A report commissioned by:

Transcription

Pregnancy and birth in Cumbria: A statistical review | January 2013
Table of Contents
1. Executive Summary
7
2. Introduction
10
3. Policy and strategy summary
12
4. Evidence
14
4.1 Perinatal mortality - causes 14
4.2 Perinatal mortality - risk factors
16
4.3 Maternity services and care provision in rural areas 17
4.3.1 Centralisation of services 18
4.3.2 Rural isolation and distance travelled to access services
19
4.3.3 Skilled staff
19
5. Intelligence
23
5.1 Definitions
23
5.2 Population summary
23
5.3 Fertility
26
5.3.1 General Fertility Rate 26
5.3.2 Total Fertility Rate
29
5.4 Live births
32
5.5 Maternal age
34
5.6 Birthweight
36
5.6.1 Low birthweight
36
5.6.2 Very low birthweight
39
5.7 Mortality
39
5.7.1 Stillbirths
40
5.7.2 Early neonatal deaths
43
5.7.3 Perinatal mortality rate
44
5.8 Labour/Delivery
46
5.8.1 Method of onset of labour
46
5.8.2 Method of delivery 47
5.8.3 Person conducting delivery
48
5.9 Antenatal assessment
49
5.10 Smoking in pregnancy
50
5.11 Workforce 51
6. Maternity services in Cumbria
53
6.1 Service provision
54
6.1.1 Staffing levels
54
6.1.2 Developing and improving services
54
6.1.3 Mapping local service provision
57
6.1.4 Other services across Cumbria
62
7. Conclusions and recommendations
64
8. Appendices
66
8.1 Appendix 1: Glossary of definitions
66
8.2 Appendix 2: Policy and strategy summary
67
8.3 Appendix 3: Risk factors for perinatal mortality
74
8.4 Appendix 4: The LA Classification 83
8.5 Appendix 5: Summary of results from the survey of women’s experiences of maternity
services 2010 for Cumbria.67 84
8.6 Appendix 6: Data from the CHIMAT Outcomes versus Expenditure tool, 2010/11 9. References
85
97
3
Table of Tables
Table 1: Local authority classification of the population of Cumbria, the North West and England.
17
Table 2: Female population aged 15 to 44 years. Cumbrian local authorities, North West and England, 2010. 24
Table 3: Female population aged 15 to 44 years. Cumbria and comparative Primary Care Trusts, 2010.
25
Table 4: General Fertility Rate. Cumbria and Cumbrian Local Authorities, England and Wales and North West,
2006 to 2010. 27
Table 5: General Fertility Rate. Cumbria and comparative Primary Care Trusts, 2006 to 2010.
28
Table 6: Total Fertility Rate per 1,000 women aged 11 to 49 years. Cumbria and Cumbrian local authorities,
England and Wales and North West, 2006 to 2010.
30
Table 7: Total Fertility Rate (per 1,000 women aged 15-44 years). Cumbria and comparative Primary Care Trusts,
2006 to 2010. 31
Table 8: Number of live births and crude birth rate (per 1,000 population). Cumbrian local authorities,
North West and England and Wales, 2006 to 2010.
33
Table 9: Number of live births and crude birth rate (per 1,000 population). Cumbria and comparative
Primary Care Trusts, 2006 to 2010. 34
Table 10: Number of births by mothers age, Cumbria 2006 to 2010. 36
Table 11: Number and percentage of low birthweight births. England and Wales, North West,
Cumbria and Cumbrian local authorities, 2006-2010.
Table 12: Percentage of low birthweight babies. Cumbria and comparative Primary Care Trusts, 2006-2010.
38
39
Table 13: Number and percentage of very low birthweight babies. England and Wales, North West and Cumbria,
2006-2010. 39
Table 14: Stillbirth rate (crude rate per 1,000 births). England and Wales, North West and Cumbria,
2004-06 to 2008-10 (pooled data).
41
Table 15: Stillbirths rate per 1,000 total births. England and Wales, North West, Cumbria and comparative
Primary Care Trusts, 2004-06 to 2008-2010 (pooled data).
42
Table 16: Perinatal mortality, rate per 1,000 total births. England and Wales, North West, Cumbria and
comparative Primary Care Trusts, 2004-06 to 2008-10.
45
Table 17: Method of onset of labour. Cumbria and local authorities, 2005 to 2009.*
46
Table 18: Method of delivery. Cumbria and Cumbrian local authorities, 2005 to 2009.
48
Table 19: Person conducting delivery. Cumbria and local authorities, 2005 to 2009.
49
Table 20: Antenatal assessment at 12 weeks, January to March 2011. Cumbria and comparative
Primary Care Trusts, North West and England and Wales. 50
Table 21: Outcomes and expenditure information for Cumbria Primary Care Trust and comparator
Primary Care Trusts, 2010-11.
52
Table 22: Maternity services provided by North Cumbria University Hospitals NHS Trust.
57
Table 23: Maternity services provided by University Hospitals of Morecambe Bay NHS Foundation Trust. 60
Table 24: Guidelines for weight gain in pregnancy.
78
4
Table of Figures
Figure 1: Population structure of Cumbria, 2010.
24
Figure 2: Female population aged 15 to 44 years. Cumbria and comparative Primary Care Trusts, 2010.
25
Figure 3: General Fertility Rate. Cumbria, North West and England and Wales, 2006 to 2010. 26
Figure 4: General Fertility Rate by local authority. Cumbria, 2010. 27
Figure 5: General Fertility Rate. Cumbria and comparative Primary Care Trusts, 2010. 28
Figure 6: Total Fertility Rate per 1,000 women aged 11 to 49 years. Cumbria, North West and England
and Wales, 2006 to 2010.
29
Figure 7: Total Fertility Rate per 1,000 women aged 11 to 49 years. Cumbrian local authorities, 2010. 30
Figure 8: Total Fertility Rate per 1,000 women aged 11 to 49 years. Cumbria and comparative
Primary Care Trusts, 2010.
31
Figure 9: Live birth rate (crude rate per 1,000 population). Cumbria, North West and England and Wales,
2006 to 2010. 32
Figure 10: Live birth rate (crude rate per 1,000 population) by local authority. Cumbria, 2010. 33
Figure 11: Percentage of live births by age of mother. England and Wales, 2006 to 2010#.
35
Figure 12: Percentage of births by age of mother. Cumbria, 2006 to 2010. 35
Figure 13: Percentage of low birthweight births. Cumbria, North West and England and Wales, 2006-2010. 37
Figure 14: Percentage of low birthweight births. Cumbria and Cumbrian local authorities, 2010. 37
Figure 15: Percentage of low birthweight births (less than 2,500grams). Cumbria and comparative
Primary Care Trusts, 2010. 38
Figure 16: Stillbirth and perinatal mortality, England and Wales, 1993-2010. 40
Figure 17: Stillbirth rate (crude rate per 1,000 births). England and Wales, North West and Cumbria,
2004-06 to 2008-10 (pooled data)L. 41
Figure 18: Stillbirths rate per 1,000 total births. Cumbria and comparative Primary Care Trusts,
2008-2010 (pooled data).
42
Figure 19: Number of deaths under 7 days as a percentage of total births. Cumbria and Cumbrian local
authorities, 2005-2009.
43
Figure 20: Perinatal mortality, rate per 1,000 total births. England and Wales, North West and Cumbria,
2004-06 to 2008-10.
44
Figure 21: Perinatal mortality rate per 1,000 total births across England, North West, Cumbria and
comparative Primary Care Trusts, 2008-10 (pooled data).
45
Figure 22: Method of onset of labour. Cumbria, 2005 to 2009.* 46
Figure 23: Method of delivery. Cumbria 2005 to 2009. 47
Figure 24: Person conducting delivery. Cumbria, 2005 to 2009. 49
Figure 25: Smoking status at delivery: smokers as a percentage of all maternities. Cumbria and comparative
Primary Care Trusts, 2010/11. 51
Table of Maps
Map 1: Location of maternity units in Cumbria.
53
5
Pregnancy and
birth in Cumbria
A statistical review
Foreword
Being born in Cumbria means being born in one of the most beautiful places on earth. The rural
environment, though undeniably attractive, brings with it challenges in providing safe and sustainable
healthcare services.
One area where this is particularly challenging is in the field of obstetrics. This report brings together
available statistical data relating to maternity care services for the last five years. In many areas Cumbrian
services are performing well, with low stillbirth and perinatal mortality rates. Investment in NHS maternity
services in Cumbria is higher than in comparable areas such as Devon and North Yorkshire.
This report forms the first part of a two-part study. The second part comprises an anonymised
case-by-case review of perinatal mortality (death of a baby shortly before or shortly after birth).
What is already clear is that a great many factors determine the outcome of any one pregnancy.
Of those lifestyle factors within our control, smoking and obesity rates undoubtedly have some of
the greatest impact.
For maternity services, there will continue to be a need to follow a ‘practice makes perfect’ approach
to care, with doctors, midwives and other health professionals maintaining their skills by performing a
critical mass of procedures in any given year. Alongside this, the challenge around the distance which
people are expected to travel for the very best care remains.
Innovative models where obstetricians and other professionals operate across a network of hospitals
need to be considered in the future as a means of squaring the circle safely and sustainably. A greater
role for family doctors and community-based midwifery services in the care of mothers and babies
also merits consideration.
The challenge for the future is to develop models of obstetric care that can get the best possible
outcomes for our rural population. This report should be considered alongside the case-by-case
review of perinatal mortality as a key contribution to that debate.
Dr Rebecca Wagstaff
Deputy Director of Public Health for Cumbria
6
1. Executive Summary
stillbirth rate is relatively unchanged (from 5.4 to 5.2
per 1,000 total birthsA). Whilst Cumbria’s perinatal
mortality rate appears to have been falling, from
7.3 per 1,000 total births in 2005 to 6.7 per 1,000
total births in 2009, this decline is not statistically
significant,3 nor was the downward trend in stillbirth
rates (4.8 to 4.5 per 1,000 total births) over the
same periodB. Early neonatal deaths have declined
at a greater rate than stillbirths, due to increased
survival of premature and low birthweight infants.4
The North West Public Health Observatory at the
Centre for Public Health, Liverpool John Moores
University were commissioned by NHS Cumbria
to produce this report as the first part of a two
phase study. The aim of this study was to provide
a statistical analysis of pregnancy and births
across Cumbria with a focus on perinatal mortality
and the associated risk factors. NHS Cumbria
has also commissioned an independent expert
clinical consortium to review all perinatal deaths
that occurred in mothers from Cumbria booked
for delivery at North Cumbria University Hospitals
NHS Trust and University Hospitals of Morecambe
Bay NHS Foundation Trust in years 2009 and
2010. This report complements the review.
This report consists of six sections as follows:
Introduction; Policy/Strategy; Evidence;
Intelligence; Maternity in Cumbria; and
Conclusions and Recommendations. There are a
number of appendices that contain a glossary of
definitions along with more detailed information
on policy/strategy and evidence.
Together, these two pieces of work will inform the
Cumbria Clinical Commissioning Group, public health
expert professionals and providers of NHS care in
Cumbria about maternity and perinatal mortality,
thus allowing local service providers to identify areas
for improvement to ensure that perinatal mortality
continues to decline across Cumbria.
North Cumbria University Hospitals NHS Trust
and University Hospitals of Morecambe Bay NHS
Foundation Trust provide maternity services across
Cumbria. There are six units in the county, four of
which are consultant-led and two are midwifeled. Over half of births in Cumbria during 2010/11
took place in North Cumbria University Hospitals
NHS Trust (65.2%). In 2010/11, NHS Cumbria had
more consultants in obstetrics and gynaecology
and more midwives per 1,000 births that the
averages for England.
The focus of this report is on perinatal mortality
as it is an important and comprehensive indicator
of the quality of maternity care.1 Perinatal
mortality is defined as the:
“death of a fetus or a newborn in the perinatal
period that commences at 24 completed weeks’
gestation and ends before seven completed
days after birth.” Perinatal mortality therefore
encompasses both stillbirths: “A baby delivered
without signs of life after 23+6 weeks of pregnancy”
and early neonatal deaths: “the death of a live born
baby occurring before seven completed days.” 2
In 2010/11, the average cost per birth in Cumbria
was £2,349.
The issues and challenges faced by maternity
service providers in Cumbria include:
• Ensuring safe and sustainable care provision
across a large geographically spread rural area;
• Meeting the needs of, and supporting vulnerable
groups, in addition to meeting the national
normal birth agenda for women. For example,
provision of neonatal services is a particular
challenge; for those living in Barrow it is 52 miles
to the nearest level two neonatal unit;
The UK perinatal mortality rate has been in decline
for over a decade, falling from 8.3 per 1,000 births
in 2000 to 7.6 per 1,000 births in 2009.13 This
decline is largely due to falls in the early neonatal
death rate (from 2.9 to 2.5 per 1,000 live births). The
A
B
The term ‘total births’ has been used in place of ‘live and stillbirths’.
Early neonatal death rate figures for Cumbria were unavailable.
7
• The requirement for additional specialist roles and
support to address the needs of the very deprived
areas, such as those found in Barrow; and
population). Both South Lakeland and Eden had
live birth rates that were significantly lower than
the rate for Cumbria.
• The continued need for hospital services to
integrate across sites, and with community
and primary care provision in local areas.
• Cumbria had a slightly higher proportion
of births to teenage mothers in 2010
compared to England and Wales (8% and
6% respectively). The proportion of births to
older mothers (aged 40 years and over), at
3%, was similar to that in England and Wales
(4%). From 2006 to 2010, the number of
births to mothers aged 40 years and over
in Cumbria decreased by 6%, the largest
percentage decrease of all of the age
groups. The largest percentage increase was
seen in the 25-29 year old group (13%).
Some of the key findings from the report are
as follows:
• In 2010, Cumbria had a lower proportion
of women of childbearing age C (34%) as
compared to the North West (39%) and
England (40%). This proportion is expected
to fall to around 30% by 2031.
• Both the General and Total Fertility Rates
in Cumbria increased from 2006 to 2010
but remained lower than the North West
and England and Wales. During this period,
Cumbria saw a larger percentage increase in
General Fertility Rate (10.2%) as compared
to the North West (8.8%) and England and
Wales (8.6%). In 2010, at local authority
level, South Lakelands’ General Fertility Rate
was significantly lower than that for Cumbria
(53.8 and 60.3 respectively). In 2010, the
Total Fertility Rate was 2.03 children for
every woman in Cumbria (the same as
the North West and slightly higher than
England and Wales at 2.00), ranging from
1.84 in Barrow-in-Furness to 2.23 in Allerdale.
• The proportion of babies born at a low
birthweight (less than 2,500 grams)
is increasing in Cumbria; however the
proportion remains lower than that
seen in the North West and England
and Wales. In 2010, 6.8% of babies born in
Cumbria were of a low birthweight compared
to 7.2% in the North West and 7.3% in
England and Wales.
• Data from the Office for National Statistics
Deaths Extract for 2005-2009 showed that
there were 55 early neonatal deaths in
Cumbria. There were no significant differences
in the percentage of early neonatal deaths
across Cumbria’s local authorities or when
compared to the North West figure. These
figures and accompanying interpretation
should, however, be viewed with caution due
to the small numbers involved.
• In the five years from 2006 to 2010, the live
birth rate has been increasing, yet is
consistently lower in Cumbria than the
North West and England. In 2010, Cumbria’s
live birth rate was 10.3 per 1,000 population
compared to 12.9 per 1,000 in the North West
and 13.1 per 1,000 in England and Wales.
There was wide variation when looking at
the live birth rate across Cumbria’s local
authorities, with the highest rate seen in
Carlisle (12.2 per 1,000 population, significantly
higher than all other local authorities) and
the lowest in South Lakeland (8.1 per 1,000
C
• When compared to England and Wales
and the North West, both the stillbirth
rate and the perinatal mortality rates
in Cumbria have followed the same
downward trend from 2004-06 to 200810, with Cumbria having lower rates
overall (across the measured years).The
stillbirth rate for Cumbria in 2008-10 was
3.7 per 1,000 total births, lower than both
Females aged 15-44 years.
8
• From January to March 2011, the
proportion of pregnant women
attending for antenatal assessmentD at
12 weeks in Cumbria (89.0%) was higher
than for both the North West (83.9%)
and England (84.2%). However, when
examining data for the comparative
Primary Care Trusts, Cumbria had the
second lowest percentage being seen
for antenatal assessment at 12 weeks
(the lowest being Devon, 85.5%), while
North Yorkshire and York had the highest
percentage (94.3%).
the North West and England and Wales rates
(both 5.1 per 1,000 total births). In the three
year period from 2008 to 2010, the perinatal
mortality rate for Cumbria was 5.6 per 1,000
total births, compared to both England (7.5)
and the North West (7.6), although this
difference was not statistically significant.
Examining perinatal mortality rates across the
comparative Primary Care Trusts reveals no
significant differences.
• There were variations in method of
delivery in Cumbria during the five year
period 2005 to 2009. For example, 10.3%
of deliveries in Cumbria were by elective
caesarean, but at local authority level this
proportion ranged from 8.2% in Carlisle to
11.2% in Copeland. During this time almost
two-thirds of all deliveries in Cumbria were
conducted by a midwife (64.5%), while
hospital doctors conducted just under a third
of deliveries (31.0%).
• In 2010/11, Cumbria and the North West
had similar percentages of women who
were smoking at the time of giving birth
(as a percentage of all maternities) at
16.1% and 17.7% respectively. These
were both higher than the percentage
for England (13.5%).
Definitions
General Fertility Rate: number of live births per 1,000 women aged 15-44 years.
Total Fertility Rate: a single measure of fertility representing the average number of children
per woman that would be born to a group of women if current age-specific patterns of fertility
persisted throughout the childbearing life.
Stillbirth: a baby delivered without signs of life after 23+6 weeks of pregnancy.
Early neonatal death: the death of a live born baby occurring before seven completed days.
Perinatal mortality: the number of stillbirths and early neonatal deaths per 1,000 live and stillbirths.
A full glossary of definitions is available in Appendix 1.
D
Women seen by a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks
and choices by 12 completed weeks of pregnancy.
9
2. Introduction
The Royal College of Obstetricians and
Gynaecologists (RCOG) suggest that such factors
have led to the loss of young life given the lack
of appropriate and timely care being available to
mothers and their babies and even the closure of
some maternity wards.11
Obstetrics refers to “the branch of medicine that
deals with the care of women during pregnancy,
childbirth and the recuperative period following
delivery”.5 Care of babies in the antenatal
period and during delivery is usually provided
by midwives,6 however, doctors or obstetricians
can become involved if a baby or its mother
has a problem or is at risk of experiencing
complications.6 Therefore, providing efficient
and high quality antenatal and labour ward care
requires midwives and obstetricians working
together in partnership.
The focus of this report is on perinatal mortality
as it is an important and comprehensive indicator
of the quality of maternity care.1 Perinatal
mortality is defined as the:
“death of a fetus or a newborn in the perinatal
period that commences at 24 completed weeks’
gestation and ends before seven completed
days after birth.” Perinatal mortality therefore
encompasses both stillbirths: “A baby delivered
without signs of life after 23+6 weeks of
pregnancy” and early neonatal deaths “the
death of a live born baby occurring before 7
completed days.”2
Maternity and newborn services are essential to
the health of the population, providing the first
significant personal experience of NHS healthcare
for many. These services are considered the
‘touchstone’ of an organisation’s quality of care.7
Everyone comes into contact with maternity
services at some point in their lives, either directly
for women and babies or indirectly, via the impact
on partners and family members.
Further definitions of terms used within this
report can be found in the glossary (Appendix 1).
