Evidence-based maternity policy?

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This post is the text of an article I wrote earlier this year, around the time Better Births, the report of the National Maternity Review, was published. The original title was ‘Stillbirth: what politicians and the media fail to understand.’ What I think many fail to understand is figures and their context – and research evidence more broadly.

It seems to me that we can only have consistently evidence-based health policy when we have a  shared commitment in public life, and in public discussion, to a National Information Standard for talking about research evidence, and indeed for promoting public health messages. 

Why do I keep tweeting NICE CG138 s1.5.24 –  which is a National Information Standard, if people will choose use it? Those of you who have read ‘Thinking Fast and Slow‘ will understand why we need it: thinking about risk often involves ‘shortcuts’ and ‘rules of thumb’ that serve well in some cases, and less well in others (another blog post is needed to explore the topic!) We can, of course, support Each Baby Counts and the work of MBRRACE-UK, and acknowledge that addressing stillbirth rates is very important, while being equally clear that each and every time data is presented it must be properly contexualised. It serves women, their babies, and their families, poorly to present information without using absolute figures, framed both ways, (when possible) in a variety of formats.

So I wrote this article to express my frustration – that the public is so often presented with partial information, or information without context. And that this ‘problem with figures’, and indeed with understanding research evidence more broadly, seems to extend to, and affect, public policy initiatives.

Looking at some news items about maternity care in recent months, I have wondered whether government policy initiatives in maternity are intended to be evidence-based, and whether the press can be persuaded to be more evidence-aware. Unfortunately, ‘Babies harmed!’ makes a more dramatic headline than ‘Giving birth in this country is safer than ever,’ and ‘There are some evidence-based things, mostly not needing technology, that we can now do to ensure high quality, respectful care for all women’(1), which is arguably the overarching message of the Better Births (2) report published by the National Maternity Review.

On 10 June 2015 Jeremy Hunt tweeted: “Shocking that 1300 babies killed or harmed during childbirth last year: we must go further&faster to make the NHS the safest system globally”.

To be clear, stillbirth or the birth of an injured baby is a tragic event, and no-one would seek to suggest otherwise. It is, of course, important to try to find out what causes such events and to work to reduce avoidable harm to the absolute minimum. It is also important that public health information is clear and accurate.

The Minister’s comment followed an article in The Times that day (3) reporting that “the annual bill for NHS negligence in pregnancy has reached 31 billion after more than 1,300 babies were killed or maimed last year.” The NHS Litigation Authority report Ten Years of Maternity Claims (4) is useful background reading here. I am struck by the fact that that report, in referring to claims relating to use of ‘CTG’ (electronic monitoring of both fetal heart rate and uterine contractions in labour, which involves interpreting trace showing these features), says nothing about the evidence base for this technology, a screening test with high sensitivity but low specificity. A NICE panel (of which I was a member) recently noted, “At present, the evidence base for use of CTG by itself to monitor high risk labours is not strong”(5), “current practice assumes CTG has greater accuracy than the evidence demonstrates(6) and, “the reliability of interpretation of CTG recordings, both between different users and when carried out by the same person [has] been shown to be variable (section 10.9)(7).

Put simply, while CG190 recommends the use of CTG in labours at higher risk of complications, “the best available evidence to guide interpretation of CTG is limited(8) and assumptions about the certainty of what is ‘proved’ by many such traces—viewed, necessarily, retrospectively even as the trace is made—are arguably unwise. (Law and science—it seems to me—are not quite the same thing.)

What the press, and perhaps politicians, consistently fail to understand is this:

  • the stillbirth rate is a curve that is high at 24-27 weeks, falls to 37-41 weeks, and rises again from approximately 42 completed weeks of gestation (9,10)
  • the overall stillbirth rate (24 weeks onwards) is 4.2 per 1000 (11), of which 1 in 3 deaths occur at term (12)—so 1.4 per 1000 births (13)
  • the rate of intrapartum stillbirth (i.e. during labour) for all births 24 weeks onwards is 0.37 per 1000 births (timing is unknown in a further 0.21 per 1000) (14)

In most cases of stillbirth (86%), the baby has died before labour begins.(15) It is important to distinguish between stillbirth pre-term and at term: the causes may well be different, and the messages we give to women at term about ‘risk’ matter (in simple terms, whether a woman is frightened or not may affect how labour unfolds—oxytocin, the birth hormone, is secreted more readily when the woman is relaxed and not fearful).

