive care units (NICUs), special care baby units (SCBUs).⁷

Common causes

These figures are taken from the last Confidential Enquiry into Maternal and Child Health (CEMACH) report:⁸

• Congenital abnormalities:
  • This is the leading cause of death.
  • It is responsible for 16% of stillbirths and 22% of neonatal deaths.
• Low birthweight:
  • Over 66% of all stillbirths, and nearly 75% of all neonatal deaths, had a birthweight of less than 2500 g.
  • The neonatal mortality rate for babies with birthweight <1500 g was 174 per thousand live births, and 369 per thousand live births for babies <1000 g.
• Gestational age:
  • Death rates decrease dramatically with increasing gestational age and just under 74% of neonatal deaths and 65% of stillbirths were born preterm.
  • 58% of babies born at 24 weeks' gestation survived the neonatal period, increasing to 77% at 25 weeks' gestation.
  • This is a marked increase compared to observations of a decade ago.
  • Survival at 27-28 weeks' gestation was 92%.
• Asphyxia, anoxia or trauma:
  • These were responsible for 7.5% of the identifiable causes of perinatal death in 2005.
• Maternal disorder:
  • These include diabetes and hypothyroidism and were accountable in 5.8% of deaths.
• Pre-eclampsia:
  • Accounted for 3% of perinatal deaths.
• Antepartum infections:
  • These accounted for 1.9% of the causes of perinatal death in 2005.
• Premature rupture of membranes.
• Rhesus haemolytic disease.
• Cord prolapse/antepartum haemorrhage.

Low birthweight

This is strongly correlated with perinatal mortality as well as the development of disease in later life. The perinatal mortality increase observed in some groups (such as socioeconomic) can be accounted for by an increased number of low birthweight infants. Much of the declining perinatal and neonatal mortality rates can be attributed to increased survival among low birthweight infants.^2,3The increased survival of low birthweight infants is a result of improved hospital-based care:⁷

• Antenatal screening/monitoring: detection of placenta praevia and pre-eclampsia; monitoring high-risk pregnancies.
• Abnormality scans and termination of malformed fetuses.
• Increase in Caesarean deliveries - for example, for breech position.
• Reduction in mid-cavity interventions.
• Control of rhesus incompatibility.
• Delay in onset and progression of premature labour.
• Induction to progress labour.
• Control maternal disorders (diabetes/hypothyroidism).

Diagnosis

• The mother may be aware of a decrease in fetal movements in many cases of stillbirth.
• Other stillbirths may be discovered at the routine antenatal check.
• An ultrasound examination is used to confirm that the fetus has died; this is seen as lack of a visible heartbeat.

Management

• Stillbirth is a devastating event for the parents and their family.
• The mother (and father) should be given time and space for reflection in a suitable environment away from the normal postnatal ward.
• They should be allowed to dress and spend time with their child. They may wish to take photos and make some memories to take with them.
  • Most hospitals have protocols in place for dealing with stillbirths, e.g. wrap the baby, offer to the mother to hold, and take photographs, hair and palm-prints.
• They will need to collect their belongings and may want to make funeral arrangements. Most hospitals can offer funeral services, if required.
• The mother will need to have:
  • Blood pressure checked.
  • Urine tested for protein.
  • Temperature taken.
  • Cervical and vaginal swabs for MC&S.
  • Blood taken for full blood count, clotting screen (including anti-phospholipid antibody and thrombophilias), Kleihauer test, HbA₁c, cultures (Listeria spp.) and serology (parvovirus B19, toxoplasmosis and cytomegalovirus) and cytogenetics.
• Labour is induced using prostaglandins administered vaginally. This does not need to be immediate, but should happen within 2-3 days.
• Hospital counsellors and chaplains may provide comfort to families of stillborn infants.
• Discuss the need, and arrange consent, for postmortem examination.

Registering a stillbirth

• Stillbirth registration began on 1 July 1927, to help protect infant life.
• As well as being an important source of historical and statistical information, it also gives parents the opportunity to have their child officially acknowledged and to give him or her names if they wish to, which can help with grief.
• Stillbirths in England and Wales must normally be registered at the hospital or local register office within 42 days of the stillbirth, but cannot be registered more than 3 months after its occurrence.¹⁰
• To register the stillbirth, the medical certificate of stillbirth issued by the doctor or midwife present at the time is required.
• The registrar will issue a certificate for burial or cremation of the stillborn infant. This certificate is usually passed to the funeral director who will make the arrangements.

Document references

1. Office for National Statistics. Infant and perinatal mortality 2008: health areas, England and Wales. September 2009.
2. Melve KK, Skjaerven R; Birthweight and perinatal mortality: paradoxes, social class, and sibling dependencies. Int J Epidemiol. 2003 Aug;32(4):625-32. [abstract]
3. Vangen S, Stoltenberg C, Skjaerven R, et al; The heavier the better? Birthweight and perinatal mortality in different ethnic groups. Int J Epidemiol. 2002 Jun;31(3):654-60. [abstract]
4. Figueras F, Figueras J, Meler E, et al; Customised birthweight standards accurately predict perinatal morbidity. Arch Dis Child Fetal Neonatal Ed. 2007 Jul;92(4):F277-80. Epub 2007 Jan 24. [abstract]
5. Gaizauskiene A, Padaiga Z, Starkuviene S, et al; Prediction of perinatal mortality at an early stage of pregnancy. Scand J Public Health. 2007 May 4;:1-6. [abstract]
6. Lepage N, Chitayat D, Kingdom J, et al; Association between second-trimester isolated high maternal serum maternal serum human chorionic gonadotropin levels and obstetric complications in singleton and twin pregnancies. Am J Obstet Gynecol. 2003 May;188(5):1354-9. [abstract]
7. Joyce R, Webb R, Peacock JL; Associations between perinatal interventions and hospital stillbirth rates and neonatal mortality. Arch Dis Child Fetal Neonatal Ed. 2004 Jan;89(1):F51-6. [abstract]
8. CEMACH - Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer - 2003-2005. December 2007.
9. SANDS. Stillbirth And Neonatal Death Society
10. General Register Office. Official information on Births, Marriages & Deaths

Internet and further reading

• Stillbirth. A stillborn baby is a baby born after the 24th week of pregnancy with no signs of life. An expert explains the emotional impact, and Lisa and Jason describe how they coped with a stillbirth. A short video from NHS Choices. (November 2009)

Acknowledgements