The World Health Organization (WHO)
recommends the use of perinatal mortality as an
indicator of maternity and newborn care as it:
Nationally, obstetric care is being provided in the
context of a growing number of care standards
and associated guidelines or recommendations
(see Section 3). This, coupled with a rising birth
rate and growing pressures upon staff providing
obstetric and maternity services, can make
service provision extremely challenging. The birth
rate in England and Wales has risen steadily over
the past decade from 604,441 live births in 2000
to 723,165 live births in 2010. This equates to
an increase in the general fertility rate from 55.8
to 65.4 and the total fertility rate from 1.66 to
2.00 children per woman.8 Although the average
age of women giving birth has remained fairly
constant over the last decade, the rate of births
to women aged under 20 years has declined and
the rate among older mothers continues to rise.8
• provides information required to improve the
health of pregnant women, new mothers and
newborns; and
• allows decision makers to identify issues,
monitor trends and inequalities and consider
changes to public health policy and practice.12
In the decade from 2000 to 2009, there has
been a downward trend in the UK perinatal
mortality rate from 8.3 per 1,000 births to 7.6
per 1,000 births.3 This decrease was largely
the result of falls in the early neonatal death
rate (from 2.9 to 2.5 per 1,000 live births)
and a more modest reduction in stillbirth rate
(from 5.4 to 5.2 per 1,000 total births). In
Cumbria, there appears to be a decline in
the perinatal mortality rate, from 7.3 per
1,000 total births in 2005 to 6.7 per 1,000
total births in 2009, however this fall was
A recent UK survey revealed a shortage in the
number of midwives providing one-to-one care9
and there are added pressures on medical staff
following the introduction of the European
Union’s 48 hour Working Time Directive.10
10
not statistically significant.3 The stillbirth
rate also decreased from 4.8 to 4.5 per
1,000 total births over the same period,
again this was not a statistically significant
reduction. E The decline in early neonatal deaths
exceeds that of stillbirths; this may be attributed
to advances in neonatal care leading to increased
survival of extremely premature infants.4 The lack
of a reduction in stillbirths has meant that the
proportion of perinatal mortality attributable to
stillbirth has risen from 50% to 66%.
across the county. Added to this is the difficulty
in trying to quantify levels of deprivation and
need in rural areas. Of the 63,000 people
on low income, benefits or tax credits in
Cumbria, only 44% (28,000) live in the 20%
most deprived areas. The majority of people
in relative poverty (56%) live outside these
deprived areas, and 38% (20,000 people)
live in rural areas. F The combination of low
income, isolated location and poor access to
transport can have a major impact on access
to antenatal care and maternity services.
These issues are explored in more detail in
Section 4.3 of this report.
Two thirds of perinatal mortality cases in the UK
are stillbirths.13 Despite a significant reduction
in stillbirth rates in high-income countries since
the development of maternity services in the
1940s, an examination of trends over the past
20 years revealed that the UK had the highest
rate of late gestation stillbirths out of the 35
highest-income nations (3.8 stillbirths per 1,000
births after 28 weeks’ gestation).14 In highincome countries stillbirth rates are higher in
ethnic minority, socially disadvantaged, and rural
populations than in ethnic majority, affluent,
and urban populations. It is important for each
geographical area to try to determine the local
causes of and risk factors for stillbirth, and the
contexts in which they occur.15
This report was commissioned by NHS Cumbria
as the first part of a two phase study. The aim
of this study was to provide a statistical analysis
of pregnancy and birth across Cumbria with a
focus on perinatal mortality and the associated
risk factors. This report complements the second
phase of work, a review of all perinatal deaths
that occurred in mothers booked for delivery at
Foundation Trust in 2009 and 2010. This review,
also commissioned by NHS Cumbria, is being
conducted by an independent expert clinical
consortium.
Cumbria, home to the Lake District, is a
predominantly rural county in the northwest of
England. It is one of the most sparsely populated
counties in the country. Over half of all births
during 2006 were in densely populated urban
areas, while almost a fifth were in sparsely
populated areas.16 Rural-urban divisions such as
this are challenging for health service organisers
E
Together, these two pieces of work will inform
the new Cumbria Clinical Commissioning
Group about maternity services and perinatal
mortality and allow public health professionals
and local service providers to identify areas for
improvement to ensure that perinatal mortality
continues to decline across Cumbria.
Early neonatal death rate figures for Cumbria were unavailable.
Information from Cumbria Joint Strategic Needs Assessment, 2009. See www.cumbria.nhs.uk/YourHealth/
PublicHealthInformation/Cumbria%20JSNA%202009.pdf
F
11
3. Policy and strategy summary
based on needs assessment of the local population
which is appropriate, clinically effective and easily
accessible through a multi-disciplinary and multiagency approach.37,39 Common themes within these
documents include: woman-centred care and the
availability of informed choice of maternity services
whilst ensuring equity of access to these services;
provision and organisation of maternity care;
considerations related to lifestyle factors (smoking,
alcohol/substance misuse) that may impact upon
pregnancy; screening; and management of specific
clinical conditions. National standards are detailed
in Box 2 and further information about each of
these standards can be found in Appendix 2.
There are numerous policy and strategy documents
providing information on guidelines and measures
of best practice to improve the quality of maternity
care for women and their children and ensure that
they have the best possible outcome.21, 22, 25, 28 Here,
we have listed a number of key national, regional
and local policy/strategy documents for maternity
care (see Box 1). Further information about each
of these documents can be found in Appendix
2. In addition, there are a number of maternity
standards, which seek to ensure the planning and
delivery of high quality care. These standards are
Box 1: Policy/Strategy documents
National
• The Government’s response to the recommendations in Frontline Care: the report of the
Prime Minister’s Commission on the Future of Nursing and Midwifery in England (2011).17
• Healthy Lives, Healthy People: Our strategy for public health in England (2010),18 accompanied
by Our Health and Wellbeing Today.19
• The NHS in England: the Operating Framework for 2011/12 (2010).20
• Clinical Guideline 62. Antenatal care: routine care for the healthy pregnant woman (2008).21 Set
to compliment the National Service Framework for Children38 as well as Maternity Matters.22
• Clinical Guideline 55. Intrapartum care: Care of healthy women and their babies during
childbirth (2007).23
• Maternity Matters: Choice, access and continuity of care in a safe service (2007).22
• Improving the quality and outcomes for maternity service users through effective
commissioning (2007).24
• National Guidelines for Maternity Services Liaison Committees (2006).25
• Joint planning and commissioning framework for children, young people and maternity
services (2006).26
• Every Child Matters (2003).27
• Delivering the Best: Midwives Contribution to the NHS Plan (2003).28
Regional
• Our Life in the North West: Tackling health inequalities locally (2008).29
Local
• Children and Young People’s Plan (2008).30
North Cumbria
• North Cumbria Clinical Strategy (2011),31 developed in line with the Closer to Home Strategy.32
South Cumbria
• The Nursing and Midwifery Strategy 2009-2014: Embracing the Future and Building
Confidence (2009).33
12
Neonatal networks
units provide various levels of care locally.
The Lancashire and South Cumbria Neonatal
Intensive Care Network was set-up in 2003 and
works closely with other networks in the North
West of England (Cheshire and Merseyside
and, Greater Manchester). The network aims
to provide the highest standards of care for
babies and their families and to develop neonatal
services within the area within the limits of the
capacity and resources available to them.35
The Department of Health’s National Strategy
for Improvement (2003)34 recommended the
development of Neonatal Networks (also known
as Perinatal Networks or Newborn Networks).
These networks aim to provide families with
‘close to home’ access to appropriate care,
thus reducing unnecessary transfer of their
baby to intensive care units further afield. They
ensure that groups of hospitals and neonatal
Box 2: National Maternity Standards
• Healthy Child Programme: Pregnancy and the first five years of life (2009)36 updates Standard
One of the National Service Framework for Children, Young People and Maternity Services.39
• National Standards for Maternity Care – Report of a Working Party (2008)37 aims to ensure
fair, safe and quality assured services for all mothers and babies.
• National Service Framework for Children, Young People and Maternity (2004)38 promotes
woman- and child-centred high quality services that are designed around meeting
individual need and reducing inequality. The final standard of this framework, the Maternity
Services standard39, clearly states that all health services must employ inclusive, multidisciplinary and multi-agency policies, services and facilities by maternity care providers.
13
4. Evidence
can include: intrauterine growth restriction
(where nutrient delivery is impaired), infection,
placental abruption (where the placenta
separates from the uterus prior to birth), preeclampsia and umbilical cord complications such
as knots or entanglement. Maternal smoking,
advanced maternal age, grand multiparity,G and
obesity are also widely recognised to increase
the risk of antepartum stillbirth. Intrapartum
stillbirths are usually the result of oxygen
restriction during labour or trauma during
delivery and often reflect a poor quality of
clinical care during delivery. Whilst complications
during pregnancy or maternal disease may cause
antepartum death, in some cases, no specific
reason can be found.41
Around 17 babies are stillborn or die shortly
after birth in the UK every day.2 In the UK,
approximately one in 200 babies is stillborn,
while in Cumbria one in 220 babies is stillborn.3
There is a growing body of evidence regarding
the underlying causes of perinatal mortality;
here we provide a short summary, with a more
detailed review (with a particular focus on risk
factors) available in Appendix 3.
4.1 Perinatal mortality - causes
Worldwide, the causes of perinatal mortality
are associated with poor maternal health,
inadequate antenatal care and inappropriate
management of complications during pregnancy
and delivery; absence of obstetric care during
complicated births is a common cause of
perinatal deaths (see Box 3). Gestational age,
low birthweight and congenital anomalies are
intermediate indicators of perinatal mortality
and are highly interrelated.40 In high-income
countries, established placental pathologies
such as those leading to intra-uterine growth
restriction (IUGR) or placental abruption are
the largest contributing cause of perinatal
deaths, with infection being the second largest
contributor.14
Depending on the amount of investigation
after stillbirth and the classification system
used, between 15% and 28% of stillbirths
are unexplained. This is illustrated by UK
figures from the Centre for Maternal and Child
Enquiries (CMACE) which reported 28% of
stillbirths in 2009 as unexplained, compared
to around 50% in earlier reports, due to a
change in classification system. The biggest
causes/associated factors for stillbirths were
major congenital anomaly (9%), antepartum
or intrapartum haemorrhage (11%) and
specific placental conditions (12%).13 Recently
published statistics indicate that stillbirths due to
congenital anomalies have decreased, however
this may be due to a reduction in the number of
post-mortem examinations being conducted.43
Other classification systems that put greater
emphasis on customised birthweight centiles
and incorporating the findings of investigations
after stillbirth report specific placental conditions
being associated with up to half of stillbirths.42
The term ‘stillbirth’ includes cases where
intrauterine death occurs before the onset of
labour (antepartum death) or during labour
(intrapartum death). The majority (~90%) of
stillbirths in high-income countries such as
the UK happen before labour (antepartum).41
Antepartum stillbirths may be associated
with fetal anomalies, placental dysfunction or
maternal medical conditions. Placental problems
A woman who has had five or more previous pregnancies.
G
14
Box 3: Causes of neonatal deaths and stillbirth
High-Income Countries (such as the UK)
Major causes
• Fetal growth restriction
• Congenital Anomaly
• Antepartum haemorrhage
• Extreme preterm birth
Modifiable factors in high-income countries
• Maternal obesity
• Maternal age ≥40 years
• Cigarette smoking
Other associated factors
• Maternal medical conditions
–– Hypertension
–– Diabetes
• Illicit drug use
• Low educational attainment
• Low socio-economic status
• No antenatal care
Worldwide Causes
• Poor maternal health
• Insufficient care during pregnancy
• Inappropriate management of complications during pregnancy and delivery
• Poor hygiene during delivery and the first critical hours after birth
• Lack of newborn care.
Other (sometimes less well understood) factors:
• Women’s social status
• Nutritional status at time of conception
• Early childbearing
• Too many closely spaced pregnancies
• Harmful practices, for example, inadequate cord care, letting baby stay wet and cold and
feeding other food
Flenady et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis, 2011
Confidential Enquiry into Maternal and Child Heath (CMACE) Perinatal Mortality 2008, 2010.
World Health Organization, Neonatal and Perinatal Mortality. Country, Regional and Global Estimates, 2006
15
4.2 Perinatalmortality-riskfactors
obesity.44,45 There are a plethora of other risk
factors, some of which present greater potential
for risk than others, that need to be considered
(see Box 4). A number of these risk factors are
discussed in Appendix 3 more detail. In addition,
potential causes, such as interventions during
birth/labour and the quality of hospital/medical
care 46 are also explored.
Deprivation, ethnicity and extremes of
maternal age are suggested as the key risk
factors in perinatal mortality in numerous
publications.13,14,43,113 From a public health
perspective, two of the most prevalent,
but modifiable risk factors are smoking and
Box4:Potentialriskfactorsforperinatalmortality
Maternal body
mass index (BMI)
Marital status
Social class
Smoking
assisted conception
Sex of baby
Pre-diagnosed medical conditions and
medical conditions identified during pregnancy
low birthweight
Ethnicity
Maternal body mass index (BMI)
Multiple birth
Parity
Previous stillbirth
Maternal age
Where/how the baby was
delivered and who by
Source: NWPHO from Cnattingus and Lamb, 2002; Freemantle et al, 2009; Samueloff et al, 1989; Smith and Fretts, 2007;
Ravelli et al, 2009; Bellad et al, 2009
16
4.3 Maternity services and care
provision in rural areas
According to the 2009 Department for
Environment, Food and Rural Affairs (Defra)
Local Authority Classification, based on 2001
populations, an estimated 74% of Cumbria’s
population live in ‘Rural’ areasH as compared to
19% of the North West and 27% of England
(see Table 1).
Across the UK, a quarter of the population reside
in rural areas,50 and it is recognised that there
are challenges and issues that arise within rural
communities, which require special attention
and consideration.47 In general, those living in
rural and more remote areas receive a different
level and range of services when compared to
their urban counterparts – more than likely a
lower level and reduced number.
In four of Cumbria’s six local authorities,
all of the population are classed as living in
rural areas.
Table 1: Local authority classification of the population of Cumbria, the North
West and England.
Name
Total
Population1
Total Urban
Total Rural
Rural%
Population
Population
(including Large
(excluding Large (including Large
Market Town
Market Town
Market Town
population)2
2
2
population)
population)
Cumbria
487,692
128,929
358,763
74%
North West
6,729,722
5,463,616
1,266,106
19%
England
49,142,130
35,916,458
13,225,672
27%
Allerdale
93,577
-
93,577
100%
20%
Barrow-in-Furness
71,908
57,211
14,697
Carlisle
100,679
71,718
28,961
29%
Copeland
69,394
-
69,394
100%
Eden
49,859
-
49,859
100%
South Lakeland
102,275
-
102,275
100%
1
Based on Census 2001 population estimates, Office for National Statistics
2
P eople living in the Large Market Towns are defined as Urban in the Rural Definition. For the purposes of classifying local
authorities these towns are considered to be Rural.
Source: Department for Environment, Food and Rural Affairs
Whilst the (previous) Governments’ reform
of maternity services to improve choice of
maternity care and continuity of support from
the same midwife throughout pregnancy until
after birth is the ideal, delivering such choices
in rural areas can present numerous challenges,
including: access to midwives and health visitors;
less access to ad-hoc services (for example,
ante- and post-natal groups and the invaluable
H
information that they may impart); 48 as well as
equity of service provision. In rural areas, cost is
clearly an influence, with problems relating to
increased staff travel costs, and time taken to
travel to rural and remote areas. Therefore, cost
per head to deliver the service will be greater in
rural areas.49 Staff recruitment, retention and
the maintenance of up-to-date midwifery skills is
also an important challenge in rural areas.
For details of the Defra LA Classification System and the definition of rural areas see Appendix 4.
17
agendas, and to tackle inequalities in health
and services within rural area areas, as well as
between rural and urban areas. Access to services
(and the implications for health outcomes) has
been identified as one of their key foci for their
research activities during 2009 to 2013 and will
look at how to best improve access either by
providing more local services or facilitating easier
access to services at a distance; and what impact
this has upon health and wellbeing.
Non-clinical factors that impact on rural
maternity care include: level of deprivation,
with many rural areas having pockets of
deprivation very close to areas of affluence;
geography and weather conditions; nature and
condition of emergency equipment; nature
of emergency back-up and support; and
expected gap between current and necessary
transfer arrangements.60 Poor public transport
infrastructure to support travel outside of rural
areas also make it difficult for women to access
services if they do not have access to a car or
other mode of transport.48 The management of
these non-clinical factors in conjunction with
clinical challenges is essential to ensure that high
quality maternity services, based upon current
best practice, are achieved.
There are therefore a number of factors that
need to be examined in further detail when
considering maternity services and the care
of pregnant women who live in rural areas (as
compared to urban areas), which all impact
upon the notion of ‘choice’ of pregnant women
living in rural areas. These include the impact
of: centralisation of services; rural isolation and
distance travelled to hospital and adequate
maternity provision in terms of available skill sets.
Some of the information detailed below will cut
across these themes.
Despite the wealth of research from other high
income countries including Australia, the USA,
Canada and New Zealand about rural versus
centralised maternity care and the impact and
implications that this has for women, their babies
and service provision, there is limited research
evidence in this field provided from the UK; the
existing research has largely been provided from a
single group in Scotland.50 Some of the available
research will be considered in Sections 4.3.1 to
4.3.3 of this report. The UK could learn from
the solutions put in place to address problems
affecting rural areas in other settings. The British
Medical Association has recommended that
rural areas should have policy distinct from that
applied in urban areas.50 In response to this,
the Department of Health and the Department
of Environment, Food and Rural Affairs funded
the development of ‘Rural Proofing for Health:
A Toolkit for Primary Care Organisations’. This
assists service providers with ‘rural proofing’
service delivery by considering the rural dimension
and ensuring that rural communities are not
disadvantaged in relation to their needs for health
services (www.ruralhealthgoodpractice.org.uk).
The Institute for Rural Health (www.rural-health.
ac.uk) also aims to ensure that rural health
issues remain high on policy and service delivery
4.3.1Centralisation of services
With the emphasis being placed upon reducing
risk in pregnancy and childbirth, smaller
community maternity units are closing or
reducing the services that they currently deliver.
Maternity services are being centralised to larger
specialist obstetric and neonatal services in
hospitals usually located in larger cities, as this is
deemed safer.51, 52 The centralisation of obstetric
and neonatal services occurring in the UK and
other high-income countries,53 is also driven by
cost, safety and the difficulties in recruitment
and retention of rural healthcare staff.51, 52, 54 It is
important to note that for low-risk multiparous
women, birth at home or in a midwifery-led unit
is not associated with an increased perinatal
mortality rate compared to consultant-led or
co-located midwifery-led units.55 However, the
rate of transfer to consultant-led units, even
for multiparous patients was 12%. This has
important implications for rural practice (see
section 4.3.2).
18
Centralisation of maternity services occurred
in Cumbria following public consultation in
2000/2001.56,57 At this time, Helme Chase
Maternity Unit in Westmorland General
Hospital (a then consultant-led unit) was facing
possible closure or a reduction of services.
As a result of the consultation, Helme Chase
became a midwifery-led unit, with complicated
pregnancies being transferred to Lancaster Royal
Infirmary, a consultant-led unit 23 miles away.
neonatal death and post neonatal death in
rural areas where there was weak or no urban
influence (even when differences in maternal
characteristics were accounted for).59 While poor
quality perinatal and infant care may be a cause,
other unmeasured risk factors (such as maternal
smoking) may also have an effect. A second
Canada-based study discovered that although
there was a lower rate of caesarean section in
rural areas, older women in rural areas had an
increased risk of perinatal mortality compared
to urban women; and the risk of perinatal death
increased with distance to the nearest hospital.53
In Canada, rural mothers had low attendance
at prenatal care and, of greater relevance, were
more likely to smoke, drink alcohol during
pregnancy, reside in a low-income community,
and had a previous low birthweight baby or
preterm birth. It is not clear whether these
sociodemographic factors are true for rural
populations in the UK or Cumbria. Another
Canadian study highlighted adverse effects on
physical and emotional wellbeing for women
from lower socioeconomic groups who have to
travel away from their home community to give
birth (www.ruralmatresearch.net/ourresearch.
htm). These data suggest that centralising highrisk care in less accessible distant urban centres,
may promote a situation that increases the risk
of perinatal mortality and morbidity in rural
areas and therefore careful consideration should
be given to such action.
