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2011
Scottish Perinatal and Infant Mortality and Morbidity Report
Scottish Perinatal and Infant Mortality and Morbidity Report 2011
© Healthcare Improvement Scotland 2013 First published March 2013 You can copy or reproduce the information in this report for use within NHS Scotland and for educational purposes. Commercial organisations must get our written permission before reproducing this report. www.healthcareimprovementscotland.org
Please contact: Healthcare Improvement Scotland Reproductive Health Programme Leslie Marr Reproductive Health Programme Manager Healthcare Improvement Scotland Elliott House 8-10 Hillside Crescent Edinburgh EH7 5EA Tel 0131 623 4710 Email [email protected] Or © Common Services Agency/Crown Copyright 2013 Brief extracts from this publication may be reproduced provided the source is fully acknowledged. Proposals for the reproduction of large extracts should be addressed to ISD Publications, Area 114a, South Gyle Square, 1 South Gyle Crescent, Edinburgh, EH12 9EB Information Services Publication enquiries ISD Customer Support Desk Gyle Square, 1 South Gyle Crescent Edinburgh EH12 9EB Tel 0131 275 7777 Email [email protected] If you would like this leaflet in a different language, large print or Braille (English only), or would like information on how it can be translated into your community language, please phone 0131 275 6665.
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CONTENTS
SUMMARY 2
RECOMMENDATIONS and FUTURE REPORTS 4
Data collection and reporting from 2013 4
1 Introduction and Methods 6
2 Trends over Time 8 2.1 Total Births 8 2.2 Stillbirths and Infant Deaths 8 2.3 Single and Multiple Births 10
3 Causes of Stillbirths and Neonatal Deaths 12 3.1 Cause of Death in Singleton and Multiple Births 12 3.2 Birthweight and Gestation Specific Mortality Rates 15 3.3 Gender Differences 16
4 Late Fetal Deaths 17
5 Post-neonatal Deaths 18
6 Maternal Age and Sociodemographic Data 20
7 Additional Information Collected in 2011 23
8 Congenital Anomalies 25
9 NHS Board Statistics 26 9.1 Stillbirths and Neonatal Deaths 26 9.2 Extended Mortality Rates and Causes of Death 29
10 Commentary 31
11 References 33
12 Appendices 35 12.1 Detailed summary of new information collected in 2011 35 12.2 Appendix tables and figures 44 12.3 Acknowledgements 72 12.4 Hospital co-ordinators 2011 73 12.5 Symbols and Abbreviations 74 12.6 Definitions 75 12.7 Denominators 76 12.8 National Statistics 77 12.9 Classification 78
2
SUMMARY
1. Total births and deaths in 2011
Total births: 58,889, continuing the very slight decline in births in recent years. 689 deaths were notified to the Survey
− 153 late fetal deaths
− 299 stillbirths
− 159 neonatal deaths
− 78 post-neonatal deaths
2. Rates of stillbirths, neonatal deaths and infant deaths among singleton and multiple births
All deaths Singleton birth deaths
Multiple birth deaths
Stillbirths1 5.1 4.8 12.7
Neonatal deaths2 2.7 2.3 15.2
Perinatal deaths1 6.9 6.5 21.9
Post-neonatal deaths2 1.3 1.3 2.3
Infant deaths2 4.0 3.6 17.5 1 Rate per 1000 total births. 2 Rate per 1000 live births.
3. Main causes of stillbirths and neonatal deaths among singleton pregnancies
Cause of death
Stillbirths (%)
Neonatal deaths (%)
Placental conditions 38 6
Antepartum haemorrhage 15 8
Congenital anomaly 12 29
Conditions associated with prematurity - 51
4. Other findings
More detailed information for each death was obtained with the revised data collection form.
The revised system for the classification of each death proved robust.
Low birthweight and prematurity continue to be associated with the highest rates of stillbirth and neonatal mortality.
There is an association between obesity, smoking and deprivation and stillbirth and infant death.
Stillbirth or neonatal death is not more likely at night or at weekends.
A postmortem examination was offered for almost all stillbirths; 61% of stillbirths had a postmortem performed.
The placenta was examined histologically in 97% of stillbirths.
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5. Congenital anomalies Most anomalies are of the heart and circulatory system. Antenatal screening provides an opportunity to reduce the rates of neural tube defects and Down's syndrome at birth.
6. NHS board variations
Most variations in the rates of stillbirths and neonatal deaths among NHS boards are likely to be related to random variation and to differing degrees of socioeconomic deprivation.
7. Commentary
Commentary is provided on the revised classification system and on new data collected for each death.
4
RECOMMENDATIONS and FUTURE REPORTS
Recommendations for the survey and for practice based on that year’s findings have been included in SPIMMR since 2009. This report for 2011 addresses many of those recommendations, improving data collection, developing and utilising a system of death classification which reflects modern knowledge and understanding and which reduced the number of deaths classified as “unexplained”. There is also evidence of improved practice with, for example, the placenta from the great majority of stillbirths now being examined histologically. In view of the substantial changes taking place in data collecting and reporting in 2013 (described below), no new recommendations are included here but the following recommendations remain relevant from the 2010 report.
1. The placenta should be examined histologically in all cases of stillbirth and in as many cases of neonatal death as is possible.
2. The benefits of a postmortem examination carried out by a perinatal pathologist
should be explained to all parents whose baby is either stillborn or a neonatal death.
3. A resource should be provided within each maternity and neonatal unit to ensure
that full details of every death relevant to the enquiry are completed and logged within the appropriate national system.
4. A standard method of reviewing all perinatal deaths at each maternity unit should
be established.
5. There should be dissemination of each annual report throughout the relevant clinical community who should discuss its relevance and implications for their own unit or working environment.
Data collection and reporting from 2013
From January 2013, the Scottish Stillbirth and Infant Death Survey was replaced by a revised UK survey MBRRACE-UK (Mothers and Babies Reducing Risk through Audit and Confidential Enquiries across the UK). This new collaboration was appointed by the Healthcare Quality Improvement Partnership (HQIP) to continue the national programme of work investigating maternal deaths, stillbirths and infant deaths, including the Confidential Enquiry into Maternal Deaths. Funding is provided by the four UK departments of health. The MBRRACE-UK programme of work will include surveillance of late fetal losses, stillbirths and infant deaths together with a rolling programme of topic specific confidential case reviews of stillbirths and mortality and morbidity cases. The first themed topic is congenital diaphragmatic hernia. Annual reports will be produced with the first report anticipated in late 2014. Unit specific reports will be provided to individual maternity and neonatal care providers.
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All units in Scotland are now registered for the web based data collection process. Scottish data will be separately analysed in addition to the UK report and will be used to inform the new patient safety programme in maternity services - Maternity Care Quality Improvement Collaborative (MCQIC ) and the Early Years Collaborative as well as to inform units at local level. A new expert group will be convened to oversee this work within Scotland.
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1 Introduction and Methods
Annual reports on perinatal mortality in Scotland have been produced since 1977. The report now also includes information on late fetal deaths (losses from 20 to 23+6 weeks gestation), late neonatal and post-neonatal infant deaths. In recent years, information on certain congenital anomalies occurring in live births, stillbirths, miscarriages and terminations has also been included. As discussed in the 2010 SPIMMR, there is a new data collection form and classification system for deaths instigated in 2011. This new system was devised by a multidisciplinary working group, facilitated by Healthcare Improvement Scotland in response to the report on trends in perinatal mortality – a review over 30 years1. The Scottish Stillbirth and Infant Death Survey (SSBIDS) and the production of the report are managed jointly by the Reproductive Health Programme of Healthcare Improvement Scotland and the Information Services Division (ISD) of NHS National Services Scotland with collaboration from the National Records of Scotland (NRS). Registered deaths (stillbirths, neonatal and post-neonatal deaths) are identified through NRS2 and detailed information for each case is obtained from designated co-ordinators in each maternity unit and associated neonatal unit. Late fetal deaths are not registered and the survey is dependent on the recognition and reporting of these by the unit co-ordinators. The co-ordinators are listed in Appendix 12.4; the survey was completely dependent on their assistance and co-operation. It should be noted that one additional neonatal death was registered with NRS in 2011 but is not included in the Survey. The death occurred many years ago but registration did not take place at the time. It is not appropriate to include this death in this report for 2011. The data collection form for each death is scrutinised for completeness and accuracy by Reproductive Health Programme staff with the cause of death receiving a final classification by the clinical advisor. Data are initially entered into an access data base and then onto an SPSS database and quality assured by Reproductive Health Programme staff. Further data checking is carried out by ISD staff who then produce tables for analysis. As perinatal reports for England and Wales have not been produced since 2009, no comparisons with other UK countries can be made though basic rates were obtained from the Office of National Statistics (ONS)3. The main body of this report describes the findings and includes key tables and figures. Most of the detailed tables are provided in Appendix 12.2. An “A” in front of a table number referred to in the text indicates that the table can be found in that appendix (eg Table A5). Revision to the 2011 report – changes to funnel plots. An error has been identified in the methodology used for plotting the x-axes in the stillbirth, neonatal death and congenital anomaly by NHS board of residence funnel charts. The funnel plots in the 2011 SPIMMR report are affected by this error. This has resulted in the control limits, that is, the lines representing two standard deviations (2SD) and three standards deviations (3SD) from the mean, being incorrectly plotted on these charts.
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It should be noted that the mortality rates for the NHS boards were correct and these have been correctly plotted along the y-axis of the funnel plots. The line plotted to represent the mean was also correct on the funnel plots. The impact of the revision of the control limits means that some data points will be re-positioned in relation to these lines on the charts. For example, in the 2011 report in Figure 9.1a, NHS Fife is more than 3 SD from the mean and on the corrected plot is now between 2 SD and 3 SD of the mean. For the majority of data points the change in position, relative to the control limits, is insignificant. However, in a small number of cases the re-positioned data point crossed from previously appearing below the 2 SD or 3 SD limit to now being above it. Similarly, for some NHS boards the re-positioned data point crossed from appearing above the 2 SD or 3 SD limit to below it. Further information, including the impact of this revision and a comparison of the original and revised charts is available at: http://www.isdscotland.org/Health-Topics/Maternity-and-Births/Stillbirth-and-Infant-Deaths/ This revised version of the 2011 report has been placed on the ISD website on 25 March 2014.
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2 Trends over Time
2.1 Total Births
There were 58,889 live and stillbirths registered in Scotland in 2011. This is 193 fewer than were registered in 2010 and continues the slight decline in births since the recent peak of 60,366 in 2008. The lowest number of recorded births since accurate birth registration was 51,548 births in 2002. By contrast, the increase in the number of births in England and Wales since 2001 continues with a rise of 0.1% in 20113. The trend in total births in Scotland over the last 35 years is illustrated in Figure 2.1.
Figure 2.1 Total births in Scotland: 1977 - 2011
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2.2 Stillbirths and Infant Deaths
Numbers and rates of stillbirths and of perinatal, neonatal and infant deaths for the last five years are shown in Table 2.2. The rates of all deaths continue to be lower than for most recent years. The lowest perinatal mortality rate of 6.9 per 1000 births achieved in 2010 was equalled in 2011, a slight rise in the stillbirth rate (to 5.1 per 1000 births) being offset by the lowest recorded early neonatal mortality rate of 1.9 per 1000 live births. In England and Wales in 2011, the stillbirth rate was 5.2 per 1000 and the perinatal mortality rate 7.6 per 10003.
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Figure 2.2 summarises rates of stillbirth, neonatal death and post-neonatal death in Scotland over the last 35 years.
Table 2.2 Stillbirths and deaths in the first year of life (numbers and rates): 2007 - 2011
2007 2008 2009 2010 2011
Live births 57781 60041 59046 58791 58590
Stillbirths 327 325 317 291 299
Early neonatal deaths 129 122 120 118 109
Perinatal deaths 456 447 437 409 408
Late neonatal deaths 59 46 45 32 50
Neonatal deaths 188 168 165 150 159
Post-neonatal deaths 84 85 70 68 78
Infant deaths 272 253 235 218 237
Rates 95% CI
Stillbirth1 5.6 5.4 5.3 4.9 5.1 4.52,5.69
Early neonatal2 2.2 2.0 2.0 2.0 1.9 1.53,2.24
Perinatal1 7.8 7.4 7.4 6.9 6.9 6.27,7.63
Late neonatal2 1.0 0.8 0.8 0.5 0.9 0.63,1.13
Neonatal2 3.3 2.8 2.8 2.6 2.7 2.31,3.17
Post-neonatal2 1.5 1.4 1.2 1.2 1.3 1.05,1.66
Infant2 4.7 4.2 4.0 3.7 4.0 3.55,4.59 1 Rate per 1000 total births. 2 Rate per 1000 live births. Source: NRS (for live births and for calculating rates) and Survey (numbers of deaths).
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Figure 2.2 Stillbirth1, neonatal2 and post-neonatal2 mortality rates: 1977 - 2011
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1 Rate per 1000 total births. 2 Rate per 1000 live births. * The definition of a stillbirth was changed from 28 weeks to 24 weeks on 1st October 1992. Source: NRS.
For the purpose of international comparison and to evaluate the effectiveness of care, the International Federation of Obstetrics and Gynaecology (FIGO) advocates the presentation of perinatal mortality data among infants weighing 1000g or more (roughly equivalent to 28 weeks gestation) and without major congenital anomaly4. The rates in Scotland over the last 5 years are presented in Table A1. Using the FIGO criteria, the stillbirth rate in 2011 was 3.1 per 1000 births, the neonatal mortality rate 0.9 per 1000 live births and the perinatal mortality rate 3.8 per 1000 births. These rates are slightly higher than in 2010 but remain lower than in all previous years.
2.3 Single and Multiple Births
In 2011, there were 57,155 singleton births, 852 sets of twins and 10 sets of triplets registered with NRS. The rate of twins was, at 14.7 per 1000 registered maternities, the lowest since 2004 and confirms the decline since the highest rate (16.0) in 2008. Single and multiple births each year for the past five years are shown in Appendix 12.2 Table A2.
Comparison of the stillbirth and neonatal mortality rates since 2007 are shown in Table A3. In 2011, the stillbirth rate was 4.8 per 1000 singleton births and 12.7 per 1000 multiple births; neonatal mortality rates were 2.3 per 1000 singleton live births and 15.2 per 1000 multiple live births.
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The outcomes for twin pregnancies with a registered birth are shown in Figure 2.3.
