Rise in stillbirths linked to lack of face-to-face appointments in first Covid wave

A lack of face-to-face appointments during the coronavirus pandemic may have contributed to stillbirths in the first wave, investigators have found.

The study by the Healthcare Safety Investigation Branch (HSIB) into 37 cases found that remote consultations may have driven down the ability to carry out key pregnancy checks, with some doctors unable to access medical records.

The review was prompted by an increase in stillbirths after the onset of labour referred to the HSIB between April and June 2020 – 45 compared with 24 in the same period in 2019.

None of the women were recorded as having Covid, but the report found the pressures and changes as a result of the pandemic may have affected the care they received.

It comes after a senior coroner recently warned that a lack of face-to-face appointments was linked to five deaths.

Sajid Javid, the Health Secretary, told the Commons on Tuesday “GPs should be offering face-to-face access” and the Government “intend to do a lot more about it”.

But the HSIB report found remote consultations resulted in fewer opportunities for physical examinations for pregnant women, meaning trends in how the baby was growing could be missed.

After 28 weeks’ gestation, not all consultations included measuring from the mother’s pubic bone to the top of the womb (a standard measure to inform baby growth), while there was a “lack of recording and plotting” of this information, HSIB said.

Some face-to-face appointments were postponed until later in the pregnancy, while in some remote consultations clinicians did not have access to clinical notes or ultrasound scan reports.

In one case a mother had to read the results of her ultrasound scan over the phone to the obstetrician because they were unable to access them.

The report also noted that some women opted not to attend appointments for fear of catching Covid, that the proportion of consultations undertaken remotely is not known and “the impact of remote consultations is not clear from this review”.

Investigating the timing of the babies’ deaths in relation to when the mothers had contact with healthcare services, the report found 19 patients showed no signs of lift at the first visit to the hospital when they were in early labour.

Of those, 11 (58 per cent) had sought healthcare advice over the phone and were advised to remain at home.

The HSIB said many of the safety risks identified in the review were already known to maternity services and exacerbated by the pandemic, for example, the level of staffing in maternity units.

Rapidly changing national Covid guidance

Other issues noted were challenges in interpreting and implementing rapidly changing national guidance on Covid, difficulties in communication by phone, and workforce demands in the NHS, which led to absence and sickness.

Kathryn Whitehill, the principal national investigator at the HSIB, said: “We recognise that the current maternity system has had success through national initiatives in reducing the number of stillbirths and that throughout the pandemic thousands of babies were delivered without any problems.

“However, our review did highlight the extreme pressure maternity services were under – they had to balance the risks associated with uncertainty and emerging evidence on Covid-19 transmission with the clinical assessments that are needed to monitor the safety of patients.”

The cause of death for the babies varied from function and structure of the placenta, uterine rupture, complications with the umbilical cord and a lack of oxygen during labour.

Jane Brewin, the chief executive of Tommy’s, the largest UK charity researching pregnancy complications and baby loss, said the report acknowledged the efforts made to keep maternity services running during the pandemic. But she added: “It also shows the impact of some mothers not getting the right care in the right place at the right time, and lessons must be learned from the lives tragically lost. It’s not always possible to know why a stillbirth happened, but sometimes there are warning signs and these babies’ lives could be saved.”

Following the report, the HSIB recommends NHS England and NHS Improvement should lead work to “collate and act on” evidence regarding the risks and benefits associated with having remote consultations while pregnant.

Another recommends that the Department of Health and Social Care commissions a review “to improve the reliability of existing assessment tools for foetal growth and foetal heart rate to minimise the risk for babies”.