The final item of business is a members’ business debate on motion S4M-12723, in the name of Margaret McDougall, on awareness of group B Streptococcus. The debate will be concluded without any question being put.
Motion debated,
That the Parliament notes with concern what it understands is the lack of public awareness regarding group B streptococcus (GBS) and the effects that it can have on newborn babies; understands that, in the UK, GBS infects over 500 babies every year and that 340 will develop early-onset GBS infection and one in 10 of them will die; believes that the incidence of early-onset GBS infection in England, Wales and Northern Ireland has remained unchanged since prevention strategies were first introduced in 2003 and that, in Scotland, it has increased from 0.21 per 1,000 live births in 2000 to 0.47 in 2012; understands that many countries, including the USA, Canada, Germany and Spain, offer routine testing for GBS at 35 to 37 weeks of pregnancy; notes that, although the Royal College of Obstetricians and Gynaecologists does not recommend routine testing, the Scottish Government is not bound by this approach, and notes calls for the Scottish Government to introduce guidelines so that hospitals in the west of Scotland and beyond provide expectant mothers with information regarding GBS and either offer routine testing or provide information on how testing can be accessed privately.
17:02
First, I thank all the members who have supported my motion and those who will speak in the debate. I also thank Jane Plumb of the Group B Strep Support charity for her briefing.
The campaign to introduce group B Streptococcus, or GBS, testing was first brought to my attention in 2013 through Jackie Watt, from Kilwinning, the grandmother of baby Lola, who tragically died after contracting Strep B shortly after her birth at Crosshouse hospital. I am delighted to say that Lola’s parents, Tracey and Stephen, now have two beautiful daughters, Brooke and Ellie, who are both thriving.
I congratulate Jackie Watt on her stoic campaign to raise awareness of GBS and to have testing offered in Scotland. Jackie’s petition, on awareness of Strep B in pregnancy and infants, is being considered by the Public Petitions Committee.
GBS is the most common cause of life-threatening infection in newborn babies. It usually lives, without causing symptoms, in human intestines and genital tracts. However, it can be passed from mother to baby at the delivery stage of labour and, unsurprisingly, it is the single biggest risk factor for a newborn baby. Given that, we would expect public awareness to be high. However, that is not the case, as my motion states, and there is a
“lack of public awareness regarding group B streptococcus (GBS) and the effects that it can have on newborn babies”.
In the United Kingdom, it has been estimated that Strep B infects more than 500 babies a year. Sadly, 50 babies die as result of contracting Strep B and around 30 suffer lifelong physical and mental disabilities.
Group B Strep Support has found that incidents of early-onset GBS are higher in Scotland than in the rest of the UK, and that the Scottish rate has increased from 12 in 2000 to 25 in 2014. That may seem like a small number, but in my view even one incident is too many when Strep B is preventable and can be identified through a relatively simple and inexpensive test, which costs around £15 in the private sector.
Indeed, 22 developed countries, including the USA, Canada, Germany and Spain, offer routine testing for GBS at 35 to 37 weeks of pregnancy. Recently, I discovered that, in the UK, around 60 per cent of obstetric units offer testing to some or all pregnant women and 76 per cent carry out tests at the mother’s request. Despite that fact, the Royal College of Obstetricians and Gynaecologists does not recommend routine testing, but the Scottish Government is not bound by that approach and it is free to issue whatever guidance it wishes to issue.
Routine screening for GBS has proven to be effective. For example, in the US, where screening was introduced in 1996, the rate fell from one to 0.24 per 1,000 live births in 2013. The University of Birmingham carried out studies into the cost effectiveness of introducing routine screening for GBS and found that £427,000 would be saved for every baby death that was avoided and £32,000 would be saved per infection that was avoided. Those figures are, of course, estimates and the figures will vary, but other cost benefit analyses have found that screening is more cost effective than risk-based approaches. Given the current financial pressures on the national health service, will the minister say in her summing up whether the Scottish Government will consider carrying out its own cost benefit analysis to see how much could be saved by adopting routine testing?
I understand that there are some concerns around testing, such as concerns about the safety of using antibiotics during pregnancy, the willingness of patients to accept testing and the enriched culture medium or ECM test not being reliable. However, the recommended antibiotic to use is penicillin, which is narrow spectrum, safe and effective against GBS. Most people know whether they have a penicillin allergy, and they can be offered an alternative.
