Investigation launched amid second 'unusual' spike in neonatal deaths in Scotland

The control limit was previously exceeded in September last year, when 21 neonatal deaths were reported.

It was the first time this had occurred since monitoring began in July 2017.

Public Health Scotland tracks the neonatal mortality rate on a monthly basis to identify any abnormal increases which are unlikely to be down to chance.

The unexpectedly high levels of neonatal mortality in September 2021 and March this year are being investigated (Source: Public Health Scotland)

The neonatal mortality rate was 5.1 per 1000 live births in September and 4.6 per 1000 in March, against an average of 1.49 per 1000 in 2019.

The recent spikes have coincided with Covid surges driven by the Delta variant and, more recently, the BA.2 Omicron strain, but it is unclear whether there is any direct link.

PHS notes that there was "a sustained period in the middle part of 2021 when neonatal and infant mortality rates were higher than pre-pandemic levels, rather than fluctuating around this level as would be expected with random variation". 

Covid infections in pregnancy are associated with a higher risk of premature delivery, and vaccination uptake in expectant mothers - while increasing - has lagged behind women of the same age.

READ MORE: Scotland's neonatal deaths spike 'not linked to Covid' in mothers or babies 

Preliminary findings from the investigation carried out following the September spike suggested that the number of infants born prematurely had been high compared to previous months, but the cause remained a mystery. 

PHS noted at the time that Covid infections in mothers or babies "[did] not appear to have played a role". 

Commenting on the latest figures, Dr Sarah Stock, an expert in maternal and foetal medicine at Edinburgh University who has co-led the Covid-19 in Pregnancy Scotland (COPS) study, said: "I think the numbers are really troubling, and I don't think we know the reasons why yet.

"What we do know is that it's not neonatal Covid - the rates of Covid-19 infection in babies are very low and deaths from Covid are thankfully very, very small, so this isn't Covid affecting babies.

"We do know that Covid-19 can affect pregnant women, and cause pregnancy complications like early birth, so that is something that we need to think about and investigate.

"The other thing are the wider impacts of Covid-19 on healthcare services and that is something that needs to be thought about as well.

"Maternity and neonatal services are stretched and continue to feel the effects of Covid on staffing.

"But we can't forget that it might be other causes altogether, so it's really important that we investigate.

"It is very unusual to see these outliers, and understanding why is going to be crucial."

Dr Sarah Stock

Dr Stock stressed, however, that the spike in deaths was "absolutely not due to the Covid-19 vaccine" which studies in Scotland and internationally consistently show is safe in pregnancy.

Earlier this week the Royal College of Midwives (RCM) warned that a survey of its members in Scotland found that half said they "rarely have enough staff to provide safe care".

Long-standing issues had been "worsened by the pandemic", said RCM, with midwives fearing that these "are already impacting on the quality of care for women and their babies".

READ MORE: Lack of transparency around neonatal deaths provides fodder for antivaxxers

Jaki Lambert, director for Scotland at the RCM, said; “Every death of a baby is a tragedy and while Scotland has seen rates steadily reducing, any peaks or trends need reviewing.

"It is good news that we have access to good quality data from Public Health Scotland but it is essential to remember that behind every one of these deaths are grieving parents and families.

"It is always important to find any cause of these death if they are known, learn from what has happened, and do all we can to reduce the rates of neonatal deaths in the future.

"As the numbers are small the statistics do not show the demographics of these tragic deaths across Scotland or if there are any patterns.

"This too is important to determine so that resources can be focused if there are regional or local issues behind them."

Data as of December 2021 shows that midwifery vacancy rates were highest in the Western Isles, Dumfries and Galloway and Highland with, respectively, 19%, 13% and 11% of posts unfilled

Separate figures from PHS show that 64.5% of mothers who gave birth in March had received at least two Covid vaccine doses, up from 23.1% in September, but this compares to around 77% overall for women aged 18-39.

Slow uptake has been blamed on mixed messaging and confusion earlier in the rollout, including reports from some mothers-to-be of midwives and GPs advising them to delay even after the jags were recommended.

READ MORE: No baby deaths among vaccinated mothers who caught Covid in pregnancy

PHS data also shows that the rate of Covid infections in pregnant women reached a record 8,621 per 100,000 in March this year, nearly 18 times higher than it was in March 2021, and three times higher than it was in September.

However, only seven pregnant women were admitted to critical care units with Covid in March compared to a peak of 23 in September, probably reflecting increased vaccine protection.

Since the pandemic began, a total of 153 pregnant women in Scotland have been admitted to critical care with Covid, of whom 137 (89.5%) were unvaccinated.

Infection about newborns, though rare, have been on the increase.

In March, 26 infants under 28 days old tested positive for Covid, pushing the neonatal infection rate to a record 675 per 100,000.

Since the pandemic began, there have been a total of 181 Covid cases in neonates in Scotland - but 118 of these (65%) were reported between September and March.

Most developed symptoms between seven and 27 days old, and 140 of the infections (77%) occurred in infants whose mothers were unvaccinated.

READ MORE: Pregnant women let down by mixed messages during Delta wave

Before the pandemic, Scotland's neonatal death rate fell by 10% between 2013 and 2019. 

A spokeswoman for the Scottish Government confirmed that investigations are underway. 

She said: “Every death is a tragedy, and our thoughts are with each of these families.

“We are working with PHS, the Scottish National Neonatal Network and the Maternity and Children Quality Improvement Collaborative to understand any possible contributing factors to ensure we continue to improve the care of the smallest and sickest babies in Scotland.

“Individual reviews of each death are undertaken as part of the Maternity and Neonatal (Perinatal) Adverse Event Review Process for Scotland, which aims to standardise and improve approaches to the review of adverse events, such as these, in maternity and neonatal settings.”

In a statement, PHS said: "Each of the losses reflected in the information reported is a tragedy for those involved.

"The review processes to identify and mitigate any contributing factors are being led by the responsible agencies, and are ongoing.

"Public Health Scotland will continue to monitor data on neonatal health outcomes to inform and support this work."