4.3.2Rural isolation and distance
travelled to access services
Money for public services is allocated by
Parliament in proportion to the number of
people living in an area without consideration
of distance travelled to access these services.57
The provision and closure of rural maternity
services is taking place against a backdrop of
other service closures in rural areas including
schools, libraries, post offices, pharmacies,
police stations and the termination of local bus
services.57 As these public services are closed or
centralised, those from rural communities face
longer journeys to access services. In the case
of maternity services, this can limit personal
choice regarding how and where they give
birth to their babies, as they have to travel
further to access what may be considered a
less personalised, but safer service in a larger
obstetric unit.58 This may be seen to accentuate
rather than address inequalities.48 Alternatively,
this may be perceived as beneficial as it gives
access to consultant-based obstetric care and
services. Two Canadian studies suggest that the
risk of perinatal death increases in proportion
to distance travelled to get to a consultant-led
unit.53,59 These findings should nonetheless
be interpreted with caution, as the distances
compared by these studies, (50-149km and
≥150km) are far greater than in Cumbria.
4.3.3Skilled staff
Whilst Maternity Matters goes some way to
defining what a skilled maternity workforce
would ideally be comprised of, it does not
say how this may be specifically translated to
meet the needs of rural areas.22 This is dealt
with at a local level, which leads to variation in
delivery and availability of services. Evidence
provided from research in Scotland suggests
that midwives, GPs and other healthcare
professionals involved in providing maternity
services in rural areas require rural-specific
training, involving wider skills and competencies
A study in Canada compared urban and rural
areas with strong metropolitan influence to
rural areas with weak or no urban influence and
found that there was a significantly greater risk
of poor perinatal outcomes including stillbirth,
19
within the community to maximise opportunities
for local delivery and decision making based on
robust risk assessments.60 It recommends that in
order to assess and manage risk, the available
levels of maternity care within local access need
to be measured and from this, strategies to
minimise risk should be considered and then
implemented. This would include identifying
high-risk pregnancies where midwife-led care
is inappropriate and obstetric-led care is vital. It
also suggests that midwives must be competent
in identifying risk factors and initiating transfer
to secondary or tertiary care for ill mothers and
babies, where required.
than for those employed in more urban
settings.60, 61, 62, 63 This is attributed to the fact
that in some instances, decision making and the
implications associated with these decisions,
are made without onsite specialist support.
Furthermore, many interventions must be
delivered in a timely manner to prevent serious
complications, thus local staff must be able
to respond promptly. Whilst this may not be
applicable in all cases, it is very pertinent in the
case of rural, midwifery-led maternity units.
The Models of Care outlined by the Remote and
Rural Midwifery ServiceI, states maternity care
in remote and rural areas should be integrated
“There will be local variations in the make-up of maternity teams and therefore some GPs will
remain directly or indirectly involved in the delivery of maternity care to low risk women,
especially women who have existing co-morbidities or intercurrent illness. Depending on the
level of care provided within local primary care settings, the GP will be required to have a
minimum set of maternity skills to manage such situations and this will therefore require to be
reflected in their training.”
Delivering for Remote and Rural Healthcare: The Remote and Rural Midwifery Service ,
The Remote and Rural Steering Group, NHS Scotland, 2008
The Expert Group on Acute Maternity Service
(EGAMS) in Scotland also produced an overview
report which included a list of core skills and
competencies required for adequate maternity
service delivery to low-risk women and the
management of obstetric emergencies in rural
and non-obstetric units (see Box 5).62,63 These
skills included amongst others: management of
normal delivery; management of breech delivery;
basic obstetric life support; neonatal resuscitation;
and initial and discharge examination of the
newborn. Within this report, there was also
a high level of self-assessed competence for
breech delivery among rural midwives compared
to urban midwives who reported themselves
as more competent for initial and discharge
examination of newborns.62
Findings from two studies exploring maternity
services in rural areas of Scotland highlighted
differences in skills required in rural maternity
services compared to urban settings.51, 61 In
addition, they indicated an increased risk of
poor birth outcomes and the greater need for
appropriate services to meet the needs of these
rural populations. Staff in rural areas felt the
need to stress their skills and competence when
assessing risk and deciding upon transfer of
women with complications to staff in receiving
urban units. The studies demonstrated high
levels of reported competence among rural
maternity care staff, particularly skills in risk
management and decision making, however,
few felt competent at ventouse lift-out delivery
and ultrasound scanning.
The Remote and Rural Health Project was established to develop a framework for sustainable healthcare within remote
and rural Scotland. The Remote and Rural Midwifery Service was implemented as part of this project. For further
information see: www.scotland.gov.uk/Publications/2008/05/06084423/3
I
20
Box 5: Core skills required (mainly by midwives) within remote and non-obstetric
units include:
• Confident to provide intrapartum care in a low technology setting;
• Comfortable to use embodied knowledge and skills to assess a woman and her baby as
opposed to using technology;
• Able to let labour ‘be’ and not interfere unnecessarily;
• Confident to avert or manage problems that might arise;
• Willing to employ other options to manage pain without access to epidurals;
• Responsible for outcomes without access to on site specialist assistance; and
• Confident to trust the process of labour and be flexible with respect to time.
Expert Group on Acute Maternity Services – Reference Report,
Scottish Executive Health Department, 2002
Case study: Insights from users and providers of maternity services in England48:
Some key findings
This research looked at the experiences of having a baby (antenatal care, labour and birth, to
the period after birth) in four rural areas in England: Eden, Berwick-upon-Tweed, South Holland
and North Devon. Highlighted below are some of the key findings (specific to the themes
already outlined above):
Pregnancy
• Rural midwives have a large geographical area of coverage and low birth rates, which can
equate to high costs that are not adequately considered during funding allocation.
• Rurality impacts upon the ability of women to access antenatal services and classes and
this is further exacerbated by differences in socioeconomic status and age of women. For
example, older women from professional backgrounds are more likely to access antenatal
classes and look for information about classes compared to teenage or young expectant
mothers; they are also more likely to have access to transport if they need to travel to
appointments and classes outside of their local area. Where there was a lack of classes due
to shortage of midwives, those older, more affluent women looked for other options such
as attending National Childbirth Trust classes, which are delivered at an additional cost –
something that may not be within the reach of many of the younger expectant mothers.
• Inconvenience of travelling to hospital - older expectant mothers did not mind travelling to
hospital if they considered that they were receiving the best care. They were also more likely
to have their own transport and attend with partners. Younger women were less likely to
have access to their own transport, having to use public transport, thus making hospital visits
potentially very disruptive and time consuming. It was suggested that this could be addressed
through the delivery of mobile services, decentralising services to GPs and up-skilling midwives
and other professionals.
continued…
21
Giving birth and beyond
• Level of rurality impacts upon provision of homebirth, as a higher number of midwives are
needed to deliver services and poor transport infrastructures make transport difficult.
• Centralising specialist services but providing more community-based maternity care is the
ideal, however, the reality is/was that the availability of local midwife-led units is limited.
• Maternity Matters22 recommends that fewer, more comprehensive specialised maternity
services are provided in conjunction with strengthened community-based maternity
services. However, this proves difficult when applied to rural areas as these specialist
services have a larger geographical area to cover.
• Rural areas can attract high proportions of migrant workers where dissemination of
information is often difficult, particularly as migrants may not speak English.
• It was highlighted that professionals do not take into account the full extent the impact of
access to services on those living in rural areas can have. Postnatal care is delivered in local
health clinics, which can mean travelling some distance for those who live in rural areas.
Those who had to rely on public transport were less likely to attend these appointments.
Useful Resources related to rural care
• Commission for Rural Communities www.defra.gov.uk/crc
• Institute for Rural Health www.rural-health.ac.uk
• Remote and Rural Areas Resource Initiative (RARARI) www.rarari.org.uk
• Rural Proofing for Health Project www.ruralhealthforum.org.uk/proofing.htm
22
5. Intelligence
Hospital admission data
Data relating to hospital admissions was
extracted from the Hospital Episode Statistics
(HES) for Cumbria. An extract was taken
according to specific criteria. These criteria
included all hospital episodes for the five years
from 2005 to 2009 by delivery method using
the Office of Population, Censuses and Surveys:
Classification of Interventions and Procedures,
4th Revision codes (OPCS-4; OPCS, 1993).
The OPCS-R codes relate to any procedure
associated with pregnancy, birth and the six
week period following birth (puerperium). These
procedures include surgical inductions (R14) J,
other (i.e. medical) inductions (R15), elective
caesarean section (R17), emergency caesarean
section (R18), forceps delivery (R21), vacuum
delivery (R22), all normal deliveries (R24.9) and
episiotomies (R27.1).
5.1 Definitions
Population statistics used to produce rates are
from the Office for National Statistics mid-year
population estimates.64
Where possible, 95% confidence intervals (CIs)
are presented in the charts, displayed as error
bars. They illustrate the limits within which we
can be 95% confident the true value lies. If one
area’s confidence intervals do not overlap that of
another area, the difference between the areas is
described as statistically significant.
Where available and appropriate, the most
recent five years of data have been presented.
Where possible, data for Cumbria Primary
Care Trust has been compared to the four
‘most similar’ and the ‘least similar’ areas as
determined by the Office for National Statistics
Area Classification for Health Areas.65 These
areas are, in decreasing similarity:
ONS Deaths Extract
Data for the period 2005 to 2009 was extracted
from the ONS deaths database for Cumbria and
its local authorities. In many cases numbers were
too small to publish.
1. North Yorkshire and York (most similar)
2. Somerset
3. Devon
5.2 Population summary
4. Great Yarmouth and Waveney
In 2010, there were an estimated 494,350
people living in Cumbria, 49% of whom were
male (243,614) and 51% were female (250,736)
(Figure 1). Of the female population, 34%
(84,091) were of childbearing age (15-44
years old); lower than the proportions for
both the North West (39%) and England
(40%) (Table 2). Across the local authorities this
proportion ranged from 30% in South Lakeland
to 37% in Barrow-In-Furness and Carlisle.
5. East Riding of Yorkshire (least similar)
Some of the numbers/rates within the report are
based on small numbers of events. Due to the
sensitive nature of some of the data and to avoid
potential identification of an individual, numbers
of five or less have been suppressed. Suppressed
numbers are represented by an asterisk
symbol (*), while data that was unavailable are
represented by ‘n/a’.
Across the five comparative Primary Care Trusts,
Somerset had the most similar number of
females (87,332) to Cumbria (Figure 2, Table 3).
It is important to consider that when working
with small numbers, a change by just one event
can impact on the resulting rate, for this reason
we would advise that caution is taken when
interpreting this data.
Surgical induction = artificial rupture of membranes (ARM).
J
23
Figure 1: Population structure of Cumbria, 2010.
Source: NWPHO from Office for National Statistics mid-year population estimates
Table 2: Female population aged 15 to 44 years. Cumbrian local authorities, North
West and England, 2010.
Area
Females aged 15-44 years
Percentage of total female
population aged 15-44 years
Cumbria
84,091
34%
North West
1,365,353
39%
England
10,482,671
40%
Allerdale
15,690
33%
Barrow-in-Furness
13,152
37%
Carlisle
19,537
37%
Copeland
11,965
35%
Eden
8,097
31%
South Lakeland
15,650
30%
24
Figure 2: Female population aged 15 to 44 years. Cumbria and comparative
Primary Care Trusts, 2010.
Table 3: Female population aged 15 to 44 years. Cumbria and comparative Primary
Care Trusts, 2010.
Females aged 15-44 years
Percentage of total female
population aged 15-44 years
Cumbria
84,091
34%
North Yorkshire and York
147,183†
36%
Somerset
87,332
32%
Devon
124,747
32%
Great Yarmouth and Waveney
36,700*
33%
East Riding of Yorkshire
56,109
33%
Area
* This is the total value for Great Yarmouth (17,086) and Waveney (19,614)
† This is the total value for North Yorkshire (100,688) and York (46,495)
25
5.3 Fertility
North West and England and Wales values (60.3
compared to 65.3 and 65.4 respectively).
5.3.1General Fertility Rate
In Cumbria during 2010, the General Fertility
Rate varied across the local authorities from
53.8 in South Lakeland to 65.3 in Carlisle (Figure
4). South Lakelands’ General Fertility Rate was
significantly lower than that for Cumbria. The
largest percentage increase from 2006 to 2010
was in Allerdale (21.7%), whilst the lowest was
in Barrow-in-Furness (1.8%) (Table 4).
The General Fertility Rate is the number of live
births per 1,000 women aged 15-44 years.66
From 2006 to 2010 the General Fertility Rate
increased across Cumbria, the North West and
England and Wales (Figure 3, Table 4). The
largest percentage increase was in Cumbria
(10.2%), compared to increases of 8.8% in the
North West and 8.6% across England and Wales.
As in previous years, during 2010 the General
Fertility Rate in Cumbria was lower than both the
In 2010, across the comparative Primary Care
Trusts, Cumbria’s General Fertility Rate (60.3) was
most similar to that of Devon (59.1) (Figure 5).
Figure 3: General Fertility Rate. Cumbria, North West and England and Wales,
2006 to 2010.
Source: NWPHO from Office for National Statistics (births datasets and mid-year population estimates)
26
Figure 4: General Fertility Rate by local authority. Cumbria, 2010.
Table 4: General Fertility Rate. Cumbria and Cumbrian Local Authorities, England
and Wales and North West, 2006 to 2010.
Area
2006
2007
2008
2009
2010
% change
2006-10
Cumbria
54.7
56.2
58.6
59.3
60.3
10.2
North West
60.0
61.6
63.8
63.8
65.3
8.8
England and Wales
60.2
62.0
63.8
63.7
65.4
8.6
Allerdale
53.0
60.0
59.9
61.2
64.5
21.7
Barrow-in-Furness
57.4
57.3
59.1
57.1
56.4
1.8
Carlisle
58.5
56.7
62.9
63.1
65.3
19.5
Copeland
59.3
56.8
58.7
58.5
62.3
11.0
Eden
54.2
52.1
55.2
57.5
55.8
18.3
South Lakeland
46.8
52.6
53.5
55.9
53.8
11.8
27
Figure 5: General Fertility Rate. Cumbria and comparative Primary Care Trusts, 2010.
Source: NWPHO from NCHOD and Office for National Statistics mid-year population estimates.
Table 5: General Fertility Rate. Cumbria and comparative Primary Care Trusts,
2006 to 2010.
Area
General Fertility Rate
2006
2007
2008
2009
2010
Cumbria
54.7
56.2
58.6
59.3
60.3
51.9
52.2
55.6
55.1
54.1
Somerset
57.3
58.5
61.5
63.8
64.9
Devon
52.0
54.4
53.4
58.4
59.1
58.8
60.7
65.1
61.1
65.0
52.6
54.4
53.4
55.3
55.2
Source: NWPHO from Office for National Statistics
28
5.3.2Total Fertility Rate
Cumbria (10.9%), whilst England and Wales
and the North West also saw increases,
albeit lower (8.1% and 7.4% respectively).
The Total Fertility Rate (also referred to as total
period fertility rate) is a single measure of fertility
representing the average number of children
per woman that would be born to a group of
women if current age-specific patterns of fertility
persisted throughout the childbearing life. It is
used as an indicator of family size.
In 2010, the Total Fertility Rate was 2.03
children for every woman in Cumbria, ranging
from 1.84 in Barrow-in-Furness to 2.23 in
Allerdale, however as we were unable to calculate
confidence intervals it is not known if these
differences were significant (Figure 6). Between
2006 and 2010, the largest increase in Total Fertility
Rate across the local authorities was in Allerdale
(23.9%), while Barrow-in-Furness was the only local
authority to see a slight decline (-2.6%; Table 6).
Between 2006 and 2010 the Total Fertility
Rate increased across Cumbria, the North
West and England and Wales (Figure 6).
Whilst a slight decline was seen between 2008
and 2009 for both the North West and England
and Wales, the Total Fertility Rate in Cumbria
continued to increase. The largest overall
increase from 2006 to 2010 was seen in
Out of the comparative Primary Care Trusts,
Cumbria had the third highest total fertility rate
in 2010 (Figure 8).
Figure 6: Total Fertility Rate per 1,000 women aged 11 to 49 years. Cumbria,
North West and England and Wales, 2006 to 2010.
Source: NWPHO from NHS IC Compendium of Population Health Indicators
29
Figure 7: Total Fertility Rate per 1,000 women aged 11 to 49 years. Cumbrian local
authorities, 2010.
Table 6: Total Fertility Rate per 1,000 women aged 11 to 49 years. Cumbria and
Cumbrian local authorities, England and Wales and North West, 2006 to 2010.
Area
2006
2007
2008
2009
2010
% change
2006 to 2010
Cumbria
1.83
1.89
1.99
2.01
2.03
10.9
North West
1.89
1.95
2.01
2.00
2.03
7.4
England & Wales
1.85
1.91
1.97
1.96
2.00
8.1
Allerdale
1.80
2.08
2.06
2.14
2.23
23.9
Barrow-in-Furness
1.89
1.87
1.94
1.89
1.84
-2.6
Carlisle
1.87
1.81
2.02
1.99
2.05
9.6
Copeland
1.99
1.91
1.96
1.95
2.06
3.5
Eden
1.88
1.83
2.00
2.08
2.04
8.5
South Lakeland
1.61
1.85
1.91
2.04
1.95
21.1
30
Figure 8: Total Fertility Rate per 1,000 women aged 11 to 49 years. Cumbria and
comparative Primary Care Trusts, 2010.
Table 7: Total Fertility Rate (per 1,000 women aged 15-44 years). Cumbria and
comparative Primary Care Trusts, 2006 to 2010.
Area
Total Fertility Rate
2006
2007
2008
2009
2010
Cumbria
1.8
1.9
2.0
2.0
2.0
1.7
1.7
1.8
1.8
1.8
Somerset
1.9
2.0
2.1
2.1
2.2
Devon
1.7
1.8
1.8
1.9
2.0
2.0
2.0
2.2
1.9
2.1
1.8
1.9
1.9
1.9
1.9
Data only available to one decimal place. Source: NWPHO from Office for National Statistics and NHS IC Compendium of
Population Health Indicators
31
5.4 Live births
and England and Wales values (12.9 and 13.1
per 1,000 respectively in 2010; Table 8).
From 2006 to 2010 there were 25,181 births
in Cumbria, equivalent to an average of 97
per week. Figure 9 shows the live birth rate (crude
rateK) for Cumbria Primary Care Trust compared
to the North West and England and Wales over
the five year period 2006 to 2010. There was a
slight increase in the live birth rate in Cumbria
from 9.9 per 1,000 population in 2006 to 10.3
per 1,000 population in 2010, however, it is
consistently lower than both the North West
When looking at the live birth rate by local authority
(Figure 10), Carlisle had a significantly higher rate
(12.2 per 1,000 population) than all of the other
Cumbrian local authorities. South Lakeland and
Eden had significantly lower rates than the other
local authorities, (8.1 per 1,000 population and
8.7 per 1,000 population respectively). Both South
Lakeland and Eden had live birth rates that were
significantly lower than the rate for Cumbria.
Figure 9: Live birth rate (crude rate per 1,000 population). Cumbria, North West
and England and Wales, 2006 to 2010.
Source: NWPHO from Office for National Statistics (births datasets and mid-year population estimates).
K
Crude birth rate is the rate of live births per 1,000 population of all ages.
32
Figure 10: Live birth rate (crude rate per 1,000 population) by local authority.
Cumbria, 2010.
Table 8: Number of live births and crude birth rate (per 1,000 population).
Cumbrian local authorities, North West and England and Wales, 2006 to 2010.
Area
Cumbria
North West
2006
2007
2008
2009
2010
No.
Rate
No.
Rate
No.
Rate
No.
Rate
No.