Figure 2.3 Outcome for twin pregnancies: 2011
Twin
pregnancies
852
Both twins Twin 1 Twin 2 Both twins
survived died died died
814 13 16 9
Source: Survey
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3 Causes of Stillbirths and Neonatal Deaths
3.1 Cause of Death in Singleton and Multiple Births
A revised classification system for causes of death was introduced in 2011. The data collection form requested more information than in previous years and asked each unit clinician completing the form to assign the principal and associated causes of death to specific categories. This information, together with copies of postmortem reports, discharge letters and perinatal summaries allowed the clinical advisor for the Reproductive Health Programme to assign a cause of death in a consistent fashion as in previous years. Obstetric factors were considered for all deaths except post-neonatal deaths. Postnatal conditions were also considered for neonatal and infant deaths. The classification options as they appear on the data collection form are shown in Appendix 12.8. There are 11 main obstetric factors with a number of subsidiaries and nine main neonatal factors, also with subsidiaries. Both groups had an additional possible assignation of “unable to classify because of inadequate information”. Details of the causes of death for singleton and multiple births are shown in Tables A4 to A7. The main causes of death for singleton births are illustrated in Figures 3.1. These are considered in more detail than multiple births as the numbers of deaths from multiple pregnancies are small and particular factors, especially prematurity, differentiate them from singleton pregnancies. The limitations of the Wigglesworth system5,6 used to classify deaths in previous reports have been discussed in detail in recent SPIMMRs. The failure of that system particularly to recognise placental conditions meant that almost two thirds of deaths could have no specific obstetric cause allocated. In 2010, 64% of singleton stillbirths and 53% of singleton neonatal deaths were placed in the “unexplained” category. The difference with the new classification system is marked. “Unexplained” deaths, with no apparent obstetric factors have been reduced to 9.7% of singleton stillbirths and 7.5% of singleton neonatal deaths. Placental conditions account for 38.3% of singleton stillbirths. Although intra-uterine growth restriction (IUGR) is frequently present among stillbirths, it is usually associated with a placental disorder which is considered to be the primary cause of death. This accounts for the low rate of IUGR (1.1%) among singleton stillbirths shown in Figure 3.1. The proportion of all stillbirths (singleton and multiple) detected with IUGR was 40.9%. Where direct comparisons of the cause of death with previous years are possible (for example congenital anomalies and antepartum haemorrhage), the proportions in 2011 are very similar to previous years. The predominant factors associated with singleton neonatal deaths are congenital anomalies (28.1%) and either extreme immaturity of less than 24 weeks gestation (13.5%) or factors associated with lesser degrees of prematurity, such as most of the respiratory (20.7%) and neurological (16.3%) disorders and infections (7.4%). Additional detail of the subsidiary causes under each main cause are shown in the appendix Tables A4 and A5.
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The obstetric and neonatal causes of death among multiple pregnancies are shown in Tables A6 and A7. Although the numbers are small (22 stillbirths and 26 neonatal deaths), the distribution of causes differs from singleton pregnancies. When stillbirths and neonatal deaths are combined, the most frequent single cause of death was twin to twin transfusion (16.7% of the 48 deaths). Congenital anomaly accounted for seven deaths (14.6%), similar to the proportion among singleton pregnancies. Most other deaths were associated with premature delivery (spontaneous, or associated with antepartum haemorrhage or iatrogenic for maternal complications especially hypertension) and subsequent complications for the neonate.
Figures 3.1 Percentage distribution of cause of death; singleton births: 2011
(a) Main obstetric factors causing death in 277 singleton stillbirths
Antepartum or
intrapartum
haemorrhage (14.8)%
Unable to classify
(8.3)%
Infection (5.1)%
Mechanical (4.3)%
Hypertensive
disorders of
pregnancy (2.2)%
Maternal disorder
(2.2)%
Associated obstetric
factors (1.1)%
Intra-uterine growth
restriction (1.1)%
Specific fetal
conditions (0.7)%
Major congenital
anomaly (12.3)%
No antecedent or
associated obstetric
factors (9.7)%
Specific placental
conditions (38.3)%
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(b) Main obstetric factors causing death in 133 singleton neonatal deaths
Infection (19.5)%
Associated obstetric
factors (13.5)%
Unable to classify
(9)%
No antecedent or
associated obstetric
factors (7.5)%
Antepartum or
intrapartum
haemorrhage (7.5)%
Specific placental
conditions (6)%
Hypertensive
disorders of
pregnancy (3)%
Specific fetal
conditions (3)%
Mechanical (2.3)%Major congenital
anomaly (28.6)%
(c) Main neonatal factors causing death in 133 singleton neonatal deaths
Major congenital
anomaly (28.6)%
Respiratory disorders
(19.5)%
Neurological disorder
(16.5)%
Extreme immaturity
(<24 wks) (13.5)%
Infection (7.5)%
Unable to classify due
to lack of information
(4.5)%
Sudden unexpected
death (3.8)%
Gastro-intestinal
disease (3)%
Other specific causes
(3)%
Source: Survey
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An important contribution to the assignation of a cause of death is made by a postmortem examination of the fetus or infant and by histological examination of the placenta. More information than in previous years was sought on both of these in the data collection form for 2011. Table A8 shows postmortem rates for stillbirths, neonatal deaths and late fetal deaths for all of Scotland and for individual hospitals in the same way as it has been reported in previous years, i.e. full postmortems as a proportion of all deaths in that category. This shows a notable decline in 2011 when compared with 2010 and reverses the rising trend of recent years. The performance of a full postmortem was reported for only 51.5% of stillbirths, 31.4% of neonatal deaths and 52.9% of late fetal deaths. Because of missing information, however, it is not entirely appropriate to use all deaths as the denominator. In addition, a proportion of deaths had a solely external or a partial postmortem examination. If these postmortems are included and rates are calculated using only those deaths for which definite information is available, the postmortem rates were 60.6% for stillbirths, 46.7% for neonatal deaths and 60.7% for late fetal deaths. Further analysis is included in Table 12.1.13. Histological examination of the placenta is of greatest importance for stillbirths; disorders of the placenta have already been shown to be the most frequent primary cause of death in this group. In 2011, the placenta was reported to have been examined histologically in 97.1% of the 270 stillbirths for which the information was available.
3.2 Birthweight and Gestation Specific Mortality Rates
To calculate the relationship of birthweight and gestation to mortality rates, it is necessary to know the distribution of these factors in all births. This information is not recorded at birth registration and is dependent on SMR02 data reported from NHS boards to ISD. SMR02 returns for the preceding year are generally incomplete at the time of preparing the annual SPIMMR due to problems with the collection and transfer to ISD of data from some hospitals. Because of this deficiency (5.9% of singleton live births at the time of compiling this 2011 report), the rates for birthweight and gestational age obtained from the SMR02 returns to date (53,528 singleton live births) are applied to the 56,877 singleton live births registered with NRS. Although the proportions may change slightly when all SMR02 data are complete, it is unlikely that this will prove significant. Data relating to this information are shown in Tables A9a and b, A10a and b and A11a and b. Among single births in 2011, 5.3% of all live births but 64.6% of stillbirths and 62.4% of neonatal deaths weighed < 2500g. Similarly, 0.9% of all babies, but 40.0% of stillbirths and 49.6% of neonatal deaths were born before 32 weeks gestation. Excluding babies with congenital anomalies gives a more refined picture of the impact of gestation and birthweight. Rates have changed little in recent years and the information in Tables A10b and A11b does not suggest that any particular birthweight or gestational age has been the main beneficiary of any improvement. Prematurity is a particular risk for multiple pregnancies; 43 of the 45 babies of twin pregnancies, of known gestation, who were stillborn or died in the neonatal period were born at less than 37 weeks gestation. Twenty three (51.6%) were born before 28 weeks gestation. The details are in Table A12.
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The causes of stillbirths and neonatal deaths can be further analysed by examining the proportion of such deaths which are small for gestational age (birthweight <5th centile for gestation). In Table A13, this information is provided for normally-formed singleton antepartum stillbirths and for intrapartum stillbirths and neonatal deaths combined (as they are likely to represent a continuum of related circumstances). As in previous years, the proportion of antepartum stillbirths small for gestational age (19.2%) is higher than among intrapartum stillbirths and neonatal deaths (3.7%). Of the 44 antepartum stillbirths who were small for gestational age, 29 (65.9%) had a specific placental disorder.
3.3 Gender Differences
Gender specific mortality rates for different causes of death are compared in Table A14. In 2011, there was little difference between the singleton stillbirth rate among females (4.9 per 1000 births) and males (4.8 per 1000). The neonatal mortality rate was 2.2 per 1000 for females and 2.5 per 1000 live births for males. The new classification system of causes of death did not reveal any gender differences.
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4 Late Fetal Deaths
Information on late fetal deaths (deaths at 20 – 23+6 weeks gestation, or earlier in pregnancy if the birthweight is ≥ 500g) has been collected since 1991 and contributes to the overall picture of reproductive outcome in Scotland. These deaths are not registered with NRS and are identified by information volunteered by local hospital co-ordinators and from SMR02 returns. In addition, some postmortem reports on such fetuses are sent directly by pathologists to the Healthcare Improvement Scotland Reproductive Health Programme. Data on these fetal deaths are, nonetheless, less robust than those on stillbirths and neonatal deaths, and are not complete, fluctuating from year to year dependent on the level of case ascertainment. In 2011, 153 late fetal deaths were identified. Ninety miscarried spontaneously and in 59 cases (39.6% of the 149 for which information was available) the pregnancy was terminated, mainly because of fetal anomaly. Twenty seven of the 153 late fetal deaths (17.6%) occurred in multiple pregnancies. This is considerably higher than the proportion of multiple pregnancies among all registered births (1.4% in 2011) and also higher than the rate of multiple pregnancies among all stillbirths (7.4%). The well documented vulnerability of multiple pregnancies is clearly demonstrated. The cause of late fetal deaths among singleton and multiple pregnancies according to the new classification system is shown in Tables A15 and A16 where comparison is made with registered stillbirths. Of the 153 late fetal deaths, 49 (32.0%) had a congenital anomaly. All but five of these pregnancies were terminated therapeutically. This compares to a congenital anomaly rate of 12.7% among stillbirths. All of the congenital anomalies found in late fetal deaths occurred in singleton pregnancies. Among spontaneous late fetal deaths, the rate of antepartum haemorrhage and infection was much higher than among stillbirths, accounting for 66.7% of spontaneous late fetal deaths. The infection was generally chorioamnionitis following rupture of the membranes. The rate of specific placental conditions causing death was 35.8% for stillbirths but 16.7% for late fetal deaths. The distribution of gestation and birthweights of the late fetal deaths is shown in Table A17.
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5 Post-neonatal Deaths
For the first time in 2011, detailed information on post-neonatal infant deaths (occurring after the first four weeks but within the first year of life) was collected on a form similar to that used for the other deaths reported here but with less obstetric detail. The causes of death were classified using the same system as for neonatal deaths. Comparisons with previous years when less information was collected and a different system of death classification was used are, therefore, limited. Information on causes of death, age and place of death and on postmortem examinations is in tables A18 – 21. In 2011, there were 78 post-neonatal infant deaths, a small increase on the previous two years, but the rate has changed little in recent years. Sudden unexpected death was the most frequent cause although the number of such deaths (17) was fewer than in 2010. Congenital anomalies accounted for 18% of the deaths as did infection. Information about post-neonatal deaths was more often lacking than for other deaths included in this report and it was impossible to allocate a cause of death in 17% of cases. Of 68 deaths for whom the location of death was known, 38.2% occurred in a neonatal unit. These deaths were mostly associated with problems developing in the neonatal period. The other frequent place of death was at home (36.8%). Over half of the deaths occurred before three months of age. Postmortems were not performed for most deaths other than sudden unexpected deaths. The proportions of deaths attributed to the various causes are presented graphically in Figure 5.
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Figure 5 Causes of 78 post-neonatal deaths: 2011
Sudden unexpected
death (21.8)%
Infection (17.9)%
Major congenital
anomaly (17.9)%
Gastro-intestinal
disease (9)%
Neurological disorder
(7.7)%
Other specific causes
(5.1)%
Respiratory disorders
(2.6)%
Injury/trauma (inc.
iatrogenic trauma)
(1.3)%
Unable to classify due
to lack of information
(16.7)%
Source: Survey
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6 Maternal Age and Sociodemographic Data
Figure 6a shows that mothers aged 20 or less or age 40 and above are more likely to experience a stillbirth. As numbers in any one year are too small for statistical analysis, maternal age over five years from 2007-2011 is compared in Figure 6b. Those aged 40 years or older were significantly more likely to give birth to a stillborn baby when compared
to mothers aged 25-34 years ( 2=14.2 p<0.001) and those aged 20 years or less were significantly more likely to experience a post-neonatal death than mothers aged 25–34
years of age ( 2=31.6 p<0.001).
Although requested, information on paternal age was often not recorded. Where available, the distribution did not appear to be of note.
Figure 6a Stillbirth and neonatal death rates1 by mothers' age2: 2011
0.00
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2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
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Ra
te
SB (295)
NND (151)
1 Rates per 1000 women who delivered in 2011 per age group. 2 Excludes records where age was unknown. Source: Survey and NRS (Table 3.14: Live Births, Stillbirths and Maternities, 2011).
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Figure 6b Stillbirth, neonatal death and post-neonatal death rates1 by mothers' age2: 2007 - 2011
0.00
1.00
2.00
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Age
Ra
te
SB (1559)
NND (830)
PNND (385)
1 Rates per 1000 women who delivered 2007-2011 per age group.
2 Excludes records where age was unknown.
Source: Survey and NRS (Table 3.14: Live Births, Stillbirths and Maternities, 2008-2011, Table 3.11, 2007).
Table 6 (a, b and c) shows sociodemographic information for the mothers who experienced a stillbirth or infant death in 2011 and for all women giving birth in Scotland. Information on deprivation is known for most cases of stillbirth and infant death as the postal code is almost always recorded. Body mass index (BMI) and smoking data were less complete but the new data collection form has increased the proportion of births where this is known. The BMI is not requested for post-neonatal deaths but is for all other categories of death (611 cases) among whom the BMI was recorded for 528 (86.4%) mothers. The smoking status of the mothers of 580 of the 689 deaths (84.2%) was reported. This is the third year in which this sociodemographic information has been recorded. In 2011 there is an association between a stillbirth and infant death and each of the known risk factors (deprivation, smoking and a raised BMI).
22
Tables 6a, b, c Percentage rates of mother's Scottish index of multiple deprivation (SIMD), body mass index, smoking status maternities1, stillbirths and infant deaths: 2011
Table 6a Mother's SIMD6 (percentages)
1 - Most deprived 2 3 4
5 - Least deprived
All mothers1 (56843) 26.3 21.3 19.0 17.6 15.8
Stillbirths (297) 32.0 23.6 17.5 16.2 10.8
Infant deaths5 (233) 36.1 22.7 20.2 9.9 11.2
Table 6b Mother's BMI2 (percentages)
Under-weight Normal
Over-weight Obese
All mothers1 (54515) 11.1 43.7 24.5 20.7
Stillbirths (272) 1.1 40.1 31.6 27.2
Infant deaths3 (120) 1.7 40.0 28.3 30.0
Table 6c Mother's smoking status4 (percentages)
Current smoker
Former / never
smoked
All mothers1 (54432) 20.3 79.7
Stillbirths (272) 29.8 70.2
Infant deaths5 (169) 31.4 68.6
1 Women delivering between April 2010 and March 2011. 2 WHO Classification: Underweight <18.50; Normal range 18.50-24.99; Overweight 25.00-29.99; Obese ≥ 30.00. 3 Only available for early and late neonatal deaths; excludes post-neonatal deaths. 4 SMR02 data is taken from Smoking history at booking. 5 Includes PNND records. 6 Scottish Index of Multiple Deprivation (SIMD) 2009. Source: Survey, SMR02.
23
7 Additional Information Collected in 2011
The data collection form, newly devised for use in 2011, resulted in the collection of a great deal more information about each death than has been available in previous years. It also reduced the need to link data with SMR02 returns. Appendix 12.1 provides a detailed summary of that additional information. The features of most interest are briefly described here with further discussion in the commentary. Some of these features could usefully be compared with the same information for all births in Scotland though the same level of detail is not always available.
