Stillbirths and Infant Mortality — [Philip Davies in the Chair]

– in Westminster Hall at 2:30 pm on 26th March 2014.

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Photo of Tracey Crouch Tracey Crouch Conservative, Chatham and Aylesford 2:30 pm, 26th March 2014

It is a pleasure to serve under your chairmanship this afternoon, Mr Davies, although there is certainly no pleasure in the subject matter of this debate. The issue of stillbirth and infant mortality is a complete and utter tragedy for parents who lose their child. I have met a number of my constituents who have experienced the loss of a baby. Mothers, fathers and siblings have been devastated, left bereft and unable to comprehend what has happened and why. It was heartbreaking to meet them. However, what is equally heartbreaking is that here in the UK, which has arguably one of the best health services in the world, we have one of the highest rates of infant mortality in Europe and other parts of the developed world. It is shocking that we have higher infant mortality rates than countries such as Croatia, Lithuania, Estonia and Slovenia.

Sadly, unlike other countries we have barely seen any reduction in infant mortality rates in the last 20 years. Almost three quarters of child deaths under the age of 15 in the UK happen during the first year of a child’s life; more than half in the child’s first 28 days; and almost 40% in the child’s first week. These statistics do not include the one in 200 pregnancies in the UK that end in stillbirth. Stillbirths account for the death of a further 4,000 babies a year.

There are many reasons for perinatal, early neonatal and neonatal deaths, but I will concentrate today only on stillbirths and on sudden infant death syndrome or, as it is perhaps more commonly known, cot death. That is not because I have no interest in other forms of infant mortality, but so I can focus the Minister’s mind at this point on a few actions that might make the difference sooner rather than later. That said, I wanted to give a wide title to the debate today because I am aware that colleagues have other issues they may wish to raise.

The figure of 4,000 stillbirths per annum is far too high. I cannot imagine the horror of having to go through labour knowing that your baby is already dead. I met one lady who gave birth to her son, Henry, at 38 weeks, but he had not grown for 16 weeks. In the intervening weeks, she had forged a bond with her unborn son, named him and planned a life ahead, but it was one that would never be fulfilled.

Our NHS is brilliant and our midwives are fantastic, but I have yet to meet a woman who has gone through pregnancy without seeing more than one midwife. One lady told me that she had seen 12 different midwives during her pregnancy, which sadly ended in stillbirth. She felt that all 12 of them had different ways of measuring her. I am not going to criticise the midwives—they do not deserve criticism—but we need to ensure continuity of care throughout gestation, to give mothers some peace of mind.

Research that the National Childbirth Trust carried out with the Women’s Institute last year into women’s experiences of maternity services highlighted the shocking statistic that 34% of women were not given the name and phone number of a midwife to contact with any concerns. We must do more to encourage people to go into midwifery, and I hope the Government’s pledge to increase the number of health visitors will help in that regard.

However, we also need to improve our standard monitoring and measuring systems, making the most of modern technology. In the case of poor Henry, who had not grown for 16 weeks, it was clear that the measuring was not as good as it could have been. I accept that not everyone agrees with me on this, but I believe that we should be looking to increase the number of scans expectant mothers receive. Having a scan at 12 weeks and again at 20 weeks is fine, but unless a mother is anticipating complications, those are the only scans she will receive.

There are examples of the successful use of increased measuring and monitoring. The Rainbow clinic at St Mary’s hospital in Manchester, which is funded by Tommy’s baby charity, has taken huge and groundbreaking steps forward in understanding the risk profiling of mothers, and it has a great success rate because of its extra monitoring and measurement. I would like to see its work rolled out. The clinic’s test on those who are deemed to be at risk—possibly due to previous multiple stillbirths or miscarriages, which we know increase the risk of future stillbirths or miscarriages—allows those in the “at risk” category to receive further monitoring and measuring in the third trimester, when placenta problems usually occur, to allow earlier delivery if necessary to prevent stillbirth.

These preventive measures involve awareness raising and risk profiling, followed by improved measuring, with new techniques and monitoring through an increased number of scans. They have led to a significant increase in healthy babies being born to women in the “at risk” group. Although the study at the Rainbow clinic is on a small scale, it has a very high success rate. However, the clinic does not have the funding to expand its work and I urge the Minister to examine its work and give it her full support.

I am not an expert on placenta. However, given that we know it starts to break down at 38 weeks but we do not induce mothers until 42 weeks—a point when we know women carrying later are more at risk of losing their baby—we need extra research into this process and to determine whether this delivery time frame is still viable. I will not dwell on that now, but it would be helpful if the Department examined both the risks and the benefits of reconsidering induction as late as 42 weeks. I have spoken to women who have had stillbirths and many of them raised this issue with me. There is genuine concern about the length of time that women are carrying babies for, particularly those at the higher risk end of the spectrum.

This issue is not all the responsibility of the NHS and it is important that we raise awareness of reduced foetal movements, so that expectant mothers can spot early signs of distress. The Count the Kicks charity has fabulous self-monitoring support, empowering mums-to-be with knowledge and confidence, including a mobile phone app and tips for dads. This understanding should be universal.

If a stillbirth does occur, it is important that the parents receive all the support they need. The third sector does an amazing job of providing advice and bereavement support for parents who lose a child before, during or shortly after birth. However, we need to ensure that parents receive good care from the health service, whether that is by ensuring the appropriate equipment is available—such as cameras and other equipment to take handprints and footprints, with staff available who know how to use it—or by providing access to all the literature and available support and advice, including bereavement services. We must also ensure that parents receive correctly handled treatment; we must remember to treat them as parents even if they do not have a baby.

Photo of Phillip Lee Phillip Lee Conservative, Bracknell

I congratulate my hon. Friend on securing this debate. As someone who has professional first-hand experience of dealing with parents who have had a stillbirth, I know that it is an emotive topic but it is essential that we discuss it. Recently, Scotland produced a report outlining that its infant mortality rates are improving and it appears that it has a different approach to education, assessment and analysis of at-risk groups.

Photo of Tracey Crouch Tracey Crouch Conservative, Chatham and Aylesford

I am grateful to my hon. Friend for his intervention. It was a coincidence that the Scottish Government released their statistics on infant mortality yesterday, which showed that Scotland now has the lowest infant mortality rates in the United Kingdom. It has managed to do that by introducing some of the measures I have already proposed in this debate, such as extra monitoring, extra targeted intervention and support for those at highest risk. That work should be rolled out across the United Kingdom.

