General fertility rate

The general fertility rate (GFR) is described as the number of live births per 1000 women aged 15–44. In England and Wales, the GFR for 2007 was 62.0, an increase compared with 2006, when the GFR was 60.2 (ONS 2008a).

In 2007, there were increases in fertility rates for all age groups, except for women aged under 20, where the fertility rate fell compared with 2006. The highest percentage increase (6.0%) was observed for women aged 40 and over. For this age group, the fertility rate has risen steadily from 7.3 live births per 1000 women aged 40 and over in 1997 to 12.1 live births per 1000 in 2007. Hence, in the last decade, the number of live births to mothers aged 40 and over has nearly doubled from 12,914 in 1997 to 25,350 in 2007 (ONS 2008a).

Total fertility rate

The total fertility rate (TFR) is the average number of children a group of women would have if they experienced the age-specific fertility rates of the calendar year in question throughout their childbearing lifespan. The TFR in the UK reached 1.95 children per woman in 2008 (ONS 2008b) (Fig. 16.1). UK fertility has not been this high since 1980.

Figure 16.1 Total fertility rate (TFR) in England and Wales.

(Source: ONS 2008b).

The UK TFR has increased each year since 2001, when it had dropped to a record low of 1.63. The current level of fertility is relatively high compared with that seen during the 1980s and 1990s. However, the TFR was considerably higher in the 1960s, peaking at 2.95 children per woman in 1964, the height of the ‘baby boom’ (ONS 2008c). Whereas two children remains the most common family size in England and Wales, an increase in childlessness among women of childbearing age has also been noted in recent years.

Birth rate

The birth rate is the number of registered live births per 1000 population, and following a decline in the 1990s is now increasing steadily from the rate in 2002 of 11.3 to a rate of 12.8 in 2007 (ONS 2008a).

Because fertility is currently rising faster among women over 30, the average age of childbearing has continued to increase slowly. The mean age for giving birth in the UK was 29.3 years in 2007, compared with 28.6 years in 2001 (ONS 2008a). This could explain, in part, the increasing number of women seeking treatment for infertility, as general fertility decreases with age. Women of 35 are known to be on average half as fertile as those of 31 (Challoner 1999).

Teenage pregnancy rate

Teenage pregnancy is defined as pregnancy experienced up to and including the age of 19 years, and is frequently further divided into pregnancies up to 15 years of age, and from 15 to 19 years. In 1998, England and Wales were reported to have the highest teenage birth rate in Europe when the birth rate of women aged 15 to 19 years was 30.6 per 1000 women in that age group (UNICEF 2001). Among the developed nations, only the United States had a higher teenage birth rate of 52.1 births per 1000. In response, the British Government introduced a range of measures including the Teenage Pregnancy Strategy in 2000, with the aim of reducing the teenage pregnancy rate by half by 2010, and producing a firm downward trend in the conception rate in the under-16 years age group. Perinatal mortality and morbidity in young mothers is higher than average, so concerted attempts by Government to improve sex education and make family planning services more accessible to young people have been included in measures to attempt to reduce the teenage conception rate.

Following the introduction of these measures, the ONS figures show teenage pregnancy rates continuing to fall (Fig. 16.2) with a reduction in both the under-18 and the under-16 rates during 2006:

Figure 16.2 Under-18 conception rate for England: 1998–2007.

(Source: DCSF 2009.)

Stillbirths

The stillbirth rate is the number of stillbirths registered during the year per 1000 registered total (live and still) births. In contrast to neonatal mortality, there has been no significant decline in the stillbirth rate since 2000. The stillbirth rate was 5.4 per 1000 total births in 2000 and 5.2 per 1000 in 2007 (Fig. 16.3). The findings from the latest CEMACH report in 2009 suggest that demographic factors known to be associated with stillbirths, such as, obesity, ethnicity, deprivation and maternal age, may be contributing to this lack of progress. In addition, over one-third (40%) of unexplained stillbirths had a birth weight below the 10th centile for gestation and a quarter (26%) of these were below the 3rd centile. This suggests that being small for gestational age may be an important contributor.

Figure 16.3 Stillbirth and perinatal death rates in England and Wales.

(Source: ONS 2008d).

Perinatal deaths

The perinatal mortality rate comprises all stillbirths and deaths in the first week of life per 1000 registered total births. The group includes all babies who have died ‘around’ the time of birth.

The perinatal mortality rate in England and Wales fell from 19.3 per 1000 in 1975 to 7.7 in 2007 (CEMACH 2009) (Fig. 16.3). As with stillbirth, maternal age, obesity, social deprivation and ethnicity remain important risk factors for perinatal mortality.

Neonatal deaths

The neonatal mortality rate is the number of deaths of babies within 4 weeks of birth per 1000 registered live births.

The neonatal mortality rate, like the other mortality rates, is declining in England and Wales and fell from 11.0 per 1000 livebirths in 1975 to 3.3 in 2007 (Fig. 16.4). The majority of neonatal deaths occur in the first day or two after birth, which closely relates the death of the baby to gestational age, labour and delivery.

