The pandemic has not only played with our lives or affected our mental health, but it has also laid bare inequalities and disadvantages faced by communities, otherwise ignored.
While the pandemic babies are no more than a miracle, new data has revealed that Black and Asian babies have higher stillbirth and infant mortality rates than their white counterparts. Stillbirth is defined as the absence of no signs of life in a baby delivered after 24 weeks of ingestion. Miscarriage is similar, but it happens in less than 24 weeks. 24 weeks is considered a period of viability, beyond which a baby can survive independently inside the uterus.
The disparities have been revealed after the Office of National Statistics (ONS) published stillbirth and infant mortality data by ethnicity for the first time. According to figures released for the period 2007 to 2019, Black babies have the highest rate of stillbirths, followed by Asian babies. There were 7.1 stillbirths per 1,000 live births among black babies born in 2019, while among Asian babies, there were 5.1 stillbirths per 1,000 live births. Among white babies, there were three stillbirths per 1,000 live births in 2019.
Data from the ONS showed that infant mortality rates are particularly high in the northwest of England and the West Midlands, where there is a substantial ethnic population, with social deprivation identified as a key factor.
Since the advent of the Covid-19 pandemic, studies from around the world have also reported a disturbing trend that depicts a significant rise in the proportion of pregnancies ending in stillbirths. According to research scientists, “pregnant women have received less care than they need because of lockdown restrictions and disruptions to health care” in many countries. This could have led to complications resulting in stillbirths.
Clea Harmer, Chief Executive at Sands (Stillbirth and neonatal death charity), said, “The most recent ONS statistics have confirmed that stillbirth rates remain highest for Black women and higher for South Asian and Asian women. We need urgent action to address this, and the government must set a target to reduce these clear inequalities in perinatal mortality.
“The good news is that for all ethnic groups the stillbirth rate is declining overall but we don’t yet know what the full impact of the Covid-19 pandemic has been. Although health inequalities relating to stillbirth had been gradually narrowing, we fear this trend may have reversed during the pandemic.
“Switching much of maternity care online because of Covid-19 may be disadvantaging some women from ethnic minority groups and we are concerned that issues of access to services have left many feeling unsure about, or delaying, raising any concerns about their pregnancy. At a time when inequalities in perinatal mortality and bereavement support have been highlighted by Covid-19, it is crucial to find ways to address these.”
Menstrual health in Covid-19
London based GP Dr Rupa Joshi explained the impact of the pandemic on menstrual and reproductive health. She said, “In general practice, we have seen many patients having issues with the menstrual cycle. In general, stress can cause it. Missing cycles, prolonged periods, and heavy bleeding can also be attributed to financial adversities and sometimes the pressure of living with multigenerational households. We have been seeing many families who have been trying to conceive babies but having difficulty due to the Covid pandemic.”
According to Dr Joshi, her sense is that many couples feel that this isn’t the right timing to bring babies into the world particularly with the uncertainty of finances, work, furlough etc.
“However, I would like to reassure families that medical care has continued as normal. In our practice, we have been able to see anti-natal patients in covid safe environments at different times, including our acute care patients. The same can be said for our postnatal checks and baby immunizations. Maternity care in hospitals has also continued as business as usual.
There has not been any reduction in normal anti-natal care such as ultrasound scans and blood tests, midwife and GP care,” Dr Joshi added.
Stillbirth and its glitches
Heena had a stillborn baby almost 10 years ago when she was 38 weeks pregnant. Speaking to Asian Voice, she shared her story and her assessment of what could have been done differently to save the pregnancy. She said that she got the scans, prenatal care, and blood tests. She said, “Because I lost my baby right at the end, what I thought was labour was me losing the baby. I went for a regular check-up.”
When asked what needs to be taken care of to avoid such unfortunate cases, Heena said, “If the baby is not moving then you should go with your gut instinct and flag it. You usually get limited scans which I don't think is enough to know what's happening inside. I haven't been given a reason why I lost my baby, but it was a placenta eruption. Why it happened, there's no reasoning. Especially first-time mothers are not confident, stress levels are different. That has a direct impact on the baby, there needs to be a more personalised approach to pregnancy or care.”
According to Heena, one shouldn’t blame or point a finger at the NHS for stillbirths. “It is not related to NHS.”
However, recently, according to a report in The Independent, NHS trust was fined £761k over avoidable death of baby in landmark prosecution. Baby Harry Richford died in November 2017 but the case has sparked an inquiry now examining almost 200 cases.
A coroner ruled the mistakes amounted to neglect by the trust which had failed to act on earlier safety warnings that could have helped prevent the tragedy.
What does the data say?