Rate
4,917
9.9
4,998
10.1
5,118
10.3
5,080
10.3
5,068
10.3
84,155 12.3 85,974 12.5 88,167 12.8 87,549 12.7 89,199 12.9
England and Wales 669,601 12.5 690,013 12.8 708,711 13.0 706,248 12.9 723,165 13.1
Allerdale
891
9.5
1,001
10.6
983
10.4
983
10.4
1,012
10.8
Barrow-in-Furness
796
11.2
796
11.2
815
11.5
763
10.8
742
10.5
Carlisle
1,170
11.1
1,123
10.6
1,225
11.7
1,255
12.0
1,275
12.2
Copeland
774
11.1
735
10.5
747
10.7
715
10.3
745
10.7
Eden
476
9.2
454
8.8
472
9.1
478
9.2
452
8.7
South Lakeland
810
7.8
889
8.5
876
8.4
886
8.5
842
8.1
33
When looking at the comparative Primary
Care Trusts, across all years (2006-2010),
Cumbria has the third lowest live birth
rate (Table 9).
Table 9: Number of live births and crude birth rate (per 1,000 population).
Cumbria and comparative Primary Care Trusts, 2006 to 2010.
Area
2006
2007
Cumbria
4,917
9.9
4,998 10.1 5,118 10.3 5,080 10.3
7,755
9.9
Devon
Rate
No.
Rate
2009
Rate
Somerset
No.
2008
No.
No.
Rate
2010
No.
Rate
5,068
10.3
7,793 10.0 8,289 10.0 8,093 10.5 7,967†
9.9
5,280 10.2 5,390 10.3 5,614 10.7 5,654 10.8
5,671
10.8
6,802
7,372
9.8
9.2
7,067
9.5
7,172
9.6
7,366
9.9
Great Yarmouth and Waveney 2,187 10.3 2,257 10.6 2,405 11.2 2,268 10.6 2,384* 11.1
3,071
9.3
3,151
9.4
3,064
9.1
3,136
9.3
3,097
9.1
*This is the total for Great Yarmouth and Waveney combined
† This is the total value for North Yorkshire and York combined
5.5 Maternal age
8%, the percentage of births to teenage
mothers (women under 20 years) in
Cumbria was significantly higher than
England and Wales (6%).
In 2010, the largest proportion of births in Cumbria
were to mothers aged 25 to 29 years (30%), whilst
for England and Wales, the largest proportions
were among 25 to 29 year olds and 30 to 34 year
olds (28% each) (Figure 11, Figure 12).
From 2006 to 2010, the number of births to
mothers aged 40 years and over in Cumbria
decreased by 6%, the largest percentage
decrease of all of the age groups. The largest
percentage increase was seen in the 25 to 29
year old group (13%) (Table 10).
In 2010, the percentage of births to mothers
aged below 25 years was significantly
higher in Cumbria (28%) compared to
England and Wales (25%). Furthermore, at
34
Figure 11: Percentage of live births by age of mother. England and Wales, 2006 to 2010#.
#Figures for 2009 do not add up to 100%
Figure 12: Percentage of births by age of mother. Cumbria, 2006 to 2010.
Source: Office for National Statistics
35
Table 10: Number of births by mothers age, Cumbria 2006 to 2010.
Age group
2006
2007
2008
2009
2010
% change
2006-10
All ages
4,917
4,998
5,118
5,080
5,068
3.1
Under 20
374
348
378
400
392
4.8
20 - 24
947
998
1,029
1,072
1,019
7.6
25 - 29
1,326
1,350
1,492
1,426
1,500
13.1
30 - 34
1,351
1,334
1,224
1,248
1,283
-5.0
35 - 39
749
810
815
766
714
-4.7
40+
170
158
180
336
160
-5.9
5.6 Birthweight
West and England and Wales (Figure 13).
However, across these years, the North West and
England and Wales saw an overall percentage
decrease in low birthweight births, while
Cumbria saw an increase.
Low birthweight may be the result of preterm
birth (before 37 weeks’ gestation) or due
to restricted fetal growth or both. Ideally,
birthweight would be evaluated using
customised birthweight centiles, in which
the birthweight is adjusted for gestation at
birth, gender, maternal height, weight and
ethnicity. Unfortunately, the data available was
insufficient. Therefore, low birthweight has been
defined using the World Health Organization
recommendation as weight at birth of less than
2,500 grams. Very low birthweight was defined
as less than 1,500 grams.
There was no consistent pattern in the proportion
of low birthweight births across Cumbrian local
authorities between 2006 and 2010, as numbers
were relatively small (Table 11). There were no
significant differences in low birthweight births
across the local authorities during 2010 (Figure
14). The percentage of low birthweight births
increased across Allerdale, Barrow-in-Furness and
Copeland from 2006 to 2010.
5.6.1Low birthweight
Across the comparative Primary Care Trusts in
2010, Great Yarmouth and Waveney (8.7%)
and East Riding of Yorkshire (7.7%) both had a
higher percentage of low birthweight births than
Cumbria (6.8%) (Figure 15).
In Cumbria, the percentages of low
birthweight births between 2006 and 2010
were consistently lower than the North
36
Figure 13: Percentage of low birthweight births. Cumbria, North West and
England and Wales, 2006-2010.
Source: NWPHO from NCHOD
Figure 14: Percentage of low birthweight births. Cumbria and Cumbrian local
authorities, 2010.
37
Table 11: Number and percentage of low birthweight births. England and Wales,
North West, Cumbria and Cumbrian local authorities, 2006-2010.
Low birthweight (<2500 grams)
2006
Cumbria
2007
2008
2009
2010
n
%
n
%
n
%
n
%
n
%
317
6.4
328
6.6
355
6.9
366
7.2
328
6.8
North West
6,853
8.1
6,554
7.6
6,743
7.6
6,540
7.5
6,336
7.2
England and Wales
52,487
7.9
51,577
7.5
52,954
7.5
52,740
7.5
52,638
7.3
Allerdale
51
5.7
72
7.2
69
7.0
52
5.3
69
6.8
Barrow-in-Furness
45
5.6
56
7.0
75
9.2
53
6.9
46
6.4
Carlisle
93
7.9
81
7.2
83
6.8
111
8.8
84
6.6
Copeland
45
5.8
45
6.1
54
7.2
57
7.9
58
8.4
Eden
32
6.7
23
5.1
32
6.8
33
6.9
25
5.7
South Lakeland
51
6.3
51
5.7
42
4.8
60
6.8
46
7.0
Figure 15: Percentage of low birthweight births (less than 2,500grams). Cumbria
and comparative Primary Care Trusts, 2010.
38
Table 12: Percentage of low birthweight babies. Cumbria and comparative
Primary Care Trusts, 2006-2010.
Percentage low birthweight (<2500 grams)
2006
2007
2008
2009
2010
Cumbria
6.4
6.6
6.9
7.2
6.8
6.3
6.5
5.9
n/a
6.4
Somerset
6.5
6.6
6.5
7.3
6.4
Devon
6.8
6.3
6.4
6.0
5.9
9.1
6.8
6.8
8.5
8.7
5.9
6.2
5.9
6.1
7.7
5.6.2Very low birthweight
Cumbria from 2006 (0.9%) to 2010 (1.2%). Data
were unavailable at local authority level.
There was little variation in the proportion of very
low birthweight births (less than 1500 grams)
across Cumbria, the North West and England
during 2010 (1.2%, 1.3% and 1.4% respectively)
(Table 13). There was no significant increase in
the percentage of very low birthweight births in
Across the comparative Primary Care Trusts
during 2010, there was little variation in the
proportion of very low birthweight births,
ranging from 0.9% in Devon and Somerset to
1.8% in Great Yarmouth and Waveney.
Table 13: Number and percentage of very low birthweight babies. England and
Wales, North West and Cumbria, 2006-2010.
Very low birthweight (<1500 grams)
2006
n
2007
%
2008
n
%
n
2009
%
n
%
2010
n
%
Cumbria
42
0.9
n/a
n/a
61
1.2
70
1.4
56
1.2
North West
1,203
1.4
1,115
1.3
1,233
1.4
1,214
1.4
1,135
1.3
England and Wales
9,849
1.5
9,344
1.4
10,287
1.5
9,924
1.4
10,184
1.4
5.7 Mortality
respectively per 1,000 total births (Figure 16).
Overall, the early neonatal mortality rate is lower
than both the perinatal mortality and stillbirth
rates, with a decline also seen from 1993 to
2010 (from 3.2 to 2.3 per 1,000 total births).
More recently, the stillbirth rate in England and
Wales has not significantly altered since 2005. In
2010, the rate of perinatal mortality in England
and Wales was lower than the North West (7.4
and 7.6 per 1,000 total births respectively).
While stillbirth, perinatal and early neonatal
mortality data is available from 1978, it is only
possible to compare the years 1993 onwards as
the definitions of stillbirth and perinatal mortality
changed in 1992.
From 1993 to 2010, the perinatal mortality
rate and the stillbirth rate in England and
Wales, declined from 8.9 to 7.4 and 5.7 to 5.1
39
Figure 16: Stillbirth and perinatal mortality, England and Wales, 1993-2010.
Source: NWPHO from Office for National Statistics Child Mortality statistics
5.7.1 Stillbirths
The stillbirth rate for Cumbria in 2008-10 was
3.7 per 1,000 live and stillbirths, lower than both
the North West and England and Wales rates
(both 5.1 per 1,000 total births) (Table 14).
When compared to England and Wales and the
North West, the stillbirth rate in Cumbria has
followed the same downward trend from 200406 to 2008-10, whilst having lower rates overall
across the measured years (Figure 17).
40
Figure 17: Stillbirth rate (crude rate per 1,000 births). England and Wales, North
West and Cumbria, 2004-06 to 2008-10 (pooled data)L.
Source: NWPHO from NCHOD and Compendium of Public Health Indicators
Table 14: Stillbirth rate (crude rate per 1,000 births). England and Wales, North
West and Cumbria, 2004-06 to 2008-10 (pooled data).
Area
Stillbirth rate per 1,000 births
2004-06
2007-09
2008-10
Cumbria
4.2
3.9
3.7
North West
5.5
5.2
5.1
England and Wales
5.5
5.1
5.1
Note: Data was unavailable at local authority level
It was not possible to compare Cumbria with the
comparative Primary Care Trusts over the same
time-frame (i.e. 2004-06 to 2008-10) as some of
the data for 2004-06 was missing (Table 15).
In 2008-10, Cumbria had the lowest rate of
stillbirths per 1,000 total births (3.7); however
this difference was not significant (Figure 18,
Table 15).
There is some overlap as 2007-09 and 2008-10 will both contain 2009 data.
L
41
Figure 18: Stillbirths rate per 1,000 total births. Cumbria and comparative Primary
Care Trusts, 2008-2010 (pooled data).
Table 15: Stillbirths rate per 1,000 total births. England and Wales, North West,
Cumbria and comparative Primary Care Trusts, 2004-06 to 2008-2010 (pooled data).
Stillbirth rate per 1,000 births
2004-06
2007-09
2008-10
Cumbria
4.2
3.9
3.7
n/a
4.6
4.5
Somerset
4.1
4.9
5.2
Devon
5.4
4.4
4.2
n/a
5.3
4.5
n/a
4.4
5.7
42
5.7.2Early neonatal deaths
There were no significant differences in the
percentage of early neonatal deaths across
Cumbria’s local authorities (Figure 19). When
comparing Cumbria and the Cumbrian local
authorities to the North West, again there does
not appear to be any significant differences.
These figures and accompanying interpretation
should, however, be viewed with caution due to
the small numbers used in the analysis.
In England and Wales there has been a steady
decrease in the early neonatal death rate from
3.2 per 1,000 live births in 1993 to 2.3 in 2010
(Figure 16) In 2009, there were 10 early
neonatal deaths in Cumbria (a rate of 1.9
per 1,000 live births). It is not possible to
generate rates at local authority level due to the
small numbers involved.
The LSOA data used to examine deaths under
7 days is based upon the usual residence of the
deceased. Therefore, such data would include
those cases where babies might have died
outside the Cumbria area after being transferred
to a special care unit. Information on actual
place of death is available in the dataset but is
not routinely used in analyses.
Data from the Office for National Statistics
(ONS) Deaths Extract for 2005-2009 showed
that there were 55 deaths in Cumbria recorded
that were under seven days. In the North West,
there were 1,126 deaths under seven days during
this period.
Figure 19: Number of deaths under 7 days as a percentage of total births.
Cumbria and Cumbrian local authorities, 2005-2009.
Source: NWPHO from ONS Deaths Extract
43
From the Office for National Statistics (ONS)
Deaths Extract information, there are some
general statements that can be made regarding
early neonatal deaths at Cumbria Primary Care
Trust level:
specific to perinatal period; haemorrhagic
and haematological disorders of the fetus;
and new born and other disorders.
5.7.3Perinatal mortality rate
When compared to England and Wales and
the North West, the perinatal mortality
rate in Cumbria has followed the same
downward trend from 2004-06 to 200810 and has lower rates overall (across the
measured years) when compared to these
two areas (Figure 20).
• Of the deaths under seven days, 47% were
males and 53% females.
• Of these deaths, 87% were attributed to
certain conditions originating in the perinatal
period, with the remaining 13% attributed to
congenital malformations and deformations
and chromosomal abnormalities.
In the three year period from 2008 to 2010,
the perinatal mortality rate for Cumbria
was 5.6 per 1,000 total births, lower than
both England (7.5) and the North West (7.6),
although this difference was not significant.
• When looking at ‘certain conditions
originating in the perinatal period’, we
can see that 35% of deaths were due to
transitory endocrine and metabolic disorders
specific to the perinatal period and 31%
due to respiratory and cardiovascular
disorders specific to the perinatal period.
The remainder were attributed to; infections
Perinatal mortality data for Cumbrian local
authorities was examined, however no significant
differences were seen. This may be due to the
small numbers involved.
Figure 20: Perinatal mortality, rate per 1,000 total births. England and Wales,
North West and Cumbria, 2004-06 to 2008-10.
Source: NWPHO from Compendium of Public Health Indicators
44
Table 16: Perinatal mortality, rate per 1,000 total births. England and Wales,
North West, Cumbria and comparative Primary Care Trusts, 2004-06 to 2008-10.
Area
Perinatal mortality rate per 1,000 total births
2004-06
2007-09
2008-10
Cumbria
6.3
6.2
5.6
North West
8.2
7.7
7.6
England and Wales
8.0
7.6
7.5
n/a
6.7
6.6
Somerset
6.4
6.9
7.0
Devon
8.2
6.2
6.0
n/a
7.6
6.6
n/a
5.9
7.9
Examining perinatal mortality rates across
the comparative Primary Care Trusts reveals
no significant differences (Figure 21). Cumbria
had the lowest rate of perinatal mortality (5.6 per
1,000 total births) while East Riding and Yorkshire
had the highest (7.9 per 1,000 total births).
Figure 21: Perinatal mortality rate per 1,000 total births across England, North
West, Cumbria and comparative Primary Care Trusts, 2008-10 (pooled data).
Source: NWPHO from Compendium of Public Health Indicators
45
5.8 Labour/Delivery
section. Of the remaining cases, 67.3% of
women went into spontaneous labour while
20.4% were induced (Figure 22). These data are
similar to that reported for the rest of England
and Wales.
5.8.1Method of onset of labour
Analysis of operation procedure data from
Hospital Episode Statistics for Cumbria from
2005-2009 found that data were incomplete;
the onset of labour was unknown in 25% of
cases. Excluding these unknowns, 12.3% of
cases were delivered by elective caesarean
Across the local authorities, the proportion of
spontaneous births varied from 70.2% in Carlisle to
62.6% in Barrow-in-Furness (Table 17, Figure 22).
Figure 22: Method of onset of labour. Cumbria, 2005 to 2009.*
*Cases with an ‘unknown’ onset have been excluded. Source: NWPHO from Hospital Episode Statistics
Table 17: Method of onset of labour. Cumbria and local authorities, 2005 to 2009.*
Area
Spontaneous
Caesarean
Surgical
Induction
Medical
Induction
n
%
n
%
n
%
Cumbria
11,823
67.3
2,151
12.3
538
3.1
n
%
1,019
5.8
Allerdale
2,214
65.8
403
12.0
96
2.9
530
15.8
120
3.6
Barrow-in-Furness
1,598
62.6
419
16.4
132
5.2
Carlisle
3,133
70.2
414
9.3
128
2.9
190
7.4
214
8.4
520
11.7
268
Copeland
1,738
66.9
314
12.1
89
6.0
3.4
375
14.4
81
3.1
Eden
1,164
68.0
201
11.7
South Lakeland
1,976
68.9
400
13.9
34
2.0
187
10.9
126
7.4
59
2.1
223
7.8
210
7.3
*Excludes ‘unknown’ onset of labour. Source: NWPHO from Hospital Episode Statistics
46
n
%
Surgical and
Medical
Induction
2,025 11.5
5.8.2Method of delivery
• The proportion of elective caesareans was
significantly lower in Carlisle (8.2%) as
compared to the other local authorities;
Between 2005 and 2009 the majority of deliveries
in Cumbria were normal (67.2%), followed by nonelective caesareans (12.5%) (Figure 23, Table 18).
The pattern was similar across the local authorities,
with a few significant differences to note:
• The proportion of ventouse deliveries was
significantly lower in Barrow-in-Furness (3.6%)
than across all other local authorities; and
• Delivery by forceps was significantly higher
in South Lakeland (4.8%) than all other
local authorities, with the exception of
Eden (3.8%).
• The proportion of normal deliveries was
significantly higher in Barrow-in-Furness
(70.7%) than all other local authorities, with
the exception of Eden (67.4%);
Figure 23: Method of delivery. Cumbria 2005 to 2009.
Source: NWPHO from Hospital Episode Statistics
47
Table 18: Method of delivery. Cumbria and Cumbrian local authorities, 2005 to 2009.
Area
Assisted Cephalic
Normal
Non-elective Elective
Forceps
Ventouse
vaginal abnormal
deliveries
caesarean caesarean
delivery
breech delivery
n
%
n
%
n
%
n
%
n
%
n
%
n
%
Cumbria
15,536 67.2 2,891 12.5 2,387 10.3 1,413 6.1 676 2.9 99 0.4 123 0.5
Allerdale
2,809 64.6
588
13.5
477 11.0 331 7.6
94 2.2 14 0.3
24
0.6
Barrow-in-Furness 2,551 70.7
418
11.6
392 10.9 129 3.6
69 1.9 10 0.3
6
0.2
8.2 379 6.8 165 2.9 26 0.5
Carlisle
3,771 67.4
720
12.9
459
62
1.1
Copeland
2,161 64.6
428
12.8
373 11.2 276 8.3
67 2.0 17 0.5
5
0.1
Eden
1,495 67.4
251
11.3
239 10.8 105 4.7
84 3.8 14 0.6
18
0.8
South Lakeland
2,749 66.4
486
11.7
447 10.8 193 4.7 197 4.8 18 0.4
8
0.2
5.8.3Person conducting delivery
• The proportion of deliveries by a hospital
doctor were significantly lower in Barrow-inFurness (25.5%) and South Lakeland (26.2%)
and significantly higher in Allerdale (35.4%)
and Copeland (35.6%) than for Cumbria
overall (31.0%);
The person conducting delivery was
unknown for a quarter (25.2%) of cases in
Cumbria during 2005 to 2009. Excluding
the unknowns, almost two-thirds of all
deliveries were conducted by a midwife
(64.5%), while hospital doctors conducted
31.0% of deliveries (Figure 24). This pattern
is repeated across the local authorities with
some significant differences to note (Table 19).
Excluding unknowns:
• The proportion of deliveries conducted by a
midwife was significantly lower in Allerdale
(62.1%) and Carlisle (62.3%) and significantly
higher in Barrow-in-Furness (69.7%) and
South Lakeland (66.7%) as compared to
Cumbria overall (64.5%).
48
Figure 24: Person conducting delivery. Cumbria, 2005 to 2009.
Table 19: Person conducting delivery. Cumbria and local authorities, 2005 to 2009.