Figure 16.4 Neonatal and infant death rate in England and Wales.

(Source: ONS 2008d).

The causes of perinatal and neonatal deaths occurring in the first week of life are obviously related and may also be responsible for later neonatal deaths; however, other factors, such as infection, may be more strongly implicated in later deaths. The reasons for reduction in the neonatal mortality rate are similar to those responsible for the decline in perinatal mortality (CEMACH 2009).

Infant mortality

The infant mortality rate is the number of deaths of infants during the first year of life (including those occurring during the first 4 weeks) per 1000 registered live births in the year.

There has been a remarkable decline in infant deaths in England and Wales, from 140 per 1000 live births in 1900 to 5.0 per 1000 in 2006 (ONS 2008d) (Fig. 16.4).

The main causes of later infant deaths include:

Predisposing causes and risk factors for fetal, perinatal and infant death

Confidential Enquiries into Maternal Deaths

In the UK, a Confidential Enquiry is undertaken into every maternal death to examine factors which may have influenced the outcome, in an attempt to make recommendations and guide future practice. A Confidential Enquiries into Maternal Deaths in England and Wales report was published for each successive 3-year period from the 1952–54 report until the 1982–84 report, and since 1985, reports have included all four countries of the UK. Ascertainment has improved over the last decade as better computer software at ONS is assisting in the recognition of maternal deaths. Reporting has improved owing to the introduction of standards surrounding maternal deaths by local supervising authority (LSA) officers, so what could appear to be an increase in deaths is attributed to improved ascertainment (Lewis 2007).

Information surrounding the care of the woman is gathered by a regional coordinating body, which is then sent to obstetric and, where appropriate, midwifery and/or anaesthetic regional assessors for comment. The assessors send a completed assessment form to the Chief Medical Officer at the Department of Health. In Scotland and Northern Ireland, the system of enquiry is similar but one panel of assessors deals with all cases.

At the Department of Health, only advisors in obstetrics, gynaecology, midwifery and anaesthetics see the forms. An analysis of the cases is undertaken and recommendations are made, highlighting areas of concern and ways of seeking to ensure improvements in future years. The top ten recommendations of the 2003–05 report, which are additional to recommendations made in previous reports, are summarized in Table 16.2.

Table 16.2 Top ten recommendations – Saving Women’s Lives report 2003–05 (Lewis 2007)

In the seventh report, Saving mothers’ lives, for the 3-year period 2003–05, maternal deaths are divided into direct deaths, which result from obstetric complications of pregnancy, labour and the puerperium, and indirect deaths, which are caused by previously existing diseases or disease that develops during or is worsened by pregnancy (Lewis 2007). Of the 295 maternal deaths assessed for this enquiry, 132 were direct deaths (a rate of 6.24 per 100,000 births) and 163 were indirect deaths (7.71 per 100,000 births). Additionally, there were 55 coincidental deaths (which are the result of causes not at all related to pregnancy, for example, road traffic accidents) and 82 late deaths in the first year after childbirth (Table 16.3).

Table 16.3 Main causes of maternal death in the UK 2003–2005 (Lewis 2007)

* Deaths during pregnancy and up to 42 days after end of pregnancy.

** Deaths from 42 days after end of pregnancy, up to 1 year.

In keeping with international convention, coincidental and late deaths are not included in maternal mortality statistics, but are examined in the Confidential Enquiry in case recommendations can be made for service providers.

Thrombosis and thromboembolism

This remains the commonest cause of direct maternal deaths in the UK, with 41 deaths reported in 2003–05. There were 33 deaths attributed to pulmonary embolism and the remaining 8 were caused by cerebral vein thrombosis. Additionally, three late deaths were due to pulmonary embolism (Table 16.3).

Key recommendations from the Confidential Enquiry report (Lewis 2007) were:

The Royal College of Obstetricians and Gynaecologists has produced guidelines for thromboprophylaxis in pregnancy and the puerperium (RCOG 2004) but the report suggests that further guidelines are needed for women with a BMI greater than 40. There is a need to raise awareness for detection of classic symptoms, especially in women perceived to be at low risk. Deaths occurred where the diagnosis had been delayed or missed, particularly within primary care or accident and emergency settings. There were also a number of women with recognized risk factors who were not offered thromboprophylaxis, emphasizing the continuing need for widespread education in this area.

Hypertensive disorders of pregnancy

This remains a major cause of maternal death (see Ch. 56), with 18 deaths attributed to this condition during 2003–05; the total number of deaths and mortality rate similar to the previous two triennia. Cerebral complications, mainly intracerebral haemorrhage, were the commonest cause of death. Despite recommendations made in previous reports, there were still substandard aspects of care associated with these deaths. Criticisms were made by panels of failure to react quickly enough to impending signs of eclampsia and lack of seniority and experience within teams caring for these women. There were also examples where healthcare professionals misdiagnosed and failed to make standard routine measurements of blood pressure and urinalysis. Midwives must be vigilant in their approach to early detection and management of any women presenting with risk factors and ensure appropriate management and referral.