According to Harrow based Obstetrician-gynaecologist, Dr Parijat Bhattacharjee, unfortunately, the numbers on stillbirths have remained consistent and constant since 2000, which is roughly between 4 to 5 per 1000 life-births. However, in 2019, according to the Office of National Statistics in the UK, even though the absolute number of stillbirths were still 2346, the number of 1000 life birth was at its lowest per 1000, 3.8 per 1000 as compared to 5 per 1000.
Dr Bhattacharjee said, “The government strategy is to reduce the rates to half by 2025, half as compared to 2010. And therefore, the aim is to have 2.6 stillbirths per 1000 life-births in the UK. A couple of reasons that are thought of why there hasn't been a significant decrease in the number of stillbirths over the last 20 years or so, is possible because of an increase in maternal age and increase in BMI or obesity. Both have been associated with an increase in stillbirths. As of today, stillbirths cannot be entirely prevented even in the most modern healthcare systems of the world. Partly because more than half of the time, no cause can be found.
Probable causes and preventive measures
Explaining further, he said, “One reason why it cannot be entirely prevented is that in more than 50 per cent of stillbirths, no cause can be found. Among the causes that can be found, however, the most common reasons are probably a small gestational age that means the foetus is not growing well, mostly because the placenta is not functioning well. Sometimes there could be underlying conditions like diabetes, high blood pressure, but in many cases, no specific cause may be found. The way strategies are being suggested or implemented now in the UK is mainly about identifying the women in which the growth of the foetus is not happening well, and interventions are planned, or aimed and directed at that.
“Regular anti-natal clinical appointments are therefore a must and at present, it's suggested that the initial appointment is generally between 10-14 weeks when the pregnancy is confirmed, dates are confirmed, and a specific test is done to make sure that there's no specific chromosomal abnormality. Blood tests are also done around this time for the same reason. And at 20 weeks, another ultrasound scan is done to check the anatomy and structure of the baby and the location of the placenta. Following this, at least from 28 weeks onwards, women would have a clinic appointment with either a midwife or an Obstetrician at the hospital every four weeks and maybe more frequently if there are any other concerns.
“During this time, an assessment of the baby's growth is generally done by checking the length of the womb of the uterus from the pelvic bone which generally corresponds to the growth of the baby as well. And if there is any concern, then one should be referred to have an ultrasound scan to confirm or refute any discrepancy in the growth. If there are concerns, then more frequent ultrasounds can be done, and more clinic appointments may be needed.
How is the NHS helping?
Dr Parijat said that it is suggested to accurately estimate this discrepancy in the growth and to plot the growth. He mentioned, “Customised growth charts are being suggested and being implemented across the NHS hospitals. Apart from this, from the patient's point of view, keeping an eye on the movement of the baby is vital and for any change in the movement or reduction in movement, one needs to contact the midwife or hospital immediately. Hopefully in meticulous anti-natal care, acting on discrepancies or concerns, optimising the time of delivery, taking care of concerns, the number of stillbirths could be potentially reduced.
The second common issue associated with stillbirth is smoking. And therefore, history and reduction in smoking and referrals to appropriate smoking cessation services are vital. The third association is an increase in BMI. Optimising weight is vital. Particularly diabetes and high blood pressure.
The general causes we look for when, unfortunately, a stillbirth happens, are done by performing tests on the mother, the baby, sometimes on the father, the placental cord, and membranes. On the mother, tests are done to rule out infections like malaria (in developing countries), e-Colli, and any other infections. Blood, urine, vaginal and cervical swabs may need to be taken. The placenta and membranes may also need to be tested for infections. Occasionally, there may be structural congenital issues in the baby which could be evident on inspection, sometimes x-rays and modern tests could give more detailed information.There could be chromosomal and genetic abnormalities.
A post-mortem is a more comprehensive test on the baby and sometimes a full post-mortem is not feasible, either because the parents do not want it or it is not possible. There are other conditions, particularly the tendency to form blood clots which is called Thrombophilia, which may be hereditary or acquired and blood tests conducted on the mother maybe will reveal this. This sometimes increases the risk of various pregnancy complications like recurring miscarriages, stillbirths, which is characteristic of specific pregnancies and growth-restricted babies. Medical conditions like thyroid, diabetes may also be associated with stillbirths therefore any medical conditions can be optimised and monitored during the pregnancy to minimise the risk. Blood-thinning medications can be given for thrombophilia.
Dr Bhattacharjee also explained that 15-20 per cent of pregnancies result in a miscarriage and the chances of another miscarriage are less than 1 per cent. He termed it as “nature’s way of doing away with an abnormal conception”. Thyroid, PCOS, diabetes, thrombosis, immunological conditions, and malefactors may also contribute to miscarriages or stillbirth.