Among all deaths, 2.5% of women reported any alcohol consumption at booking as compared to 3.7% of women in the Scottish population in 2011 who admitted to drinking during pregnancy7.
Substance misuse (not including alcohol) was reported in 6.5% of all women in the survey compared to 1.6% recorded in SMR02 during 2009/108.
Medicinal drug use of any kind was reported in just under one quarter of all women experiencing a stillbirth. Antidepressants and bronchodilators were the most frequently reported.
Twenty seven percent of women who experienced a stillbirth, neonatal death or late fetal death had a medical (including psychiatric) disorder. Psychiatric disorders were the most frequent.
Whilst 63.2% of the pregnant population in Scotland had booked by 12 weeks gestation (SMR02 data for 2010/11), 68.8% of those who experienced a stillbirth, 77.5% of neonatal and 79.1% of late fetal deaths were booked for pregnancy care before 12 weeks gestation.
Of those who experienced a stillbirth, 49.4% were booked for consultant obstetric delivered antenatal care. 61.3% received some consultant obstetrician care antenatally.
Among stillbirths, birth was planned at a consultant unit at booking for 87% births, and at the onset of labour for 94% of births; 92% actually took place in a consultant unit. 4% of stillbirths occurred at home.
Intra-uterine transfers (before delivery) took place among 1.4% of stillbirths, 16% of early neonatal deaths and 4.5% of late neonatal deaths. A further 8.7% of early neonatal deaths and 32.6% of late neonatal deaths were transferred to other units after birth.
Most stillbirths underwent an induced labour and vaginal delivery. Most neonatal deaths experienced either a spontaneous labour or elective caesarean section. 39% of early neonatal deaths and 49% of late neonatal deaths were delivered by caesarean section. In Scotland, for the year ending 31st March 2011, 22.6% of live births were induced and 27.9% were delivered by caesarean section9.
24
The importance of a precise definition of “intrapartum death” was confirmed. Although 9.6% of stillbirths were reported as such, when the definition was tightened to “alive at the onset of professional care in labour”, the percentage fell to 7.2%.
In 2011, stillbirths were no more frequent than expected at weekends and neonatal deaths were less frequent. Birth at night was also not a risk factor, an increased rate of stillbirths and of neonatal deaths in the evening probably being related to daytime inductions and life support management decisions.
The great majority of deaths were offered a postmortem examination (99% of stillbirths) and in 75% of cases this was by a consultant obstetrician or neonatologist. The rate of authorised postmortems varied from 30% of late neonatal deaths to 61% of stillbirths. Eighty three percent of authorised postmortem examinations performed on post-neonatal deaths were at the instruction of the Procurator Fiscal.
The placenta was examined histologically in 97% of stillbirths and 92% of late fetal deaths.
25
8 Congenital Anomalies
The annual SPIMMR has, for a number of years, reported data on selected congenital anomalies among pregnancies terminated as a consequence of prenatal diagnosis, stillbirths and live births up to one year of age. Information on birth prevalences among singleton pregnancies of neural tube defects, cardiovascular anomalies, orofacial clefts, and trisomies 13, 18 and 21 is presented in Tables A22 and A23a, with the addition of terminated pregnancies in Table A23b. As it takes considerably longer to gather this anomaly data than mortality data, the information is always one year behind the rest of the report and includes the five years up to 2010. Much of the data relating to congenital anomalies are derived using record linkage techniques. These techniques link the data which relate to the same individual on different datasets. For example, to find out the number of babies born alive with spina bifida, the data on the Scottish Birth Record, which describes problems identified with the baby, is joined with data from hospital admissions in the first year of life. This linked file is then searched for individuals who have a record on either or both databases which suggests spina bifida. Such an approach is necessary because there are inevitably some babies where the relevant diagnosis has not been recorded properly on one or other of these two databases. It is not straightforward to link individuals across different datasets and it can be particularly problematic with babies because they may not have a first name whilst in hospital and their surname may not be the same as the mother's surname, and it may change. ISD has been modifying the way that record linkage is performed and has recently implemented a technique which relies more heavily on the use of Community Health Index (CHI) numbers and less heavily on the previous approach of probability matching. Inevitably, this has changed the number of individuals identified with various conditions. The new approach has been used for all the congenital anomaly rates shown in the tables of this report. There has, therefore, been some revision of the numbers and rates reported for previous years. The difference between the rates in Tables A23a and A23b appears to reflect the effect of prenatal screening, particularly for neural tube defects and chromosomal anomalies. The rates of neural tube defects reported at birth are consistently about half of the total rate reported when terminated pregnancies are included (0.56 per 1000 births and 1.05 per 1000 births respectively in 2010). The reduction in births with Down's syndrome is about a third (0.92 per 1000 at birth and 1.34 per 1000 including terminated pregnancies). Spontaneous miscarriages (which probably occur frequently when anomalies are present) are not included in these data. The most common congenital anomalies are those of the heart and circulatory system. Many of these anomalies may not be detected antenatally and/or may be of minor significance and are not incompatible with normal life. There are, therefore, very few pregnancies terminated for anomalies in this group.
26
9 NHS Board Statistics
9.1 Stillbirths and Neonatal Deaths
Much of the information presented for all deaths in Scotland included in this report is shown by individual NHS board in Tables A24 - A27. The relatively small numbers of stillbirths and neonatal deaths in one year in individual NHS board areas (especially in the smaller NHS boards) mean that variations from year to year are heavily influenced by the effect of chance and are therefore generally not statistically significant. This effect is mitigated to some extent by aggregating years and Figures 9.1a and 9.1b show the stillbirth and neonatal mortality rates for individual NHS boards based on aggregated data for the past five years. Funnel plots showing standard deviations from the mean make allowance for small populations and allow ready recognition of outliers. There are variations in practice among NHS boards over the registration of very preterm births and in order to take this into account, only neonatal deaths born at 24 weeks gestation or more are shown in Figure 9.1b. The neonatal mortality rates (excluding deaths of babies born before 24 weeks gestation) for all NHS boards are within 3 standard deviations of the mean and differences are, therefore, likely to be largely the effect of random variation because of small numbers. As in 2010, the rate of stillbirths in Fife is more than 2 standard deviations above the mean but the rate in 2011 fell to 5.6 per 1000 births, much closer to the Scottish rate of 5.1. The persisting high rate when aggregated over five years remains because of the relatively high rates in 2008 and 2010. Similarly, the rate of stillbirths in Greater Glasgow and Clyde is also more than 2 standard deviations above the mean after a relatively high rate (6.6) in 2011. As well as small numbers resulting in fluctuating rates from year to year in individual NHS Boards, variations in reproductive outcomes are also likely to be related to population differences with areas of greater socio-economic deprivation experiencing higher mortality rates.
27
Figure 9.1a Stillbirth rates1 by NHS board of residence2: 2007 - 2011
Western Isles
Greater Glasgow &
Clyde
Grampian
Lanarkshire
LothianForth Valley
Shetland
A & AOrkney
Dumfries & Galloway
Highland
Fife
TaysideBorders
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
0 2000 4000 6000 8000 10000 12000 14000
Number of births
Rate
per
1000 b
irth
s
Data
Average
2SD limits
3SD limits
1 Rate per 1000 births. 2 Records that could not be aligned to an NHS board via their postcode have been assigned to the board of the hospital of occurrence. Source: NRS and Survey
28
Figure 9.1b Neonatal mortality rates1 by NHS board of residence2: 2007 - 20113
Western Isles
Greater Glasgow &
Clyde
Grampian
Lanarkshire Lothian
Ayrshire & Arran
Shetland
Forth ValleyOrkney
Dumfries & Galloway
Highland
Fife
Tayside
Borders
1.0
1.5
2.0
2.5
3.0
0 2000 4000 6000 8000 10000 12000 14000
Number of live births
Rate
per
1000 l
ive b
irth
s
Data
Average
2SD limits
3SD limits
1 Rate per 1000 live births. 2 Six NND could not be allocated to an NHS board. 3 Excludes any neonatal deaths below 24 weeks gestation Source: NRS and Survey
29
9.2 Extended Mortality Rates and Causes of Death
All of the deaths in different NHS board areas described in this report (late fetal deaths, stillbirths, neonatal deaths and post-neonatal deaths) are summarised in Tables A27a and b which provide an overview of all reproductive losses from mid-pregnancy to the end of the first year of life. For Scotland as a whole, the extended perinatal mortality rate was 11.7 per 1000 total births including late fetal deaths (95% CI, 10.81, 12.58). This is similar to recent years but is not entirely accurate because of the variable reporting of late fetal losses. The stillbirth, neonatal death and post-neonatal death rates for each NHS board are summarised graphically in Figure 9.2. The aim of combining rates in this way is to eliminate any variations among NHS boards caused by misclassification or by deferring death from one time period to another. Late fetal deaths have been excluded from Figure 9.2.
Figure 9.2 Stillbirth, neonatal and post-neonatal mortality rates by NHS board of residence: 2011
0 2 4 6 8 10 12 14
Western Isles
Tayside
Shetland
Orkney
Lothian
Lanarkshire
Highland
Greater Glasgow & Clyde
Grampian
Forth Valley
Fife
Dumfries & Galloway
Borders
Ayrshire & Arran
Scotland
NH
S b
oa
rd o
f re
sid
en
ce
Rates
Stillbirth NND PNND
9.1
12.8
11.0
8.1
3.6
9.6
8.5
7.2
10.6
10.0
8.3
8.7
0.0
12.2
9.1
Source: NRS and Survey
Because of the small numbers of deaths experienced within each NHS board, more detailed analysis in this report is not appropriate.
30
9.3 Congenital Anomalies The information on the selected congenital anomalies in Scotland discussed in Section 8 is shown by NHS boards for five years aggregated (2006 - 2010) in Tables A30, and rates are charted graphically for neural tube defects, Down's syndrome and heart and circulatory system anomalies in Figures A29. There is no evidence of a significant variation in rates among NHS boards for neural tube defects. NHS Lothian has a rate of Down’s syndrome more than 2 standard deviations above the mean for Scotland and there is marked variation among NHS boards in the prevalence of anomalies of the heart and circulatory system. It is beyond the remit of this report to speculate on the reasons for these variations but the establishment of a national congenital anomaly audit might provide valuable evidence to explain the differences. Table 9.3 summarises the results of prenatal screening by each NHS board. Each NHS board area shows similar reductions in the incidence of neural tube defects and Down’s syndrome at birth with very few pregnancies terminated for cardiovascular disorders. Few babies are stillborn or die as neonates with the latter disorders (Tables A4 and A5) indicating that most are not of major clinical significance.
Table 9.3 Rates of selected fetal anomalies among singletons with congenital anomalies by NHS board of residence: 2006 - 2010
NHS board of residence
Neural Tube defects
Down’s Syndrome
Cardiac anomalies
1* 2** 1* 2** 1* 2**
Scotland 1.02 0.53 1.67 1.10 9.42 9.31
Ayrshire and Arran 1.34 0.70 1.39 1.23 10.98 10.87
Borders 1.14 0.38 1.14 0.76 5.52 5.33
Dumfries and Galloway 1.98 1.13 1.84 0.57 6.23 6.09
Fife 1.35 0.55 1.90 0.95 6.60 6.40
Forth Valley 0.88 0.69 0.63 0.63 6.30 6.30
Grampian 1.20 0.55 2.20 0.93 12.05 11.74
Greater Glasgow and Clyde 0.64 0.48 1.26 1.05 7.22 7.18
Highland 1.41 0.67 2.22 1.75 18.41 18.41
Lanarkshire 0.95 0.62 1.31 1.05 8.21 8.18
Lothian 0.90 0.36 2.24 1.50 12.34 12.27
Orkney 1.04 0.00 2.09 2.09 8.34 7.30
Shetland 0.00 0.00 4.90 1.63 15.52 15.52
Tayside 1.33 0.46 1.79 0.77 7.45 7.09
Western Isles 0.85 0.00 1.71 0.85 5.98 5.98 1* Rate per 1000 births of anomaly diagnosed prenatally with subsequent termination plus stillbirths plus live births up to one year of age. 2** Rate per 1000 births of the specified anomaly (ie excluding unregistered pre-viable births). Source: ISD Scottish Congenital Anomalies Register (linked SMR01, SMR02, SMR11, SBR and SSBID records)
31
10 Commentary
The lowest perinatal mortality rate in Scotland’s history was achieved in 2010 and was equalled in 2011. A slight rise in the rate of stillbirths to 5.1 per 1000 births in 2011 from 4.9 in 2010 was balanced by a further decline in early neonatal deaths, creating a perinatal mortality rate of 6.9 per 1000 births. The rate of all deaths other than early neonatal deaths rose slightly in 2011 but remained below the levels of all recent years and below the rates for England and Wales reported by the Office for National Statistics in 20113. Interest in reducing the rates of stillbirth in the United Kingdom has increased with petitions from SANDS10 to all of the UK governments and a high profile publication in the Lancet11
. A recent paper has identified the maternal and fetal risk factors for stillbirth, demonstrating the importance of sociodemographic factors and the high prevalence of IUGR among stillbirths12. The introduction in Scotland of improved and more comprehensive data collection about each death and of a revised classification system reflecting modern understanding is, therefore, timely. Sociodemographic data has only been collected for the annual SPIMMR since 2009 and has not always been very complete. The new data collection form has, however, improved this considerably and the important contribution of maternal age, smoking, obesity and deprivation to stillbirths and to neonatal and infant deaths is confirmed in the data for 2011. Although IUGR was only classified as the main cause of death in a small number of stillbirths, over 40% of stillbirths in Scotland in 2011 did have some degree of growth restriction. Similarly, Gardosi et al12 found IUGR to be the single factor most commonly associated with stillbirth. It can be argued that IUGR is a manifestation of other primary pathology and it is known that healthy placental development and function is essential for healthy fetal development. Up until 2011, the Scottish classification system for stillbirths and neonatal deaths did not include placental conditions. Its inclusion now shows placental pathology as the primary cause of death in 38% of singleton stillbirths. Placental infarction, deficient villus maturation and fetal thrombotic vasculopathy were the most frequently identified conditions. The importance of histological examination of the placenta of all stillbirths is clear and in 2011, this examination was carried out in at least 95% of stillbirths and similar proportions of late fetal deaths and early neonatal deaths. The inclusion of placental conditions together with other modernisations in the new classification system of the causes of death has meant that the proportion of deaths classified as “unexplained” fell from 64% for singleton stillbirths in 2010 to under 10% in 2011. Those now classified as “unexplained” (or, more appropriately, “no associated obstetric factors”) can now be considered genuine rather than a consequence of an inadequate classification system. Despite the improved data collection system, it remains difficult to collect adequate information on all deaths either because no data collection form was submitted or the form was inadequately completed. It was impossible to assign any obstetric cause of death because of inadequate information in 8% of singleton stillbirths and 9% of singleton neonatal deaths. The problem was much less common when a multiple pregnancy was involved. This proportion of cases with inadequate information is despite the work of Reproductive Health Programme staff to encourage complete data submission. The future collection of data on a web-based UK system should be carefully monitored.