We must be very clear about the bereavement services and support that people receive. A local charity in Kent, Abigail’s Footsteps, is working with the Royal College of Nursing to establish a national standard of bereavement training that it would like to see universally implemented. That is absolutely fantastic. On top of that, however, one of the best ways to accomplish good care in all the areas I have mentioned is to create the job specification of bereavement midwives within the NHS. This suggestion is supported by Sands, the leading stillbirth and neonatal deaths charity. I fully support this proposal and urge the Minister to consider introducing a nationally recognised job specification for bereavement midwives, which I believe would ensure the best possible mental health of, and support for, parents whose babies die before, during or shortly after birth.

I am aware that people have suggested that this will be an additional cost to the NHS, but we need to remember that the cost to the NHS of supporting people with mental health concerns, as well as loss of productivity, because they have lost a child is significant—some £1.5 billion to £2.5 billion. Therefore, an early investment in such support services will make a massive difference.

A bereavement midwife would be familiar with all relevant policies and procedures. They could ensure that all protocols are up to date and that relevant paperwork and equipment is always available; ensure that there are high standards in bereavement care in every relevant hospital department; and liaise with others within the hospital, such as chaplains, neonatal and paediatric pathologists and mortuary staff. They would also be able to promote good communication and building relationships with primary care providers such as GPs, as well as external bodies, including the registrar of births and deaths, and to ensure that patients have access to all appropriate available support and literature.

We are lagging behind on stillbirths, and I think the Minister will agree that we need to do more. I have outlined just a few suggestions that would help, as proposed by those who work in maternity care and who have suffered the loss of their own baby during pregnancy.

As tragic as a stillbirth is, the sudden death of a baby who was born, named, taken home and then fell asleep never to wake again is something I cannot even begin to imagine. Sudden infant death syndrome, or cot death, was dramatically reduced due to the outstanding success of the “Back to Sleep” campaign that the Government launched in the mid-1990s. The campaign, reminding parents that babies should sleep on their back, not side or front, was highly successful and led to an outstanding drop in the number of cases of babies who died of sudden infant death syndrome. As a result of that campaign, the number dropped from five babies a day in the mid-1980s to five babies a week, where it has stubbornly remained ever since, even 20 years later.

Access to information is vital. The first thing we need to do is reinstate the literature that new mothers used to receive when they left hospital with healthy babies. Unfortunately, the helpful “Safer sleep” guide was caught up in the Cabinet Office’s bonfire of public sector communications, and now new mothers are expected to rely on other organisations providing information. The Bounty pack is brilliant, although it is not necessarily immediately available or universal; however, the information provided in it could be life-saving. Risk profiling is essential if we are to reduce SIDS. Mothers need to understand the dangers of alcohol, smoking, vitamin deficiency and obesity, both during and after pregnancy, as a matter of course and not just as an optional extra, because those are the biggest causes of preventable perinatal death.

The Lullaby Trust and Bliss do wonderful work together and are helping my own local authority in Medway, which has multiple areas of deprivation, to identify risk and support professionals targeting intervention. This is essential. The statistics speak for themselves. The cross-party report published recently by colleagues, entitled “1001 Critical Days”, found that 26% of babies in the UK are estimated to be living within complex family situations, which can heighten the risks for a baby’s well-being, and that drug and alcohol problems affect more than 109,000 babies. Targeting resources at higher-risk families, parents and babies will help reduce SIDS. It is essential to ensure that support and information are there for those who have premature babies, have babies young, or who are living in complex situations.

Furthermore, if we are really going to tackle infant mortality and reduce our embarrassingly high rates, we need to support, encourage and promote breastfeeding and improve access to “Healthy Start” vitamins, which are currently only accessible via named chemists. These should be available at all chemists. Investment should be made in both universal and targeted services, as recommended by the Healthy Child Programme. Where targeting has not made an impact—for example, vitamin D supplementation—universal approaches should be considered if they are also cost-effective. We need to highlight the message that this is not an optional extra, but is vital to ensuring foetal welfare.

We must improve awareness of smoking cessation services and the harm caused to unborn children by smoking. Similarly, we need to ensure that people understand the dangers of smoking for those who have been born. We must also do more to discourage binge drinking during pregnancy. I was shocked to learn that 18% of women still binge drink—that is, drink more than six units in one session—while pregnant, often leading to foetal alcohol syndrome.

I know I have not covered everything in this debate, but I hope it is a useful start. I thank the Royal College of Paediatrics and Child Health, Tommy’s, Sands, Kent Sands, Bliss, the Lullaby Trust, Abigail’s Footsteps, Together for Short Lives, the National Childbirth Trust, the Women’s Institutes and Bounty for their briefing materials in advance of this debate. And I thank, in particular, the mothers and fathers I have met who have spoken movingly about their own personal tragic experience.

The Prime Minister said he wants to make sure that Britain is the best place to end life. Today, I am calling for us to work together to make Britain the best place to start life and give every expectant mother all the support they deserve. I look forward to the Minister’s response and the contributions of other Members, and thank them for taking the time to be here this afternoon to discuss this important issue.

Photo of Tim Loughton Tim Loughton Conservative, East Worthing and Shoreham 2:45 pm, 26th March 2014

It is a pleasure to serve under your chairmanship, Mr Davies. I congratulate my hon. Friend Tracey Crouch on an excellent speech and on raising the profile of this much neglected but hugely important subject for many of our constituents who have been through the pain of stillbirth, infant mortality or perinatal mortality.

I am, slightly shamelessly, going to use this debate as a further opportunity to plug the ten-minute rule Bill that I put before the House on 14 January, with the support of my hon. Friend the Member for Chatham and Aylesford and other hon. Members. I am pleased to see the Under-Secretary of State for Health, my hon. Friend Jane Ellison here, as she sat in on that ten-minute rule Bill. I am glad that her colleague at the Department of Health has now, I hope, agreed on a meeting to take that forward; some of us can take constituents affected by stillbirth to that meeting and see whether we can bring about the change in the law that I will come back to in a minute.