Area
Hospital doctor
Midwife
Other (inc. GP)
n
%
n
%
n
%
Cumbria
5,398
31.0
11,223
64.5
768
4.4
Allerdale
1,198
35.4
2,105
62.1
85
2.5
Barrow-in-Furness
632
25.5
1,727
69.7
120
4.8
Carlisle
1,418
31.6
2,795
62.3
274
6.1
Copeland
931
35.6
1,667
63.7
17
0.7
Eden
501
29.8
1,104
65.6
77
4.6
South Lakeland
718
26.2
1,825
66.7
195
7.1
5.9 Antenatal assessment
England (84.2%) and the North West (83.9%).
However, when examining data for the
comparative Primary Care Trusts, Cumbria
had the second lowest percentage being
seen for antenatal assessment at 12 weeks
- 89.0% (the lowest being Devon, 85.5%).
North Yorkshire and York had the highest
percentage (94.3%).
In Cumbria, figures for January to March 2011
show that 89% of women had been seen
by a midwife or a maternity healthcare
professional, for health and social care
assessment of needs, risks and choices by
12 completed weeks of pregnancy (Table
20). This was higher than the figures for both
49
Table 20: Antenatal assessment at 12 weeks, January to March 2011. Cumbria and
comparative Primary Care Trusts, North West and England and Wales.
Area
Antenatal assessment at 12 weeks
%
n
Cumbria
89.0
1,411
North West
83.9
23,430
England
84.2
184,549
94.3
2,051
Somerset
89.9
1,540
Devon
85.5
2,191
92.9
695
91.0
725
Source: NWPHO from CHIMAT Infant Mortality Indicators and Department of Health Midwifery Statistics Q4 2010-11.
5.10Smoking in pregnancy
Figure 25 looks at women who are smoking at
the time of giving birth as a percentage of all
maternities across the comparative Primary Care
Trusts for 2010/11. In Cumbria, 16.1% of women
smoked at delivery (as a percentage of all
maternities), while the highest level of smoking
was seen in Great Yarmouth and Waveney
(24.6%) and the lowest in Devon (9.4%)
In 2010/11, Cumbria and the North West had
similar percentages of women who were
smoking at the time of giving birth (as a
percentage of all maternities) at 16.1% and
17.7% respectively. These were both higher
than the percentage for England (13.5%).
50
Figure 25: Smoking status at delivery: smokers as a percentage of all maternities.
Cumbria and comparative Primary Care Trusts, 2010/11.
Source: Department of Health Smoking Status at Time of Delivery (SSATOD)
5.11 Workforce
• High expenditure on maternity services does
not necessarily equate to good outcomes.
For example, East Riding of Yorkshire Primary
Care Trust had the third highest cost per birth
(£2,351) but had the highest reported rates of
perinatal mortality and stillbirth.
Data from the Child and Maternal Health
Observatory (CHIMAT) on expenditure and other
aspects of services for Cumbria and comparative
Primary Care Trusts in 2010/11 are summarised
in Table 21.
The Maternity and Newborn Outcomes versus
Expenditure tool is available at http://atlas.
chimat.org.uk/IAS/ovet#maternity Further data
charts for Cumbria and comparator Primary
Care Trusts from this tool can be found in
Appendix 6.
Some key points for consideration are:
• Compared to the comparator Primary Care
Trusts, Cumbria had the lowest rate of perinatal
mortality, the second highest cost per birth,
as well as the second highest proportion of
registered midwives per 1,000 births.
51
Table 21: Outcomes and expenditure information for Cumbria Primary Care Trust
and comparator Primary Care Trusts, 2010-11.
PCT
Perinatal
Stillbirth
mortality
rate per
rate per
1,000
1,000
births
births
Cost per
birth (£)
Obstetrics and
Paediatric Registered
Gynaecology
consultants midwives
consultants
(FTE) per
(FTE) per
(FTE)*
1,000
1,000
per 1,000
births
births
births
Cumbria
4.72
4.1
2,349
2.9
3.2
35.4
North Yorkshire
and York
6.87
4.4
2,292
3.1
3.1
31.5
Somerset
5.79
4.4
2,291
2.6
3.3
31.2
Devon
5.81
3.6
2,274
2.9
3.7
37.8
Great Yarmouth
and Waveney
5.02
2.5
2,351
3.0
4.2
32.2
East Riding of
Yorkshire
9.31
6.1
2,339
2.3
2.8
32.4
*FTE = Full time equivalent
52
6. Maternity services in Cumbria
• West Cumberland Hospital (Whitehaven) Consultant led; and
Maternity services in Cumbria are provided by
Foundation Trust. There are four consultant led units
and two midwife led units (see Box 6 for definitions):
• Penrith Community Hospital - Midwife led.
University Hospitals of Morecambe Bay
NHS Foundation Trust
• Furness General Hospital - Consultant led;
North Cumbria University Hospitals
NHS Trust
• Royal Lancaster Infirmary - Consultant led; and
• Westmorland General Hospital (Helme Chase)
- Midwife led.
• Cumberland Infirmary (Carlisle) - Consultant led;
Map 1: Location of maternity units in Cumbria.
Source: North West Public Health Observatory. © Crown copyright. All rights reserved. NWPHO/DH (licence 100020290). March 2011
53
Box 6: Types of maternity unit
Consultant led units
Staffed with doctors, midwives and consultant obstetricians and can deal with complex and
straightforward deliveries. These units can carry out all medical interventions in childbirth and
have anaesthetists available to provide, for example, epidurals.
Midwife led units
Do not have consultants working there and only offer services to women who are likely to
have uncomplicated natural births. These units provide an environment in which women are
supported to give birth without medical intervention or high levels of medication for pain
relief. Generally there are no anaesthetists or surgeons available. Should difficulties arise,
women are quickly transferred to a large hospital.
Dr Foster Birth Guide, www.drfosterhealth.co.uk/birth-guide
6.1 Service provision
Further analysis of staffing in Cumbria
Primary Care Trust can be found on the
children’s services mapping website at: www.
childrensmapping.org.uk/topics/maternity
6.1.1 Staffing levels
Data from the Child and Maternal Health
Observatory (CHIMAT) for 2010/11 reveals the
following:
6.1.2 Developing and improving services
North Cumbria
• There were 2.9 consultants in obstetrics
and gynaecology and 35.4 midwives per
1,000 births, higher than the England
averages (2.5 and 30.1 per 1,000 births
respectively).
has been working in numerous ways to improve
maternity services in areas such as preconception
care, pregnancy testing, antenatal and postnatal
care and health education.
• The majority of births in Cumbria Primary
Care Trust in 2010/11 occurred at North
Cumbria University Hospitals NHS Trust, with
65.2% of all babies being born there.
The focus of this work has been drawn from a
number of areas of Maternity Matters22 with the
aim of improving access to care for women at
times and locations that are convenient.69 Some
examples of this work are detailed in Box 7.
• Cumbria Primary Care Trust spent on average,
£2,349 per birth.68
54
Box 7: Examples of work to improve maternity services, North Cumbria
1. North Cumbria University Hospitals NHS Trust offers a Post Natal Listening Service to enable
women to discuss any aspect of their maternity care. On discharge, all mothers are issued
with a postcard to provide feedback on their experience – this can be either named or
anonymous. Feedback is monitored by supervisors and midwives. Examples of action taken
following patient feedback include; lengthening of entonox tubing to aid greater mobility
during labour; and ensuring a birthing ball is available in every room.
2. North Cumbria University Hospitals NHS Trust was highly commended in an awards
programme for its provision of services to teenage parents across a wide geographic,
mostly rural area. The Trust uses strategically placed groups and small satellite units to
effectively reach pregnant teenagers across the region. This flexibility ensures that all
teenage parents and parents-to-be have access locally to a named midwife with a specialist
interest in teenage pregnancy, who can offer advice and support. Satellite services are
provided on an ‘as and when’ basis if a pregnant teenager is unable to get to an existing
unit, and support can be arranged on a one-to-one basis. Parent Craft classes are provided
specifically for teenage mothers, providing a range of advice and support across a range of
areas, such as cooking, baby care, benefits and lifestyle choices.
South Cumbria
national guidance from the National Institute
for Clinical Excellence (NICE) and the Clinical
Negligence Scheme for Trusts (CNST) and is
available for all maternity staff electronically with
links from all staff computers. Some examples
of work taking place across the Trust to improve
maternity services are detailed in Box 8.
University Hospitals of Morecambe Bay NHS
Foundation Trust have developed a maternity
dashboard, based on Royal College of Obstetricians
and Gynaecologists (RCOG) guidance, to plan and
improve their maternity services. 70 All maternity
guidance has also been reviewed in line with
55
Box 8: Working to improve maternity services, South Cumbria
1. The Fresh Eyes Approach to Cardiotocography (CTG) monitoring: Traditional CTG monitoring
involves the interpretation of printed traces of fetal heart rate and maternal contractions,
to provide an indication of the wellbeing of the foetus. It is widely felt that this system is
open to misinterpretation. In March 2012, University Hospitals of Morecambe Bay NHS
Foundation Trust adopted a Fresh Eyes Approach71 aimed at enhancing the accuracy of CTG
interpretation, by using a ‘buddy system’ whereby tracings are viewed by more than one
person. The Trust reports that this new approach is already proving to help with improved
and safer practice.
2. Following recommendations made in the Nursing and Midwifery Council review of the
University Hospitals of Morecambe Bay NHS Foundation Trust,72 changes have been made
in two areas:
a) Governance arrangements: all maternity staff have been trained in incident reporting
and are encouraged to pro-actively report risk and upload details to the risk register.
Incident reporting has increased by 100% in the past year, with a significant decrease in
harm reported. In addition a number of senior staff have been appointed; a governance
lead now manages a midwifery risk manager, an audit midwife and a practice mentor to
ensure continuation and development of robust governance arrangements.
b) The role of supervisors of midwives: the role has been refocused to ensure supervisors
are guided by their primary principle of ‘protecting the public’. In March 2012, the
Nursing and Midwifery Council stated “there is evidence that supervisors of midwives
are providing leadership and driving the cultural changes necessary to ensure the safety
of women and their babies remain the focus of their activity”.73 The outcome of further
Nursing and Midwifery Council inspection in June 2012 was that the monitoring of
the role can now be handed back to the Local Supervising Authority demonstrating
renewed confidence following continued improvements.
Following the report, other areas in the country have picked up on failings within their
own organisations around the supervision of midwives and have used lessons learnt from
University Hospitals of Morecambe Bay NHS Foundation Trust to improve practise within
their own service.
3. Significant effort has been invested in looking at organisational culture within the maternity
directorate across the Trust health economy over the past 18 months. Whilst previously,
midwives had seen themselves as part of a locality, the aim was to try and change this so they
saw themselves as part of a cross bay service with the same goals and aspirations. Following
consultation with all maternity staff about their values and beliefs in relation to care they or
their family would expect to receive, a philosophy of care has been developed. Once finalised,
staff will be asked to commit to the philosophy which will be clearly displayed across the
three University Hospitals of Morecambe Bay NHS Foundation Trust sites.
56
6.1.3Mapping local service provision
was initially sourced from the Dr. Foster Birth
Guide, which contains data for each of the
hospitals as supplied by the units themselves, but
only for the financial period 2006/07.74 A list was
sent out to the respective Trusts for confirmation
and update where applicable.
This section contains information gathered
through a mapping exercise conducted as part of
this study during June and July 2011. A number
of key contacts within each Trust, such as Heads
of Midwifery and Children’s Commissioners were
contacted and asked to provide information on
local service provision and best practice.
This is also supported by further information
that was requested from the Trusts asking them
about the services they offered; what process
they have in place to ensure quality and that
national standards are met; particular issues/
challenges they face; examples of success; and
future plans and developments.
Table 22 and Table 23 show maternity services
that are available in the obstetric or maternity led
units within University Hospitals of Morecambe
Bay NHS Foundation Trust and North Cumbria
University Hospitals NHS Trust. This information
North Cumbria
Table 22: Maternity services provided by North Cumbria University Hospitals NHS Trust.
Service area
North Cumbria University
Hospitals NHS Trust
Service
West
Cumberland Penrith
Cumberland
Infirmary Hospital
Hospital
CL
ML
Antenatal clinic
Consultant Led (CL) or Midwife Led (ML)
7
3
7
NHS antenatal classes
3
3
3
NHS antenatal classes (evening and weekend)
Antenatal
Women only classes
CL
evenings
3
3
7
3
3
Specialised classes for multiple births
7
7
3
Specialised classes for Teenagers
3
3
3
Specialised classes for Eastern European groups
7
3
7
Specialised classes for caesarean birth
7
7
3
3
10-14 wks
(ideally 12
wks)
7
3
10-14 wks
(ideally 12
wks)
Ultrasound scans
Dating scan
Anomaly scan
7
19-20+6wks
7
Nuchal translucency (NT) scan
3
7
19-20+6wks
3
The combined test (NT scan plus a blood test)
3
7
3
The triple test (blood test for hCG, alpha feto protein
and uE3)
7
7
7
The quadruple test (triple test plus inhibin A)
3
3
3
Amniocentesis
3
7
3
Chorionic villus sampling
7
7
7
continued…
57
Service area
North Cumbria University
Hospitals NHS Trust
Service
West
Cumberland Penrith
Cumberland
Infirmary Hospital
Hospital
Maternity ward
Labour
Labour wards/rooms
Postnatal wards/rooms
Antenatal/day assessment rooms
LDRP rooms (single rooms used for delivery and
postnatal care)
Neonatal
Birthing pool
Postnatal
ML
CL
3
10 LRDP
single rooms
7
3
13 rooms shared use
Single rooms available for women to recover following birth
Staffing
CL
10 rooms shared use
3
one
room
with a
pool
6
12
4
7
3
6
3
3
Home births
3
3
3
Water births
3
3
3
Neo-natal intensive care unit
7
7
7
High dependency unit
7
7
7
Special Care Baby Unit
3
7
10 cots
24 hour breastfeeding support from trained staff or
volunteers
3
3
3
Paediatrician
3
7
3
Obstetrician
3
7
3
Anaesthetist
3
7
3
Dedicated obstetric anaesthetist
FTE Midwives
3
34
7
7.75
3
32
FTE Community Midwives
18
7
16
• North Cumbria University Hospitals NHS
Trust provides antenatal care, homebirths
and births in Penrith’s birth centre, as well
as postnatal care to women in their
homes by midwives and maternity support
workers.
• Satellite Obstetric Clinics have been
established whereby Consultants travel
out to the community instead of women
travelling to clinic. These are already in place
at Maryport and Workington, and it is hoped
that more can be developed in other areas.
• Midwifery care is provided throughout the
community. Settings include GP surgeries,
Children’s Centres and Fire Stations.
• A supervisor of midwives is available twenty
four hours a day, seven days a week to
support mothers in relation to any request or
concerns they may have.
58
• A midwifery manager has responsibility for
child protection across North Cumbria. Each
community base has a community midwife
who coordinates child protection referrals.
The community midwives have close links
with Children’s Services.
• The development and implementation of a
more robust preceptorshipM programme to
ensure retention of trained midwives. This
will help address the national shortage of
midwives.
• Midwives with special interests e.g. drug
and alcohol misuse, teenage pregnancy,
and child protection, meet monthly with
representatives from Children’s Services and
Health Visiting. There are also midwives who
specialise in infant feeding, bereavement and
research and development. Peer supporters
work with Children’s Centres to offer
breastfeeding support in the community.
Maternity support workers are also trained to
offer breastfeeding support.
• Patients identified as having a history
of mental health problems, anxiety or
depression are referred to obstetric clinic
and have weekly access to a community
psychiatric nurse.
• Three assistant practitioners deliver smoking
cessation advice to parents-to-be.
• Data is routinely collected annually on
homebirths and births in the Penrith
birth centre.
Planned/Future Developments
Local issues
is currently undergoing a review of midwifery
services in order to deliver safe sustainable 21st
century services. Within the review there will
be a Consultant Midwife post which will lead
on the public health agenda and address health
inequalities.
A key issue highlighted for North Cumbria
University Hospitals NHS Trust was geography,
which was seen as a continuing challenge to
service delivery.
There were numerous examples of successes
highlighted, including:
• Amalgamation of the on-call service provision
across east Cumbria which has enabled
midwives to maintain their intrapartum skills
thus ensuring a more sustainable service.
M
Preceptorship refers to a period of practical experience and training for student midwives, under the supervision of an
expert in the field.
59
South Cumbria
Service area
Table 23: Maternity services provided by University Hospitals of Morecambe Bay
NHS Foundation Trust.
Service
Antenatal
Antenatal clinic
3
3
3
NHS antenatal classes
3
3
3
NHS antenatal classes (evening and weekend)
3
3
3
Women only classes
7
7
7
Specialised classes for multiple births
7
7
7
Specialised classes for Teenagers
3
3
3
Specialised classes for Eastern European groups
7
7
7
Specialised classes for caesarean birth
3
3
7
3
12 wk
20 wk
3
8-12 weeks
20-22 weeks
3
10-14 weeks
19-21 weeks
Ultrasound scans
Dating scan
Anomoly scan
Nuchal translucency (NT) scan
7
7
7
The combined test (NT scan plus a blood test)
7
7
7
The triple test (blood test for hCG, alpha feto
protein and uE3
3
3
3
The quadruple test (triple test plus inhibin A)
3
3
3
Amniocentesis
3
3
3
Chorionic villus sampling
7
7
Maternity ward
3
3
7 single rms 7 single rms
1 x 22 bed
1x24 beds
1 assessment 1 assessment
area
area
Labour wards/rooms
Postnatal wards/rooms
Antenatal/day assessment rooms
Labour
Westmorland
Furness
Royal
General
General
Lancaster
Hospital
Hospital
Infirmary
(Helme Chase)
CL
CL
ML
LDRP rooms: (Single rooms used for delivery and
postnatal care)
Single rooms available for women to recover
following birth
7
3
3 single rms
1x6 beds
7
7
7
1
10
8
4
Birthing pool
3
3
3
Home births
3
3
3
Water births
3
3
3
60
Service area
Westmorland
Furness
Royal
General
General
Lancaster
Hospital
Hospital
Infirmary
(Helme Chase)
CL
CL
ML
Service
Staffing
Postnatal Neonatal
Neo-natal intensive care unit
7
2 cots
7
High dependancy unit
7
8 cots
7
Special Care Baby Unit
4 cot
8 cots
7
3
3
3
24 hour breastfeeding support from trained staff
or volunteers
Paediatrician
3
3
7
Obstetrician
3
3
7
Anaesthetist
3
3
7
7
30.83
6.40
3
52.63
11.49
7
11.47
6.69
Dedicated obstetric anaesthetist
FTE Midwives
FTE Community Midwives
• Dashboards are used to measure quality
standards and targets throughout the Trust.
This has been developed for maternity
services requirements. Audits, Risk
Management, and Education and Training are
undertaken and sit within the Governance
structure for the division and the larger Trust.
• Services are provided across the geographical
areas of Morecambe Bay, with acute settings
at Barrow-in-Furness, Lancaster and a
midwife led unit at Westmorland. There are
additional satellite services at Ulverston and
Queen Victoria, Morecambe.
• Antenatal, intrapartum and postnatal care
is provided across the sites with additional
services in the satellite areas in community
settings and at home. Service provision is
24/7 in acute settings.
Local issues
There were a number of issues/challenges
highlighted:
• How to ensure the equity of service provision
across a large geographically spread rural
area with specific urban areas.
• This is considered to be a multi-disciplinary
service supported by many additional
agencies such as Children’s Centres, the
Mental Health team, Family Support team
and Children’s services.
• Meeting the public health agenda of ensuring
that the needs of vulnerable groups are met and
well supported as well as meeting the national
normal birth agenda for women. This was
considered particularly difficult in Barrow where
difficulties in providing appropriate neonatal
services had been highlighted, with 52 miles to
travel between there and the nearest level 2 unit.P
• Data is routinely collected by the named
linked specialist midwives and information
analyst. It is also collected within the Trust
through systems such as GuruN and CHKSO.
N
The data system used by Morecambe Bay Acute Trust
A privately-run data company, see www.chks.co.uk for further information.
O
P
Level two units are consultant led. Level one units are midwife led.