32
In addition to improving the classification of causes of death, useful new information on all deaths was collected in 2011. This information will only be collected for one more year (2012), after which Scotland will become part of the UK MBBRACE system. With two years of data, however, it is hoped to compare some of the findings among deaths with other births in Scotland and it is proposed that this is done as part of the 2012 SPIMMR report. Particular features which would be worthy of comparison include the following, if available in the general reproductive population:
Alcohol and substance misuse
Medicinal drug use
Medical disorders (including psychiatric)
Gestation of pregnancy at booking and nature of antenatal care
Two particularly valuable features emerged as a result of the additional information collected in 2011. Firstly, there was confirmation of the value of a more precise definition of “intrapartum death”. By defining this as “baby alive at the onset of professional care in labour”, uncertain cases are excluded and it is possible to concentrate on such cases which may well be potentially avoidable. Secondly, and at a time when evidence is emerging of higher death rates in hospital out of hours and at weekends, it is gratifying to see that this did not apply to stillbirths and neonatal deaths in Scotland which occurred during 2011.
33
11 References
1. NHS National Services Scotland and NHS Quality Improvement Scotland. Trends in perinatal mortality in Scotland - a review over 30 years [online]. 2009 [cited 2012 Jan 9]; Available from http://www.healthcareimprovementscotland.org/his/idoc.ashx?docid=b6c375e3-f074-4fcc-bae6-25e6221ac2ea&version=-1
2. General Register Office for Scotland. Births, deaths and other vital events – quarterly
figures [online]. 2011 [cited 2012 Jan 16]; Available from: http://www.gro-scotland.gov.uk/statistics/theme/vital-events/general/bmd-quarterly/index.html
3. Office of National Statistics. Births and deaths in England and Wales, 2011. 2011 [cited
2013 Jan 20]; Available from http://www.ons.gov.uk/ons/rel/vsob1/birth-summary-tables--england-and-wales/2011/births-and-deaths-in-england-and-wales--2010-statistical-bulletin.pdf
4. FIGO. Standing committee on perinatal mortality and morbidity. Report of committee
following a workshop on monitoring and reporting perinatal mortality and morbidity. London: Chameleon Press Ltd; 1982. p12.
5. Cole SK, Hey EN, Thomson AM. Classifying perinatal death: an obstetric approach. Brit
J Obstet Gynaecol. 1986; 93: 1204-12. 6. Hey EN, Lloyd DJ, Wigglesworth JS. Classifying perinatal death: fetal and neonatal
factors. Brit J Obstet Gynaecol. 1986; 93: 1213-23.
7. Matheson M. Scottish Parliamentary Question S4W-10299: John Mason, Glasgow Shettleston, Scottish National Party, date lodged: 17/10/2012 [online]. 2012 [cited 2013 Mar 21]; Available from: http://www.scottish.parliament.uk/parliamentarybusiness/28877.aspx?SearchType=Advance&ReferenceNumbers=S4W-10299&ResultsPerPage=10 .
8. ISD Scotland. Data quality assurance: assessment of maternity data 2008-2009. 2010
[cited 20113 Mar 21]; http://www.isdscotlandarchive.scot.nhs.uk/isd/files//DQA-Assessment-of-Maternity-Data-SMR02-2008-to-2009.pdf.
9. ISD Scotland. Live births by mode of delivery and induced: year ending 31 March. 2012
[cited 2013 Mar 21]; Available from: http://www.isdscotland.org/Health-Topics/Maternity-and-Births/Publications/2012-11-27/mat_bb_table4.xls?7491702#'Scotland (1976-2011)'!A1
10. MacDowel T. Scottish Parliament petition 1291: why 17? campaign: saving babies’ lives
in Scotland. 2009 [cited 2012 Jan 9]; Available from http://archive.scottish.parliament.uk/business/petitions/docs//PE1291.htm
11. The Lancet stillbirths series [Online]. c2011 [cited 2013 Mar 21]. Available from:
http://www.thelancet.com/series/stillbirth
34
12. Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. BMJ2013;346:f108
35
12 Appendices
12.1 Detailed summary of new information collected in 2011
This appendix details, in a summarised form, new information obtained from the revised Scottish Stillbirth and Infant Death Survey (SSBIDS) data collection form first used for deaths occurring in 2011. Full detailed tables are available from Healthcare Improvement Scotland on request. The results are generally expressed as percentages of those deaths for which the information was available. Although there was a high level of completion of forms, not all questions were answered for every case and the relevant information was sometimes either not applicable or unknown. For example, the question on ethnicity was answered for 592 of the 689 deaths reported in 2011. The proportion of each ethnic group is therefore expressed as a percentage of 592. In the following results, the number used as a denominator is generally given in brackets. The total number of each category of deaths recorded was: 153 late fetal deaths (LFD) (20-23+6 weeks gestation) 299 stillbirths (SB) 109 early neonatal deaths (ENND) (up to 7 days) 50 late neonatal deaths (LNND) (8-28 days) 78 post-neonatal deaths (PNND) (29 days – 1 year). Depending on the nature of the information, the results are described for all deaths combined or for the different categories of deaths separately with appropriate denominators. 12.1.1 Ethnicity and employment
Ethnicity of mother, all deaths (592): 85.5% British 5.6% other European 4.1% South Asian (India or Pakistan) 4.9% others. Mother’s employment, all deaths (513): 71.3% in employment or education. Father’s employment, all deaths (484): 88.2% in employment or education.
12.1.2 Alcohol consumption and drug misuse
Weekly alcohol consumption prior to pregnancy, all deaths (487): None 48.7% 1-7 units: 32.2% 8-14 units: 13.8% >14 units: 5.3%
36
The proportions were very similar for all categories of deaths. Only 2.4% of 525 women reported any alcohol consumption at the time of booking. Substance misuse, other than alcohol, was reported for 6.5% of 603 women with no obvious differences between categories of death.
12.1.3 Medicinal drug use for those who experienced stillbirths 230 women (76.9%) reported no drug use (other than supplements or folic acid) in pregnancy. The following categories of medicine were reported: Antidepressants (taken by 8 women) Bronchodilators (8) Antihypertensives (5) Analgesics (5) Gastro-intestinal agents (5) Anticoagulants (4) Steroids (4) Insulin (4) Iron (3) Thyroid medication (3) Anti-emetics (2) Oral hypoglycaemics (2) Methadone (2) Migraine medication (2) Anticonvulsants (1) Progestogen (1) Nicotine patches (1)
12.1.4 Non obstetric disorders (medical or psychiatric) Information was available about specified non obstetric disorders (including medical and psychiatric) for 524 women who experienced a stillbirth, neonatal death or late fetal death. Of those women, 26.7% reported a specified non obstetric disorder. There was a similar distribution of disorders for all categories of death. Psychiatric disorders were substantially the most frequently reported affecting 8.6% of these women.
12.1.5 Previous pregnancy losses
Table 12.1.5 Percentage of previous pregnancy losses: 2011
Category of death1
Previous miscarriage
(%)
Previous termination
of pregnancy (%)
Previous stillbirth
(%)
Previous neonatal death (%)
Stillbirth 22.1 12.1 1.8 0.4
Neonatal death 28.7 8.9 3.8 1.0
Late fetal death 31.3 12.8 2.4 0.8 1 Depending on the category and previous loss, information available was for the following numbers of cases: stillbirths 222 – 263, neonatal deaths 105 – 129, late fetal deaths 120 – 147. Source: Survey
37
12.1.6 Booking for confinement, antenatal care and planning
Table 12.1.6a Percentage booking by end of 12th and 20th week of gestation: 2011
Category of death
Booking ≤ 12 weeks gestation
(%)
Booking ≤ 20 weeks gestation
(%)
Stillbirths (266) 68.8 95.1
Early NND (84) 77.4 95.2
Late NND (27) 77.8 96.3
Late fetal deaths (134) 79.1 98.5
Scotland1 63.2 -
1 Women delivering in Scotland 2010/11. Source: Survey, SMR02
Table 12.1.6b Percentage booking by type of antenatal care: 2011
Category of death1
Booked for consultant led antenatal care
(%)
Booked for midwife led
antenatal care (%)
Received some antenatal care
from consultant1
(%)
Stillbirths (267) 49.4 50.6 65.6
Early NND (87) 58.6 41.4 84.9
Late NND (32) 78.1 21.9 90.3
Late fetal deaths (140) 50.7 49.3 69.3 1 Denominators for this column were 279 for stillbirths, 93 for early NNDs, 31 for late NNDs and 140 for late fetal deaths.
Birth planned at consultant unit: Stillbirths (275): 87.3% Early neonatal deaths (99): 92.9% Late neonatal deaths (44): 97.7% Late fetal deaths (146): 92.5% Elective caesarean section planned: Stillbirths (283): 7.4% Early neonatal deaths (99): 11.1% Late neonatal deaths (42): 19% Late fetal deaths (149): 6.2% Intra-uterine transfers: Stillbirths (283): 1.4% Early neonatal deaths (100): 16% Late neonatal deaths (44): 4.6% Late fetal deaths (149): 3.4%
38
12.1.7 Labour
Table 12.1.7 Percentage of deaths by type of labour: 2011
Category of death Spontaneous
(%) Induced
(%) No labour
(%)
Stillbirths (286) 24.5 62.2 13.3
Early NND (98) 62.2 13.2 24.5
Late NND (44) 54.5 15.9 29.5
Late fetal deaths (146) 39.7 57.5 2.7 Source: Survey
Planned place of delivery at onset of labour The proportion of each category of death with delivery planned at a consultant unit at the onset of labour was as follows:
Stillbirths (279): 93.9%
Early neonatal deaths (100): 96.0%
Late neonatal deaths (44): 97.7%
Late fetal deaths (148): 95.3%
12.1.8 Delivery
Table 12.1.8a Place of birth for each category of death: 2011
Category of death
Consultant obstetric unit
(%)
Alongside midwifery unit1 (%)
Freestanding midwifery unit2
(%) Home
(%)
Stillbirths (290) 92.1 2.8 0.3 4.1
Early NND (102) 90.2 2.9 2.0 3.9
Late NND (44) 97.7 2.3 0.0 0.0
Late fetal deaths (151) 96.0 3.3 0.7 0.0 1 Midwifery unit at same location as consultant unit. 2 Midwifery unit at location independent from consultant unit. Source: Survey
Table 12.1.8b Mode of delivery for each category of death: 2011
Category of death
Spontaneous vertex
(%)
Prelabour caesarean section (%)
Labour caesarean section (%)
Stillbirths (285) 67.0 11.9 3.5
Early NND (99) 43.4 23.2 16.2
Late NND (43) 41.9 30.2 18.6
Late fetal deaths (138) 85.5 0.0 0.7 Source: Survey
39
Urgent caesarean sections Percentage of caesarean section deliveries classified as urgent or emergency (number of caesarean sections in brackets): Stillbirths (44): 63.6% Early NNDs (39): 84.6% Late NNDs (20): 90%
Table 12.1.8c Percentage of breech presentations at delivery and vaginal breech deliveries: 2011
Category of death1
Breech presentation at
delivery (%)
Vaginal breech
delivery (%)
Stillbirths 21.5 13.0
Early NND 30.8 10.1
Late NND 35.1 7.0
Late fetal deaths 24.2 13.8² 1 Denominators (cases with information available) for each column were: SB - 274 and 285; ENND - 91 and 99; LNND - 37 and 43; LFD - 128 and 138 2 Only one caesarean section was reported among late fetal deaths, so recording was poor. Source: Survey
Figure 12.1.8d Percentage distribution of time of birth1 for stillbirth, early and late neonatal death and late fetal deaths: 2011
0
5
10
15
20
25
30
35
40
45
50
SB (294) ENND (100) LNND (41) LFD (142)
Pe
rce
nta
ge
00:00 - 07:59
08:00 - 15:59
16:00 - 23:59
1 Excludes records where time of birth was missing.
Source: Survey
40
Birth at the weekend Figure 12.1.8e Percentage of each category of death occurring at a weekend (Saturday or Sunday), compared to expected 29% if deaths evenly distributed throughout the week: 2011
0
5
10
15
20
25
30
35
Expected SB (299) ENND (109) LNND (50) LFD (153)
Pe
rce
nta
ge
Source: Survey
12.1.9 Terminations of pregnancy
Percentage of each category of death recorded as a termination of pregnancy: Stillbirths (284): 6.0% Early NNDs (100): 4.0% Late fetal deaths (149): 39.6%
12.1.10 Multiple pregnancies Most information about multiple pregnancies is included earlier in this report and in Appendix 12.2. Additional information is as follows: “Lost” twins 23 pregnancies with a stillbirth were identified as multiple early in the pregnancy but only 22 of these pregnancies delivered as multiples. Three pregnancies with a fetus papyraceous were reported, two were registered as stillbirths and one was a late fetal death. The loss of one twin at an early stage of the pregnancy was also reported among one early NND. Birth order Twins 1 and 2 were at equal risk. Among all categories of death, 34 were twin 1 and 35 twin 2. Chorionicity Among all deaths, 38 multiple pregnancies were dichorionic, diamniotic, 23 were monochorionic, diamniotic and 3 monochorionic, monoamniotic.
41
12.1.11 Intrapartum deaths 25 of 260 stillbirths (9.6%) were reported as “intrapartum deaths” but only 20 of 278 stillbirths (7.2%) were reported as “alive at the onset of professional care in labour”. 8 of 92 early NNDs (8.7%) were attributed to “intrapartum asphyxia”; no late NNDs were so attributed, making an overall rate of 5.9% of neonatal deaths due to intrapartum asphyxia.
12.1.12 Neonatal deaths
Table 12.1.12a Apgar scores for neonatal deaths (percentage): 2011
Apgar score
At 1 minute At 5 minutes At 10 minutes
Early NND
Late NND
Early NND
Late NND
Early NND
Late NND
0 - 3 44 11 32 4 17 3
4 - 7 20 13 27 10 17 6
8 - 10 17 14 20 23 15 9
Total known 81 38 79 37 49 18
Source: Survey
Cord blood gases Among early neonatal deaths, cord blood was reported as not taken in 50 cases (61.7% of 81 with the information). The arterial pH was reported for 26 cases and was <7.2 in 15 (57.7%); the venous pH was reported for 21 cases and was <7.2 in 7 (33.3%). The equivalent reported figures for late NNDs were: Not taken: 18 (64.3% of 28) Arterial pH <7.2: 4 out of 12 (33.3%) Venous pH <7.2: 1 out of 13 (7.7%) Transfers after birth Early NNDs (92): 8.7% Late NNDs (43): 32.6%
42
Figure 12.1.12b Percentage distribution of time of death for early and late neonatal deaths1: 2011
0
5
10
15
20
25
30
35
40
45
00:00 - 07:59 08:00 - 15:59 16:00 - 23:59
Time
Pe
rce
nta
ge
ENND (108)
LNND (50)
1 Excludes records where time of birth was missing. Source: Survey
Figure 12.1.12c Percentage of neonatal deaths occurring at a weekend compared to expected 29% if deaths evenly distributed throughout the week: 2011
0
5
10
15
20
25
30
35
Expected ENND (109) LNND (50)
Pe
rce
nta
ge
Source: Survey
43
12.1.13 Postmortem (PM) examinations
Table 12.1.13 Postmortem (PM) examinations: 2011
Category of death PM offered
(%)
PM authorised
(%)
Full PM authorised1
(%)
PM report sent to
RHP2,1 (%)
Stillbirths (284) 98.9 60.6 89.5 95.9
Early NND (97) 93.8 52.6 78.4 90.2
Late NND (41) 90.2 29.3 83.3 100.0
Late fetal deaths (148) 99.3 60.7 91.0 94.4 1 Percentage is of all PMs authorised. 2 Reproductive Health Programme of Healthcare Improvement Scotland. Source: Survey
Staff offering PM (541 of all stillbirths, NNDs and late fetal deaths combined) Consultant obstetrician or neonatologist: 75.2% Other trained medical staff (associate specialist or staff grade): 1.5% Senior trainee doctor (ST3 or above): 15.0% Junior trainee doctor (below ST3): 0.2% Midwife: 6.8% Other: 1.3% PM examination by Procurator Fiscal Stillbirths, NNDs and late fetal deaths (564): 3.2% Post-neonatal deaths (44): 47.7%
12.1.14 Histological examination of placenta completed Stillbirths (279)1: 97.1% Early NNDs (90): 92.2% Late NNDs (31): 61.3% Late fetal deaths (153): 91.5% 1 The relevant question was completed for 271 stillbirths but the RHP received evidence that 286 placentas (95.7% of all stillbirths) were examined histologically. A copy of the pathology report was seen by the RHP for 237 stillbirths.