I echo the accolades that my hon. Friend the Member for Chatham and Aylesford bestowed on all the organisations that have an interest in this matter and have for many years, quietly but assiduously, been campaigning for better care for people bereaved by stillbirths or who lose their children at an early age, giving support and advice and campaigning for improvements and changes in the law.

This is quite a complicated area. Although the debate is entitled “Stillbirths and Infant Mortality”, we talk about neonatal deaths, perinatal deaths and post-neonatal deaths—those deaths between 28 days and a year after birth—as well as infant and stillbirth mortality rates. However, across all those fields the record of the United Kingdom is not good. My hon. Friend contrasted the UK’s record with the great progress made on sudden infant deaths, particularly on cot deaths, during the “Back to Sleep” campaign. A concerted, focused and well promoted campaign led to a decrease of more than two thirds in the horrific spate of cot deaths that afflicted so many families. It is perplexing and worrying that, although there has been some progress in reducing mortality rates across the board, pre and post-birth, they still remain alarmingly and unacceptably high, certainly compared with European partners.

Total perinatal mortality rates now stand at some 7.4 per 1,000 live births in this country. In comparison, the figure for Finland, which has the best record on this front, is 3.2 per 1,000 live births, and even Portugal, which has challenging questions to face about infant health, has a rate of 3.8 per 1,000 live births. We are still way behind. An awful lot of those perinatal mortalities, particularly the stillbirths among them, remain completely unexplained.

We also have to add miscarriages to the figures, which apply only to the official recognition of stillbirths as embryos born dead after 24 weeks. Those figures, of course, do not include miscarriages, yet more than one in five pregnancies in this country ends in miscarriage, which means that more than a quarter of a million of our constituents are affected by miscarriages each year. The problem is huge.

Most miscarriages happen in the first three months of pregnancy. Some women may hardly know that they have had a miscarriage, and some may have miscarriages without knowing they were pregnant in the first place, but many women, including some constituents who have come to me since I presented my ten-minute rule Bill, have miscarriages well into their pregnancy, when the grief, trauma and distress of losing a hoped-for child is that much greater.

The way in which we support women who have been through such experiences is also worrying. Research by the Miscarriage Association found that 45% of women who have experienced a miscarriage did not feel well informed about what was happening to them. Only 29% feel that they were cared for emotionally, and nearly four out of five, 79%, received no aftercare. We know that at least one in six women—a very large number—experience some form of perinatal mental health problems. That has a great cost, socially and emotionally to those women and financially to our national health service. It is a false economy not to ensure that we support those women, whether they have suffered a miscarriage early or late, or whether they have suffered a perinatal mortality either before or after birth.

Photo of Phillip Lee Phillip Lee Conservative, Bracknell

On the subject of false economies in the national health service, historically we have spent significant sums on antenatal care without a lot of evidence to support that expenditure. Does my hon. Friend agree that we need to concentrate resources in the appropriate hands? We need appropriately staffed maternity units—there are worrying statistics about midwifery-led versus obstetric-led maternity services—and by doing that we can address our infant mortality rates, which compare poorly with those of our European neighbours. As politicians, we must also accept that doing that would involve reconfiguring services. There would be fewer maternity units and perhaps more obstetricians.

Photo of Tim Loughton Tim Loughton Conservative, East Worthing and Shoreham

My hon. Friend has great hands-on experience, and he knows a lot more about this subject than I do. He opens a far greater debate on the accessibility of maternity services. I am sure I am not alone in having marched and campaigned for the retention of midwifery-led maternity services at a local hospital. Interestingly, the biggest growth in mothers giving birth at that hospital has been among those who live outside the Worthing catchment area. Those mothers choose to go to the hospital.

Photo of Phillip Lee Phillip Lee Conservative, Bracknell

I want my hon. Friend to know that I campaigned to close my local midwifery-led unit because it was not delivering many babies—it was delivering less than one baby a day. I have real concerns about the potential for increased infant mortality in such midwifery-led units.

Photo of Tim Loughton Tim Loughton Conservative, East Worthing and Shoreham

It is horses for courses. I am glad to say that my maternity unit delivers well in excess of 3,000 babies a year. It is a centre of excellence, and the customer votes with her feet by choosing to go there from outside the area. My hon. Friend is absolutely right that the assessment of units must be primarily based on the quality and safety of care for mothers, but I fear we are straying slightly beyond stillbirths and infant mortality rates into the availability of maternity services and hospitals. You would not want us to go there, Mr Davies.

My hon. Friend also raises an interesting point about delivering services in the most appropriate way. There are certain constituencies of women and certain parts of the country where the problem is that much greater. To take one of the classifications, the infant mortality rate in the UK overall is 4.4 deaths per 1,000 live births, but the variations for mothers born outside the United Kingdom are worrying. For babies of mothers born in the Caribbean, the figure more than doubles to 9.6 deaths per 1,000 live births. For babies of mothers born in Pakistan, the rate is 7.6 deaths per 1,000 live births, and so on.

There are also regional variations, particularly for perinatal mortality overall. In the south-west, the figure is 4.7 deaths per 1,000 live births, but in the north-east it is 5.8 deaths per 1,000 live births—a 23% difference. Why are there those differences? We simply do not have enough research; we have not commissioned and are not doing enough research to find out why certain types of women and certain geographical locations are faring worse. Such research would enable us to focus, say, additional scans or support services, or whatever is required, to ensure that we make the best use of our NHS resources. My first call is for there to be rather better research across perinatal mortality.

Photo of Gregory Campbell Gregory Campbell DUP, East Londonderry

On geographical differences, we heard earlier about the improvement recently reported in Scotland. Does the hon. Gentleman agree that when Ministers from across the United Kingdom and beyond meet either at a joint ministerial council or at other levels, best practice, where it has been established, should be carefully researched and, where possible, implemented immediately?

Photo of Tim Loughton Tim Loughton Conservative, East Worthing and Shoreham

I agree. My hon. Friend Dr Lee gave the example of Scotland, where people have clearly examined the matter a bit further; they appear to be achieving more than people in other parts of the United Kingdom. We should be sharing that best practice, rather than being parochial and not sharing it beyond the United Kingdom, with or without Scotland after 18 September. That goes beyond sharing ministerial best practice on health issues; I would guess that not just health considerations but deprivation, housing and other local environmental factors are involved, too. More than just the Health Ministers of the respective parts of the United Kingdom need to be involved. If we compare deprivation with infant mortality rates, some signs certainly start to emerge.