It is estimated that complications of labour are the cause in 1 in 12 cases of stillbirth—this includes all stillbirths at or later than 24 weeks.(16) Fetal surveillance in labour, and intervention, may make a difference to the rate of intrapartum stillbirths; in some—but not all—of these labours CTG is in use (complications can occur in a labour not identified as being, or having become, at higher risk of complications, and the labour may still be ‘low risk’ when a baby is, sadly, born dead). Similarly, surveillance and intervention may make a difference to the rate of neonatal deaths (i.e. in the first 28 days after birth), currently 1.8 per 1000 live births.(17) The difficulty is not knowing in advance, or retrospectively, in which labours surveillance by midwifes or obstetricians might make, or did make, a difference.

Considering disability, only a very small proportion of cerebral palsy cases are caused by events during birth, and it is thought that at least 90% have an antepartum cause.(18)

It is in this context that Jeremy Hunt announced his plan to halve stillbirths and deaths among new-born babies by 20% by 2020, and by 50% by 2030, with the Department of Health (19) announcing:

… a £2.24 million fund [will] help trusts to buy monitoring or training equipment to improve safety, such as cardiotocography (CTG) equipment to monitor babies’ heartbeat and quickly detect problems, or training mannequins that staff can practise emergency procedures on.”

This prompted leading maternity activist Mary Newburn  (formerly Head of Research at NCT) to respond:

Jeremy Hunt … is strong on rhetoric but weak on detail. Evidence that ‘digital equipment’ saves lives is limited, so let’s not kid ourselves and get caught up in a technology race.(20)

She referred to the variation in clinical outcomes in maternity care across NHS trusts that is not explained by population differences, and added:

Clinical leadership from doctors and midwives; effective multi-disciplinary team working, including joint training; effective communication—both between staff and staff with service users; plus psycho-social support for women provided by continuity of midwifery care are all important, but not a quick fix. Look up the evidence (including the Cochrane review on ‘midwife-led-continuity-models’, by Sandall et al) and use it!

Better Births has now made evidence-based recommendations on the points that Mary mentions, and more, though at time of going to press with this article I, like many others, have not yet had time to read all seven evidence reports on which the main report is based (one needs time to appraise and reflect). A comment beneath the Maternity Review publication notice (21) makes a key point:

This all sounds wonderful—but says nothing that all those working in maternity services don’t already know and hasn’t been said before in previous maternity reviews. What this report doesn’t explain is how this is going to be achieved when finances are continuously being cut (in all areas of the NHS) and whether the review will be upheld and taken seriously by the powers that be.”

But what has funding already been given for? In general, more equipment, with a focus on use of CTG, in both the Sign up to Safety campaign endorsed by the NHS Litigation Authority (22) and the preventing avoidable harm in maternity care Department of Health capital fund scheme 2015 to 2016.(23)

But remember, in 86% of stillbirths, the baby has died before labour begins. So where might attention be focused to make a difference in these cases? In an extraordinary moment of speaking truth to power, a group of epidemiologists, researchers and others, including the Royal College of Obstetricians and Gynaecologists, wrote to The Guardian last November that public health is the key to cutting stillbirths:

…[the] proposed ‘maternity safety champions’ and the provision of ‘high-tech digital equipment’ offer no solution for the majority of stillbirths, which occur before labour.  Most preventable stillbirths in the UK are attributable to social factors that are shaped by poverty, deprivation, and income inequality: cigarette smoking, obesity, diabetes, alcohol use—with stillbirths being twice as common among mothers living in England’s poorest 10% of regions than the richest 10%. Resolving such a disparity is undeniably challenging; but even small improvements to population health far outweigh any ‘one-by-one’ approach … if the UK government wants any real hope of halving the stillbirth rate by 2030, it would do better to reverse the proposed cuts to public health funding—which provides vital services, such as stop-smoking programmes—and increase efforts to address the social factors that cause ill-health from the very start of life.(24)

What of the quality of maternity care generally? Indisputably there are improvements that need to be made—though among informed commentators there is agreement that services are safer than they have ever been (see for example the Better Births report on the significant improvement in quality and outcomes over the last decade (25))—in order to achieve the WHO’s preferred definition of quality, which includes women’s experience and woman-centred care, effective, efficient, equitable, timely and safe care.(26)

Some very simple measures to promote such quality of care could be based on current NICE guidance: for example, the CG190 Quality Standard for care of healthy women in labour and birth, summarised by Mary Newburn.(27)

Commissioners have a duty (a ‘best practice’ obligation, and a somewhat ambiguous one (28)) to take NICE recommendations into account in maternity service specifications. It will be interesting to see how soon commissioning can be effective in changing clinical practice at local level, and whether commissioners will cooperate effectively with local authorities to take public health measures that can reduce the stillbirth rate—indeed, whether they understand that they need to. Equally interesting to see whether, in time, press reporting about maternity becomes more evidence-aware, and national policy initiatives more evidence-based. The introduction to the newly published Saving Babies’ Lives care bundle from NHS England (p8—implement, and gather evidence en route (29)) might be encouraging or discouraging, depending on your point of view.