44
12.2 Appendix tables and figures
Table A1 FIGO tabulation: 2007 – 2011 2007 2008
1 2009
1 2010
1 2011
1
Registered Births 58108 6035
4 59351 5908
2 58884
Less than 500g
Total 62 32 49 34 37
Stillbirths 37 21 37 28 28
ENN Deaths 24 11 12 6 8
LNN Deaths 1 - - - 1
500g or over
Total births 58046 6032
2 59302 5904
8 58847
Stillbirths 288 304 279 262 270
ENN Deaths 102 95 92 99 92
LNN Deaths 58 44 45 30 48
of which with lethal malformations
Total births 63 75 79 60 74
Stillbirths 21 34 39 28 35
ENN Deaths 30 31 26 27 25
LNN Deaths 12 10 14 5 14
1000g or over
Total births 57803 6006
2 59089 5881
4 58623
Stillbirths 220 239 212 189 203
ENN Deaths 59 59 65 56 61
LNN Deaths 34 34 27 18 26
of which with lethal malformations
Total births 49 62 61 47 57
Stillbirths 11 25 24 16 22
ENN Deaths 26 28 23 26 22
LNN Deaths 12 9 14 5 13
Rates 95% CI
Excluding all births <500g
Major Malformation rate 1.09 1.24 1.33 1.02 1.26 0.99-1.58
Stillbirth rate 4.96 5.04 4.70 4.44 4.59 4.06-5.17
Neonatal rate 2.77 2.32 2.32 2.19 2.39 2.01-2.82
Perinatal rate 6.72 6.61 6.26 6.11 6.15 5.53-6.82
Excluding all major malformations and other births <500g
Stillbirth rate 4.6 4.48 4.05 3.97 4.00 3.5-4.54
Neonatal rate 2.04 1.63 1.64 1.65 1.73 1.41-2.1
Perinatal rate 5.85 5.54 5.17 5.19 5.14 4.58-5.75
Excluding all births <1000g
Stillbirth rate 3.81 3.98 3.59 3.21 3.46 3-3.97
Neonatal rate 1.62 1.55 1.56 1.26 1.49 1.19-1.84
Perinatal rate 4.83 4.96 4.69 4.17 4.50 3.98-5.08
Excluding all major malformations and other births <1000g
Stillbirth rate 3.62 3.57 3.18 2.94 3.09 2.66-3.58
Neonatal rate 0.96 0.94 0.93 0.73 0.89 0.67-1.17
Perinatal rate 4.19 4.08 3.90 3.45 3.76 3.28-4.29 1 Excludes any births < 22 wks gestation and unknown birthweight. Source: Survey, SMR02, NRS
45
Table A2 Registered singleton and multiple pregnancies: 2007 – 2011
2007 2008 2009 2010 2011
Singleton pregnancies 56309 58433 57473 57208 57155
Twin pregnancies 882 953 922 919 852
Triplet pregnancies 9 9 14 12 10
Quadruplet pregnancies 2 - 1 - -
Quintuplet pregnancies - - - - -
Twinning rate1 15.4 16.0 15.8 15.8 14.7 1 Rate per 1000 pregnancies resulting in registered births. Source: NRS
Table A3 Stillbirth and neonatal deaths for singleton and multiple births: 2007 - 2011
2007 2008 2009 2010 2011
Total Births 58108 60366 59363 59082 58889
Singleton 56303 58427 57471 57204 57153
Multiple 1805 1939 1892 1878 1736
Stillbirths 327 325 317 291 299
Singleton 298 298 293 265 277
Multiple 29 27 24 26 22
Neonatal deaths 188 168 165 150 159
Singleton 156 137 133 124 133
Multiple 32 31 32 26 26
Rates
Stillbirth mortality rate 1 5.6 5.4 5.3 4.9 5.1
Singleton 5.3 5.1 5.1 4.6 4.8
Multiple 16.1 13.9 12.7 13.8 12.7
Neonatal mortality rate 2 3.3 2.8 2.8 2.6 2.7
Singleton 2.8 2.4 2.3 2.1 2.3
Multiple 18.0 16.2 17.1 14.0 15.2 1 Rate per 1000 singleton or multiple total births. 2 Rate per 1000 singleton or multiple live births. Source: NRS, Survey
46
Table A4 Obstetric causes of death for singleton stillbirths and neonatal deaths: 2011 Cause of death Stillbirth Early NND Late NND
Total 277 93 40
Major congenital anomaly 34 25 13
Central nervous system 7 3 -
Cardiovascular system 6 6 5
Respiratory system - 2 -
Gastro-intestinal system 1 1 1
Musculo-skeletal system 5 3 5
Multiple anomalies 6 2 1
Chromosomal disorders 9 5 1
Metabolic diseases - 1 -
Urinary tract - 2 -
Hypertensive disorders of pregnancy 6 1 3
Pregnancy induced hypertension - - 1
Pre-eclampsia 6 1 1
HELLP syndrome - - 1
Eclampsia - - -
Antepartum or intrapartum haemorrhage 41 9 1
Placenta praevia 1 - -
Placental abruption 36 7 1
AP/IP haemorrhage - other 4 2 -
Mechanical 12 3 -
Prolapse cord 1 1 -
Cord around neck 2 - -
Other cord entanglement or knot 6 - -
Uterine rupture before labour 1 - -
Shoulder dystocia 2 1 -
Mal-presentation - breech - 1 -
Maternal disorder 6 - -
Pre-existing hypertensive disease 1 - -
Pre-existing diabetes 2 - -
Other endocrine conditions 1 - -
Maternal disorder - other 2 - -
Infection 14 20 6
Maternal infection - viral - - 1
Ascending infection - chorioamnionitis 14 20 5
Specific fetal conditions 2 3 1
Twin-twin transfusion - - -
Feto-maternal haemorrhage 1 - -
Non immune hydrops 1 2 -
Iso-immunisation - - 1
Fetal condition - other - 1 -
Specific placental conditions 106 4 4
Placental infarction 48 2 2
Massive perivillous fibrin deposition 3 - -
Deficient placental villus maturation 23 1 -
Chronic villitis 2 - -
Chronic intervillostitis 1 1 1
Fetal thrombotic vasculopathy 20 - 1
Cord hypocoiling 1 - -
Cord hypercoiling 5 - -
Placental condition - other 3 - -
Intra-uterine growth restriction 3 - -
Associated obstetric factors 3 16 2
Intrapartum anoxia 2 6 -
Obstetric factors - other - - -
Oligohydramnios - 1 -
Premature rupture of membranes 1 2 -
Spontaneous premature delivery - 7 2
No antecedent or associated obstetric factors 27 5 5
Unable to classify 23 7 5
Source: Survey
47
Table A5 Neonatal causes of death for singleton neonatal deaths: 2011
Cause of death Early NND
Late NND
Total 95 40
Major congenital anomaly 25 13
Central nervous system 3 -
Cardiovascular system 6 6
Respiratory system 2 -
Gastro-intestinal system 1 1
Musculo-skeletal system 3 4
Multiple anomalies 2 1
Chromosomal disorders 5 1
Metabolic diseases 1 -
Urinary tract 2 -
Extreme immaturity (<24 wks) 16 2
<22 weeks gestation 1 -
22 to 24 weeks gestation 15 2
Respiratory disorders 24 4
Severe pulmonary immaturity 8 -
Surfactant deficiency lung disease 5 1
Pulmonary hypoplasia 7 1
Other (eg pulmonary haemorrhage, pneumonia, iatrogenic) 4 2
Gastro-intestinal disease - 4
Necrotising enterocolitis (NEC) - 4
Neurological disorder 18 4
Hypoxic-ischaemic encephalopathy (HIE) 10 1
Intraventricular / periventricular haemorrhage 8 3
Infection 3 7
Sepsis (generalised) 2 6
Pneumonia 1 -
Meningitis - 1
Injury/Trauma - -
Other specific causes 3 1
Malignancies / tumours 1 -
Specific conditions 2 1
Sudden unexpected death 3 2
Sudden unexpected natural death (includes SIDS) 1 1
Neonatal death - cause not ascertained 2 1
Unable to classify due to lack of information 3 3 Source: Survey
48
Table A6 Obstetric causes of death for multiple stillbirths and neonatal deaths: 2011 Cause of death Stillbirth Early NND Late NND
Total 22 16 10
Major congenital anomaly 4 2 1
Central nervous system - - -
Cardiovascular system - - -
Respiratory system - - -
Gastro-intestinal system - - -
Musculo-skeletal system - - -
Multiple anomalies 1 1 1
Chromosomal disorders 3 1 -
Metabolic diseases - - -
Urinary tract - - -
Hypertensive disorders of pregnancy 2 1 -
Pregnancy induced hypertension - 1 -
Pre-eclampsia 2 - -
HELLP syndrome - - -
Antepartum or intrapartum haemorrhage 5 2 -
Placenta praevia - - -
Placental abruption 3 2 -
AP/IP haemorrhage - other 2 - -
Mechanical 1 - -
Prolapse cord - - -
Cord around neck - - -
Other cord entanglement or knot 1 - -
Uterine rupture before labour - - -
Shoulder dystocia - - -
Mal-presentation - breech - - -
Maternal disorder - - -
Pre-existing hypertensive disease - - -
Pre-existing diabetes - - -
Other endocrine conditions - - -
Maternal disorder - other - - -
Infection 1 3 -
Maternal infection - viral - - -
Ascending infection - chorioamnionitis 1 3 -
Specific fetal conditions 4 2 2
Twin-twin transfusion 4 2 2
Feto-maternal haemorrhage - - -
Non immune hydrops - - -
Iso-immunisation - - -
Fetal condition - other - - -
Specific placental conditions 1 - -
Placental infarction - - -
Massive perivillous fibrin deposition 1 - -
Deficient placental villus maturation - - -
Chronic villitis - - -
Chronic intervillostitis - - -
Fetal thrombotic vasculopathy - - -
Cord hypocoiling - - -
Cord hypercoiling - - -
Placental condition - other - - -
Intra-uterine growth restriction 2 1 -
Associated obstetric factors - 3 6
Intrapartum anoxia - - -
Oligohydramnios - - -
Premature rupture of membranes - - 1
Spontaneous premature delivery - 3 4
Obstetric factors - other - - 1
No antecedent or associated obstetric factors 2 - 1
Unable to classify - 2 -
Source: Survey
49
Table A7 Neonatal causes of death for multiple neonatal deaths: 2011
Cause of death Early NND
Late NND
Total 16 10
Major congenital anomaly 2 1
Central nervous system - -
Cardiovascular system - -
Gastro-intestinal system - -
Musculo-skeletal system - -
Multiple anomalies 1 1
Chromosomal disorders 1 -
Metabolic diseases - -
Urinary tract - -
Extreme immaturity (<24 wks) 6 -
<22 weeks gestation 3 -
22 to 24 weeks gestation 3 -
Respiratory disorders 5 4
Severe pulmonary immaturity 2 3
Surfactant deficiency lung disease - -
Pulmonary hypoplasia 1 -
Other (eg pulmonary haemorrhage, pneumonia, iatrogenic) 2 1
Gastro-intestinal disease - 1
Necrotising enterocolitis (NEC) - 1
Neurological disorder 1 -
Hypoxic-ischaemic encephalopathy (HIE) - -
Intraventricular / periventricular haemorrhage 1 -
Infection 2 3
Sepsis (generalised) 2 3
Pneumonia - -
Meningitis - -
Injury/Trauma - -
Other specific causes - 1
Malignancies / tumours - -
Specific conditions - 1
Sudden unexpected death - -
Sudden unexpected natural death (includes SIDS) - -
Neonatal death - cause not ascertained - -
Unable to classify due to lack of information - - Source: Survey
50
Table A8 Full postmortem (PM) examinations of late fetal deaths, stillbirths and neonatal deaths by hospital: 2011
NHS Board/Hospital of death
LFD SB NND All events
No. % PM No. % PM No. % PM No. % PM
Scotland 153 52.9 299 51.5 159 31.4 611 46.6
Ayrshire & Arran
Crosshouse Hospital 14 42.9 15 60.0 7 42.9 36 50.0
Other1 - - 1 0.0 1 0.0 2 0.0
Borders
Borders General Hospital - - 5 40.0 1 100.0 6 50.0
Other1 - - 1 0.0 - - 1 0.0
Dumfries & Galloway
Cresswell Maternity Hospital 8 87.5 1 0.0 - - 9 77.8
Other1 - - - - 1 100.0 1 100.0
Fife
Forth Park Maternity Hospital 7 57.1 21 38.1 11 45.5 39 43.6
Forth Valley
Stirling Royal Infirmary 11 63.6 13 76.9 4 50.0 28 67.9
Other1 - - 2 100.0 2 0.0 4 50.0
Grampian
Aberdeen Maternity Hospital 2 50.0 22 54.5 9 22.2 33 45.5
Dr. Gray's Hospital 2 0.0 2 50.0 1 100.0 5 40.0
Other1 - - 3 66.7 - - 3 66.7
Greater Glasgow & Clyde
Royal Maternity Hospital 8 100.0 37 62.2 20 20.0 65 53.8
Southern General Hospital 12 58.3 41 43.9 15 13.3 68 39.7
RHSC, Glasgow - - - - 16 12.5 16 12.5
Paisley Maternity Hospital 17 47.1 23 60.9 9 22.2 49 49.0
Other1 - - 2 50.0 3 33.3 5 40.0
Highland
Caithness General Hospital - - 1 100.0 1 0.0 2 50.0
Raigmore Hospital 1 100.0 12 16.7 7 57.1 20 35.0
Other1 - - - - 1 0.0 1 0.0
Lanarkshire
Wishaw General Hospital 31 22.6 22 50.0 13 15.4 66 30.3
Other1 1 100.0 1 100.0 - - 2 100.0
Lothian
RHSC, Edinburgh - - - - 1 100.0 1 100.0
St. John's at Howden 1 0.0 12 50.0 1 0.0 14 42.9
New Royal Infirmary 38 63.2 33 57.6 21 52.4 92 58.7
Other1 - - 1 100.0 - - 1 100.0
Tayside
Ninewells Hospital - - 24 41.7 12 50.0 36 44.4
Other1 - - 2 0.0 - - 2 0.0
Islands - - 2 50.0 2 0.0 4 0.0 1 Includes births at home. Source: Survey
51
Table A9a Singleton live births, stillbirths and neonatal deaths by birthweight: 2011p
Birthweight (g)
Live births
NRS Live
births Stillbirths NND
No. % No. No. % 95% CI No. % 95% CI
Total 53528 100.0 56877 277 100.0 133 100.0
<1500 405 0.8 430 115 41.5 34.3,49.8 63 47.4 36.4,60.6
1500-2499 2406 4.5 2557 64 23.1 17.8,29.5 20 15.0 9.2,23.3
2500-3499 25791 48.2 27405 56 20.2 15.3,26.3 30 22.6 15.2,32.2
3500-4499 23686 44.2 25168 38 13.7 9.7,18.8 14 10.5 5.7,17.7
4500+ 1235 2.3 1312 3 1.1 0.2,3.2 1 0.8 0,4.3
Not known 5 0.0 5 1 0.4 - 5 3.8 1.2,8.8 p Provisional SMR02. Source: SMR02 and Survey
Table A9b Singleton live births, stillbirths and neonatal deaths by gestation: 2011p
Gestation (weeks)
Live births
NRS Live
births Stillbirths NND
No. % No. No. % 95% CI No. % 95% CI
Total 53528 100.0 56877 277 100.0 133 100.0
<24 14 0.0 15 - - - 19 14.3 -
24-27 102 0.2 108 71 25.6 20,32.3 29 21.8 14.6,31.4
28-31 379 0.7 403 40 14.4 10.3,19.7 18 13.5 8,21.4
32-36 2512 4.7 2669 62 22.4 17.2,28.7 22 16.5 10.4,25.1
37+ 50492 94.3 53651 104 37.5 30.7,45.5 42 31.6 22.8,42.7
Not known 29 0.1 31 - - - 3 2.3 0.4,6.7 p Provisional SMR02. Source: SMR02 and Survey
Table A10a Normally-formed birthweight specific singleton stillbirth mortality rates1: 2007 – 2011
Birthweight (g) 2007 2008 2009 2010 2011p
Total 5.3 4.6 4.4 4.2 4.3
Under 1500 203
.7 166.5 186.4 182.1 179.6
1500-2499 25.