Last year there were 3,558 stillbirths; in 2011 there were 3,811 and in 2003 there were 3,612. The stillbirth level has remained persistently high for a long time. One in 200 pregnancies ends in stillbirth, but stillbirths are currently defined in law as being after 24 weeks of gestation, which still means that there are 15 times more stillbirths than cot deaths—the progress on cot deaths was alluded to earlier. The problem with the definition is that it masks the higher number of stillbirths that happen before the 24-week gestation qualification currently in legislation. If a woman gives birth to a stillborn child at 23 weeks and six days or earlier, the child counts not as a stillbirth but as another “miscarriage.”

That was the case for my constituent Hayley, who came to see me and was present when I presented my ten-minute rule Bill in January. She had been through the dual tragic experience of giving birth to a stillborn son at about 19-and-a-half weeks. She had to have her pregnancy induced, and she went through labour. She experienced all the pains and anguish of labour in a hospital for more than 24 hours before giving birth to her son. She and her partner, Frazer, held their son and took handprints and photographs. To all intents and purposes, their son had been born, but sadly born dead. In the eyes of the law, their son did not exist, because he had been born after less than 24 weeks. That child had no recognition in the eyes of the law. Some months afterwards, Hayley tragically went on to have a miscarriage after five or six weeks. Those two experiences were different—that is in no way to belittle the pain, anger and trauma of going through a miscarriage—but in the eyes of the law, they were identical: neither of those children was recognised as having been born.

That is what my Bill is all about. Since introducing it, I have been swamped by the experiences of women and families up and down the country. To take one example, a woman gave birth at about 21 weeks to twins. It might have been slightly more than 20 weeks—I forget now—but it was less than 24 weeks. One of the children was born just alive and lasted for a few hours. The other twin was born dead. As the first was born alive, albeit at less than 24 weeks, that child was recognised. The other twin, born dead, did not exist. How traumatic and cruel is that on the part of the state? Someone gave birth and had two dead children, but only one existed in the eyes of the law. That is why the law needs to change.

I will persist with the Bill well beyond the confines of this Parliament, when it will expire because of the constraints of this place, until I persuade the Government to take the issue on. It is about fairness and recognition for people who have had to go through trauma, anguish and pain unimaginable to those of us lucky enough to have had healthy, albeit slightly annoying, children. It is not acceptable for those who have lost a child before that child was ever able to breathe then to have the second blow of the state not recognising that child.

My Bill would amend the Births and Deaths Registration Act 1953, but not in a way that says that we should redefine the 24-week limit. I do not want to make it 23 weeks or 22 weeks; this has absolutely nothing to do with abortion thresholds and things like that. I want to make a differentiation between what are clearly miscarriages and instances of when women, to all intents and purposes, go through all the pains and experiences of giving birth to a child. The definition in my Bill of a “stillborn child” does not mean a child born dead from 24 weeks’ gestation onwards, but

“a child which has issued forth from its mother and which did not at any time breathe or show any other signs of life, following the recognised processes of labour including regular, painful uterine contractions resulting in progressive cervical effacement and dilation; and the expression ‘still-birth’ shall be construed accordingly.”

It is a bit technical and a bit physical, but it is a way of giving some comfort to mothers: if they gave birth to a stillborn child, it would be a birth. The Bill would say that they had had a child, that there had not been a miscarriage and that the state should recognise that.

We have not introduced the Bill to meddle with the abortion laws—it has nothing to do with that—and it is not intended to meddle with bereavement leave entitlements or benefit entitlements. The more enlightened employers of someone who has been through such an experience would give the employee some allowance on the time they need to get over the death. For them to receive some sort of closure and to give them the support and relief that they desperately need to be able to move on, the state needs to recognise what they have been through in giving birth to a stillborn child.

At the moment, a hospital or clinical practitioner can issue a certificate of birth. It has no status in law. It is of some comfort to some people, but it is certainly not sufficient comfort for many of our constituents. That is why I am putting forward the changes to the law. They are simple and do not involve a lot of cost, but they would offer huge support, relief and comfort for mothers and their partners who have been through these sorts of experience.

As well as wanting to change the law and calling for better research into why we appear to be so vulnerable to perinatal mortality and stillbirths, we need greater research and better guidance. I do, however, pay tribute to the existing guidance, particularly that issued by the Royal College of Obstetricians and Gynaecologists on recurrent first and second trimester miscarriage, and some of the best practice.

I echo the points that my hon. Friend the Member for Chatham and Aylesford made about foetal alcohol syndrome, which strays slightly beyond the confines of the debate. When I was a shadow Health Minister, I considered the issue. I visited children’s homes in Copenhagen that specialised in children born with foetal alcohol syndrome. In many cases, the child was born to parents from Greenland’s Inuit community, which has high alcoholism rates. A lot of research has been done on that in Denmark.

It is undeniable that a lot of our children are being damaged due to excessive drinking through pregnancy and that an awful lot of that is not being properly diagnosed. In my simple layman’s view, a lot of the symptoms have parallels with autism and the autism spectrum, and there may be links between autism and foetal alcohol syndrome.

The issue is very little researched in this country, but it potentially affects an awful lot of our children, and we need to do much more to identify it. More importantly, we need to give clear, stark, but accessible warnings to women about the practical perils of drinking irresponsibly at all stages during pregnancy. That is not to say that pregnant women must not drink at all, but we need to set out clearly what is and is not tolerable, just as we should for women who smoke during pregnancy.

To make a side point—a point I made during a debate on the Children and Families Bill—I cannot understand why the Government have set criminalising smoking in cars with children in them as a priority, yet have done nothing to criminalise, if that is the principle they want to follow, smoking for pregnant women whose foetuses are in rather more confined spaces than the back of a car. Smoking and drinking are highly damaging to children before and after they are born. People are irresponsible if they do that, and we need a much clearer and more pungent health message to mothers. We need to disseminate best practice better than we do now, whether that is from Scotland or other parts of the country that appear to have achieved some success in reducing some of these mortality rates.

This is a bigger public health crisis than we have given it credit for. I have met constituents and heard some tragic stories from around the country of families who have been through stillbirths and other perinatal mortalities. We need to take this issue much more seriously.

