The Covid-19 pandemic has brought major disruption to health services all over the world, leading to fears of adverse outcomes for individuals whose health care requirements are not caused by the virus. These worries have extended to maternity care, with Unicef warning that Covid-related disruptions globally could mean over 200,000 additional stillbirths in a range of low and middle-income countries over 12 months. Concerns closer to home about a possible rise in a particular type of stillbirth (after 37 weeks’ gestation) early in the pandemic prompted a national review on the matter by the Healthcare Safety Investigation Branch (HSIB), a patient safety body in England.
In this blog, we look at the evidence around stillbirths and other adverse outcomes for babies in Britain during the pandemic.
Stillbirths and the pandemic
Every baby lost to a stillbirth is one too many and a truly tragic event for all involved – and thankfully they are rare. In 2019, around 1 in 255 births resulted in a stillbirth in England and Wales, and it was around 1 in 302 in Scotland. Stillbirth rates in recent years had been decreasing every year up to 2019 – since 2014 in England and Wales, and since 2016 in Scotland.
When the Covid-19 pandemic started, there were concerns from emerging international evidence that indicated stillbirth rates were rising, and the HSIB announced it would review stillbirths occurring after the onset of labour after 37 weeks’ gestation, due to an increase in England compared to 2019. The main worry wasn’t infection from Covid-19 itself, but that disruption to health care services – or a reduced willingness to access those services – meant that women may be receiving poorer quality care or were not accessing maternity care.
Due to those concerns, the Office for National Statistics (ONS) published provisional data for England and Wales up to September 2020. Thankfully, it showed that stillbirth rates had continued a downward trend, and for each month in 2020 were below the five-year average.
Data from Public Health Scotland (PHS) shows there was an increase in stillbirth rates in Scotland after the March lockdown, but they were still lower than some historical rates and have decreased since.
Other adverse outcomes for babies
Determining whether a baby’s death is a stillbirth or a neonatal death (which is within 28 days of birth) is not always easy, so it’s important to look at the rate of these as well as extended perinatal mortality rates (a combination of the two).
Data from Scotland shows that, for the months after the first national lockdown last March, there were no increases in either rate. There is currently no published data covering England and Wales.
Perinatal mortality is also not the only adverse outcome, as surviving babies could also have been born preterm and/or had low birth weights, which can have consequences for later outcomes. Data from the ONS, covering England and Wales, shows the rates of preterm births and low birthweights decreased in 2020 – continuing previous improvements. Data for Scotland also show no shifts for preterm births with gestations under 32 weeks, and small decreases in the percentage of births with gestations between 32-36 weeks and under 37 weeks.
How were maternity services impacted by the pandemic?
Using Hospital Episode Statistics (HES), we’re able to look at monthly changes in English hospital care where the main speciality of the treatment was obstetrics, or where the patient was under the direct care of a midwife.
The number of attendances for midwife-led outpatient appointments saw no changes following the introduction of the first national lockdown on 23 March last year. However, other measures of maternity care delivery decreased between March and April (obstetric outpatient attendances by 9% and maternity admissions by 8%).
The decreases, however, are fairly moderate compared to changes in all A&E attendances and some other outpatient attendances, with forthcoming analysis by the Nuffield Trust showing that trauma and orthopaedics, ophthalmology, and cardiology outpatient attendance also had larger decreases. The numbers of obstetric outpatient attendances and maternity admissions also started to increase again after the initial drop, and haven’t since returned to the levels seen in April last year.
But this may hide other changes. A survey of obstetric units in the UK reported “substantial and heterogeneous maternity service modifications”, including significant use of remote consultations and changes to screening pathways for gestational diabetes. Midwives’ sickness absence rates were also higher in April 2020 than 12 months earlier.
These indicators of quality also focus on hospital care, and we don’t know how community and primary care responded to maternity care needs.
From the perspective of expectant families, another change during the pandemic was the well-publicised ban in some places on a partner, relative or friend accompanying pregnant women during their care. The loss of that support – which can be important in highlighting to clinicians when issues arise or as advocates in pregnant women’s care choices – brought frustration and worry to many, and led NHS England to issue guidelines twice in late 2020 to ensure that it could happen.
The overall impact
Fortunately, in Britain there has been no evidence of an increase in stillbirth rates or other adverse outcomes for babies during the pandemic, but this doesn’t mean that the period hasn’t had an impact on related services or longer-term trends.
Some indicators (such as the levels of obstetric outpatient attendances and maternity admissions, midwife sickness absence rates, service modifications and access to support for pregnant women) do show that the services and support that protect against the risk of stillbirths may have been negatively impacted. It’s also impossible to know what would have happened to stillbirth rates without the pandemic. They might have improved further in 2020, following the improvements in previous years.
And we are unable to tell if different population groups have been disproportionately affected. Evidence prior to the pandemic shows that there are ethnic and socioeconomic inequalities in relation to stillbirths. Could these pre-existing inequalities have been exacerbated during the pandemic? We must continue timely monitoring of all stillbirths.
However rare, every one is a devastating experience for all involved. If any could have been prevented in the past year, we have a duty to learn from them.
About this data
A stillbirth is defined as a baby born after 24 or more weeks' completed gestation and who did not, at any time, breathe or show signs of life. They can occur antepartum – describing the period before childbirth – and intrapartum – describing the period after the onset of labour.
Normally, ONS and PHS derive stillbirth rates from birth registrations, which were deferred during the pandemic. Both organisations therefore used birth notifications from their NHS rather than to registrations during the pandemic to calculate rates. All the 2020 data from ONS covering England and Wales is classed as provisional, For Scotland PHS state that December 2020 data, extracted in January, is provisional. For further information on the data sources, please see the ONS and PHS websites.
The Scottish rates by month fluctuate more than the combined England and Wales rates, and is likely a result of there being fewer births in Scotland than England and Wales (i.e. lower denominator).
Northern Ireland data was not included in this analysis due to suspension of birth registrations resulting in inaccurate denominators.
For the HES data the following definitions were used:
- All admissions - The number of first episodes in any period of care as an admitted patient.
- Outpatient attendances - The number of appointments that were attended by patients.
The survey of obstetric units in the UK represented 42% of the 194 obstetric units.
Fisher E (2021) “Stillbirths and other adverse outcomes for babies in Britain during the pandemic”, Nuffield Trust comment.