3 21.6 20.3 19.0 22.6
2500-3499 3.1 3.1 2.6 2.3 1.9
3500-4499 0.9 1.0 1.2 1.1 1.5
4500+ 1.8 0.8 1.5 2.4 1.5 1 Rate per 1000 total births (excl. stillbirths and neonatal deaths with lethal malformations). p Provisional SMR02. Source: SMR02 and Survey
52
Table A10b Normally-formed gestation specific singleton stillbirth mortality rates1: 2007 – 2011
Gestation (weeks) 2007 2008 2009 2010 2011p
Total 5.3 4.6 4.4 4.2 4.3
<24 - - - - -
24-27 370.2 239.6 312.1 286.9 345.5
28-31 117.3 101.9 91.9 105.0 78.1
32-36 25.8 21.2 20.9 17.6 19.5
37+ 2.0 2.1 1.8 1.7 1.8 1 Rate per 1000 total births (excl. stillbirths and neonatal deaths with lethal malformations). p Provisional SMR02. Source: SMR02 and Survey
Table A11a Normally-formed birthweight specific singleton neonatal mortality
rates1: 2007 – 2011
Birthweight (g) 2007 2008 2009 2010 2011p
Total 2.1 1.7 1.6 1.6 1.7
Under 1500 175
.1 109.0 113.5 134.5 130.2
1500-2499 4.2 2.9 2.5 2.1 4.3
2500-3499 0.7 0.9 0.6 0.5 0.6
3500-4499 0.3 0.2 0.6 0.4 0.3
4500+ - 1.5 - 0.8 0.8 1 Rate per 1000 live births (excl. neonatal deaths with lethal malformations). p Provisional SMR02 Source: SMR02 and Survey
Table A11b Normally-formed gestation specific singleton neonatal mortality rates1:
2007 – 2011
Gestation (weeks) 2007 2008 2009 2010 2011p
Total 2.1 1.7 1.6 1.6 1.7
<24 * * * * *
24-27 263.2 162.8 205.6 251.3 260.8
28-31 57.4 18.2 25.4 36.6 35.1
32-36 2.4 3.3 2.1 1.1 4.5
37+ 0.5 0.6 0.6 0.4 0.4 1 Rate per 1000 live births (excluding neonatal deaths with lethal malformations). * Rates not calculated as SMR2 data is incomplete. p Provisional SMR02 Source: SMR02 and Survey
53
Table A12 Stillbirths and neonatal deaths by gestation for twins: 2011 Gestation (weeks)
Both twins died Twin 1 died Twin 2 died
Total SB NND SB NND SB NND
Total 8 10 6 7 7 9 47
Under 20 - - - - - - -
20-23 - 2 - - - 2 4
24-27 4 6 1 3 - 5 19
28-36 4 - 4 (1) 4 (3) 6 (1) 2 20
37-41 - - 1 - 1 (1) - 2
Not known - 2 - - - - 2 Includes 4 sets of twins where one twin suffered a neonatal death and the co-twin suffered a late fetal death or a post-neonatal death. Includes 6 deaths from congenital anomaly (shown in brackets). Other Twins: 4 sets where one twin was a late fetal death. 8 sets where both twins were late fetal deaths. 3 sets where one twin died in the postnatal period. Triplets and Quadruplets: Ten sets of triplets were registered in 2011. Among these 30 babies there was one stillbirth. Source: Survey
Table A13 Proportion of normally-formed singleton infants who are small for
gestational age (SGA) by death classification: 2011
Obstetric Classification
Antepartum stillbirth
Intrapartum stillbirth
& neonatal death
Total SGA % Total SGA %
Total 229 44 19.2 109 4 3.7
No antecedent or associated obstetric factors 26 1 3.8 11 - 0.0
Antepartum or intrapartum haemorrhage 38 4 10.5 13 - 0.0
Associated obstetric factors 1 - 0.0 20 1 5.0
Hypertensive disorders of pregnancy 4 1 25.0 6 - 0.0
Infection 11 - 0.0 29 - 0.0
Intra-uterine growth restriction 3 1 33.3 - - -
Maternal disorder 6 - 0.0 - - -
Mechanical 11 2 18.2 4 - 0.0
Specific fetal conditions 2 - 0.0 4 - 0.0
Specific placental conditions 104 29 27.9 10 3 30.0
Unable to classify 23 6 26.1 12 - 0.0 Source: Survey
54
Table A14 Main obstetric factors by gender causing death in singleton stillbirths and neonatal deaths: 2011
Obstetric classification
Stillbirths 1 Neonatal deaths 2
Males Females Males Females
Total 142 135 72 61
No antecedent or associated obstetric factors 11 16 8 2
Antepartum or intrapartum haemorrhage 25 16 5 5
Associated obstetric factors 2 1 12 6
Hypertensive disorders of pregnancy 2 4 2 2
Infection 3 11 16 10
Intra-uterine growth restriction 2 1 - -
Major congenital anomaly 18 16 18 20
Maternal disorder 5 1 - -
Mechanical 7 5 1 2
Specific fetal conditions 2 - 1 3
Specific placental conditions 51 55 2 6
Unable to classify 14 9 7 5
Rates
Total 4.8 4.9 2.5 2.2
Antecedent or associated obstetric factors 0.4 0.6 0.3 0.1
Antepartum or intrapartum haemorrhage 0.9 0.6 0.2 0.2
Associated obstetric factors 0.1 0.0 0.4 0.2
Hypertensive disorders of pregnancy 0.1 0.1 0.1 0.1
Infection 0.1 0.4 0.5 0.4
Intra-uterine growth restriction 0.1 0.0 - -
Major congenital anomaly 0.6 0.6 0.6 0.7
Maternal disorder 0.2 0.0 - -
Mechanical 0.2 0.2 0.0 0.1
Specific fetal conditions 0.1 - 0.0 0.1
Specific placental conditions 1.7 2.0 0.1 0.2
Unable to classify 0.5 0.3 0.2 0.2 1 Rate per 1000 singleton total births. 2 Rate per 1000 singleton live births. Source: Survey
55
Table A15 Singleton late fetal deaths, therapeutic and spontaneous; by obstetric classification, comparison with stillbirths: 2011
Obstetric Cause
Late Fetal Deaths Stillbirth
Therapeutic Spontaneous
No. % No. % No. %
Total 54 100.0 68 100.0 277 100.0
Major congenital anomaly 44 81.5 * * 34 12.3
Hypertensive disorders of pregnancy - - - - 6 2.2
Antepartum or intrapartum haemorrhage * * 22 32.4 41 14.8
Infection 6 11.1 18 26.5 14 5.1
Intra-uterine growth restriction - - - - 3 1.1
Maternal disorder - - - - 6 2.2
Mechanical - - - - 12 4.3
Associated obstetric factors * * * * 3 1.1
Specific fetal conditions * * - - 2 0.7
Specific placental conditions - - 14 20.6 106 38.3
No antecedent or associated obstetric factors - - 8 11.8 27 9.7
Unable to classify - - - - 23 8.3 * Indicates values that have been suppressed due to potential risk of disclosure. Source: Survey and SMR02
Table A16 Multiple late fetal deaths, therapeutic and spontaneous, by obstetric classification, comparison with stillbirths: 2011
Obstetric cause
Late Fetal Deaths Stillbirth
Therapeutic Spontaneous
No. % No. % No. %
Total 5 100.0 22 100.0 22 100.0
Major congenital anomaly - - - - 4 18.2
Hypertensive disorders of pregnancy - - - - 2 9.1
Antepartum or intrapartum haemorrhage - - * * 5 22.7
Infection * * 17 77.3 1 4.5
Intra-uterine growth restriction - - - - 2 9.1
Maternal disorder - - - - - -
Mechanical - - - - 1 4.5
Associated obstetric factors - - - - - -
Specific fetal conditions * * - - 4 18.2
Specific placental conditions - - * * 1 4.5
No antecedent or associated obstetric factors - - * * 2 9.1
Unable to classify - - - - - - * Indicates values that have been suppressed due to potential risk of disclosure. Source: Survey and SMR02
56
Table A17 Late fetal deaths notified to the survey by birthweight and gestational age: 2011
Gestational age (weeks)
All weights
Birthweight (g)
<200 200- 300- 400- 500- 600- 700- 800- 900- 1000- 1100+ NK
Total 153 17 19 32 33 15 3 3 1 - 1 1 28
<20 - - - - - - - - - - - - -
20 46 10 10 15 1 - - - - - 1 1 8
21 44 3 6 13 11 3 - - - - - - 8
22 41 1 - 3 19 6 1 1 1 - - - 9
23 21 2 3 1 2 6 2 2 - - - - 3
Not known 1 1 - - - - - - - - - - - Source: Survey Table A18 Cause of post-neonatal deaths by age at death: 2011
Cause of death
Age at death (months) Total
1-2 3-5 6-8 9-11 No. %
Total 40 26 7 5 78 -
Percent 51.3 33.3 9.0 6.4 - 100.
Gastro-intestinal disease 6 1 - - 7 9.0
Infection 8 3 1 2 14 17.9
Injury/trauma (inc. iatrogenic trauma) - 1 - - 1 1.3
Major congenital anomaly 10 4 - - 14 17.9
Neurological disorder 3 3 - - 6 7.7
Other specific causes 2 1 1 - 4 5.1
Respiratory disorders - 1 1 - 2 2.6
Sudden unexpected death 8 5 2 2 17 21.8
Unable to classify due to lack of information 3 7 2 1 13 16.7
Source: Survey
Table A19a Post-neonatal mortality rates1 by cause of death (old classification):
2007-2011
Cause of death 2007 2008 2009 2010 2011
All Causes 1.45 1.42 1.19 1.16 1.33
Major congenital anomaly 0.33 0.60 0.41 0.37 0.24
Perinatal causes
Asphyxia related 0.03 0.03 0.00 0.02
Immaturity related 0.36 0.27 0.19 0.19
Infection 0.16 0.08 0.03 0.07 0.24
External causes 0.05 0.03 0.03 0.07
Sudden unexpected death in infancy 0.43 0.23 0.32 0.36 0.29
Miscellaneous
Specific conditions 0.07 0.07 0.03 0.02
Remaining causes 0.02 0.10 0.17 0.07 Source: Survey
57
Table A19b Post-neonatal mortality rates1 by cause of death: 2011
Main cause of death Total Rate
Gastro-intestinal disease 7 0.12
Infection 14 0.24
Injury/trauma (inc. iatrogenic trauma) 1 0.02
Major congenital anomaly 14 0.24
Neurological disorder 6 0.10
Other specific causes 4 0.07
Respiratory disorders 2 0.03
Sudden unexpected death 17 0.29
Unable to classify due to lack of information 13 0.22 1 Rate per 1000 live births Source: Survey
Table A20 Post-neonatal deaths by cause of death and place of death: 2011
Main cause of death Labour ward
Neonatal unit Hospice Home Other Missing Total
Total 3 26 1 24 14 10 78
Gastro-intestinal disease - 6 - - - 1 7
Infection 1 10 - 1 1 1 14
Injury/trauma (inc. iatrogenic trauma) - - - - - 1 1
Major congenital anomaly 1 5 1 2 2 3 14
Neurological disorder - 2 - 3 1 - 6
Other specific causes - - - 3 1 - 4
Respiratory disorders - 2 - - - - 2
Sudden unexpected death 1 - - 8 8 - 17
Unable to classify due to lack of information - 1 - 7 1 4 13
Source: Survey
Table A21 Post-neonatal deaths by postmortem and cause of death: 2011
Main cause of death Yes No No PM Total
Total 26 24 28 78
Gastro-intestinal disease - 1 6 7
Infection 5 1 8 14
Injury/trauma (inc. iatrogenic trauma) - 1 - 1
Major congenital anomaly 1 5 8 14
Neurological disorder 1 1 4 6
Other specific causes 3 1 - 4
Respiratory disorders - - 2 2
Sudden unexpected death 16 1 - 17
Unable to classify due to lack of information - 13 - 13 Source: Survey
58
Table A22 Singletons born in Scotland & detected1 with congenital anomaliesa at birth or during infancy2; numbers by anomaly and year: 2006 - 2010
Congenital anomaly 2006r 2007r 2008r 2009r 2010
Neural tube Defects 18 35 35 29 31
Anencephalus 2 2 5 4 4
Spina bifida +/- hydrocephalus 12 30 24 23 22
Encephalocoele 5 3 6 2 5
Hydrocephalus3 18 17 19 16 21
Anomalies of the heart & circulatory system4 486 506 510 548 541
Heart 274 306 285 332 309
Circulatory system 233 235 243 243 264
Cleft palate 45 61 75 61 73
Cleft lip +/- cleft palate 37 49 62 45 37
Trisomy 13 3 5 3 1 2
Trisomy 18 10 10 14 10 13
Down's Syndrome 53 69 60 72 51 a See codes used for definition of congenital anomalies. 1 Anomalies have been located from the diagnostic summaries contained within the linked source data comprising profiles of neonatal and inpatient hospital discharge records, stillbirth notifications, Scottish birth record and death registrations. 2 All Infants followed up from birth for period of one year to allow detection of anomalies from hospital inpatient records or NRS death registrations. 3 Hydrocephalus is not included in the Neural Tube Defects total. 4 Infants may be diagnosed with both heart and circulatory anomalies but are only counted once Anomalies of heart and circulatory system. r Revised. Source: ISD Scottish Congenital Anomalies Register (linked SMR01, SMR02, SMR11, SBR and SSBID records). SPIMMR Congenital Anomaly ICD-9 Codes ICD-10 Codes
Neural Tube Defects 740, 741, 742.0 Q00, Q01, Q05, Q07.0 Anencephalus 740 Q00 Spina bifida +/- Hydrocephalus 741 Q05,Q07.0 Encephalocele 742.0 Q01 Hydrocephalus 742.3 Q03 Anomalies of the heart and circulatory system 745-747,425.3; 394-411*; Q20-Q28, I42.4 414-417*; 424.0-425.2*; 425.4-426.9* Heart 745-746 Q20-Q24 Circulatory system 747 Q25-Q28 Cleft Palate 749.0 Q35 Cleft lip +/- Cleft palate 749.1-749.2 Q36-Q37 Trisomy 13 758.1 Q91.4- Q91.7 Trisomy 18 758.2 Q91.0-Q91.3 Down's Syndrome 758.0 Q90 * These codes are taken to be congenital anomalies if used on death certificates.