Photo of Jim Shannon Jim Shannon Shadow DUP Spokesperson (Health), Shadow DUP Spokesperson (Transport), Shadow DUP Spokesperson (Human Rights)

I apologise for not being here on time; I had a Committee to go to. This issue is important to all of us here, as well as to those outside the Chamber. In Northern Ireland, there are four infant fatalities a week. The UK mainland has 17 to 19 infant fatalities a day. Obviously, the populations are different, but that figure tells its own story. Does the hon. Gentleman feel—perhaps it will be in the Minister’s response—that those in the health service should consider why the infant mortality rate is so low in Northern Ireland?

Photo of Tim Loughton Tim Loughton Conservative, East Worthing and Shoreham

I agree with my hon. Friend, who is a co-sponsor of my Bill. Mr Campbell made references to Northern Ireland, and earlier in my speech—I think before my hon. Friend entered the room—I did flag up the regional differences between parts of the United Kingdom. Far more research must be done to discover why certain parts of the United Kingdom are affected more or less than others and why women of certain ethnic backgrounds are affected more. We simply do not have the level of research to discover why such things are happening so we cannot better target our resources, as my hon. Friend the Member for Chatham and Aylesford mentioned earlier.

Finally, we need more work on mental health support for women before and after giving birth. There have been too many tragic stories of women self-harming or, in extreme cases, taking their own life and those of their children. We need better targeting of resources and better diagnosis of mental health problems. We need health visitors—I hope we will get the phalanx of new health visitors that the Government have rightly committed to provide—who can work with new parents and get into homes, where there is a much better chance of spotting problems. They can refer on to mental health services or parenting skills classes through children’s centres. That will form an important part of dealing with the epidemic of perinatal mental illness, in particular for first-time mothers.

This is an important subject for constituents across the country. The Minister is sympathetic to the problem and the Government would like to do more. Working with the royal colleges and some of the excellent charities, which have worked tirelessly over many years, we can get a better solution for better support for families who suffer from the pain of infant or perinatal mortality and hopefully do more to prevent the problem from occurring in the first place.

Photo of Andrew Gwynne Andrew Gwynne Shadow Minister (Health) 3:11 pm, 26th March 2014

It is a pleasure to serve under your chairmanship, Mr Davies. I pay tribute to Tracey Crouch for securing this important and sensitive debate. There are few more pressing issues than protecting the health of small babies and reducing the deaths of babies under one.

I want to put on the record my appreciation of the Rainbow clinic at St Mary’s hospital in Manchester. Mancunians—I am proud to be one—are incredibly proud of the work not only of the Rainbow clinic, but of St Mary’s in general. It is a centre of excellence for Greater Manchester and the north-west, and I am not just saying that because I was born there as a premature baby almost 40 years ago. It genuinely is a superb facility not only for babies, but for mums, and I commend its work, just as the hon. Lady has done.

Members on both sides of the House will know from their experiences and as constituency MPs the heartbreak and pain that the death of an infant can cause a family. I was particularly touched by the powerful speech by Tim Loughton about stillbirth. From a recent tragic occurrence in my family where stillborn twins were induced, I sadly know just how painful such an experience can be not only for parents, but for family members and how upsetting losing a child before birth can be. I know how unfair the law is; those children are not legally recognised by the state. The hon. Gentleman is absolutely right that it is important that the law be changed to reflect the realities, so that parents and grandparents can get closure, support and relief during such dreadful occasions.

We have seen some significant advances over the decades. It is easy to forget where we have come from, but we should recognise the work of health professionals and scientists to reduce the infant mortality rate in England and Wales to its lowest levels. In 1981, there were 11.1 infant deaths per 1,000 live births. In 2011, that had dropped to 4.2 per 1,000, equating to a 62% decrease over 30 years. It is worth reminding ourselves that, in 1911, before the introduction of the social security system and the NHS, the rate was 130 deaths per 1,000 live births.

One result of the major improvements in public health over the 20th century, such as slum clearances, the provision of fresh water, mass inoculation, health screening and the NHS, has been a huge reduction in the tragedy of infant mortality. I am proud that the previous Labour Government reduced infant mortality by 27% between 1997 and 2010, which equates to more than a thousand fewer baby deaths a year. As we have heard today, however, there is no room for complacency. Hundreds of babies still die each year from perinatal respiratory problems, bowel failure or infection. Such deaths are not evenly distributed across our society, which raises critical questions as to how we tackle health inequalities. In his groundbreaking report on these matters, Sir Michael Marmot said that

“one quarter of all deaths under the age of one would potentially be avoided if all births had the same level of risk as those to women with the lowest level of deprivation”.

Things are getting better, however. We achieved our ambition to narrow the gap of infant mortality by at least 10% between routine and manual socio-economic groups and the England average, but there is still far more work to do.

Office for National Statistics infant mortality statistics for 2011 show that infant mortality rates were highest for babies with fathers employed in semi-routine occupations, such as shop assistants or care assistants. One of the Minister’s predecessors as Minister responsible for public health, Anne Milton, has said that disadvantaged groups and areas have higher infant mortality rates and that poor health outcomes such as that are often linked to social factors, including education, work, income and the environment. I welcome the Government’s recognition of the link between poverty, housing, diet, neighbourhood and health, a point which was made powerfully by the hon. Members for East Worthing and Shoreham and for Chatham and Aylesford. We must continue to tackle the conditions that cause health inequalities and the unfair distribution of infant mortality across society. There is no good reason why, in the seventh richest country on this planet, the likelihood of a family’s baby surviving its first year of life should depend on their socio-economic background. Will the Minister address directly the inequalities around infant mortality and still birth?

We should also note that women over 40 are at greater risk of having a baby who dies before it is one year old. Women under 20 are at greater risk, too. Will the Minister’s speech address how health services can be specifically targeted to support pregnant women over 40 and under 20?

There is a growing understanding that early intervention is the key to preventing infant mortality. The Royal College of Paediatrics and Child Health states:

“The evidence quite clearly states that early intervention is the best form of prevention. Early intervention will not only lead to significant financial savings in the medium to long term, it is underpinned by sound science.”

A healthy pregnancy begins before conception. Action on health issues before pregnancy can prevent many problems for the mother and baby.

