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Health in Scotland 2002

CHAPTER 3

WOMEN'S AND CHILDREN'S HEALTH

Women's Health in Scotland

Despite gradual improvements in life expectancy and the implementation of specific initiatives - such as the cervical and breast cancer screening programmes which have led to earlier detection and treatment and improvements in survival ¹ - there are worrying trends in Scottish women's health. Work comparing Scotland's health in an international context has recently been completed for PHIS and the results make sobering reading, particularly the comparison of trends in female mortality in Scotland with other Western European countries ².

Mortality rates from all causes among working age Scottish women have declined over the last 50 years. However, in comparison with 16 other Western European countries, the decrease in Scotland has been less marked and Scotland has been ranked with the highest mortality in this age group since 1958 (Figure 3.1).

Trends in individual causes of death from the same study show that for many causes Scotland's position in a European context is worsening. Scotland had the highest mortality rate and thus the highest ranking among working age women for oesophageal cancer (a rate which has risen since the 1970s), lung cancer (consistently ranked highest since the 1950s) and ischaemic heart disease (where the rate is falling but still lags behind other countries). Perhaps the most striking is the trend for lung cancer mortality (Figure 3.2).

Mortality due to liver cirrhosis has risen steeply among Scottish working age women since the mid 1990s. In contrast, the trend in mortality from 'external causes' (i.e. injuries, drownings, violence) shows a marked improvement for Scottish women: the rate has dropped since the 1980s and now stands below the European mean figure.

Table 3.1: Female deaths and death rates, selected causes, 1991-2002, Scotland

Given this backdrop of mortality from many avoidable causes of death, an important question is whether there are any signs of positive changes in the well-established behavioural risk factors that impact on health.

Smoking

Smoking among adult women did decrease considerably between the late 1970s (42% in 1978) and mid 1990s (29% in 1994) but has since remained relatively static ³. The 1998 Scottish Health Survey (SHS98) reported that 32% of women aged 16-74 years were current smokers ⁴ and also showed a strong social class gradient in relation to cigarette smoking, with women in the manual social classes being much more likely to smoke (53%) than those in the non-manual social classes (10%). Scotland still appears to have one of the highest smoking prevalences among women of any country in Western Europe ⁵.

Diet and Physical Activity

The SHS98 reported that the proportion of women eating fruit at least once a day had risen (52% in 1995 vs 58% in 1998), as had the number of women eating potatoes, pasta or rice at least five times a week (59% in 1995 to 68% in 1998). Women in the 16-44 age group were more likely than men to have eaten raw vegetables or salad twice or more weekly (60% vs 40%).
In comparison with England, women in Scotland were less likely to have eaten wholemeal bread (16% vs 22% in 1998), were less likely to have eaten high fibre cereals and more likely to have eaten fried food, chocolate, crisps or biscuits.

Obesity levels rose between 1995 and 1998 to 18.8% among women aged 16-64 ⁴ and Scotland appears to have one of the highest, if not the highest, levels of obesity for women in Europe ⁵. In 1998 ⁴ only 27% of adult women achieved the guideline for physical activity of participating in 30 minutes or more of moderate or vigorous activity on at least five days a week.

Problem Drinking

Alcohol consumption among women is increasing. The proportion of women exceeding the recommended maximum weekly intake of 14 units a week increased from 13% in 1995 to 15% in 1998 ⁴. Young women were even more likely to exceed the weekly limits - 24% of women aged 16-24 in 1998. Women in social classes 1 and 2 (non-manual) have the highest levels of consumption over a weekly period but women in manual social classes are most likely to consume six or more units on their heaviest drinking day of the week. The concern expressed in previous CMO's reports on this issue have been reinforced by the confirmation in 2002 of a positive association between excessive alcohol consumption and breast cancer. More is said on this in Chapter 4.