On the criticism of the ECM test not being reliable, it is correct to state that it is not 100 per cent accurate and, indeed, it will not identify which babies will develop early-onset GBS infection. However, it is much better than relying on risk factors alone, which is the current guidance, and it is highly predictive of GBS carriage status when it is done properly, within five weeks of delivery. Essentially, we must remember that the ECM test is a test to identify risk, not to diagnose a condition.
Guernsey and trusts such as the London North West Healthcare NHS Trust offer universal screening, which has been welcomed by patients and health professionals alike. Previous screening surveys have found that health professionals want to be able to offer antenatal testing for group B Strep using ECM tests, women would like it to be offered, and infection rates have notably fallen where universal screening has been introduced.
I hope that I have laid out a firm argument as to why routine GBS testing should be offered by the NHS in Scotland. As studies have shown, it is cost effective, and on every piece of data, universal testing has been proven to dramatically reduce incidences, whereas risk-based testing seems to mean an increase in incidences.
The guidance from the Royal College of Obstetricians and Gynaecologists has been overtaken by events, with more maternity units offering testing regardless of the guidelines or, indeed, as I said earlier, introducing universal screening. Given that the Scottish Government is not bound by that guidance, I urge it to introduce updated guidelines so that there is consistency and standardised care across all hospitals and expectant mothers can be confident that they are receiving accurate information about GBS and whether they can be offered routine testing, or are given information on how testing can be accessed privately. I ask the Scottish Government whether it will consider carrying out a cost benefit analysis to find out what the benefits of that would be, so that no other family will have to suffer the trauma that the parents of baby Lola have experienced.
17:09
I thank Margaret McDougall for bringing this very important debate to the chamber this evening.
The death of any child is very traumatic for the parent, especially if it happens at a time when they should be in a state of joy and celebration. I cannot imagine what it would be like to have a newborn or a small infant die when everyone else is hoping to celebrate. It must have been a dreadful situation for the parents of Lola. Certainly if it is preventable, we should try to ensure that it is prevented.
Margaret McDougall said that the current evidence from the Royal College of Obstetricians and Gynaecologists has to some extent been overtaken. In looking at the royal college’s website, I noted that it did another evidence-based survey to look at the whole issue of GBS. It concluded in December 2014 that the situation should remain the same and there should be no routine screening. I find that strange to some extent, given that it was updating the information.
As Margaret McDougall said, it is felt that there is a benefit to screening, not just to the families who are expecting a lovely newborn but to the baby who will suffer the consequences of Strep B. The consequences for the newborn baby are not particularly nice. For some, Strep B can lead to meningitis, which can cause deafness, blindness and other symptoms. Sometimes those symptoms are short-lived, but I dare say that parents of those young babies go through a very traumatic time, when they are full of anxiety, not knowing whether their little baby is going to live or not.
There is a risk and we have to be mindful of it. If the clinicians are stating that there is a risk in carrying out the process routinely, perhaps we should listen. However, they also state that, in the high-risk categories, there is not a problem with going ahead with the screening. We should perhaps be looking at the criteria for what is high risk and what is not. It is crucial that we ensure that parents have the information available to them. They need the information so that they can be informed in making a choice.
There are occasions when parents’ choice is perhaps better than clinical choice. If the expectant parents believe that it is in their interests and the interests of their newborn baby, or their baby who is to be born, to do the test, that test should be carried out.
I hope that, when the minister sums up, she will take cognisance of parental choice against clinical choice.
17:13
I congratulate Margaret McDougall on securing the debate. It is vital that we keep reassessing our approach to conditions such as GBS and their prevention in order that Scottish patients receive the most appropriate treatment.
In Scotland, patients are screened for GBS infection if they are deemed to be at risk. However, a number fall through the net, which can have terrible consequences. A child who contracts GBS is at risk of death or disability. It must be heartbreaking for the mother to know that a bacterium that she carried, which was largely harmless to her, has caused a problem for her child. That is why we need to continue to reassess how we deal with this condition.
There is also an on-going cost to the state, which was estimated at £67 million by the 2007 health technology assessment study. Many more cases of GBS infection in newborn babies could be prevented by routine screening to identify all women carrying GBS, rather than using the current strategy of screening those with risk factors, who might not actually be carrying GBS.
The test itself does not carry risk. However, there are concerns about its accuracy and there is a fear that routine testing could lead to many thousands of women being offered antibiotics that they do not need.