59
Table A23a Singletons born in Scotland & detected1 with congenital anomaliesa at birth or during infancy2; rates per 1,000 births by anomaly and year: 2006 - 2010
Congenital anomaly 2006r 2007r 2008r 2009r 2010
Neural Tube Defects 0.35 0.64 0.61 0.52 0.56
Anencephalus 0.04 0.04 0.09 0.07 0.07
Spina bifida +/- hydrocephalus 0.23 0.55 0.42 0.41 0.40
Encephalocoele 0.10 0.05 0.11 0.04 0.09
Hydrocephalus3 0.35 0.31 0.33 0.29 0.38
Anomalies of the heart & circulatory system4 9.33 9.19 8.94 9.76 9.78
Heart 5.26 5.56 4.99 5.91 5.59
Circulatory system 4.47 4.27 4.26 4.33 4.77
Cleft palate 0.86 1.11 1.31 1.09 1.32
Cleft lip +/- cleft palate 0.71 0.89 1.09 0.80 0.67
Trisomy 13 0.06 0.09 0.05 0.02 0.04
Trisomy 18 0.19 0.18 0.25 0.18 0.24
Down's Syndrome 1.02 1.25 1.05 1.28 0.92 See footnotes at Table A22.
Table A23b Singletons born in Scotland & detected1 with congenital anomaliesa at
birth, during infancy2; or aborted3 because of pre-natal diagnosis; rates per 1,000 births by anomaly and year: 2006- 2010
Congenital anomaly 2006r 2007r 2008r 2009r 2010
Neural Tube Defects 0.84 1.16 1.03 1.03 1.05
Anencephalus 0.35 0.31 0.33 0.36 0.40
Spina bifida +/- hydrocephalus 0.42 0.74 0.54 0.52 0.54
Encephalocoele 0.10 0.11 0.16 0.16 0.11
Hydrocephalus4 0.42 0.36 0.42 0.45 0.51
Anomalies of the heart & circulatory system5 9.50 9.28 9.02 9.87 9.91
Heart 5.39 5.65 5.08 6.02 5.71
Circulatory system 4.51 4.27 4.26 4.33 4.77
Cleft palate 0.86 1.13 1.31 1.09 1.32
Cleft lip +/- cleft palate 0.71 0.89 1.09 0.80 0.67
Trisomy 13 0.17 0.18 0.16 0.05 0.04
Trisomy 18 0.52 0.36 0.44 0.41 0.38
Down's Syndrome 1.80 1.93 1.56 1.76 1.34 a See codes used for definition of congenital anomalies in Table A22. 1 Anomalies have been located from the diagnostic summaries contained within the linked source data comprising profiles of neonatal and inpatient hospital discharge records, stillbirth notifications, Scottish birth record and death registrations. 2 All Infants followed up from birth for period of one year to allow detection of anomalies from hospital inpatient records or NRS death registrations. 3 Refers to the therapeutic abortions notified in accordance with the Abortion Act 1967. 4 Hydrocephalus is not included in the Neural Tube Defects total. 5 Infants may be diagnosed with both heart and circulatory anomalies but are only counted once Anomalies of heart and circulatory system. r Revised. Source: ISD Scottish Congenital Anomalies Register (linked SMR01, SMR02, SMR11, SBR and SSBID records).
60
Table A24 Stillbirth mortality by NHS board of residence; numbers and rates1: 2007 – 2011
NHS board2
2007 2008 2009 2010 2011
No. Rate No. Rate No. Rate No. Rate No. Rate
Scotland3 327 5.6 325 5.4 317 5.3 291 4.9 299 5.1
Ayrshire & Arran 27 6.9 17 4.3 18 4.6 20 5.2 17 4.4
Borders 2 1.7 8 7.0 9 7.7 7 6.0 6 5.4
Dumfries & Galloway 6 4.0 7 4.9 8 5.3 8 5.5 1 0.7
Fife 23 5.6 30 6.9 23 5.5 35 8.3 24 5.6
Forth Valley 16 4.7 18 5.2 11 3.3 16 4.8 16 5.0
Grampian 32 5.2 31 4.9 29 4.5 25 4.0 26 4.1
Greater Glasgow and Clyde 94 6.8 80 5.6 76 5.4 71 5.0 94 6.6
Highland 17 5.5 14 4.2 23 7.2 12 3.7 15 4.8
Lanarkshire 32 4.9 36 5.2 44 6.6 36 5.6 29 4.4
Lothian 51 5.4 48 4.8 47 4.8 48 4.9 45 4.6
Orkney - - 3 13.8 2 10.0 - - - -
Shetland 1 4.1 - - 4 14.4 - - 3 12.2
Tayside 25 5.9 33 7.4 23 5.2 13 3.0 23 5.2
Western Isles 1 3.8 - - - - - - - - 1 Rate per 1000 total births. 2 NHS Argyll & Clyde was dissolved 31st March 2006 and the administration area was split in to two sub-areas that now fall under NHS Greater Glasgow & Clyde and NHS Highland. 3 Records that could not be aligned to an NHS board via their postcode have been assigned to the board of the hospital of occurrence. Source: Survey and NRS.
61
Table A25 Neonatal mortality by NHS board of residence; numbers and rates1: 2007 – 2011
NHS board
2
2007 2008 2009 2010 2011
No. Rate No. Rate No. Rate No. Rate No. Rate
Scotland3 188 3.3 168 2.8 165 2.8 150 2.6 159 2.7
Ayrshire & Arran 21 5.4 15 3.8 12 3.1 7 1.8 14 3.6
Borders 2 1.7 2 1.8 3 2.6 5 4.5 1 0.9
Dumfries & Galloway 6 4.0 5 3.5 3 2.0 5 3.6 3 2.1
Fife 20 4.9 20 4.6 19 4.6 16 3.7 13 3.0
Forth Valley 7 2.1 12 3.5 10 3.0 5 1.6 6 1.9
Grampian 13 2.1 11 1.7 17 2.6 13 2.1 11 1.7
Greater Glasgow & Clyde 47 3.4 51 3.6 37 2.6 40 2.8 41 2.9
Highland 6 2.0 3 0.9 9 2.8 9 2.9 13 4.2
Lanarkshire 17 2.6 11 1.6 11 1.7 18 2.8 19 2.9
Lothian 30 3.2 26 2.6 27 2.8 17 1.7 25 2.5
Orkney 1 5.3 - - - - 2 9.8 - -
Shetland 2 8.2 4 14.4 - - - - - -
Tayside 15 3.6 8 1.8 17 3.9 13 3.0 10 2.3
Western Isles 1 3.8 - - - - - - 3 12.8 1 Rate per 1000 total births. 2 NHS Argyll & Clyde was dissolved 31st March 2006 and the administration area was split in to two sub-areas that now fall under NHS Greater Glasgow & Clyde and NHS Highland. 3 Records that could not be aligned to an NHS board via their postcode have been assigned to the board of the hospital of occurrence. Source: Survey and NRS.
62
Table A26 FIGO Classification stillbirth and neonatal death by NHS board of residence1: 2011
NHS board of residence
Stillbirths Neonatal deaths
Weighing 500g +
Weighing 1000g + and normally
formed
Weighing 500g +
Weighing 1000g + and normally
formed
Scotland 270 181 140 52
Ayrshire & Arran 17 9 12 3
Borders 5 3 1 1
Dumfries & Galloway 1 1 3 1
Fife 20 15 12 6
Forth Valley 15 13 6 1
Grampian 23 20 10 3
Greater Glasgow & Clyde 85 53 39 17
Highland 12 6 10 5
Lanarkshire 27 21 16 4
Lothian 39 23 18 6
Orkney - - - -
Shetland 3 2 - -
Tayside 23 15 10 4
Western Isles - - 3 1
Outwith Scotland - - - -
Rates2
Scotland 4.6 3.1 2.4 0.9
Ayrshire & Arran 4.4 2.3 3.1 0.8
Borders 4.5 2.7 0.9 0.9
Dumfries & Galloway 0.7 0.7 2.1 0.7
Fife 4.7 3.5 2.8 1.4
Forth Valley 4.7 4.1 1.9 0.3
Grampian 3.6 3.2 1.6 0.5
Greater Glasgow & Clyde 6.0 3.7 2.8 1.2
Highland 3.9 1.9 3.2 1.6
Lanarkshire 4.1 3.2 2.5 0.6
Lothian 4.0 2.3 1.8 0.6
Orkney - - - -
Shetland 12.2 8.2 - -
Tayside 5.2 3.4 2.3 0.9
Western Isles - - 12.8 4.3 1 Records that could not be aligned to an NHS board via their postcode have been assigned to the board of the hospital of occurrence. 2 Stillbirths per 1000 total births, neonatal deaths per 1000 live births. Source: Survey, NRS
63
Table A27a Pregnancy losses from 20 weeks gestation to end of first year1: 2011
NHS board of residence
2
Fetal deaths
Live births
Stillbirths
Early neonatal deaths
Late neonatal deaths
Neonatal deaths
Post- neonatal deaths
Infant deaths
Scotland 153 58590 299 109 50 159 78 237
Ayrshire & Arran 14 3887 17 9 5 14 12 26
Borders - 1108 6 1 - 1 2 3
Dumfries & Galloway 8 1396 1 2 1 3 1 4
Fife 7 4268 24 12 1 13 4 17
Forth Valley 11 3154 16 4 2 6 5 11
Grampian 4 6276 26 6 5 11 8 19
Greater Glasgow and Clyde 32 14067 94 19 22 41 15 56
Highland 5 3090 15 12 1 13 3 16
Lanarkshire 32 6502 29 15 4 19 6 25
Lothian 39 9794 45 19 6 25 15 40
Orkney - 205 - - - - - -
Shetland - 242 3 - - - - -
Tayside 1 4366 23 7 3 10 7 17
Western Isles - 235 - 3 - 3 - 3 1 Live birth data are taken from NRS and all other numbers are from the survey. 2 Records that could not be aligned to an NHS board via their postcode have been assigned to the board of the hospital of occurrence. Source: NRS, Survey
64
Table A27b Pregnancy loss rates from 20 weeks gestation to end of first year1: 2011
NHS board of residence
2
Late fetal deaths
3
Still births
4
Perinatal 4
Neonatal 5
Post- neonatal
5
Infant 5
Extended 3
(20 wks - 1yr) ('total loss')
Scotland 2.6 5.1 6.9 2.7 1.3 4.0 11.7
Ayrshire & Arran 3.6 4.4 6.9 3.6 3.1 6.7 14.5
Borders - 5.4 6.3 0.9 1.8 2.7 8.1
Dumfries & Galloway 5.7 0.7 1.4 2.1 0.7 2.9 9.3
Fife 1.6 5.6 8.2 3.0 0.9 4.0 11.2
Forth Valley 3.5 5.0 6.0 1.9 1.6 3.5 11.9
Grampian 0.6 4.1 5.1 1.8 1.3 3.0 7.8
Greater Glasgow & Clyde 2.3 6.6 8.3 2.9 1.1 4.0 12.8
Highland 1.6 4.8 8.1 4.2 1.0 5.2 11.6
Lanarkshire 4.9 4.4 6.9 2.9 0.9 3.8 13.1
Lothian 3.9 4.6 6.5 2.6 1.5 4.1 12.6
Orkney - - - - - - -
Shetland - 12.2 12.2 - - - 12.2
Tayside 0.2 5.2 6.8 2.3 1.6 3.9 9.3
Western Isles - - 12.8 12.8 - 12.8 12.8 1 Live birth data are taken from NRS and all other numbers are from the survey. 2 Records that could not be aligned to an NHS board via their postcode have been assigned to the board of the hospital of occurrence. 3 Rate per 1000 total births + late fetal deaths. 4 Rate per 1000 total births. 5 Rate per 1000 live births. Source: NRS, SMR02 and Survey
65
Figure A28a FIGO classification stillbirth rates1 (normally formed >= 1000g); by NHS board of residence2: 2007 – 2011
Western Isles
Greater Glasgow &
Clyde
Grampian
Lanarkshire
Lothian
Forth Valley
Shetland
Ayrshire & ArranOrkney
Dumfries & Galloway
Highland
Fife
Tayside
Borders
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
0 2000 4000 6000 8000 10000 12000 14000
Number of births
Rate
per
1000 b
irth
s
Data
Average
2SD limits
3SD limits
1 Rate per 1000 births. 2 Four stillbirth records could not be matched to an NHS board. Source: Survey (See Figure A28b for health board labels)
66
Figure A28b FIGO classification neonatal death rates1 (normally formed >= 1000g); by NHS board of residence2 : 2007 – 2011
Greater Glasgow &
Clyde
Grampian
Lanarkshire
Lothian
Forth Valley
Tayside
Ayrshire & Arran
Shetland
Dumfries &Galloway
Highland
Fife
Western Isles
Borders
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
0 2000 4000 6000 8000 10000 12000 14000
Number of live births
Rate
per
1000 l
ive b
irth
s
Data
Average
2SD limits
3SD limits
1 Rate per 1000 live births. 2 One neonatal death record could not be matched to an NHS board. Source: Survey
67
Figure A29a Neural Tube Defects1 rates2 by NHS board of residence: 2006 – 2010
Greater Glasgow &
Clyde
Grampian
LanarkshireLothianForth Valley
TaysideA & A
Orkney
Dumfries & Galloway
HighlandFife
Western Isles
Borders
0.0
0.5
1.0
1.5
2.0
0 2000 4000 6000 8000 10000 12000 14000
Number of singleton births
Rate
per
1000 s
ing
leto
n b
irth
s
Data
Average
2SD limits
3SD limits
See Figure A28b for NHS board labels. 1 Singletons detected with NTD at birth, during infancy or aborted. 2 Rate per 1000 singleton births. Source: ISD Scottish Congenital Anomalies Register (linked SMR01, SMR02, SMR11, SBR and SSBID records)
68
Figure A29b Down's Syndrome1 rates2 by NHS board of residence: 2006 - 2010
Western Isles
Greater Glasgow &
Clyde
Grampian
Lanarkshire
Lothian
Forth Valley
Shetland
A & A
Orkney
D & G
Highland
FifeTayside
Borders
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
0 2000 4000 6000 8000 10000 12000 14000
Number of singleton births
Rate
per
1000 s
ing
leto
n b
irth
s
Data
Average
2SD limits
3SD limits
See Figure A28b for NHS board labels. 1 Singletons detected with Down's Syndrome at birth, during infancy or aborted. 2 Rate per 1000 singleton births. Source: ISD Scottish Congenital Anomalies Register (linked SMR01, SMR02, SMR11, SBR and SSBID records)
69
Figure A29c Heart and circulatory system anomalies1 rates2 by NHS board of residence: 2006 – 2010
W Isles
Greater Glasgow &
Clyde
Grampian
Lanarkshire
Lothian
Forth Valley
Shetland
Ayrshire & Arran
Orkney
D & G
Highland
Fife
Tayside
Borders5.0
7.0
9.0
11.0
13.0
15.0
17.0
19.0
0 2000 4000 6000 8000 10000 12000 14000
Number of singleton births
Rate
per
1000 s
ing
leto
n b
irth
s
Data
Average
2SD limits
3SD limits
See Figure A28b for NHS board labels. 1 Singletons detected with heart and circulatory system anomalies at birth, during infancy or aborted. 2 Rate per 1000 singleton births. Source: ISD Scottish Congenital Anomalies Register (linked SMR01, SMR02, SMR11, SBR and SSBID records)
70
Table A30a Singletons born in Scotland & detected1 with congenital anomaliesa at birth or during infancy2; rates per 1,000 births by health board of residence: 2006 – 2010
Neural Tube
Defects Cleft
Palate
Cleft Lip +/- Cleft Palate
Heart & Circulatory
System
Patau syndrome
(Trisomy 13)
Edwards syndrome (Trisomy
18)
Down's syndrome
(Trisomy 21)
Scotland3 0.53 1.13 0.82 9.31 0.05 0.21 1.10
Ayrshire & Arran 0.70 0.75 0.91 10.87 0.11 0.27 1.23
Borders 0.38 1.14 0.95 5.33 0.00 0.00 0.76
Dumfries & Galloway 1.13 0.85 0.85 6.09 0.28 0.28 0.57
Fife 0.55 1.25 0.65 6.40 0.10 0.15 0.95
Forth Valley 0.69 1.01 1.45 6.30 0.13 0.25 0.63
Grampian 0.55 1.10 0.89 11.74 0.03 0.38 0.93
Greater Glasgow & Clyde 0.48 1.27 0.82 7.18 0.03 0.25 1.05
Highland 0.67 1.14 0.67 18.41 0.20 0.20 1.75
Lanarkshire 0.62 0.92 0.72 8.18 0.00 0.16 1.05
Lothian 0.36 1.28 0.67 12.27 0.00 0.07 1.50
Orkney 0.00 2.09 1.04 7.30 0.00 1.04 2.09