The hon. Member for East Worthing and Shoreham made a powerful point about understanding risk factors such as exposure to smoke and prenatal drug or alcohol use by mothers, but there are also positive steps that pregnant women can take to improve their and their unborn baby’s health, such as maintaining a healthy diet and weight, getting the right vitamins, taking folic acid and regularly being physically active. Women need proper advice, information and support to help them to understand the risk factors and make informed, healthy choices. What is the Department of Health doing to promote early intervention, and what resources is the Minister making available for that?

Of course, appropriate information continues to be important during pregnancy and after the child is born. Midwives and health visitors are our most crucial resource in ensuring that women have the information they need at every stage, and in supporting the development of confident, effective parenting. Forming trusting relationships with the women they care for is a critical part of the process, but many women do not have one midwife or health visitor whom they see regularly and with whom they can build a relationship. I hope that the Minister will explain what steps the Government are taking to deal with the problem and improve the consistency of care that women receive in pregnancy and after the birth of their child.

Two hundred babies a year die of sudden infant death syndrome and I welcome the work of the Lullaby Trust and the charity Bliss, which do an important job in advising and supporting parents in that connection. Tragically, five babies a week die without any explanation. Thanks to the “Back to Sleep” campaign, which advised parents to encourage their children to sleep on their backs, the figure is down from five babies a day in the mid-1980s; but five babies a week is still five too many, and I should like to know what the Minister and the Department are doing to try to reduce the figure further.

We have come a long way, but we still have some way to go. Advances in medical science must be matched by provision of NHS services and other social services in every part of the country. No one should be significantly disadvantaged by where they live. For pregnant women and young mothers to take responsibility for their health and that of their babies, they need the warm embrace of a strong system of health care, advice and support. If we want the coming decades to be characterised by further falls in infant mortality, and if we want many fewer families to suffer the terrible tragedy of a baby’s death, we need a continued, concerted and co-ordinated effort throughout Government.

I congratulate the hon. Member for Chatham and Aylesford on securing the debate, because it is important to discuss the matters in question. It was perhaps remiss of me not to convey the apologies of my hon. Friend Luciana Berger, the shadow Minister who leads on these issues. Sadly, just before the debate, she dislocated her shoulder and hopefully she is now receiving excellent NHS treatment at accident and emergency. I know she would want to pass on her thanks and appreciation to the hon. Member for Chatham and Aylesford for securing the debate and raising an important matter.

Sitting suspended for a Division in the House.

On resuming—

Photo of Jane Ellison Jane Ellison The Parliamentary Under-Secretary of State for Health

It is a pleasure to serve under your chairmanship, Mr Davies. Like others who have spoken today, I congratulate my hon. Friend Tracey Crouch on securing a debate on a sensitive issue that it is incredibly vital that our nation make more progress on. I apologise that the

Under-Secretary of State for Health, my hon. Friend Dr Poulter, whose portfolio covers this policy, is not here to respond, but I undertake to report back to him and to refer him to colleagues if I am unable to respond to anything today.

The death of a baby, whether during pregnancy or following birth, is of course a tragedy. Colleagues have eloquently described the devastating impact on families of losing a baby to stillbirth or during the first year of life. Although stillbirth is now at its lowest recorded rate in England since the definition changed in 1993, a study published in The Lancet in 2011 ranked the UK 33rd worldwide on stillbirths, below a great many other high-income countries. As has been said, being in that place in the league table is not a record we can be proud of. We are making progress, which I will describe, but as everyone accepts we clearly need to do more and to be in a better place. Similarly, infant mortality rates are at historic low levels, but still higher than the European Union average.

Although the stillbirth rate has decreased dramatically over the past 50 years, until recently it had not declined significantly since the 1990s. My hon. Friend referred to that sense of stalled progress. Thus, the rate for England and Wales in 1993, when the current definition was introduced, was 5.7 stillbirths per 1,000 total births. By 1999 the rate had fallen to 5.3, but 12 years later, in 2011, it had not really changed, at 5.2. It is encouraging that the rate has now started to fall. The rate for 2012 was 4.8 stillbirths per 1,000 total births, which is the lowest rate recorded in England since the definition changed. Although that is a statistically significant fall, which we all welcome, we recognise that the decline in stillbirths in the UK has not kept pace with that in other comparable countries. My hon. Friend also demonstrated that across the UK we do not necessarily have even rates of progress. The decline in the infant mortality rate has been more encouraging, that in England falling from 5.2 to 4 deaths per 1,000 live births between 2002 and 2012, although that remains higher than the EU average, as I said.

Such reductions are welcome, but the rates in England are still high and there is considerable scope for future reduction. That is why we have a wide range of initiatives in place that will help to reduce stillbirth and infant mortality rates, and tackle health inequalities. The shadow Minister, Andrew Gwynne, and others, were right to refer to the relevance of this issue. It remains a source of concern that we sit where we do in international league tables.

What can be done to reduce the number of stillbirths? As colleagues have said, stillbirth has many causes, some of which are known and some not. That is one of the challenges: we are so used to identifying exactly what a problem is, what we need to do and the resources necessary to tackle it; but here we are in slightly strange terrain, in that we know some things but not enough. The known causes include lifestyle issues such as smoking and obesity; medical causes affecting the woman, baby or placenta; demographics; and the safety and effectiveness of the maternity care given.

On reducing the risk of stillbirth, an important first step is to raise the issue’s profile, so that people are aware that it needs to be dealt with and is not simply one of those things to be accepted and about which little can be done. It is not acceptable to have one of the worst stillbirth rates in comparison with similar countries. We have therefore included stillbirth and neonatal mortality as an area of improvement for the NHS in its outcomes framework. We have identified it as an area in which we need to do much better.

A range of research has been conducted that demonstrates that women who access antenatal care late have poorer outcomes. Early access to antenatal care is therefore pivotal to improving health and well-being outcomes for women and their babies. In line with the guidelines of the National Institute for Health and Care Excellence, women should have an assessment of their health and social care needs, risks and choices as early as possible in pregnancy. That enables midwives to provide pregnant women with important lifestyle messages —for example, about diet, exercise, smoking and drinking —and to identify any pre-existing conditions that might require additional support. I will say more about public health later, but I can only share in the alarm expressed by Members at some rates of drinking—quite heavy drinking—during pregnancy, for example. According to the national statistics on that, there is great variation between local authorities. I will touch later on one of the reasons why we think public health sits so well within local authorities, which are in a position to tackle that regional variation.