61
• Areas such as Barrow-in-Furness are
identified as having large pockets of
deprivation and therefore additional specialist
roles and support and input in to how to best
serve this population are required.
• Development of the vaginal birth after
caesarean (VBAC) clinics and review of
resources to enable the provision of specific
midwifery led areas at Royal Lancaster
Infirmary and Furness General Infirmary.
However, there were also a number of successes:
• Aim to increase the rate of water births
by installing another birth pool at Royal
Lancaster Infirmary and remodelling
midwifery provision at Furness General
Infirmary to support women-centred care.
• In the Furness area, community midwives
have designated hours to work with
vulnerable (predominantly young) mums
through Children’s Centres. In Lancaster,
community midwives work slightly differently
– no one has designated hours, however
a number of midwives call into Children’s
Centres on a regular basis/as needed.
• The introduction of a clinical strategy to
support the development of clear clinical
pathways across maternity services in primary
and secondary providers.
6.1.4Other services across Cumbria
• Specialist roles and groups for mental health,
substance misuse and teenage pregnancy
are implemented across the Bay although
some areas are more developed than others.
There are also ‘specialist midwives’ in
domestic violence, substance misuse, teenage
pregnancy, mental health, safeguarding,
screening and public health. Such specialist
roles are being developed through multiagency working, and the development of
policies and procedures. The Substance
Misuse midwife in Furness works very closely
with the community drug and alcohol team.
The Domestic Violence midwife is a part of
the Domestic Violence Champions Network
(see Section 6.1.5), the mental health midwife
is an important member of the antenatal and
postnatal mental health group.
• Across Cumbria, the ‘My little baby’
campaign run by Smokefree NorthWest
offers pregnant women a text service and
helpline number that provides support and
guidance to help them to quit smoking. This
project is particularly important in light of the
fact that babies born to mothers who smoke
are 40% more likely to be stillborn or die
within the first four weeks of life. For further
information see: www.smokefreenorthwest.
org/support-pregnant-women-quit-smoking
• Carbon Dioxide testing for pregnant women
(as recommended in National Institute for
Health and Clinical Excellence Guidance
26)75 is available at Royal Lancaster Infirmary
(funded by North Lancashire Primary Care
Trust), however it is not currently available in
Furness or Westmorland General Hospitals.
• Clear lines of leadership and management in
clinical settings following restructure of services.
• Run by Project John Ltd, ‘Project John’
provides supported housing for teenagers
with concomitant mental health and drugalcohol problems. For further information see
www.projectjohn.co.uk: and
Planned/Future Developments
University Hospitals of Morecambe Bay NHS
Foundation Trust highlighted a number of future
plans and developments, for example:
62
• In Carlisle and Eden, the ‘Let go’ project
provides support to victims of domestic
violence helping them to increase
their physical safety to ensure their
emotional and mental wellbeing (www.
churchestogethercumbria.co.uk/domestic%20
violence.htm) In addition, the North Cumbria
based initiative ‘Not in my Home’ provides
information and links to support for victims
of domestic violence. (www.notinmyhome.
co.uk). The Domestic Violence Champions
Network now operates across the county
with Champions from a wide range of
organisations and agencies. University
Hospitals of Morecambe Bay NHS Foundation
Trust have a representative from maternity
who attends Champions network meetings,
disseminates information and resources, and
updates colleagues. High risk women across
Cumbria can be referred for support via the
Independent Domestic Violence Advisor
managed by the ‘Let go’ project.
63
7. Conclusions and
recommendations
in common with the UK, the stillbirth rate has
remained relatively stable during the period
covered in this report.
Around 5,000 babies are born in Cumbria each
year. For the majority of pregnant women in the
county, their experience of pregnancy and birth
will be a good one. However, for some, this will
not be the case, with the pregnancy ending in
stillbirth or early neonatal death. For others, their
baby may have complications after birth, related
to low birthweight or prematurity meaning they
require additional support, such as neonatal
intensive care.
In Cumbria, perinatal mortality and stillbirth rates
are lower than those seen across the North West
and England and Wales, and are comparable to
other rural areas. Further reducing the perinatal
mortality rate is a challenge as the causes are
multifactorial and complex and it is difficult to
neatly group them into diagnoses and risk factors,
to be targeted and removed or altered. Rather,
it is important that the characteristics of the
environment (both physical and social) that have
caused the patterns of mortality are determined
and changed.76 Suggested interventions to
reduce stillbirth include: improvement of health
and wellbeing of women before, during, and
after pregnancy; detection and management
of women at risk during pregnancy; and
improvement of information and standards of
maternity care.29, In particular, efforts should be
directed to ensure identification of risk factors
needing high-risk care in pregnancy, particularly
those associated with intrauterine growth
restriction or placental problems as these are the
most common causes of stillbirth in the UK. In
a rural setting such as Cumbria appropriate risk
stratification of women at booking is critical to
ensure that women receive appropriate antenatal
and intrapartum care.
The birth rate, General Fertility Rate and Total
Fertility Rates in Cumbria all increased over the
past five years; however they remain lower than
the regional and England and Wales averages.
These rates also vary widely across the county’s
local authorities. If the proportion of women of
childbearing age in Cumbria falls as predicted,
this could mean a further decline in the birth rate
in future years.
Births to teenage mothers are higher than
for the England and Wales average, therefore
greater effort is needed to reduce teenage
conceptions in the areas with the highest rates.
Interventions could include improved sex and
relationship education in schools and improving
the accessibility of appropriate sexual health
services for teenagers.
Over two-thirds of babies born in Cumbria are
delivered normally, with the proportion of normal
deliveries being significantly higher in Barrowin-Furness than most other local authorities
– possibly due to issues of access. Variations in
delivery method across the local authorities exist,
for example, 10.3% of deliveries in Cumbria were
by elective caesarean, but at local authority level
this proportion ranged from 8.2% in Carlisle
to 11.2% in Copeland. Almost two-thirds of
all deliveries in Cumbria were conducted by a
midwife, while hospital doctors conducted just
under a third of deliveries.
The proportion of babies born with low
birthweight (less than 2,500grams) has slightly
increased in Cumbria. However the proportion
remains lower than that seen in the North West
region and England as a whole. Low birthweight
is known to be strongly linked to smoking during
pregnancy and deprivation, with low birthweight
babies at higher risk of illness during infancy and
poorer health outcomes later in life, including
diabetes and cardiovascular disease.
It is positive to note that perinatal mortality
rates continue to decline in Cumbria although,
64
At the start of 2011, the proportion of pregnant
women attending for antenatal assessmentQ
at 12 weeks in Cumbria was higher than the
regional and national proportions. However,
when examining data for the comparative
Primary Care Trusts, Cumbria had the second
lowest percentage being seen. This is an area
of prenatal care provision and screening for
disorders (e.g. syphilis and pre-eclampsia) that
can be improved. Women who book later in
pregnancy have higher perinatal mortality,
possibly due to missed opportunities to identify
potential obstetrics problems and institute
appropriate management plans. In high-income
countries, the identification of pregnancies
which are at highest-risk of placental dysfunction
and intrauterine growth restriction and
instituting appropriate management are likely to
achieve reductions in the numbers of stillbirths.15
are classified as low- or high-risk, how their
risk status is re-evaluated at each visit and how
delivery is planned. Some centralisation of
maternity services has already occurred across
Cumbria, with further centralisation a continuing
possibility. Such centralisation can deliver safer
services but impact on the distance that people
have to travel to access services most appropriate
for them as the closure of local services may
mean that individuals in rural localities have
further to travel. As a link between perinatal
death and increased distance travelled to
hospital has been identified,55, 56 it is important
to consider access to care that such changes to
services might bring.
Both the North Cumbria Hospitals NHS Trust
Foundation Trust are working hard to develop
and improve the already high quality maternity
services they offer.
The percentage of women who were smoking
at the time of giving birth (as a percentage of
all maternities) was higher in Cumbria than the
national average. As smoking during pregnancy
is associated with increased risk of miscarriage
and low birthweight it is vital that smoking
cessation interventions that provide support to
quit during (and after) pregnancy are improved.
There is lack of public awareness that particular
lifestyles can increase risks in pregnancy and
birth outcomes. Adequate preconception
and antenatal care can substantially reduce
stillbirth rates therefore health promotion and
interventions to target these risks and address
disparity are a priority.29
It is hoped that this report provides
epidemiological evidence that will allow
maternity service providers to build their
knowledge to help them deliver more effective
services to meet the needs of Cumbria’s
population. Maternity services cannot make
improvements in isolation; they must work
in partnership with other agencies such as
education, housing, employment, and social
services.23 In addition, new models of care will
be required in the future.
This report is the first phase of a two part
study. The second phase is a review of all
perinatal deaths that occurred in mothers
booked for delivery at North Cumbria University
Hospitals NHS Trust and University Hospitals
of Morecambe Bay NHS Foundation Trust in
2009 and 2010. This review, also commissioned
by NHS Cumbria, is being conducted by an
independent expert clinical consortium.
This report demonstrates that there are
numerous challenges faced by those charged
with providing maternity services in Cumbria.
The main difficulties are due to issues of rurality
and deprivation as highlighted in section 4.3 of
this report (maternity services and care in rural
areas). In particular, how women’s pregnancies
Women seen by a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks
and choices by 12 completed weeks of pregnancy.
Q
65
8. Appendices
8.1 Appendix 1: Glossary of definitions
Antenatal
the period before birth; during or relating to pregnancy
Antepartum death
stillbirth before labour
Biparous
the birth of two offspring in a single birth
Early neonatal the first 7 days of life
Grand multiparous
a woman who has given birth five or more times
Intrapartum death
stillbirth during labour
Intrauterine
within the uterus
Late neonatal after 7 days of life but before 28 completed days of life
Maternity the period during pregnancy and shortly after childbirth
Multiparousa woman who has given birth two or more times. Also used to
describe the birth of more than one offspring at once
Multiple birth
the birth of two or more babies produced in the same gestation period
Neonatal death
the death of a live born baby during the first 28 completed days of life
Nulliparous
a woman who has never completed a pregnancy beyond 20 weeks
Obstetricthe branch of medicine related to pregnancy, childbirth and the
postpartum period
Parity
the number of times a female has given birth to a fetus
Periconceptional
the period from before conception to early pregnancy
Post natal
the period immediately after birth, extending for about six weeks
Postpartum
the period shortly after childbirth
Primipara a woman in her first pregnancy
Singleton birth a baby born singly
Stillbirth the loss of a fetus occurring in the uterus or during labour after 24
completed weeks of pregnancy
Uniparous
the birth of one offspring
66
8.2 Appendix 2: Policy and strategy
summary
maintaining and strengthening links with other
early years. A fuller story on the health of England
is set out in Our Health and Wellbeing Today,
which accompanied the white paper.79
National policy and strategy
The Government’s response to the
recommendations in Frontline Care: the
report of the Prime Minister’s Commission
on the Future of Nursing and Midwifery
in England (2011)77 stresses the Government’s
acknowledgement of the “significant
contribution that nurses and midwives make to
the health and wellbeing of the population.”
The 20 recommendations outlined in Frontline
Care are clustered into seven themes: the
socioeconomic value of nursing and midwifery;
high quality, compassionate care; health and
wellbeing; caring for people with long-term
conditions; promoting innovations in nursing and
midwifery; nurses and midwives leading services;
and careers in nursing and midwifery. All of
these recommendations are to go some way
to helping to enhance/produce a high quality
service that provides safe and effective care.
The NHS in England: the Operating
Framework for 2011/12 (2010)80 focuses upon
more qualitative aspects of patient feedback
to provide insight into what women and their
families think of maternity care and services from
preconception care, through to pregnancy and
after birth. It considers how this can be utilised
to identify and work to address issues present
in service delivery. Choice and continuity of care
are seen as key in this document.
NICE Clinical Guideline 62. Antenatal care:
routine care for the healthy pregnant
woman (2008)81 highlights the need to address
inequalities in maternity service provision. It
consists of 11 components providing evidencebased information for use by clinicians and
pregnant women to make decisions about
appropriate treatment in specific circumstances
(see Box 9). It provides information on best
practice for clinical care of all pregnancies and
comprehensive information on antenatal care. It
focuses on improving outcomes for women who
require additional care or previously experienced
stillbirth or neonatal death. There is an emphasis
on how care is delivered and by whom, including
issues of ensuring equity of access to care for
disadvantaged women and women’s views
about service provision. This guidance is set to
compliment the National Service Framework for
Children38 as well as Maternity Matters.82
Healthy Lives, Healthy People: Our strategy
for public health in England (2010)78 includes
plans to improve the integration of high
quality services as a way to achieve one of the
Government’s key priorities – early intervention
and prevention – ensuring positive outcomes for
children and parents. This strategy also highlights
aspects of child and maternity services, such
as, incorporating nursery care for pre-school
children; the Healthy Child programme (providing
community and primary care support for families);
and increased investment in Health Visitors and
67
Box 9: Components of NICE Clinical Guideline 62
1. Woman-centred care and informed decision making;
2. Provision and organisation of care;
3. Lifestyle considerations (including alcohol consumption and smoking in pregnancy);
4. Management of common symptoms of pregnancy;
5. Clinical examination of pregnant women;
6. Screening for haematological conditions;
7. Screening for fetal anomalies;
8. Screening for infections;
9. Screening for clinical conditions (including gestational diabetes and pre-eclampsia);
10.Fetal growth and wellbeing; and
11.Management of specific clinical conditions (including pregnancy beyond 41 weeks and
breech presentation at term).
Clinical Guideline 62. Antenatal care: routine care for the healthy pregnant woman,
The National Institute for Health and Clinical Excellence (NICE), 2008
It also highlights the ‘Antenatal Assessment
Tool’, which aims, through the administering
of a routine, structured questionnaire, to
support routine antenatal care and identify
women who may need additional care for a
number of reasons. It looks at women who: can
remain within or return to the routine antenatal
pathway of care; may need additional obstetric
care for medical reasons; and may need social
support and/or medical care for a variety of
socially complex reasons.
and wishes. This document highlights the need
for the maternity workforce, including GPs,
midwives and obstetricians, to be competent
at supporting women with their decision
making and breaking the barriers of women’s
misconception of care.
Improving the quality and outcomes for
maternity service users through effective
commissioning (2007)83 is a self-assessment
tool for commissioners to assess and develop
current capacity and capability to effectively
commission maternity services. Commissioning
practice is supported by access to appropriate
information to ensure services meet the needs
of the local population and address health
inequalities. It covers the following: assessing
need and reviewing service provision; shaping
the structure of supply; managing demand;
clinical decision making; managing performance;
and patient and public feedback.
Maternity Matters: Choice, access and
continuity of care in a safe service (2007)22
describes four national choice guarantees: choice
of how to access maternity services, choice of
type of antenatal care, choice of place of birthR
and choice of place of postnatal care. The aim
of these choice guarantees is for women to be
able to make well-informed decisions about their
maternity care according to individual needs
R
Women have the following options for choosing place of birth: at home; midwifery-led unit (MLU); consultant-led unit (CLU).
68
National Guidelines for Maternity Services
Liaison Committees (2006)84 suggests ways
in which local Maternity Services Liaison
Committees can work effectively to integrate
perspectives from commissioners, service
providers and service users for the planning,
monitoring and improvement of services.
Maternity Services Liaison Committees need
to be involved in developing strategies for the
delivery of maternity services.
antenatal and neonatal screening; screening
for Intrauterine Growth Restriction; maternal
nutrition; and weight management.
Local policy and strategy
The Cumbria Children’s Trust Children
and Young People’s Plan (2008)30 has
been developed in order to improve services
and sustainable outcomes for children and
young people, to reduce inequality and social
disadvantage. It sets out the aims, objectives and
actions to achieve this with five key priorities; for
children to “be healthy, stay safe, make positive
contribution, achieving economic well being,
enjoy and achieve.”
Joint planning and commissioning
framework for children, young people and
maternity services (2006)85 includes examples
of good practice, advice and tools to aid
children’s trusts to develop comprehensive and
integrated service provision in each local area to
children, young people and maternity services.
North Cumbria
North Cumbria Clinical Strategy (2011)31
seeks to implement new models of care for
North Cumbria University Hospitals NHS Trust’s
clinical services as consulted upon in 2008. For
maternity services, the strategy aims to have
one consultant-led service delivered across two
sites supported by an anaesthetist to ensure
all emergencies receive a response within 30
minutes. As there will be a small number of
deliveries at each site, cross-site rotas will be
introduced in order to maintain standards. The
strategy was developed in line with the Closer
to Home Strategy32 (see Box 10 for the strategy
vision and aims) and a number of consultation
exercise outcomes. The Closer to Home Strategy
was developed by NHS Cumbria in 2007/08 for
the provision of more health services closer to
people’s homes. The North Cumbria Clinical
Strategy differs from the agreement in the Closer
to Home Strategy in that a different model of
delivery will be implemented while retaining
services at both sites.
Every Child Matters (2003)27 sets out proposals
to improve the delivery of services to children,
young people and families. The Green Paper
proposes supporting parents and carers;
early intervention and effective protection;
accountability and integration – locally,
regionally and nationally; and workforce reform.
Delivering the Best: Midwives Contribution
to the NHS Plan (2003)28 recommends an
initiative called Birthrate Plus. Birthrate Plus is a
workload analysis tool to assist midwives in the
planning and decision making of the maternity
workforce. The tool calculates the number of
midwives needed whilst considering the number,
type and complexity of birth to put in place the
relevant skill mix and staffing ratios.
Regional policy and strategy
Our Life in the North West: Tackling
health inequalities locally (2008)29 is a
self-assessment framework which includes
maternity service models of provision. The
following interventions are in place, with the
most vulnerable and at risk groups targeted:
promotion of early booking and regular
attendance to antenatal care; needs and risk
assessment in early pregnancy; pre-conceptual
care; smoking cessation during pregnancy;
South Cumbria
The Nursing and Midwifery Strategy 20092014: Embracing the Future and Building
Confidence (2009)33 outlines the University
Hospitals of Morecambe Bay NHS Trust’s vision
and plan to deliver high standards of maternity
69
care. There are six key themes against which
care will be provided: caring with kindness and
compassion; providing safe care in clean and
comfortable environments; listening to patients
and improving the way we work; developing
confident, ambitious and inspirational leaders;
working with partners for the benefit of patients;
and a questioning and analytical nursing and
midwifery workforce. Included in Theme 2 (safe
care in clean and comfortable environments) the
Trust aims to develop a Nursing and Midwifery
quality assurance framework which will assess
the context, process, outcomes and experience of
care, identify risk and inform future developments
for improvement. In addition, the Trust has
implemented Birthrate Plus to support this.
Box 10: Closer to Home Strategy: Visions and Aims
• To help more people keep fit and well for longer;
• Greater involvement of patients and citizens in shaping the delivery of services and
managing their own care and conditions;
• To provide more services in the community by strengthening the capacity of community
and primary care services, including providing local beds where necessary;
• To complement these local services with acute hospitals providing the specialist services
that they are uniquely able to provide and to the standards of the best in the country;
• Services to reflect local priorities, with local doctors, nurses and other professionals playing
a greater role in setting local priorities;
• Services which are more responsive to what patients and their families need, such as fewer
and shorter admissions to hospital; and
• To repatriate and re-provide as much secondary care as possible within Cumbria.
North Cumbria Clinical Strategy,
NHS Cumbria & North Cumbria University Hospitals NHS Trust, 2011
National Standards
delivered – through local programmes providing a
service emphasising on parent support, integrated
services and vulnerable children and families.
Healthy Child Programme: Pregnancy and
the first five years of life (2009)86 updates
Standard One of the National Service Framework
for Children, Young People and Maternity
Services.39 It details the recommended standard
for delivery of the key role of the Healthy Child
Programme – an early intervention and public
health programme for children and families
– in promoting and improving the health and
wellbeing of children. The publication informs
that the Healthy Child Programme needs to
adapt to this changing environment – changes
in public expectation and in the way services are
National Standards for Maternity Care –
Report of a Working Party (2008)87 aims to
ensure fair, safe and quality assured services for
all mothers and babies. The 30 evidence-based
standards cover a wide spectrum of maternity care,
including early pregnancy services, women with
social needs, supporting families who experience
bereavement, pregnancy loss, stillbirth or early
neonatal death, documentation and confidentiality,
and staffing. Box 11 details five of the standards
considered most relevant to this report.