Original publication details (how to cite) follow the references.

References

1………. High quality, respectful care for all women: a concept detailed in the Birthrights Letter to the National Maternity Review, 2015 http://www.birthrights.org.uk/2015/08/letter-to-the-national-maternity-review/

2………. Better Births—Improving Outcomes of maternity series in England London, Maternity Review, 2016 https://www.england.nhs.uk/2016/02/maternity-review-2/

3………. Smyth C. NHS errors leave 13,00 babies dead or maimed. Times, 10 June 2015 http://www.thetimes.co.uk/tto/health/news/article4465692.ece

4……… NHS Litigation Authority, 2012. Ten Years of Maternity Claims. http://www.nhsla.com/safety/Documents/Ten%20Years%20of%20Maternity%20Claims%20-%20An%20Analysis%20of%20the%20NHS%20LA%20Data%20-%20October%202012.pdf

5………. NICE, 2014. CG190 Intrapartum Care for Healthy Women and Babies. https://www.nice.org.uk/guidance/cg190/evidence  (see paragraph 10.3.10.4)

6……… See 5, paragraph 10.3.10.2

7………. See 5, paragraph 10.3.10.5

8……… See 5, paragraph 10.3.10.6

9……… Manktelow BM et al, on behalf of the MBRRACE-UK collaboration. Perinatal Mortality Surveillance Report UK Perinatal Deaths for births from January to December 2013. The Infant Mortality and Morbidity Group, University of Leicester, 2015 https://www.npeu.ox.ac.uk/mbrrace-uk/reports  (see Table 10, page 60)

10…….. Hilder L, Costeloe K, Thilaganathan B. Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality. BJOG 1998;105:169–173  http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1998.tb10047.x/full

11…….. See 9, page iv

12…….. See 9, page xiii

13…….. Office for National Statistics, 2015. Pregnancy and ethnic factors influencing births and infant mortality: 2013. http://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/bulletins/pregnancyandethnicfactorsinfluencingbirthsandinfantmortality/2015-10-14  (see paragraph 1)

14…….. See 9, Table 3, page 22 (for both figures)

15…….. Calculated from 9, Table 2, page 21

16…….. See 9, page xiii

17…….. See 9, Table 3, page 22

18…….. NHS Choices, 2014. Cerebral Palsy—Causes. http://www.nhs.uk/Conditions/Cerebral-palsy/Pages/Causes.aspx

19…….. Department of Health, 2015. New ambition to halve rate of stillbirth and infant deaths https://www.gov.uk/government/news/new-ambition-to-halve-rate-of-stillbirths-and-infant-deaths

20……. Newburn N, 2015. Letter to the Guardian on Jeremy Hunt and how to address stillbirths and neonatal deaths. 16 November http://marynewburn1.com/2015/11/16/letter-to-the-guardian-on-jeremy-hunt-and-how-to-address-stillbirths-and-neonatal-deaths/

21…….. NHS England, 2016. Maternity Review sets bold plan for safer, more personal services https://www.england.nhs.uk/2016/02/maternity-review-2/

22…….. NHS Litigation Authority, 2016. Maternity Sharing Event http://www.nhsla.com/Safety/Pages/Maternity-sharing-event.aspx

23…….. Department of Health, 2015. Preventing avoidable harm in maternity care—Department of Health capital fund 2015 to 2016—successful bids https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/505164/Preventing_avoidable_harm_in_maternity__successful_bids_A.pdf

24……. Tennant P and 35 other signatories. Public health the key to cutting stillbirths. The Guardian, 25 November 2015  http://www.theguardian.com/lifeandstyle/2015/nov/25/public-health-the-key-to-cutting-stillbirths

25…….. See 2, paragraph 2.6

26……. See 1, referenced copy, page 5

27…….. Newburn M, 2016. New year—new NICE quality standards for care during labour and birth http://marynewburn1.com/2016/01/05/new-year-new-nice-quality-standards-for-care-during-labour-and-birth/

28……. NICE, 2014. Court Judgement: what it means for commissioners and providers https://www.nice.org.uk/news/feature/court-judgement-what-it-means-for-commissioners-and-providers-and-using-nice-guidance-and-standards

29……. O’Connor D. Saving Babies’ Lives A care bundle for reducing stillbirth. London, NHS England, 2016 https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf

Originally published by HealthWatch, the UK charity established 1991 to promote science and integrity in medicine. Please cite as ‘Stillbirth: what politicians and the media fail to understand’. Williams C. HealthWatchUK Newsletter 2016;101:1,6.

 

 

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