Shetland 0.00 0.82 1.63 15.52 0.00 0.82 1.63
Tayside 0.46 0.87 0.71 7.09 0.00 0.10 0.77
Western Isles 0.00 4.27 2.56 5.98 0.00 0.00 0.85 a See codes used for definition of congenital anomalies in Table A22 1 Anomalies have been located from the diagnostic summaries contained within the linked source data comprising profiles of neonatal and inpatient hospital discharge records, stillbirth notifications, Scottish birth record and death registrations. 2 All Infants followed up from birth for period of one year to allow detection of anomalies from hospital inpatient records or NRS death registrations. 3 Exclude cases where health board of residence could not be assigned. Source: ISD Scottish Congenital Anomalies Register (linked SMR01, SMR02, SMR11, SBR and SSBID records)
71
Table A30b Singletons born in Scotland & detected1 with congenital anomaliesa at birth, during infancy2, or aborted3 because of pre-natal diagnosis rates per 1,000 births by health board of residence: 2006 - 2010
Neural Tube
Defects Cleft
Palate
Cleft Lip +/- Cleft Palate
Heart & Circulatory
System
Patau syndrome (Trisomy
13)
Edwards syndrome (Trisomy
18)
Down's syndrome (Trisomy
21)
Scotland4 1.02 1.13 0.82 9.42 0.12 0.42 1.67
Ayrshire & Arran 1.34 0.75 0.91 10.98 0.21 0.43 1.39
Borders 1.14 1.14 0.95 5.52 0.00 0.19 1.14
Dumfries & Galloway 1.98 0.85 0.85 6.23 0.42 0.85 1.84
Fife 1.35 1.25 0.65 6.60 0.15 0.35 1.90
Forth Valley 0.88 1.01 1.45 6.30 0.13 0.25 0.63
Grampian 1.20 1.10 0.89 12.05 0.17 0.65 2.20
Greater Glasgow and Clyde 0.64 1.27 0.82 7.22 0.07 0.39 1.26
Highland 1.41 1.14 0.67 18.41 0.20 0.34 2.22
Lanarkshire 0.95 0.92 0.72 8.21 0.00 0.33 1.31
Lothian 0.90 1.30 0.67 12.34 0.16 0.52 2.24
Orkney 1.04 2.09 1.04 8.34 0.00 1.04 2.09
Shetland 0.00 0.82 1.63 15.52 0.00 0.82 4.90
Tayside 1.33 0.87 0.71 7.45 0.05 0.20 1.79
Western Isles 0.85 4.27 2.56 5.98 0.00 0.00 1.71 a See codes used for definition of congenital anomalies in Table A22 1 Anomalies have been located from the diagnostic summaries contained within the linked source data comprising profiles of neonatal and inpatient hospital discharge records, stillbirth notifications, Scottish birth record and death registrations. 2 All Infants followed up from birth for period of one year to allow detection of anomalies from hospital inpatient records or NRS death registrations. 3 Refers to therapeutic abortions notified in accordance with the Abortion Act 1967. 4 Exclude cases where health board of residence could not be assigned. Source: ISD Scottish Congenital Anomalies Register (linked SMR01, SMR02, SMR11, SBR and SSBID records)
72
12.3 Acknowledgements
Thanks are due to the clinical co-ordinators, midwifery, neonatal, pathology and secretarial staff who complete the SSBID Survey forms throughout Scotland. We also thank the staff of the National Records of Scotland who provide the basic data on births and deaths essential for the conduct of the Survey. The full SPIMMR is available only as a web edition via a link on the Healthcare Improvement Scotland website (www.healthcareimprovementscotland.org) and within Scottish Health Statistics, the ISD website (www.isdscotland.org/Health-Topics/Maternity-and-Births/Stillbirth-and-Infant-Deaths) and a summary of the report is distributed widely among reproductive health professionals in Scotland via the newsletter of the NHS Healthcare Improvement Scotland Reproductive Health Programme. Members of SPMMRAG 2010/2011 Sean Ainsworth Scottish Neonatal Consultants Group Ruth Batten Scottish Neonatal Nurses Group Sandra Bonnellie Statistician, Napier University Catherine Calderwood Scottish Government, (ex officio) Jim Chalmers Information Services Division, (ex officio) Margaret Evans Paediatric Pathology Chair Mairi Harvey Public Partner, Healthcare Improvement Scotland Chris Lennox Reproductive Health Programme, Clinical Advisor Healthcare Improvement Scotland, (ex officio) Leslie Marr Reproductive Health Programme Manager Healthcare Improvement Scotland, (ex officio) Morag Martindale Royal College of General Practitioners Dina McLellan Royal College of Obstetricians and Gynaecologists Gillian Smith Royal College of Midwives Healthcare Improvement Scotland Support Team Naomi Fearns Reproductive Health Programme Audit Coordinator Kenny Gifford Reproductive Health Programme Administrator Information Services Division Support Team Samantha Clarke Information Analyst Kirsten Monteath Information Analyst
73
12.4 Hospital co-ordinators 2011
NHS Board Hospital Co-ordinators
Ayrshire & Arran Ayrshire Maternity Unit, Crosshouse Hospital
Gordon Dobbie
Catherine Freckleton
Janis Gladwinfield
Borders Borders General Hospital
Clare Ketteridge
Brian McGowan
Dumfries & Galloway
Cresswell Maternity Unit, Dumfries & Galloway Royal Infirmary
Heather Armstrong
Anne Torrance
Dr. Stephen Wisdom
Fife Forth Park Hospital Victoria Hospital
Jeana Arnott
Morag Telfer
Graham Tydeman
Forth Valley Stirling Royal Infirmary Forth Valley Royal Infirmary
Pamela Bean
Hilary MacPherson
Fiona Sinclair
Grampian
Aberdeen Maternity Hospital Vivienne Anderson
Peter Danielian
Catherine Hauptfleisch
Dr Gray’s Hospital, Elgin Neil Maclean
Greater Glasgow and Clyde
Princess Royal Maternity Hospital Allan Jackson
Jackie McGeoch
Alan Mathers
Dawn Kernaghan
Lynn Wright
Paisley Maternity Unit Dr Andrew Quinn
Royal Hospital for Sick Children, Glasgow Marianne Cloherty
Jennifer Docherty
Dr. Barbara Holland
Beverly Montgomery
Southern General Hospital
Sandra Bonner
Alan Cameron
Cheryl Gaughan
Janice Gibson
Highland Caithness General Hospital Philip Boabang
Raigmore Hospital
David Herd
George Farmer
Debbie Mackay
Michelle Rodriguez
Julie Smith
Lanarkshire Wishaw General Hospital Dina McLellan
Ann Cunningham
Lothian Royal Hospital for Sick Children, Edinburgh Janet Burns
Sheila Wurr
Simpson Centre for Reproductive Health, Royal Infirmary, Edinburgh
Corrine Love
Karen Edgar
St John’s Howden Sarah Court
Ann Reid
Tayside Ninewells Hospital
Heather Clark
Professor Gary Mires
Britta Peters
Rajesh Sharma
Western Isles Western Isles Hospital Catherine McDonald
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12.5 Symbols and Abbreviations
The following symbols and abbreviations have been used:
.. not available - nil 0.0 negligible AP Antepartum APH Antepartum haemorrhage CMACE Centre for Maternal and Child Enquiries CNS Central nervous system CVS Cardiovascular system END Early neonatal death FIGO International Federation of Gynaecology and Obstetrics HMD Hyaline membrane disease HPD Histological placental dysfunction ICE International Collaborative Effort IP Intrapartum ISD Information Services Division IUD Intrauterine death IUGR Intrauterine growth restriction IVH Intraventricular haemorrhage LFD Late fetal death LND Late neonatal death NND Neonatal death NRS National Records of Scotland PM Postmortem PNND Post-neonatal death SB Stillbirth SGA Small for gestational age SMR02 Scottish Morbidity Record (maternity dataset) SPIMMR Scottish Perinatal and Infant Mortality and Morbidity Report SSBIDS Scottish Stillbirth and Infant Death Survey SUDI Sudden unexpected death in infancy
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12.6 Definitions
Stillbirths Section 56(1) of the Registration of Births, Deaths and Marriages (Scotland) Act 1965 defined a stillbirth as a child which had issued forth from its mother after the 28th week of pregnancy and which did not breathe or show any other sign of life. The Still-Birth (Definition) Act 1992, which came into effect on 1 October 1992, amended Section 56(1) of the 1965 Act (and other relevant UK legislation), replacing the reference to the 28th week with a reference to the 24th week. Perinatal deaths refer to stillbirths and deaths in the first week of life. Neonatal deaths refer to deaths in the first four weeks of life.
Early neonatal deaths refer to deaths in the first week of life. Late neonatal deaths refer to deaths in weeks two to four of life.
Post-neonatal deaths refer to deaths after the first four weeks but before the end of the first year. Infant deaths refer to all deaths in the first year of life. Late fetal deaths refer to infants born dead at 20-23+6 weeks of pregnancy or earlier in pregnancy if the birthweight is 500g or more. Rates Stillbirth and perinatal death rates are based on the total of live and stillbirths. Neonatal, post-neonatal and infant death rates are based on live births only. Late fetal death rates are based on the total of live and stillbirths and late fetal deaths.
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12.7 Denominators ISD - figures
Table Numbers
2, 3 Singleton
Total Births Live births
57153 56876
A10, A11 Multiple
1736 1714
A10a, A11a Singleton
denominator numerator denominator numerator
Total Births NF SB 1
Live births NF NND 2
Total 57083 243 56839 95
Under 1500 523 94 422 55
1500-2499 2610 59 2548 11
2500-3499 27438 51 27392 17
3500-4499 25193 37 25161 7
4500+ 1314 2 1312 1
nk 5 - 4 4
A10b, A11b Singleton
denominator numerator denominator numerator
Total Births NF SB 1
Live births NF NND 2
Total 57083 243 56839 95
<24 13 - 13 17
24-27 171 59 107 28
28-31 435 34 399 14
32-36 2715 53 2659 12
37+ 53718 97 53630 21
nk 31 - 31 3
GRO(S) - figures
Table Numbers
A14 Singleton
Male Female
Total Births Live births Total Births Live births
29397 29255 27758 27622
Total births
A27a, A31-A33 + Late Fetal
Total Births Live births Deaths
Scotland 58889 58590 59040
Ayrshire & Arran 3904 3887 3918
Borders 1114 1108 1114
Dumfries & Galloway 1397 1396 1405
Fife 4292 4268 4299
Forth Valley 3170 3154 3181
Grampian 6302 6276 6305
Greater Glasgow 14161 14067 14192
Highland 3105 3090 3110
Lanarkshire 6531 6502 6563
Lothian 9839 9794 9878
Orkney 205 205 205
Shetland 245 242 245
Tayside 4389 4366 4390
Western Isles
235 235 235
1 Normally formed stillbirths 2 Normally formed neonatal deaths
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12.8 National Statistics
The United Kingdom Statistics Authority has designated these statistics as National Statistics, in accordance with the Statistics and Registration Service Act 2007 and signifying compliance with the Code of Practice for Official Statistics. Designation can be broadly interpreted to mean that the statistics:
• meet identified user needs; • are well explained and readily accessible; • are produced according to sound methods, and • are managed impartially and objectively in the public interest. Once statistics have been designated as National Statistics it is a statutory requirement that the Code of Practice shall continue to be observed. Further details on National Statistics are contained at the National Statistics website (http://www.statistics.gov.uk). Pre-Release Access Under terms of the "Pre-Release Access to Official Statistics (Scotland) Order 2008", ISD are obliged to publish information on those receiving Pre-Release Access ("Pre-Release Access" refers to statistics in their final form prior to publication). The standard maximum Pre-Release Access is five working days. Shown below are details of those receiving standard Pre-Release Access and, separately, those receiving extended Pre-Release Access. Standard Pre-Release Access:
Scottish Government Health Department NHS Board Chief Executives NHS Board Communication leads Members of the Reproductive Health Advisory Group Members of SPMMRAG
Extended Pre-Release Access Extended Pre-Release Access of 8 working days is given to a small number of named individuals in the Scottish Government Health Department (Analytical Services Division). This Pre-Release Access is for the sole purpose of enabling that department to gain an understanding of the statistics prior to briefing others in Scottish Government (during the period of standard Pre-Release Access).
Scottish Government Health Department (Analytical Services Division) Early Access for Management Information These statistics will also have been made available to those who needed access to ‘management information’, ie as part of the delivery of health and care: Early Access for Quality Assurance These statistics will also have been made available to those who needed access to help quality assure the publication: Members of SPMMRAG
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12.9 Classification
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