The key recommendations (Lewis 2007) for the management of pregnancy-induced hypertension (PIH) include:

Haemorrhage (Chs 54 & 68)

Table 16.3 lists 14 direct deaths due to haemorrhage in 2003–05; in addition, a further 3 deaths from uterine rupture and genital tract trauma are included, which in previous triennia were reported in a separate section (Lewis 2007). The maternal mortality rate remains similar to that for 2000–02 in the UK. Haemorrhage followed caesarean section in 11 of the 14 maternal deaths. Haemorrhage remains a major cause of maternal death throughout the world, and it is estimated that a quarter of all maternal deaths are due to haemorrhage (WHO 2005).

The midwife is often the first person to see the woman who may present with acute pain or bleeding. The midwife should always refer a woman who complains of abdominal pain in early pregnancy to a doctor. Similarly, a woman presenting with pain and tender abdomen may have a concealed haemorrhage.

Postpartum haemorrhage will always remain a risk, and midwives must be trained appropriately to manage the situation whilst awaiting medical aid. The woman’s haemodynamic status should be checked in pregnancy and when anaemia is detected it should be appropriately treated. Midwives caring for women at home or in birth centres should have access to immediate resuscitation facilities until additional medical assistance can be provided.

The key recommendations made by the CEMACH report 2003–05 encompass many of these points and can be summarized as:

Genital tract sepsis (Ch. 52)

The most recent Confidential Enquiry (Lewis 2007) found there were 18 deaths in 2003–05 attributed directly to genital tract sepsis, and a further 4 deaths in which infection may have played a significant part. This represents an increase from 13 direct deaths in the 2000–02 report. Midwives must be vigilant in the detection and management of any signs of infection. The growing trend towards early discharge from hospital, especially following operative delivery, and reduced postnatal visiting may adversely influence puerperal sepsis rates. The spread of disease can be rapid and devastating; therefore, early detection and treatment are essential. Whilst numbers are small, cases of substandard care are identified throughout the last report, highlighting that care fell short of generally accepted standards.

Amniotic fluid embolism

There were 19 deaths, including two late deaths, from amniotic embolism in 2003–05 (Lewis 2007), which appears to be an increase from the two previous triennia, but this may be due to increasing efforts in the UK to correctly ascertain this difficult-to-diagnose event. The care of women suffering from this condition is the same as for any maternal collapse before, during or after labour. About 35% of the cases assessed were considered to have received suboptimal obstetric/midwifery care, but this condition carries a high mortality despite prompt treatment and good intensive care. Risk factors include higher maternal age, and, as the average age of childbearing is increasing, this may influence future statistics. Sudden collapse in labour is a common feature in this condition, which should be suspected in any woman regardless of type of labour or delivery. There is little evidence guiding practice towards prevention or treatment and further research would increase understanding and provide information on best practice in its management. A large nationwide prospective study by the United Kingdom Obstetric Surveillance System (UKOSS) to discern the actual incidence of amniotic fluid embolism is currently in progress.

Indirect causes of maternal death

In 2003–05, the rate for mothers’ deaths from indirect causes, such as from pre-existing or new medical or mental conditions aggravated by pregnancy (Chs 55 and 69), such as heart disease or puerperal psychosis, had not changed significantly since the previous report (Lewis 2007). Indirect causes outnumber direct causes of death in the UK, whereas worldwide they account for about 20% of maternal deaths (WHO 2005). The commonest cause of maternal death in the 2003–05 triennium was cardiac disease, with 48 deaths attributed to this cause, which has risen clearly since the late 1980s. Although these deaths are classified as indirect maternal deaths, this may change in future reports because lifestyle changes, such as the rising maternal age and obesity in the population, are increasing the incidence of cardiac complaints in the childbearing population generally.

The number of deaths from suicide (Ch. 69), the most common single cause of maternal death in the 2000–02 report (58 deaths), decreased to 37 in 2003–05. This decrease probably indicates that previous recommendations to identify women at risk and offer specialized support services in the antenatal period have been heeded. Most suicides were late deaths, occurring more than 42 days but less than one completed year after the end of the pregnancy.

It has been recognized for some time that the underlying root causes of maternal mortality are often social or other non-medical reasons. As with previous UK Confidential Enquiry reports, analysis of the data for 2003–05 reveals that women were more likely to die during pregnancy or childbirth if they were from the most disadvantaged groups in society – socially excluded, lower socioeconomic groups, the very young, and women from certain ethnic communities. It is also clear that vulnerable women with complex social requirements most need care in pregnancy but are least likely to access and maintain contact with maternity services.

Midwives should ensure that services are planned to meet the needs of the most vulnerable women in our society. There should be safeguards built into monitoring systems to ensure that women shown to be at higher risk do not ‘slip through the net’ (DH 2007).

Midwives should be aware of their professional accountability when caring for women with psychiatric and psychological problems during pregnancy and the puerperium. They should be vigilant in identifying women at risk, and have access to appropriate sources of referral should problems arise. Working within the remit of their professional boundaries, it is essential for midwives to have access to appropriate mental health practitioners at all times.