The use of antibiotics in pregnancy and labour is the subject of increasing concern, and current UK guidance recommends against unnecessary use. Studies in the USA have shown that only broad-spectrum antibiotics carry a risk in pregnancy, not the narrow-spectrum antibiotics that are recommended for use here against GBS infection, as Margaret McCulloch mentioned in her speech. Concerns about the antibiotics causing negative effects on the mother or her baby have been mostly disproven.
More widely, there is concern about growing antibiotic resistance due to overuse, which rightly leads to a reluctance to prescribe antibiotics unless it is absolutely necessary to do so. That said, when lives are at stake, surely they should be used.
There are also concerns that the test can tell only whether a woman is carrying GBS, not whether their unborn baby will become unwell. Testing cannot completely predict which mothers will or will not have GBS by the time that they go into labour. Up to 49,000 women a year whose tests would say they have GBS will actually be clear by the time that they give birth. Conversely up to 43,000 women a year whose tests would come back clear might be carrying GBS by the time they go into labour. That means that those who needed no treatment could be unnecessarily treated while those who tested clear could be given a false sense of security.
That said, as a result of screening programmes in other countries, the number of GBS infections in newborn babies has fallen significantly. In the USA, it has fallen by more than 80 per cent; in Spain by 86 per cent; in Australia by 82 per cent; and in France by nearly 72 per cent. However, in the UK, routine screening for GBS is not offered and the incidence has increased, leaving more babies exposed to the life-threatening illness. Therefore, it might be that a number of approaches must need to be taken in order to offer the greatest protection, possibly including routine screening combined with retesting if risk factors are present.
This is a complex issue, but at its heart is the safe delivery of healthy babies and, therefore, we cannot be complacent. We need to learn from other countries that have succeeded in saving lives and preventing disability. I therefore urge the Scottish Government to look again at this issue to ensure that we are offering the best care for unborn babies.
17:17
I, too, commend Margaret McDougall for bringing this important but difficult issue to the attention of Parliament and for gaining cross-party support for her motion.
As we have heard, GBS infection is an uncommon but potentially serious and life-threatening infection of neonates and young infants. Early-onset infection occurs in the first week of life, and late-onset infection occurs up to about the first 90 days.
Strep B is a bacterium that lives in the gut or vagina, and sometimes in the back of the nose and throat. It is usually harmless to the person who is carrying it and 99 per cent of the babies of the 20 per cent to 30 per cent of pregnant women who are estimated to be carriers are born without any health complications. Extremely rarely, GBS infects a newborn baby through transmission from the vagina during labour, and this is symptomised by the baby being lethargic, not feeding well, being irritable, having an abnormally high or low temperature, heart rate or respiration rate, and their blood pressure may be low. About 60 per cent to 70 per cent of GBS infection is early onset and develops within the first seven days of life. When the diagnosis is made, speedy treatment with antibiotics, usually penicillin, is effective.
Late-onset infection occurs after the first week, and up to about 90 days, and usually causes meningitis, which again may be treated very successfully when diagnosed. However, sadly, a small number of babies suffer serious consequences including deafness, blindness or brain damage, and a few die of complications.
Although GBS rarely causes significant harm, it has to be taken seriously, and parents and the people who are looking after pregnant mums should keep it in the back of their minds in the later stages of gestation. To that end, the Royal College of Obstetricians and Gynaecologists has drawn up guidelines on prevention of early-onset neonatal GBS and has produced educational material for patients.
NHS boards have also produced circulars that detail the main risk factors. I have seen as an example the information that was circulated to all staff and managers in obstetrics by NHS Forth Valley in 2013. Its guidance on prevention of early-onset GBS and management of babies born to mothers with it is detailed.
Nonetheless, Group B Strep Support has claimed that midwives and other professionals have a poor understanding of GBS and that countries that have national screening programmes—there are several—have lowered the rate of infection. The charity’s demands for routine screening are based on the experience of those other countries.
That is why I said at the outset that we are discussing a difficult issue. The United Kingdom National Screening Committee, which gives expert advice on screening issues to the NHS and ministers in all four parts of the UK, advised in 2012 against a national GBS screening programme for pregnant women on the ground that the benefits of such a programme would not outweigh harm. That advice was repeated last year.
Several reasons are given for the UKNSC’s recommendations; it is worth repeating them. Many women carry Strep B and most of their babies are born safely and without infection. Screening all women in late pregnancy cannot predict which babies will develop GBS infection. Moreover, testing is not reliably accurate and false negatives are possible, with carriers of GBS testing negative. Most babies who are severely affected by GBS infection are born prematurely, before the suggested time for screening. Finally, a large number of women carriers at low risk would get unnecessary treatment and the overuse of antibiotics might well lead to the development of antimicrobial resistance, which is a serious problem for the modern NHS.