Social and Economic Factors

Health behaviours cannot be examined in isolation. Lone parents, who are predominantly female, are particularly vulnerable to poverty and exclusion. In 1998, 92,145 (23%) of Income Support (IS) claimants received the lone parent premium ⁶. In that year it was estimated that lone parent households represented 6% of all households in Scotland ⁷, a proportion which is predicted to rise to 7.7% by 2012. In some areas the proportions are much higher: in Glasgow City in 1998, 10.7% of all households were estimated to be lone parent households.

Employment and economic activity levels are clearly relevant to health. The economic activity rate among women has risen from 65.1% in 1985 to 73% in 2001, while the actual employment rate has climbed from 56.9% in 1985 to 69.8% in 2001 ⁸. However, the gap in pay levels between men and women persists: women's earnings were 72% of men's in 1977 for full-time employees, narrowing slightly to 80% by 1997 ⁹. Women earn 30-40% less than men in similar jobs when they work part time.

In nine out of ten incidents of domestic abuse, the victim, where the victim's gender is known, is female. The latest published figures ¹⁰, show that 38,500 incidents of domestic abuse were recorded by the police in 2001, a rise of 5% on the previous year. Dealing with domestic abuse is an important partnership issue at a local level.

Provision of Maternity Services

Continuing the declining trend of recent years, there were 52,828 live and stillbirths in Scotland in 2001, the lowest number recorded since civil registration began in 1855 (Figure 3.3).

Actuarial projections suggest that the birthrate in Scotland will fall to approximately 40,000 deliveries by the year 2010. The 2001 twinning rate was 14.9/1000 maternities, slightly but not significantly higher than the rate of 14.0/1000 in 2000. There has been an upward trend in the past five years.

The mother's age at first birth continues to rise, as shown in Figure 3.4, which illustrates a double peak in late teens and 20s. Although the general trend is for mothers to delay having their first baby (average 25.1 years in 1992 and 26.4 in 2001), this pattern is most evident in areas of low deprivation where the mean age is 29 years. Women from areas of high deprivation are much more likely to have had their first baby aged 18 or 19 and this is also reflected in higher morbidities and poorer maternal and fetal outcomes. Only 2% of women have babies over the age of 40, whereas the percentage of mothers giving birth aged 35 or over has doubled in the last decade from 8.1% to 16.2%. The rate of teenage pregnancy remains high and within the 13-15 year old category, while slowly declining, still remains higher than in most developed countries.

The trend of reduced family size is continuing with 46% of births being to primiparous women, 48% to para 1-3 women and only 6% to women of over para 3. Most high parity women are delivered in consultant-led maternity units reflecting the increase in risk.

Table 3.2: Births in Scotland

(The maternity data presented are extracted from the ISD Sexual and Reproductive Health: Births in Scottish Hospitals 2001; the Scottish Perinatal Mortality and Morbidity Advisory Group Scottish Perinatal and Infant Mortality and Morbidity Report 2001 and Births in Scotland Report 2002: Operative Vaginal Delivery and the SEHD Expert Group on Acute Maternity Services Reference Report 2001.)

The spontaneous vertex delivery rate (normal, head first) has fallen from 72.4% to 65.2% with a wide maternity unit variation (range 54%-75%) that cannot be explained on case mix alone. Vaginal breech delivery has steadily declined from 0.9% to 0.5% reflecting the worldwide change with the increasing use of external cephalic version and caesarean section. The assisted vaginal delivery rate (ventouse and forceps) has remained constant at approximately 12% but with a marked decrease in forceps use (6.9%) and a proportionate rise in ventouse (5.4%) reflecting a change in clinical practice. There is still wide and unexplained obstetric unit variation throughout Scotland (10.1% to 33.8%).

The overall caesarean section rate has been steadily rising from 14.6% to 21.9% with significant obstetric unit variation in 2001 (14.5% to 27.3%), unexplained wholly by case mix and is illustrated in Figure 3.5. Both emergency and elective caesarean section rates have increased to 14% and 7.9% respectively. The main indications for caesarean section have remained constant including failure to progress, fetal distress, breech presentation and repeat caesarean section. However, there has been a significant rise in maternal choice to have a section without clinical indication. This overall trend has been projected to continue to rise, reaching 25% by 2010.