The Department and NHS England are working with a number of key partners, including the stillbirth charity Sands, Public Health England, the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists, to take forward a stillbirth prevention work programme. The programme covers a range of initiatives, including raising awareness of the known risk factors among pregnant women and health professionals. That will ensure that women receive consistent advice on how to minimise the risk of stillbirth—including the importance of healthy eating and the other lifestyle issues that have been raised—are aware of foetal movement and what is normal for their baby, and know where to go for help if they suspect there is a problem. It is important that each stillbirth is investigated and lessons are learned. We are therefore working with NHS England to explore how standardised perinatal death reviews could be introduced.

Growth-restricted babies are up to eight times more likely to be stillborn than non-growth-restricted babies. My hon. Friend the Member for Chatham and Aylesford is aware of the encouraging results we have achieved in reducing the stillbirth rate in the three regions where uptake of the Perinatal Institute’s growth assessment protocol training package—the GAP programme—was most prevalent. Following discussions with the Perinatal Institute, NHS England is encouraging uptake of the programme across the NHS in England. More than 75% of trusts in England have already signed up for that training.

Photo of Tracey Crouch Tracey Crouch Conservative, Chatham and Aylesford

Will the Minister elaborate slightly on that training? Given the example of my constituent whose son, Henry, was stillborn at 38 weeks but had not grown for 16 weeks, the measurement tools currently available to midwives are clearly simplistic and some more sophisticated technology for measurement could well be of use. Will she elaborate on whether the new system is using more sophisticated technology? That is one reason why having an extra scan could help with early intervention, by identifying any growth problems sooner.

Photo of Jane Ellison Jane Ellison The Parliamentary Under-Secretary of State for Health

My hon. Friend has asked an extremely good question. I hope she will allow me to reply after the debate—I do not have an answer readily to hand, as the subject is not in my policy portfolio. I will come back to her on that, because it is a good question.

Although we know some of the risk factors for stillbirths, other causes are unknown, and it is important that we gain a greater understanding of those. The NHS National Institute for Health Research funds a range of research relating to causes, risk factors and prevention of stillbirth and neonatal death. Both the NIHR Cambridge and the NIHR Imperial biomedical research centres have ongoing research programmes on women’s health, including research relevant to the prevention of stillbirth and neonatal death.

In addition, the NIHR health technology assessment is funding three significant trials. The first is a £6 million trial of an intelligent system to support decision making in the management of labour using the cardiotocogram, or CTG. The second is a £1.4 million trial of nicotine replacement therapy in pregnancy, led by the university of Nottingham. The third is a £1.2 million trial of physical activity as an aid to smoking cessation during pregnancy, led by St George’s, university of London.

My hon. Friend referred to the Tommy’s stillbirth research centre at the university of Manchester, which is conducting innovative research that focuses on the unborn baby’s life support machine—the placenta. It has opened the Manchester placenta clinic, which combines specialised antenatal care for pregnancies affected by foetal growth restriction with front-line research into why the condition occurs and how it might be treated. The Government also fund MBRRACE-UK, or Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the United Kingdom, which is continuing the national Confidential Enquiry into Maternal Deaths and national surveillance of late foetal losses, stillbirths and infant deaths.

I turn now to bereavement support and counselling, which were quite rightly raised during the debate. It is obviously important that women who have suffered a miscarriage, stillbirth or neonatal death receive evidence-based care, in an appropriate location, which supports both their physical health and their emotional well-being. In December 2012, NICE published clinical guidance that offers evidence-based advice on the diagnosis and management of ectopic pregnancy and miscarriage in early pregnancy—that is, up to 13 completed weeks of pregnancy.

We expect maternity care providers and commissioners to give due regard to NICE guidance and to ensure that there are comprehensive, culturally sensitive services and facilities for the management and support of families who have experienced a miscarriage, stillbirth or neonatal death. Skilled staff should of course be available to support parents. I take on board entirely the point that that picture might sometimes be inconsistent. Clearly, we have to work towards greater consistency. As I often say when we have debates such as this, it can only be a good thing that Parliament continues to demonstrate its great interest in this area, as we can demonstrate to those who provide and plan our health services that Parliament has shown a particular interest. Today’s debate provides another opportunity for us to do that.

In May 2012, the then Secretary of State, my right hon. Friend Mr Lansley, pledged that women who have suffered a miscarriage would get more support from the NHS. Over the past two years, the Department has awarded £35 million in capital funding to improve NHS birthing environments, including facilities for bereaved parents.

My hon. Friend the Member for Chatham and Aylesford raised the issue of scans. There are currently no plans to introduce routine scans in the third trimester of pregnancy to monitor foetal growth and development. I recognise that there is a challenge to that policy. The UK national screening committee advises Ministers and the NHS in all four countries of the UK about all aspects of screening policy, and supports implementation. It uses evidence based on research, pilot programmes and economic evaluation, and assesses the evidence for programmes against a set of internationally recognised criteria. If stakeholder organisations, individuals or Members feel that there is enough evidence published in peer-reviewed journals to consider screening for a condition in the third trimester of pregnancy, they can submit a policy proposal to the national screening committee. That might well be something that my hon. Friend wishes to consider.

I turn briefly to the subject of the registration of stillbirths. I say briefly, because I know that the Under-Secretary of State for Health, my hon. Friend the Member for Central Suffolk and North Ipswich, is meeting my hon. Friend Tim Loughton in early April to discuss his ten-minute rule Bill on the registration of stillbirth. That Bill aims to amend the Births and Deaths Registration Act 1953 to provide that parents may register the death of a child stillborn before the threshold of 24 weeks’ gestation. That Act, as amended by the Still-birth (Definition) Act 1992, provides for the registration of all babies stillborn after 24 weeks’ gestation. When a baby is stillborn, the doctor or midwife who attended the delivery or who examined the baby’s body after birth gives the parents a medical certificate certifying the stillbirth.

Although some parents are very distressed that they cannot legally register the birth of a baby born before 24 weeks who did not breathe or show any signs of life, others would be distressed at the possibility of having to do so. Getting the right balance between those conflicting wishes is challenging, but the existing system, whereby hospitals can issue local commemorative certificates—my hon. Friend the Member for East Worthing and Shoreham alluded to those in his remarks—for those parents who want them goes some way to addressing the issue. I know that he will have more questions and challenges for my hon. Friend the Member for Central Suffolk and North Ipswich, and will want to discuss those at that meeting in April. I recognise that he has signalled his intention to take the matter forward.