I have a great deal of sympathy with the concerns of the people who seek screening for pregnant women, because to have a badly infected baby is one of the worst nightmares a mum can have. However, I also understand that Governments have to rely on their expert advisers to give them the right information before they embark on new regimes. Equally, I have no doubt that those who lobby for a change of heart will continue to make their valid case. I also have no doubt that experts will revisit their decision and look at the facts again in future years to see whether there are any new factors which might change their opinion.
However, the most important thing to be done now is to ensure that all concerned are made aware of GBS and that steps are taken regularly to reinforce that awareness by whatever are considered to be the most effective means in a 21st century society. Thankfully, GBS infection is not common, but one serious complication or death is one too many, as I am sure we all agree.
17:22
I congratulate my colleague Margaret McDougall on securing the debate. I commend members who have highlighted the issue in some way over the past four years: Margaret McDougall, Rhoda Grant, Nanette Milne and Kenny Gibson.
I pay tribute to Jane Plumb, who is the chief executive of Group B Strep Support, and Jackie Watt for their passion and persistence in raising awareness about the bacterium and the risk that it poses to the youngest infants and babies who are yet to be born. They have pursued the issue through the Public Petitions Committee, argued the case for more comprehensive screening and asked challenging but always fair and informed questions of the Scottish Government and the health professions. Equally, the committee has received some valuable and useful evidence from the Government and others that highlights existing practice and the work that is already under way to address group B Strep.
An important debate is under way about how we prevent the bacterium from leading to infection and illness in newborns—illnesses that can put precious young lives at risk. Why are so many mothers unaware of Strep B? Is our approach to Step B out of kilter with that of some of our nearest neighbours, including the Republic of Ireland? Why do we not test and screen more women? Whom do we test and are we testing them in the right way? We need to grapple with those issues.
Obviously, making parents aware is paramount, as well. Does Margaret McCulloch agree that the Scottish Government is listening to the Public Petitions Committee and is revisiting the information on the “Ready Steady Baby!” website and that that is to be welcomed?
If that is what the Government is doing, I welcome it. However, it is a problem that women who are pregnant are not aware of Strep B and that it can seriously damage babies. If women cannot be tested through the NHS, they can do it privately. That information is on the Public Petitions Committee website, but not everybody accesses that information or knows that it is there.
Group B Strep can be present in many women and it can go unnoticed without causing any harm and without any symptoms manifesting. However, for pregnant women, Strep B can be a cause of bacterial infection in their newborn babies. Each year in the UK, about 340 babies develop an early onset GBS infection. Most babies who are infected can be treated successfully and go on to make a full recovery and have a healthy and happy infancy. However, as has been said, for some the infection can be much more serious. It can lead to septicaemia, pneumonia and meningitis and it can be life threatening. Some babies never fully recover and live for the rest of their lives with blindness, deafness, learning disabilities or cerebral palsy. Others die.
The concern about the level of early-onset GBS infections is that the rate has remained static in the rest of the UK but, as the motion sets out, in Scotland it has risen. The number of cases is not huge, but as I have explained, the consequences can be devastating. It seems to be logical that the Scottish Government should therefore consider the merits of the arguments that are being presented by people such as Jackie Watt. Her concern is that cases are slipping through the net because our approach concentrates on women who are affected by certain risk factors. For example, they might experience certain illnesses in their pregnancy or might have their child prematurely.
Jackie Watt advocates following the example of other developed countries where women are screened more generally and antibiotics are administered more widely. We do not want to provide intravenous drips to anyone if it can be avoided, but best practice from elsewhere suggests that administering antibiotics to more mothers helps to prevent early-onset infection.
We want to follow the best medical advice from bodies such as the UKNSC but, equally, we could test more women. It was suggested in evidence to the Public Petitions Committee that clinicians in Scotland could be ahead of the curve in supporting more women to be tested. However, questions were raised about whether testing is robust enough, given that we do not have consistent guidelines to direct a more general approach to it.
I simply put it to the Government that the recorded increase in the incidence of infection should focus minds and allow us to take a closer look at how we reduce the risk of GBS to the health of newborns. Margaret McDougall and the Strep B campaigners have brought an issue of the utmost importance to the Parliament. We must hear the voices of those campaigners, interrogate the evidence that is before us and do all that we can to protect the next generation.