70
Box 11: Five key standards for maternity care
1. Maternity booking and planning of care
At the first contact, pregnant women should be offered information about locally available
services to allow them to choose the most appropriate options for pregnancy care, birth and
postnatal care. All midwives, obstetricians and GPs must be competent to assist women in
considering their options for antenatal, birth and postnatal care and the clinical risks and
benefits involved. A risk and needs assessment including previous obstetric, medical and
social history, must be carried out to ensure that every woman has a flexible plan of care
adapted to her own particular requirements for antenatal care and delivery.
2. Neonatal care and assessment
The newborn infant physical examination is a key element of the child health surveillance
programme. All examinations of the baby should be performed by a suitably qualified
healthcare professional who has up-to-date training in neonatal examination techniques.
All newborn infants should have a complete clinical examination within 72 hours of birth.
Appropriate recommendations by the National Screening Committee should be followed.
3. Supporting families who experience bereavement, pregnancy loss, stillbirth or
early neonatal death
Providers of maternity care need to ensure support and information [that includes details about
investigations (including post-mortem), birth and death registration and options for disposal of
the body] for women and their families both during the acute time of the event and continuing
through the weeks or months afterwards. This includes comprehensive, culturally sensitive,
multidisciplinary policies, services and facilities. Parents of stillborn babies or babies with
identifiable medical or physical problems should receive timely and appropriate care and support
in an appropriate environment. Maternity services should provide appropriate facilities including en
suite toilet and shower and the provision of beds for both the woman and her partner. Information
should be given to the woman and her partner about the grieving process, including local support
offered and other agencies which also offer support following stillbirth or early neonatal death.
4. Clinical governance
A comprehensive clinical governance framework monitors the quality of care provided to women
and their families, encourages clinical excellence, enables the continuous improvement of
standards and provides clear accountability. Safety is the top priority in clinical care.
5. Development, implementation and review of local maternity services strategy
Effective development of a maternity service which meets the needs of the local population
relies on an agreed strategy developed by key stakeholders working within the national service
framework. Maternity services need to be appropriate, acceptable and accessible to women and
their families. It is important that women are involved in the planning and monitoring of services.
The provision of maternity services should be based on an up-to-date assessment of the needs of
the local population, and the assessment and planning of services should take into account the
availability of information technology equipment and networks, local transport services, access
to facilities for wheelchairs or baby buggies and for women with physical, sensory or learning
disabilities, and access for women from disadvantaged or minority groups.
Standards for Maternity Care – Report of a Working Party,
Royal College of Obstetricians and Gynaecologists, 2008
71
National Service Framework for Children,
Young People and Maternity (2004)38
promotes woman- and child-centred high quality
services that are designed around meeting
individual need and reducing inequality. It also
highlights that maternal and neonatal outcomes
are poorer for those from disadvantaged,
vulnerable or excluded groups. The framework
consists of eleven standards, each containing
markers of good practice and clearly states
all health services must employ inclusive
multi-disciplinary and multi-agency policies,
services and facilities. The final standard of this
framework, the Maternity Services standard,39
clearly states that all health services must employ
inclusive, multi-disciplinary and multi-agency
policies, services and facilities by maternity care
providers. It is in place to facilitate the NHS,
local authorities and their partner agencies to
establish high quality service provision for all
children and young people and their parents or
carers. The interventions listed in the publication
cover the following areas of maternity services:
woman-focused care; care pathways and
managed maternity care networks; inclusive
services; pre-conception care; pre-birth care;
birth; post birth care for mothers; post birth
care for babies; quality of care; training and
development; and planning and commissioning
maternity services. Details of markers of good
practice as highlighted in the report are shown
in Box 12.
72
Box 12: Markers of Good Practice
1. All women are involved in planning their own care with information, advice and support
from professionals, including choosing the place they would like to give birth and
supported by appropriately qualified professionals who will attend them throughout their
pregnancy and after birth.
2. Maternity services are proactive in engaging all women, particularly women from
disadvantaged groups and communities, early in their pregnancy and maintaining contact
before and after birth.
3. All services facilitate normal childbirth wherever possible, with medical interventions
recommended only when they are of benefit to the woman and/or her baby.
4. Maternity services are commissioned within a context of managed care networks and include a
range of provision for routine and specialist services for women and their families, for example:
• Routine ante-natal and post-natal care services;
• Services for women with more complex pregnancies who may require multi-disciplinary
or multi-agency care;
• Services for women who request support for coping with domestic violence;
• Services for disabled women;
• Services for women and their partners who request support to stop smoking;
• Services for women and their partners who are substance misusers; and
• Services for women and their partners who have mental health problems.
5. Managed maternity and neonatal care networks include effective arrangements for
managing the prompt transfer and treatment of women and their babies experiencing
problems or complications.
6. All women and their babies receive treatment from health care professionals competent
in resuscitation for both mother and infant, newborn examination and in providing
breastfeeding support. Services promote breastfeeding, whilst supporting all women
whatever their chosen method of feeding.
7. Women who use local maternity services are involved in improving the delivery of these
services, and in planning and reviewing all local hospital and community maternity services.
National Service Framework for Children, Young People and Maternity Services
Standard 11: Maternity Services, Department of Health, 2007
73
8.3 Appendix 3: Risk factors for
perinatal mortality
stillbirths, 29% had a pre-existing medical
problem. The most common problems were
pre-eclampsiaT (6%), psychiatric disorders (4%),
diabetes (3%) and endocrine disorders (2%).2
Maternal ethnicity
Research has shown that mothers from ethnic
minority groups are significantly more likely to have
stillbirths and neonatal deaths.13, 88 Figures from
CMACE for 2009 show that in England, mothers
of Black ethnic origin were 2.1 times more likely to
have stillbirth and 2.4 times more likely to have a
neonatal death compared to mother of White ethnic
originS. In addition, Asian mothers were 1.6 times
more likely to have either a stillbirth or neonatal
death compared to mothers of White ethnic origin.2
Here, we look at the top three of these disorders
that complicate pregnancy, hypertension (high
blood pressure), diabetes and psychiatric disorders.88
High blood pressure
Hypertensive disorders in pregnancy have been
named as the leading cause of maternal and
perinatal mortality in the developed world. The
presence of either high or low blood pressure
during pregnancy has also been associated with
babies who are small for gestational age89,90 with
half of women with severe pre-eclampsia giving
birth preterm.91
A study by Balchin et al.88 looked at gestational
age and perinatal mortality of White, South Asian
and Black women who were nulliparous, across
15 maternity units in northwest London. They
found that the risks of perinatal mortality and
antepartum stillbirth in mothers with post-term
(beyond 41 completed weeks from the first day of
the last menstrual period) births increased earlier
in pregnancy in South Asian and Black women
compared to White women. Black women had
a lower perinatal mortality rate before 32 weeks
gestation compared to White women, however the
rate was higher thereafter. The highest perinatal
mortality rate was amongst South Asian women at
all gestational ages, with increased odds at term.
Although South Asian and Black women showed
higher numbers of perinatal deaths compared to
White women, they all follow the same pattern
with numbers decreasing from 24-40/41 weeks
and then increasing thereafter. The most important
factor associated with antepartum stillbirth among
White women was placental abruption, whilst for
South Asian and Black women it was birthweight
below 2000 grams.
Women at high risk of hypertensive disorders
during pregnancy are those with hypertensive
disease during a previous pregnancy; chronic
kidney disease; autoimmune disease; type 1 or
type 2 diabetes; or chronic hypertension.91 NICE
Clinical Guideline 107 Hypertension in pregnancy:
the management of hypertensive disorders
during pregnancy contains recommendations for
the diagnosis and management of hypertensive
disorders during pregnancy.91
Diabetes
Diabetes is characterised by high levels of glucose
(a form of sugar) in a person’s blood because his/
her pancreas does not produce enough insulin (a
hormone) to help the body use glucose properly.92
There are three types of diabetes that can affect
pregnant women:93
• Type 1 diabetes – occurs when the body
cannot produce insulin and usually starts in
childhood. People with this type of diabetes
take insulin to control their blood sugar.
Women will usually know if they have the
condition before they become pregnant.
Medical conditions - pre-diagnosed and
identified during pregnancy
The CMACE Perinatal Mortality Report 2009
reported that among mothers who have
S
Some caution should be taken when interpreting these figures as ethnicity is often self-reported.
T
A condition in which hypertension arises in pregnancy in association with significant amounts of protein in the urine.
74
• Type 2 diabetes – occurs when the body
can’t produce enough insulin, or when
the insulin that is produced doesn’t work
properly. People who are overweight and
women over the age of 40 are most at risk,
however younger people can also develop
the condition, particularly those of Asian
and black origin. Treatment involves tablets
to lower blood glucose or insulin injections.
Pregnant women may have been diagnosed
before or during pregnancy.
Women are more likely to develop gestational
diabetes if they:
–– are overweight (body mass index greater
than 30);
–– have previously given birth to a large baby
(weighing over 9.9lb);
–– had gestational diabetes in previous
pregnancies;
–– have a family history of diabetes; and/or
–– are of south Asian, black Caribbean or
Middle Eastern ethnic origin.
• Gestational diabetes – only occurs during
pregnancy, can occur at any stage (most
commonly in the second half) and will go
away once the woman has given birth.
It develops when the body fails to make
enough insulin to meet the extra demands of
pregnancy. It can often be controlled through
diet, however in some cases, tablets or insulin
injections may be required.
Women who have gestational diabetes
during pregnancy are twice as likely to
develop type 2 diabetes later in life.
Diabetes during pregnancy puts both mother
and baby at increased risk of complications
(see Box 13). As babies born to diabetic
mothers are often larger than normal, women
with diabetes are strongly advised to give birth
with the support of a consultant-led maternity
team in a hospital.
Box 13: Risks associated with diabetes during pregnancy.
Risks to the woman:
Women with type 1 or type 2 diabetes are at increased risk of:
• Having a large baby, therefore a potentially more difficult birth requiring induction or a
caesarean section.
• Having a miscarriage.
• Women with type 1 diabetes may develop new problems, or existing problems may get worse,
for example with their eyes (diabetic retinopathy – damage to the retina which can eventually
lead to blindness) and their kidneys (diabetic nephropathy – progressive kidney disease).
Risks to baby
• Perinatal mortality.
• Abnormal development, for example, congenital abnormalities (heart abnormalities in particular).
• Health problems shortly after birth (such as heart and breathing problems) that require
hospital care.
• Developing obesity or diabetes later in life.
NHS Choices, Diabetes and Pregnancy, 2011
75
hormones during maternal mental illness.99, 100
Women who have previously had a mental health
problem are at increased risk of becoming ill again
during pregnancy (or in the first year after birth).
The risks of specific mental disorders are increased
by poverty, stress, exposure to violence and low
social support.
Women with Type 1 and Type 2 diabetes have
been shown to have high rates of perinatal
mortality, with both types of diabetes carrying
similar levels of risk.U,90 The risk of perinatal
mortality in this group is four times that of
the general population. Women with Type 1
or Type 2 diabetes are also at increased risk of
giving birth to a baby with congenital anomalies
or perinatal morbidity.90 Women with Type 2
diabetes were more likely to come from a Black,
Asian or other ethnic minority group and from a
deprived area.
Antenatal and postnatal mental disorders, from
anxiety disorders and depression through to
schizophrenia and postnatal psychotic disorders,
can severely impact the health and wellbeing of
not only the mother, but her infant and other
family members. The NICE clinical guideline
45 provides recommendations on the care,
treatment and support for women who are
diagnosed with a mental health disorder during
pregnancy or in the postnatal period.101
NICE clinical guideline 63 sets out
recommendations for the management of
diabetes and related complications throughout
all stages of pregnancy: preconception,
antenatal, neonatal and postnatal care.94
Mental health problems (psychological
disorders)
Maternal body mass index
Overweight and obesity
Several studies have recognised that women
with mental health problems during pregnancy
are at increased risk of pregnancy, birth and
neonatal complications.95, 96, 97, 98 Depression and
anxiety disorders in early pregnancy are related
to a risk of preeclampsia,95 while Gold et al
found a considerably higher foetal mortality risk
in women with any mental health disorder prior
to pregnancy, particularly those with affective
disorders.96 A further study by Howard et al.
highlighted a higher proportion of stillbirths
and neonatal deaths in women with a history of
psychotic disorders.97
Obesity is known to increase pregnancy
complications including gestational diabetes
and hypertensive disorders, thus increasing the
risk of preterm birth and adverse outcomes i.e.
perinatal mortality. In 2009, 10% of women
who had a stillbirth or neonatal death had
a Body Mass Index (BMI) of 35 or more V.13
However, women who are only moderately
overweight are also at increased risk.102 This is a
concern considering the expanding waistbands
and increasing levels of obesity in the general UK
population and other developed countries. In the
UK, trends in crude rates show a decrease in the
proportion of women within the ideal BMI group
and an increase in the overweight and obese
groups over a 15 year period.103
Women who develop maternal mental disorders
are less likely to approach prenatal care and opt
for poor health choices including under-eating
and lack of sleep which can disturb adequate
weight gain. Furthermore, women with maternal
mental disorders are more likely to smoke,
consume alcohol and use drugs. Maternal high
blood pressure, pre-eclampsia and early and
difficult delivery are influenced by raised stress
U
V
Maternal overweight is a preventable risk
factor for poor outcomes and it is suggested
that the rate of perinatal mortality is related to
socioeconomic status in developed countries.104
Research has identified a significant correlation
This study looked at perinatal mortality and congenital anomaly rates after 24 weeks completed gestation only among
women diagnosed with diabetes at least one year prior to their estimated due date.
Figures for England, Wales, Northern Ireland and the Crown Dependencies.
76
between maternal obesity and health
inequalities,105,103 with a 2010 study into maternal
obesity by CMACE reporting that 34% percent
of pregnant women living in England with a
BMI ≥35 were in the most deprived quintile.105
This is further supported by Heslehurst et al,
who reported the demography of obese women
as older, more parous and living in the more
deprived quintile areas.103 A study conducted in
Denmark found obese women were more likely
to have been single, unemployed, received less
than ten years of schooling, smoked more than
10 cigarettes a day and were multiparous.106
Obese mothers are more likely to give birth to
large-for-gestational-age babies.105 Furthermore,
obese nulliparous women are at an increased
risk of preterm delivery, consequently increasing
negative outcomes. It is thought that this is due
to increased odds of pre-eclampsia.107
Box 14: Obstetric complications common amongst women with a high BMI
before or during pregnancy.
• Birth defects such as heart defects, neural tube defects, and other abnormalities;
• Difficulty seeing all of the baby’s organs and estimating the baby’s weight with ultrasound;
• Difficulty monitoring the baby’s heart rate tracing with the fetal heart monitor;
• Gestational diabetes; • Pre-eclampsia;
• Problems having epidural and other anaesthesia;
• Delivery by emergency caesarean section;
• Heavy bleeding after delivery;
• Increased risk of forming abnormal blood clots;
• Bladder and kidney infections;
• Wound infection;
• Large babies with birthweight above the 90th percentile;
• Less likely to have successful vaginal birth after caesarean section; and
• Increased risk of stillbirth.
Obfocus, BMI and Pregnancy, 2009
www.obfocus.com/high-risk/BMI/BMI%20and%20Pregnancy.htm
77
The stillbirth rate for mothers with a BMI of 35
or more is significantly higher than the general
population; 8.6 per 1,000 singleton births ≥24
weeks’ gestation compared to 3.9 per 1,000
total births respectively.108 Furthermore, a metaanalysis estimated the stillbirth risk among obese
women to be nearly twice that of women of
normal weight108 and a Danish study found the
risk of stillbirth more than doubled among
obese women.
In the past, pregnant women would have their
weight measured at every antenatal check.
However, weight is now only measured at the first
booking-in appointment and then again only if
there is a concern about the woman’s weight. By
having an initial measure of weight, it is possible
for BMI to be calculated and identify where weight
(that was present pre-pregnancy) may be an issue;
and also address where any additional ante/post
natal care may be required. The care of women who
are obese (BMI ≥35) may differ to those who are
not in terms of, for example, being under the care of
a consultant due to increased risk of complications
during pregnancy and while giving birth.
There is a lower risk of perinatal mortality
among women with low BMI and the risk
increases with increasing BMI.109 The perinatal
mortality rate for mothers with a BMI of ≥35 is
9.8 per 1,000 total births compared to 5.2 per
1,000 total births of the general population,
almost twice the rate.105
Although there are no official guidelines as to
how much weight is best for a woman to gain
during pregnancy, guidelines formed from
anecdotal evidence are shown in Table 24.
Table 24: Guidelines for weight gain in pregnancy.
Pre-pregnancy BMI
BMI
Total weight gain
Rates of weight gain
2nd & 3rd trimester
(average range/week)
Underweight
Less than 18.5
13kg to 18kg
(28lb to 40lb)
0.5kg to 0.6kg
(1lb to 1.3lb)
Normal weight
18.5 to 24.9
11kg to 16kg
(25lb to 35lb)
0.4kg to 0.5kg
(0.8lb to 1lb)
Overweight
25 to 29.9
7kg to 11kg
(15lb to 25lb)
0.2kg to 0.3kg
(0.5lb to 0.7lb)
Obese
30 or more
5kg to 9kg
(11lb to 20lb)
0.2kg to 0.3kg
(0.4lb to 0.6lb)
Source: Baby Centre, Weight gain in pregnancy.110
Women who are classed as super-obese (BMI
≥ 50) are more likely to have illnesses caused
by being overweight (co-morbidities) or preexisting medical conditions such as chronic high
blood pressure and Type 1 or Type 2 diabetes.111
Evidence also suggests that compared to all
other obese and non-obese women, those
women who are considered ‘super-obese’ have
higher rates and are more likely to suffer from a
number of conditions during pregnancy, which
have implications for both maternal and baby
health, including: preeclampsia, gestational
diabetes mellitus, fetal deaths, large-forgestational-age babies and caesarean delivery.111
78
Box 15: Recommendations for obese women of child-bearing age and obese
pregnant women.
• Pre-conception counselling;
• Folic acid supplementation;
• Appropriate provision of antenatal care;
• Measuring height and weight and calculating BMI;
• Access to appropriate information highlighting maternal and fetal risks of maternal obesity;
• Maternal surveillance and screening for gestational diabetes;
• Planning labour and delivery;
• Risk and needs assessment; and
• Service organisation.
CMACE, Maternal obesity in the UK: findings from a national project, 2010
CMACE and RCOG, Management of Women with Obesity in Pregnancy, 2010
Obfocus, BMI and Pregnancy, 2009
Pre-pregnancy counselling is recommended to
obese women of child-bearing age (BMI of 30 or
more) in order to make them aware of the risks
of obesity during pregnancy and childbirth. This
should involve access to appropriate information,
advice and support to lose weight prior to
pregnancy (Box 15).
and highlight dietary and physical activity
interventions for weight management before,
during and after pregnancy.114 Such interventions
are required to address the risks associated
with being overweight or obese thus improving
pregnancy outcomes.
Research looking at gestational weight loss
in women found that is was beneficial (for
overweight and obese women) in decreasing
the risk of pregnancy complications such
as preeclampsia and non-elective c-section,
although it did not substantially affect the risk of
perinatal mortality in these two groups.112 It did,
however, increase the risk of adverse outcomes
such as preterm delivery and babies being
small-for-gestational-age in normal weight,
overweight and obese mothers; and thus has the
potential to increase perinatal mortality where
preterm delivery is a risk factor.
As discussed above, maternal overweight and
obesity increases the risk of adverse outcomes.