Although infant mortality rates are at an historically low level, health inequalities remain and often reflect inequalities by socio-economic group, ethnicity, geographical area and age. There is a threefold difference in infant deaths rates between professional groups and manual groups. Mothers born in the Caribbean, west Africa, Pakistan and Bangladesh have rates between one and a half times and twice the national average. The greatest numbers of infant deaths and the highest rates are to be found in the most deprived parts of big cities such as Birmingham and Bradford. Young mothers under 20 have the highest risk of infant mortality—almost 60% higher than that for mothers aged 20 to 39, with young lone mothers at even greater risk. That is a terrible catalogue of loss, for the families concerned, for their communities and for the nation as a whole.

There has, however, been some progress in reducing those inequalities in recent years. The difference in the infant mortality rate between the routine and manual group, for example, and the population as a whole has narrowed from 18% in 2002-04 to 9% in 2009-11. We are looking to build on that progress, and that is why we have made reducing these inequalities a priority for the whole of the new health system, working with PHE and NHS England, and backed that up with new legal duties on access to and outcomes from services.

Professor Sir Michael Marmot has been referred to during the debate. He said in his post-2010 health inequalities review that there is a social gradient in health, whereby the lower a person’s social position is, the worse his or her health will be. He recommended that action should be proportionate to the level of disadvantage, including on his first priority of giving every child the best start in life, with which none of us would disagree.

On a practical note, we are strengthening the health visitor service, which Members were right to highlight. We are conscious that it is an important pledge and crucial to infant health and early child development. We are increasing the number of health visitors by 50%—4,200—by 2015. We are also doubling—by 1,600—the number of places on the family nurse partnership programme, which supports vulnerable young mothers over the same time scale. Sure Start children’s services also have a role to play.

The family nurse partnership has an exceptional record of successful intervention, particularly in the lives of young and vulnerable mothers. It has supported many thousands of them throughout the country through pregnancy and birth, and sustained the life chances of the child and the mother. I will quote a nice comment from one of the young women who were helped by this service. She said of her family nurse:

“Margaret doesn’t tell me what to do but helps me make good decisions about my baby, my life and how to be a great mum. I’m excited about my future and seeing my baby grow up. My partner and I became engaged last October and next year I start university”.

That is typical of a young life that has been turned round by effective intervention at a critical moment—not just the mother’s life but, critically, the life of her child also. We are delighted to support the family nurse partnership and to see it grow.

As expected, reference was made to midwives. It is vital to have the appropriate number of trained midwives available in the NHS. Since May 2010, the number has increased at twice the rate of the number of births. There are now 1,500 more midwives than in May 2010, and more than 5,000 in training who are due to qualify in the next three years. Obviously, Health Education England has been given a mandate by the Government in this area, but I completely accept the point about consistency of midwife care and support. That very good point was well made, and I will ensure that it is made to the NHS.

Photo of Tracey Crouch Tracey Crouch Conservative, Chatham and Aylesford

I am delighted to hear that there are 5,000 midwives in the training programme. Are they receiving dedicated bereavement training?

Photo of Jane Ellison Jane Ellison The Parliamentary Under-Secretary of State for Health

Again, if my hon. Friend will forgive me, I will respond to that question after the debate. I would not want to get the answer wrong.

We have touched throughout the debate on public health, which sits within my portfolio. National action must be complemented by local action. I mentioned the extraordinary range of indicators that I see regularly on issues such as drinking in pregnancy. It makes the case for why the transfer of responsibility for public health from the NHS to local government is sensible. We have backed that with £5.4 billion over two years, and a public health outcomes framework that focuses on health inequalities and key indicators in infant mortality such as low birth weight, which is associated with prematurity and is a significant cause of infant mortality and poor infant and child health.

Some of that local action is already being taken. My home city of Bradford has an excellent record in addressing infant mortality, despite having some of the worst outcomes. It established the Born in Bradford project, a long-term cohort study of 14,000 pregnant women and their children to improve understanding of health and sickness in babies and children, tracking their health throughout pregnancy and childhood into adult life.

In Salford, which is closer to home for the shadow Minister, the city council’s health improvement service offers activities to support new mums and children, including breastfeeding, weaning, exercise and socialising, and it is working to improve MMR vaccine uptake among black and minority ethnic and other groups, where uptake remains low despite our good national statistics.

In Birmingham, pregnancy outreach workers employed by the social enterprise, Gateway family services, tackle health inequalities in infant mortality by bridging the gap between women who need support and the agencies that provide it. Those are three illustrations of some of the imaginative projects that are under way. I hope we will see more and more local government adopting best national practice and responding to the particular challenges in their areas. Some of the contrasts are stark, and local government, which knows its communities well, is well placed to respond to them.

My hon. Friend the Member for Chatham and Aylesford referred to cot deaths. We have made reducing infant mortality an area of improvement for the NHS. Comprehensive advice to parents about reducing the risk of cot death is available on the NHS Choices website, which includes a wealth of other advice. In 2012, the NHS launched the Start4Life information service for parents. They can receive regular e-mails, videos and texts about pregnancy and the first eight months of their baby’s life. It is a free digital service to provide quality-assured advice at the right moments for parents, who can sign up online for it.

The Department has also included advice about the risk of sudden infant death in the Healthy Child Programme, which is the universal programme for all children from the start of life and includes preventive services for children with additional risks. Obviously, anything more we can do to highlight the available advice and support would be valuable, and Parliament has a great role to play in that regard, as do MPs in their constituencies, and local government. The advice is there, but the challenge is always to ensure that it gets to vulnerable groups, and accessing advice across a whole range of health information is difficult.

I thank my hon. Friend for securing this debate, and other Members for their contributions. It further raises the profile of this vital issue of stillbirth and infant death. I assure the House that the Department is working collaboratively with partners, including charities such as Sands and Bliss, the royal colleges and others on a range of initiatives to help to reduce the number of tragic deaths. The Department is always open to new ideas and to working with partners throughout the health sector. We welcome these debates and the opportunity to engage further in any way that Members believe will help us to move forward in this vital area of policy for all our constituents.

Sitting suspended.