Out-of-hours birth in Scotland 'puts newborn at increased risk of dying'

Published on Thursday 15 July 2010 15:54

BABIES who are born outside normal working hours are more likely to die than other infants, a large Scottish study reveals.

• The study raises concerns over standards of NHS out-ofhours. care Picture: AFP/Getty

The worrying findings, published in the British Medical Journal, suggest that births which happen outside of Monday to Friday, 9am to 5pm, are 45 per cent more likely to lead to death.

It means between five and ten baby deaths in Scotland a year - and between 50 and 100 in the UK - are estimated to be due to the increased risks of being born outside normal hours. About 70 per cent of births take place at these times.

The research adds to growing concerns about the standards of out-of-hours care delivered by the NHS in Scotland and across the UK.

Last month, fears were raised about the quality of locum doctors provided by agencies, who often provide evening and weekend cover in Scottish hospitals.

The latest study, based on more than a million births, suggests lower levels of staffing and less availability of senior doctors out-of-hours could be one possible explanation for the higher risks faced by babies born outside the normal working day.

Campaigners last night described the findings as "shocking".

The researchers, from Cambridge University, used detailed data from Scottish national registries which analysed full-term births and infant deaths in Scotland between 1985 and 2004.

Births in the normal working week were defined as those between Monday and Friday, 9am to 5pm, with out-of-hours at all other times. For the purposes of the study, neonatal death was defined as a death during the first four weeks of life which was not related to a congenital abnormality, such as a heart defect. During the period studied, there were 539 neonatal deaths.

The risk of death was 4.2 per 10,000 live births during the working week, but rose to 5.6 per 10,000 at all other times.

The researchers said the higher rate of deaths found out-of-hours was due to an increased risk of death linked to intrapartum anoxia - lack of oxygen during the birth which leaves the baby unable to breathe.

The experts said the findings represented a relatively small but significant risk of one to two extra deaths per 10,000 live births due to oxygen deprivation.

They concluded the additional risk linked to delivering out-of-hours was estimated to account for around one in four of these types of death.

Gordon Smith, professor of obstetrics and gynaecology at Cambridge University, said: "The primary message of this isn't women should be terrified if they have to go into hospital in the middle of the night. It is more for the people who organise healthcare to think these are all potentially preventable deaths.

The risk to any individual is small, but by changing things you might prevent in the region of between five and ten deaths per year in Scotland."

Prof Smith, who is originally from Glasgow, said while the researchers only looked at deaths, it was likely there would be similar increases in risk due to birth out-of-hours in cases where children survived but were left with conditions such as cerebral palsy due to lack of oxygen.

"Anything you do to remove this discrepancy between day and night would be likely to have other benefits," he said.

Prof Smith said hospitals needed to examine what staff and services they had available at night, such as making sure operating theatres were available to deal with women needing an emergency Caesarean.

"If you walk around a hospital at 3am, things look very differently than at 3pm," he said.

"It is also things like the availability of operating theatres (and] staff to resuscitate the baby.

"It is the number of staff, possibly the profile of staff, probably the facilities available.

"Often there will be additional staff to support an operating theatre during the day who wouldn't be there during the night. But all we can do is speculate on the reasons."

Being able to deliver the baby quickly, such as by having a Caesarean, is key to preventing harm if the child shows signs of not getting enough oxygen during labour.

Janet Scott, research manager at neonatal death charity Sands, said: "It is shocking that some babies are dying in our maternity units because the quality of care at night and at weekends is of a poorer standard than care during working hours.

"This is completely unacceptable. A baby's life should not rest on whether or not they are born in office hours."

Dr Tahir Mahmood, vice-president of the Royal College of Obstetricians and Gynaecologists, said: "All women admitted to the maternity unit should be provided with one-to-one care in labour by a midwife and an experienced obstetrician.

"The interpretation of a baby's heart rate tracings (known as CTG] requires special knowledge and experience. Quite often subtle changes in the CTG as early warning signs of asphyxia can only be interpreted by experienced doctors and junior doctors need to be supported and educated to acquire this skill.

"It is crucial to have experienced obstetricians working in labour ward during the out-of-hours period."

Gillian Smith, director for Scotland at the Royal College of Midwives, said concerns over differences in care out-of-hours had been raised for several years. She added it was important lessons were learned from the study.

A Scottish Government spokeswoman said: "This data is very valuable and we welcome it, but it's important to note it is now at least six years out of date - and since 2004 infant mortality in Scotland has fallen.

"Since the data was gathered there has been a 32 per cent rise in the number of consultant obstetricians, with the Scottish Government also funding the training of 20 advance neonatal nurse practitioners and investing a further 100,000 in neonatal education."

KEY QUESTIONS OVER RESEARCH

Professor Gordon Smith on his research.

What is the main finding of this paper?

There was a small additional risk of babies dying in the first four weeks of life if they were born outside the hours of a normal working week

What was the cause of death?

The excess of deaths was due to increased rates of babies dying due to shortage of oxygen. This would include cases where there was a major complication of labour and delivery, such as rupture of the uterus (womb).

What was the size of the increased risk of death?

The proportional increase was 40-50 per cent above the baseline risk of deaths due to anoxia. If the risk was the same at all times of the week as it was during Monday to Friday, 9am to 5pm, about one in four of these deaths would be prevented. It should be emphasised this is not a common type of death. The additional risk was equivalent to about 1-2 additional deaths per 10,000 births.

Can the finding not be explained by the fact births in a normal working week are more likely to be low risk, eg; planned Caesareans?

No. The study was able to identify planned Caesareans and the association persisted after excluding these.

What might be the cause of the increased risk?

It may be related to the immediate availability of nursing or medical staff to allow immediate delivery in emergencies. It could also reflect reduced access to facilities, such as operating theatres.

What might be done to address this problem?

One approach may be to raise provision of midwifery and obstetric staff to allow better staffing out of hours. Another may be determining minimum levels of access to operating theatres and support staff at all times.