In comparison, at the other end of the weight
spectrum, it must also be acknowledged that
being underweight too has implications upon
maternal and fetal health; with women with low
BMI (less than 18.5) being more likely to give
birth to a small-for-gestational-age baby111 and
preterm delivery. Therefore pregnancies among
women who are overweight or underweight are
considered high-risk.104
Underweight
A study exploring perinatal outcomes of women
of low weight and low BMI at conception, during
pregnancy and at delivery shows a correlation
between these women and prematurity, low
birthweight and delivery complications. Authors
highlight the need for management of nutrition
through pregnancy in order for better delivery
outcomes.115
Effective local strategies should include referral
criteria, facilities and equipment, care in
pregnancy, place and mode of birth, provision of
anaesthetic services, management of obstetric
emergencies and postnatal advice.113 In addition,
recent guidance has been produced to encourage
79
Poor nutrition
and baby.125 It has therefore been suggested
that care-providers need to focus upon the fact
that the demographic distribution of pregnant
women will continue to shift, with more women
having children in to older age.125
Poor nutrition prior to conception, during early
pregnancy and during the third trimester of
pregnancy is associated with preterm birth and low
birthweight.116 High carbohydrate intake in early
pregnancy is associated with suppressed placental
growth, particularly if combined with low dairy
and protein intake during late pregnancy.117 It has
also been reported that the frequency of food
consumption and meal patterns during pregnancy
influences pregnancy outcome (birthweight and
timing of delivery) which can cause complications
for the baby.118 Blincoe relates poor diets in women
before and during pregnancy with low birthweight
and reports that teenagers and those living in
poverty are at highest risk.119
Historically, there have been higher rates of
perinatal mortality in older mothers due to
congenital and chromosomal anomalies, however,
these rates have reduced due to the introduction
of screening programmes as well as the availability
of elective abortion (although this is not available
in all countries).126 In England and Wales during
2009, babies of mothers aged 40 and over had the
highest stillbirth and perinatal mortality rates at 7.7
and 10.6 per 1,000 total births respectively.120
A significant relationship has been found to exist
between advance maternal age and adverse
outcomes such as intra uterine growth restriction
(IUGR), low birthweight, congenital malformations
and perinatal mortality.125, 126 However, it has
been suggested by some that age alone (as an
independent risk factor) does not increase the risk
of perinatal mortality and that other contributing
factors may therefore need to be considered.125,126
It is also evident that mothers aged over 40
years may be more susceptible to pre-term birth,
gestational diabetes and preeclampsia (the latter
two of which can cause the former)121; as well
as babies who are small for gestational age and
higher rates of ante- and intra-partum stillbirth.125
A recent study by Lisonkova et al. looked at birth
outcomes for older mothers of twins and found
that twins of older mothers were more likely to
be born preterm (less than 37 weeks) however
they were at no greater risk of other adverse birth
outcomes.140
With British government guidelines emphasise
the need for a balanced diet and vitamin
and mineral supplementation, intervention
strategies to improve nutrition before and
during pregnancy are necessary for improving
outcomes.115 Midwives are most appropriate at
advising nutritional health to pregnant women.
However, barriers including cost, availability,
access and family eating habits affect women’s
coerce to change their diets, particularly those
from a low income background.119
Maternal age
Maternal age is said to affect the risk of perinatal
mortality, with higher levels of stillbirth and
perinatal mortality among mothers who are from
younger (under 25 years) or older (over 40 years)
age groups.2,120,121 This is particularly pertinent
in the present day with high, and in some areas
increasing, numbers of teenage pregnancies.122
In addition, more women are having children
later in life, with the number of women in their
forties giving birth doubling in the ten years from
1998 to 2008.123 This trend may be anecdotally
attributed to factors such as lifestyle choice,
improved education and career prospects,
and improvements in methods of assisted
reproduction.124 Pregnancy and birth for older
mothers carries increased risk for both mother
The evidence appears mixed when considering
whether young maternal age has an impact upon
pregnancy outcomes or not.127, 128 Adolescent
pregnancies have been shown to increase the
risk of medical complications including low
birthweight, prematurity and increased risk of
perinatal mortality.129,130 Other risk factors that
have been associated with adverse pregnancy
outcomes in younger mothers include being
80
of Black ethnic origin, having a lower level of
education, being a single parent, inadequate
prenatal care and smoking during pregnancy.131
However, these risks may also be associated with
older mothers, or indeed mothers of all ages.
has proved interventions such as cognitive
behaviour and motivational interviewing, incentives
and nicotine replacement therapy can reduce the
number of women continuing to smoke in late
pregnancy therefore reducing low birthweight and
preterm birth and in turn improving outcomes.
There is a connection between smoking in
pregnancy and social disadvantage and for that
reason maternity care providers need to meet the
requirements of the local population ensuring
support to those living in poverty, poor social
support and lack of education.
Smoking during pregnancy
Although it has been noted that smoking
during pregnancy is declining in high-income
countries,132 an estimated one third of all
perinatal deaths in the UK are caused by
smoking.133 In 2009, 27% of mothers who
had stillbirths and 28% of mothers whose
babies died in the neonatal period smoked
during pregnancy.13 Babies born to smokers
are at an increased risk of Sudden Infant Death
Syndrome.134
Assisted reproduction (e.g. IVF)
Research has shown that assisted conceptions
can increase excess perinatal deaths, particularly
for singleton pregnancies.136, 138
Research by Helmerhorst et al suggests that
singleton pregnancies from assisted reproduction
have a significantly worse perinatal outcome
than those non-assisted singleton pregnancies,
but this is less so for twin pregnancies. In twin
pregnancies, perinatal mortality was lower in
assisted compared to natural conception.136
Women who smoke during pregnancy increase the
risk of complications including low birthweight,
preterm birth, placental abruption and placenta
previaW thus affecting perinatal outcome.
Maternal smoking is strongly associated with
low birthweight and it has been reported that
“the greater number of cigarettes smoked during
pregnancy, the less well the foetus grows and
develops.”133 Evidence shows infants of mothers
who smoke during pregnancy are more likely to
be born small-for-gestational-age in comparison
to non-smokers,134 and other research has
demonstrated maternal smoking in the third
trimester of pregnancy as an autonomous
predictor for birthweight percentile.135
Multiple pregnancies
It is well documented that multiple pregnancies
pose greater risks for both mother and foetus
compared to singleton births. Rates of twin
pregnancies are said to have more than doubled
in the past 20 years and higher order multiple
births have increased six fold.137 In general, twin
and multiple births have been shown to have
higher perinatal mortality rates than singleton
births.137, 138 In the UK over the decade 20002009, the perinatal mortality rate in twins
significantly decreased from 33.6 to 24.6 per
1,000 total births, whilst the stillbirth rate also
fell from 16.7 to 12.1 per 1,000 live births.2
However, it is still widely acknowledged that
twins remain at a much higher risk of stillbirth
(2.5 times greater) and neonatal deaths (6.4
It should also be noted that women who do not
smoke, but are exposed to second-hand smoke
during pregnancy, have an amplified risk of giving
birth prematurely or to a low birthweight baby,
thus increasing the probability of mortality.133
In view of the interconnected correlation of
smoking, low birthweight babies and adverse
perinatal outcomes, it is essential that all maternity
care settings promote smoking cessation. Evidence
Placenta previa is low-lying placenta after 20 weeks of pregnancy. If the placenta covers the cervix at the end of pregnancy
the vagina will be blocked and the baby will therefore need to be born by caesarean section. See www.babycentre.co.uk/
pregnancy/complications/placentapraevia
W
81
by de Jonge et al. in 2009 found no significant
differences between rate of perinatal mortality
and morbidity and whether births took place in
the home or hospital.144 These findings conflict
with previous studies on home births by Bastian
et al and Pang et al., however both studies have
limitations such as sample size.145, 146 The risks
associated with home births have been identified
as: breech presentation, twins and post-term births.
times higher) when compared to singleton
births.2 There is also a marked difference in the
cause of death between singleton and twin
births, with figures for specific fetal conditions
and major congenital anomalies being 2% and
9% compared to 21% and 11% for singleton
and twin births respectively (i.e. twin births have
higher prevalence).
A study by Payne et al. found that preterm
twins have lower perinatal mortality rates
than singletons of the same birthweight and
gestational age.139 A more recent study by
Lisonkova et al. examining maternal age and
twin births found that, while twins born to older
women were more likely to be born preterm (<37
weeks) they were at no greater risk of being born
very preterm (<33 weeks).140 Those twins born
to older mothers were not at an increased risk
of perinatal mortality or mechanical ventilation,
and were not small for gestational age when
compared to twins of younger women. The same
study found that twins born to older multiparous
mothers were, however, at a higher risk of being
admitted to neonatal intensive care.
An earlier United Kingdom study found a
significantly higher perinatal mortality rate for
births booked under an independent midwife
compared with births in NHS units from 2002 to
2005. The authors concluded that evidence shows
low-risk home birth is no less dangerous than
in hospitals, however, women require adequate
information regarding risks and potential outcomes
in order to make informed decisions.147
Method of delivery
Babies who are born breech have greater risk
of perinatal mortality and morbidity than those
born with vertex X presentation.148 The Centre
for Maternal and Child Enquiries report that in
2009, the majority of stillbirths and neonatal
deaths were vertex presentation at delivery (76%
and 68% respectively).13 Twenty-one percent
of stillbirths and 28% of neonatal deaths were
breech presentation; of these 87% of stillbirths
and 67% of neonatal deaths were delivered
vaginally. The report notes that presentation is
unlikely to be causally related to death.
Gender of baby
It has been suggested that males have higher
perinatal mortality rates compared to females.
Specifically, research in the US has highlighted
that overall perinatal mortality rates and
mortality rates at low birthweights are relatively
higher among male births; while at heavier
birthweights, perinatal mortality rates are
relatively higher among female births.141, 142 A
study by Sheiner et al. found higher rates of
gestational diabetes, complications during labour
and caesarean section among women carrying
male foetuses, with the authors concluding that
“male gender is an independent risk factor for
adverse pregnancy outcome.”143
Birthweight and gestational age
Low birthweight is considered to be the “single,
strongest predictor of infant survival”149, p.378 with
the chance of an infant surviving the perinatal
period being closely related to its weight at birth.
As such, birthweight should be considered as a
potential confounding variable when looking at the
effect of other factors upon perinatal mortality.150
Place of birth
There are a number of maternal risk factors that
may be seen to increase the risk (after adjusting
for confounding variables) of perinatal mortality
The relationship between perinatal mortality and
morbidity and place of birth is unclear. A study
X
Head down and in the fetal position, also termed cephalic presentation.
82
due to their tendency to cause low birthweight,
namely: assisted conception, earlier stillbirth,
higher maternal age, maternal diabetes, lower
socioeconomic status, single mother, first birth
and smoking during pregnancy.151
for interventions to increase awareness on the
association of alcohol consumption and smoking
during pregnancy on fetal outcome, particularly
amongst high-risk groups.
Of those mothers who had stillbirths in 2009,
57% were in employment at the time of
booking. Comparable figures for employment
levels among women who have live births were
not available.
Messer reports that in England and Wales during
2009, perinatal mortality rates were highest for
very low birthweight babies (under 1,500 grams)
at 256.2 per 1,000 total births.120 For stillbirths,
the majority of very low birthweight babies
were also of low gestational age (24–27 weeks).
Most stillbirths (67%) were preterm (less than
37 completed weeks of gestation). Additionally,
of all preterm stillbirths, 63.8% belonged to the
very low birthweight category.
In England and Wales during 2009, the highest
rates of perinatal mortality were seen in babies
born to father’s who are in ‘semi-routine’,
‘routine’ and ‘other’ professions (8.4, 8.5 and
10.8 per 1,000 live and still births respectively).
Birthweight may also be directly linked with
gestational age in that babies who are delivered
early (pre-term, early gestational age) are more
likely to be of low birthweight, and therefore
focus may be placed upon reducing/preventing
the number of pre-term births and thus reducing
the risk of perinatal mortality.149 For neonatal
deaths, the mortality rates decrease as the
gestation increases. Babies born pre-term (<37
weeks) have a much higher risk of mortality than
babies born at term (37+ weeks).2
8.4 Appendix 4: The LA Classification
Inequalities and employment
3. Other Urban: districts with fewer than 37,000
people or less than 26% of their population
in rural settlements and larger market towns.
The Defra LA Classification gives six Urban/Rural
Classifications:
1. Major Urban: districts with either 100,000
people or 50% of their population in urban
areas with a population of more than 750,000.
2. Large Urban: districts with either 50,000
people or 50% of their population in one of
17 urban areas with a population between
250,000 and 750,000.
Perinatal mortality is linked to deprivation. In
2009, mothers who had stillbirths and neonatal
deaths were significantly more likely to be
deprived compared to the general population.
Mothers in the most deprived areas were 1.6
times more likely to have a stillbirth than those in
the least deprived areas.2
4. Significant Rural: districts with more than
37,000 people or more than 26% of their
population in rural settlements and larger
market towns.
5. Rural-50: districts with at least 50% but
less than 80% of their population in rural
settlements and larger market towns.
A recent study of the factors associated with
unhealthy behaviours during pregnancy for
a group of women in Dublin found a higher
occurrence of smoking during pregnancy and
lower periconceptional folic acid supplement use
among mothers in lower social classes.152 There
were, however, similar proportions of alcohol
consumption during pregnancy across all social
class groups. The study expresses the need
6. Rural-80: districts with at least 80% of their
population in rural settlements and larger
market towns.
For further information see: http://archive.defra.
gov.uk/evidence/statistics/rural/rural-definition.
htm#defn
83
Survey question
Score
needed to
be in highest
scoring 20%
of trusts
NCUHT
Score
UHMBT
Score
8.5 Appendix 5: Summary of results from the survey of women’s experiences of
maternity services 2010 for Cumbria.67
Were you given a choice of having your baby at home?
84
83
80
Dating scan: was the reason for this scan clearly
explained to you?
89
89
93
Were the reasons for having a screening test for Down’s
syndrome clearly explained to you?
89
87
88
20 week scan: was the reason for this scan
clearly explained to you?
92
92
93
During labour, could you move around and
choose the most comfortable position?
82
80
89
During labour and birth, did you get the pain relief you wanted?
82
83
84
If you had a cut or tear requiring stitches, how soon after
the birth were the stitches done?
61
57
63
Did you have skin to skin contact with
your baby shortly after the birth?
90
85
89
Did you have confidence and trust in the staff
caring for you during the labour and birth?
89
89
89
If you had a partner or a companion with you during your
labour and delivery, were they made welcome by the staff?
94
91
95
Were you (and/or your partner or a companion) left alone by
midwives or doctors at a time when it worried you?
84
84
84
Thinking about your care during labour and birth, were you
spoken to in a way you could understand?
93
92
93
Thinking about your care during labour and birth, were you
involved enough in decisions about your care?
87
88
89
Overall, how would you rate the care received
during your labour and birth?
87
88
91
Care in
hospital
after the
birth
(Postnatal
care)
Looking back, do you feel that the length of your stay in
hospital after the birth was appropriate?
76
80
86
After the birth of your baby, were you given the
information or explanations you needed?
76
81
79
After the birth of your baby, were you treated
with kindness and understanding?
83
82
88
Feeding the
baby during
the first
few days
Did you feel that midwives and other carers
gave you consistent advice?
62
66
65
Did you feel that midwives and other carers gave
you active support and encouragement?
69
73
71
Survey
section
Care during
pregnancy
(Antenatal
Care)
Labour
and birth
Staff
during
labour and
birth
Performance compared to national average
Better
About the same
84
Worse
8.6 Appendix 6: Data from the CHIMAT
Outcomes versus Expenditure tool,
2010/11
This chart shows the cost per birth compared
to perinatal mortality rate per 1000 births for
Cumbria Primary Care Trust. The total cost per birth
in Cumbria Primary Care Trust was £2,349. The
perinatal mortality rate per 1000 births in Cumbria
Primary Care Trust is 4.72 per 1000 live births.
Cumbria Primary Care Trust data
Perinatal Mortality
85
This chart shows the obstetrics and gynaecology
consultants/midwife ratio compared to
perinatal mortality rate per 1000 births for
Cumbria Primary Care Trust. The obstetrics
and gynaecology consultant/midwife ratio in
Cumbria Primary Care Trust is 0.08.
86
consultants (Full time equivalent - FTE) per 1000
births compared to perinatal mortality rate per
1000 births for Cumbria Primary Care Trust. The
obstetrics and gynaecology consultants per 1000
births in Cumbria Primary Care Trust is 2.9.
87
This chart shows the registered midwives (FTE)
per 1000 births compared to perinatal mortality
rate per 1000 births for Cumbria Primary Care
Trust. The registered midwives per 1000 births in
88
This chart shows the paediatric consultants (FTE)
per 1000 births compared to perinatal mortality
rate per 1000 births for Cumbria Primary Care
Trust. The paediatric consultants per 1000 births
in Cumbria Primary Care Trust is 3.2.
89
Stillbirths
total expenditure on maternity services per birth
in Cumbria Primary Care Trust was £2,349. The
stillbirth rate in Cumbria Primary Care Trust is 4.1
per 1000 births.
This chart shows the expenditure on maternity
services per birth compared to stillbirth rate per
90
consultants/midwife ratio compared to stillbirth
rate per 1000 births for Cumbria Primary
Care Trust. The obstetrics and gynaecology
consultant/midwife ratio in Cumbria Primary
Care Trust is 0.08.
91
consultants (FTE) per 1000 births compared
to stillbirth rate per 1000 births for Cumbria
Primary Care Trust. The obstetrics and
gynaecology consultants per 1000 births in
92
This chart shows the registered midwives (FTE)
per 1000 births compared to stillbirth rate per
1000 births for Cumbria Primary Care Trust.
The registered midwives per 1000 births in
93
This chart shows the paediatric consultants (FTE)
per 1000 births compared to stillbirth rate per
The paediatric consultants per 1000 births in
94
Comparison between 2009/10 and
2010/11, Cumbria Primary Care Trust
change in cost per birth in Cumbria Primary Care
Trust was £-0.06. The difference in perinatal
mortality rate per 1000 births in Cumbria
Primary Care Trust was -2.14.
Perinatal Mortality
This chart shows the cost per birth compared
to the change in perinatal mortality rate per
95
Stillbirths
The change in cost per birth in Cumbria Primary
Care Trust was £-0.06. The difference in stillbirth
rate in Cumbria Primary Care Trust was -0.74 per
1000 births.
This chart shows the change in cost per birth
compared to the change in stillbirth rate per
96
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Authors
• Alyson M Jones
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M (2010). Examining autonomy’s boundaries: a
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independent midwifery. Birth; 37(4), 280-287.
• Rebecca Harrison
• Karen Swarbrick
• Clare Perkins
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Acknowledgments
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Nutrition; 65, 470–479.
We would like to thank Sacha Wyke, Jennifer
Mason, Lynn Deacon, Matthew Hennessey
and Nicola Leckenby of the North West Public
Health Observatory for their assistance in the
production of this report.
We also greatly appreciate the input and
contribution from Anne Musgrave, Janet
Crewdson, Denise Lightfoot, Stephanie Preston
and Lesley Lewthwaite of North Cumbria University
Hospitals NHS Trust; Sacha Wells and Liz Strickland
of University Hospitals of Morecambe Bay NHS
Foundation Trust; Julie Maddocks of CMACE; Anne
Cooke of NHS Cumbria; and Dr Alexander Heazell
of Manchester Academic Health Services Centre,
The University of Manchester.
This report was commissioned by Dr Rebecca
Wagstaff, Deputy Director of Public Health,
NHS Cumbria.
105
North West Public Health Observatory
Centre for Public Health – Research Directorate
Faculty of Health and Applied Social Sciences
Liverpool John Moores University
Henry Cotton Building
15-21 Webster Street
Liverpool
L3 2ET
Tel. (0151) 231 4535
Fax (0151) 231 4552
Email [email protected]
www.nwpho.org.uk
www.cph.org.uk
ISBN: 978-1-908029-98-0 (Print version)
ISBN: 978-1-908029-99-7 (PDF version)
Published January 2013

A report commissioned by:

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