The high rates of neonatal deaths associated with some forms of delivery (see table 3.3) are likely to be causally related to the underlying condition dictating the mode of delivery, rather than the actual delivery.

Table 3.3: The neonatal death rates for 1991-2000

The consultant obstetric unit induction rate has remained steady at approximately 27% but with wide unit variation (range 23% to 42%) unexplained by case mix alone. Virtually no induction occurs in community midwifery units.

In 2001, 7.3% of all live births were born prematurely (before 37 weeks of pregnancy). Of all births 7.6% were defined as low birthweight (below 2500 g), with 6.3% weighing 1500-2499 g and 1.3% less than 1500 g. The pattern and aetiology of low birth weight and premature delivery have remained constant since 1976.

A member of the neonatal team was involved in 20% to 25% of all hospital deliveries, with 10% to 15% of babies requiring admission to a special care facility. The average anaesthetic involvement in a consultant obstetric unit in 2001 is illustrated in Table 3.4.

Table 3.4

The average postnatal hospital stay has decreased from 4.8 days to 3.7 days over the past decade, with average stays for spontaneous, assisted vaginal and all caesarean section deliveries being 3 days, 3.5 days and 4 days respectively. Many units, however, operate a policy of very early discharge (under 24 hours) into the community.

The Government target was to reduce the population of women smoking during pregnancy to 20% by 2010. Figure 3.6 shows a slight decrease in the population of women of all ages, who smoke at booking, from 28.7% in 1998 to 25.3% in 2001.

The rates of stillbirths, perinatal, neonatal and infant deaths for 2001 are shown in Table 3.5. The trends since 1974 are shown in Figure 3.7.

Table 3.5:

Although there is a clear upward trend in multiple pregnancy rates in recent years, the time trend since 1856 is complex with current rates being similar to the mid-20th century. Real and sustained association has been demonstrated between increased risk of multiple birth and increasing maternal age (inverted 'v' with a peak at 35 to 39 years), parity, height and affluence. While the association between maternal age and multiple pregnancy is well described, it is important not to take the other factors in isolation due to the probability of variable interaction. Multiple pregnancy was shown to be associated with a two-fold increase compared to singleton pregnancies of hypertensive disorders (OR 1.99: 95% CI 1.91-2.98) and post partum haemorrhage (OR 2.44: 95% CI 2.12-2.36).

There is a higher vaginal breech and caesarean section delivery for multiple compared to singleton pregnancies. The risk of death from any cause is higher among multiple compared to singleton pregnancies with increased rates of prematurity and low birthweight babies. However, the effects of prematurity account for a disproportionate number of deaths among multiple births. Both the stillbirth rate of 16.8 per 1000 multiple total births and the neonatal death rate of 24.7 per 1000 multiple live births are slightly higher than in 2000 but not significantly.

While only 2.8% of births are multiple, they account for over 25% of admissions to neonatal units. Over the last five years, admission to a neonatal unit for over 48 hours occurred in only 6% of singleton pregnancies, 38% of twins and 88% of higher order multiple births, reflecting the increased morbidity and health service utilisation of multiple pregnancy.

Data on babies with selected congenital anomalies in Scotland were collated from 1995-1999 to complement the data contained within the Scottish Programme for Clinical Effectiveness in Reproductive Health and ISD publication Babies with Anomalies: a Scottish Overview 1999. (Table 3.6) The observed prevalence of the trisomy conditions was consistent with observed European rates, while the cardiovascular, cleft anomalies and neural tube defects reflected similar rates from the previous 10 years in Scotland.

Table 3.6: Congenital Anomalies per 1000 births in Scotland 1995-1999

Chapter 3 continued

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