17:28
I thank members for their contribution to the debate and the valid points that they have raised and, in the case of members such as Nanette Milne and Rhoda Grant, answered.
It is without doubt distressing to all involved when a baby dies. I express my deepest sympathies to the families who have been affected by group B Streptococcus. I reassure everyone in the Parliament that the Scottish Government is absolutely committed to quality and safety and to the person-centred care of mothers and babies in the NHS throughout Scotland. Care is based on best practice and the underpinning guidelines that are used in the NHS. Those are not developed in isolation; they are the result of consideration of the best available evidence.
As many members are aware, evidence on group B Streptococcus was extensively reviewed in November 2012 by the UK National Screening Committee. That independent expert advisory group used all the available medical evidence on the risks and benefits of screening all pregnant women. Indeed, the evidence base that was examined was the largest that the NSC has been required to look at, and it included extensive comments from interested groups and members of the public via public consultation.
The NSC agreed that a national screening programme for group B Streptococcus should not be introduced. The NHS in Scotland is following that advice. I am sure that members would agree that all our work should be evidence based and we must listen to professionals. Of course, if the evidence changes and the advice of the professionals changes, the Government will respond to that.
Many members are aware of the reasons that were stated for that position, which include the fact that testing cannot completely predict which mothers will or will not have group B Streptococcus by the time that they go into labour. As Nanette Milne pointed out, mothers can have it at one point in time but not later on; similarly, they may not have it earlier on in the pregnancy but they can develop it later.
Estimates suggest that between 13,000 and 49,000 women each year whose tests would say that they have group B Streptococcus would be clear of the virus by the time that they give birth. Just to clarify, 17,000 to 25,000 pregnant women in the UK would need to be treated with prophylactic antibiotics each year to prevent one death from group B Streptococcus. That is approximately one in 30 pregnant women.
Does the minister agree that, in relation to reducing the anxiety of the parents, it is perhaps better to test, given the risk to the unborn child of an expectant mother’s high anxiety?
I will come on to the point that Dennis Robertson raises.
We need to be absolutely clear that screening is not a risk-free option. There are implications, which I am sure all members are familiar with, including microbial resistance to antibiotics and the risk to some women of an allergic reaction to antibiotics in pregnancy. I am sure that all women who have been pregnant will know that they do not want to take any drugs during pregnancy that they do not need to take.
I also want to pick up on the various statistics that were presented around the rate of infection in Scotland. I caution members against that, given that these infections are not notifiable under the terms of the Public Health etc (Scotland) Act 2008.
Surveillance of Streptococcal B infection in Scotland is based on laboratory-confirmed reports that are received through the electronic reporting system, which is called electronic communication of surveillance in Scotland, or ECOSS.
Although there are limitations around that data—particularly prior to 2009, when ECOSS had not been fully implemented—the figures show that the number of laboratory-confirmed reports of group B Streptococcal infections, including early and late onset infections, has not changed significantly in the past six years.
Despite all that I have said, I can categorically state that I agree with everybody in the chamber that the death of even one baby is one death too many. That is why I am reassured that a programme of research is under way to develop improved practices in the management of potential group B Streptococcal infection. Those research studies include looking at appropriate rapid identification methods.
As much of that research is due to be completed around the end of this year, it is hoped that the NSC will be in a position to evaluate the case for a screening programme with the most up-to-date evidence later this year or early next year.
I am also reassured that we are developing better communications for pregnant women on the issue, as Nanette Milne said in her valuable contribution and as Dennis Robertson has just indicated.
An example is the informative booklet “Ready Steady Baby! A guide to pregnancy, birth and early parenthood”, along with the accompanying website and mobile phone application, for expectant families. That source of information, which was funded by the Scottish Government and given to all expectant families in Scotland, has recently been updated to include two sections on GBS.
We need to open up a conversation between clinicians, midwives, maternity nurses and families about the risks. For some families, the risk will be higher—for example, among mothers who have previously given birth to a baby who has had the infection; women who have had high temperatures or other symptoms of infection during labour; and women who have had urinary tract or vaginal infections. We need to make women more aware of the risks, especially if they have had those kinds of symptoms, and they need to have a conversation about whether testing or medication is necessary.
Although I freely accept that in practice progress around the infection may not be moving fast enough for some, I assure members that progress is being made, and that I will maintain a keen interest in ensuring that the best possible evidence is put into practice for the mothers and babies of Scotland.
I thank members for taking part in this important debate.
Meeting closed at 17:35.Previous
Decision Time