The purpose of this Supplementary Report is to enable individual Trusts and Health Boards to understand their local stillbirth, neonatal death and extended perinatal death mortality rates and to give local teams an insight into clinical performance based not just on crude mortality rates, but also having taken account of at least some of the important socio-demographic factors that influence pregnancy outcomes.
Importantly the figures for individual Trusts and Health Boards are compared with other Trusts and Health Boards which provide care to women with similarly high or low risk pregnancies. This is based on the highest level of complex neonatal care provision, and for those organisations which do not provide high level complex neonatal care it is based on the number of women who deliver each year in their organisation. NHS Trusts and Health Boards have then been rated within these groups, comparing their mortality rate to the group average using the traffic light system used in the main report published in June. Guidance is provided to Trusts and Health Boards as to the action they should take based on their rating.
Symptoms of maternal postnatal depression have previously been associated with an increased risk of adverse effects on child development, including behavioural problems, cognitive difficulties, and attachment issues. This study found that resilience (or positive adaptation to adversity) was associated with two factors: 1) the mother’s positive feelings about parenting, and 2) the child’s nonverbal communication at 15 months. The identification of these factors provides insight about opportunities for early intervention with women identified with postnatal depression that can potentially support mother-child interaction, fostering child development and later child resilience. Read the paper in Plos One.
“Saving Lives, Improving Mothers’ Care - Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13”
Led by the MBRRACE-UK team at the National Perinatal Epidemiology Unit at the University of Oxford this report details the findings of maternal mortality surveillance 2011 to 2013 in the UK and the lessons learned from the confidential enquiries into maternal deaths of women with mental health-related problems, substance misuse, cancer and blood clots and women who died by homicide.
Overall, the maternal mortality rate in the UK continues to fall largely as a result of a reduction in deaths from ‘direct’ pregnancy causes. However the rate of deaths from ‘indirect’ causes has not reduced significantly. These are deaths from conditions not directly due to pregnancy but existing conditions which are exacerbated by pregnancy, for example, women with heart problems. More of these deaths will need to be prevented in the future to reach the UK Government target of a 50% reduction in maternal deaths by 2030.
The care of more than 100 women who died by suicide during pregnancy or in the year after giving birth between 2009 and 2013 was reviewed in detail. One in eleven of the women who died during or up to six weeks after pregnancy died from mental health-related causes. However, almost a quarter of all maternal deaths between six weeks and a year after birth are related to mental health problems, and one in seven of the women who died in this period died by suicide. Although severe maternal mental illness is uncommon, it can develop very quickly in women after birth; the woman, her family and mainstream mental health services may not recognise this or move fast enough to take action.
The care for women with substance misuse problems and those living socially complex lives was also reviewed. The messages for future care echoed those for women with mental health problems, including the need for joined up multi-agency care to ensure that these women do not fall through the cracks between services. The report also contains messages for the future care of women with cancer and those at risk of blood clots, which is the primary cause of ‘direct’ maternal deaths.
Necrotising enterocolitis and late onset sepsis are devastating complications of preterm birth. The pathology of neither is fully understood, but is associated with immaturity of the protective functions of the gut. One aspect of this relates to the millions of helpful bacteria that normally live in the gut and whose presence is essential for our well-being. We know that babies born prematurely do not usually acquire a normal diverse population of helpful bacteria in their gut; it has been hoped that giving them helpful bacteria (probiotics) like those found in healthy full term babies will strengthen the gut defences and provide protection.
We chose to examine whether the probiotic Bifidobacterium breve strain BBG-001 protects babies from necrotising enterocolitis, sepsis and death; the full protocol describing the trial in detail is available at www.npeu.ox.ac.uk/pips/protocol. Half of the babies in the trial were allocated to receive the probiotic and half to receive an identical inactive placebo product. When the PiPS trial was planned, there had been no reports of probiotics helping in this regard. However, as the trial progressed there were a number of publications all using different probiotics. The results have been combined and strongly suggest that probiotics might reduce both necrotising enterocolitis and death. We monitored these publications and were concerned not only about the quality of some of them but also questioned whether it is acceptable to combine trials using different probiotics when the scientific data suggest that different probiotics have different effects. Despite advice from some neonatologists that probiotics should be used routinely, the PiPS Trial Steering Committee advised that recruitment should continue and we reached our target in July 2013 with 1,315 babies born between 23 and 30 weeks’ gestational age taking part in the trial.
In total, 1,310 babies completed the trial making this the biggest study so far of probiotics in preterm babies and big enough for us to be very confident about the results (we were unable to use the results from only five babies). Furthermore we believe that the population of babies in the trial is typical of the babies in our neonatal units.
As with other trials we did not find any complications associated with giving probiotics, but neither did we find any evidence that the probiotic that we gave protected the babies from necrotising enterocolitis, sepsis or death.
This result does not support the routine use of this probiotic and, we believe, challenges the validity of combining the results of trials using different probiotics.
We are very grateful to all of the staff who made this trial possible, to the Yakult Honsha Co Ltd. Tokyo who provided the interventions, but were not involved in any other aspect of the trial, and above all to the families who gave permission for their babies to take part.
The study was funded by the UK National Institute for Health Research Health Technology Assessment programme.
Stillbirth affects around 1 in 200 pregnancies in high-income countries and is a devastating and traumatic event for women and their families. Guidance on contact between parents and their stillborn baby has changed over time and has been based on mixed evidence.
NPEU researchers Julie Hennegan, Jane Henderson and Maggie Redshaw have published a systematic review of the published evidence on the impact of contact with the stillborn baby on parental mental health, well-being and satisfaction. Their review found conflicting and sparse evidence on the impact of holding the stillborn baby on mothers’ mental health and well-being, both in the short and longer term. The studies reviewed consistently found that mothers valued contact with their stillborn baby and were satisfied with their decision to have this contact.
Led by the MBRRACE-UK team at the University of Leicester, this report details the findings from review of 130 term stillbirths, of which 85 were examined in detail by a panel of clinicians including midwives, obstetricians and pathologists.
The enquiry found that half of all term, singleton, normally-formed, antepartum stillbirths had at least one element of care that required improvement which may have made a difference to the outcome. Opportunities missed in two thirds of cases included: correctly identifying women with risk factors for diabetes and offering them testing; and appropriate screening and monitoring the growth of the baby. Almost half of the women had contacted their maternity units with concerns that their baby’s movements had slowed, changed or stopped. In half of these cases there were missed opportunities to potentially save the baby including a lack of investigation, misinterpretation of the baby’s heart trace or a failure to respond appropriately to other factors. Internal hospital reviews were only documented for a quarter of the deaths and their quality was highly variable. A post-mortem was carried out in only half of the cases, but most were of satisfactory or good quality. A generally good standard of bereavement care was provided for parents immediately following birth, including the offer of the opportunity to create memories of their baby. Read the full report for the detailed findings and the key actions for improving services to help prevent the terrible heartache experienced by three families every day across the UK. Follow us on Twitter @TIMMSleicester@mbrrace
Are you a researcher looking to get back into work after a career break for family, health or caring reasons? If you've been away from the world of work for at least two years, hold a science or related degree, and a doctorate or at least three years research experience you may be eligible for a Daphne Jackson Fellowship. Applications are now open for three University of Oxford sponsored Daphne Jackson Fellowships - for more information see the University's vacancy pages. To talk about potential opportunities for pursuing a Daphne Jackson Fellowship with us at the NPEU please contact Maria Quigley for an informal discussion.