Meeting of the Parliament

Meeting date: Tuesday, March 3, 2020

Official Report 866KB pdf

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Pre-eclampsia (Diagnosis)

The final item of business is a members’ business debate on motion S5M-20650, in the name of Miles Briggs, on improving diagnosis of pre-eclampsia. The debate will be concluded without any question being put.

Motion debated,

That the Parliament understands that the condition pre-eclampsia affects at least 6% of all pregnancies in Scotland, and that 70% of women admitted to hospital with suspected pre-eclampsia do not actually have the condition, which it considers results in cost implications for the healthcare system and unnecessary stress and inconvenience for the women and families involved; further understands that, in 2016, the National Institute for Clinical Excellence (NICE) published guidelines recommending blood testing of placental growth factor (PlGF), stating that PlGF-based testing “can help rule out the condition in women presenting with suspected pre-eclampsia”, and that this testing is currently being implemented in NHS England; believes that PlGF-based testing is not routinely used in Scotland despite repeated calls for its implementation by the charity, Action on Pre-eclampsia; considers that there is a disparity in care for pregnant women in Scotland, including in the Lothian region, compared with England, and notes the calls on the Scottish Government to address what it sees as this disparity.

17:03  

I thank colleagues from across the chamber who signed the motion allowing today’s debate, and I commend a number of fellow elected representatives who have campaigned on the issue for a number of years—longer than I have—including Kenneth Gibson MSP and Patricia Gibson MP. I also pay tribute to and welcome the continuing good work of Action on Pre-eclampsia.

Pre-eclampsia, which most often demonstrates itself through high blood pressure, is the most common of the serious complications of pregnancy. Mild pre-eclampsia affects up to 10 per cent of first-time pregnancies and severe cases affect one to two in 100 pregnancies. It is caused by a poorly functioning placenta—an organ that joins the mother and baby and supplies the baby with nutrients and oxygen from the mother’s blood.

Although we do not know exactly the root cause of pre-eclampsia, medical science is expanding our knowledge every day. By definition, pre-eclampsia occurs after 20 weeks—earlier in very rare cases—and the majority of cases occur in the third trimester. This multisystem disorder can affect different parts of the body including the liver, kidneys and the cardiovascular and clotting systems.

I therefore decided to bring this debate to Parliament to discuss the pathways currently available for expectant mothers and the available opportunities to improve the diagnosis of the condition and the care of Scottish mothers who have it. The current clinical pathway in Scotland for pre-eclampsia includes taking blood pressure and urine measurements, but both blood pressure and proteinuria are relatively poor at predicting its clinical onset and progression. Indeed, it is estimated that 70 per cent of women admitted to hospital with suspected pre-eclampsia do not have the condition. Understandably, that has cost implications for our NHS and puts those women and their families under significant and unnecessary stress in many cases, as well as the inconvenience of their being hospitalised.

There is a solution, though, which is the use of placental growth factor testing, which I will discuss. It has been part of the National Institute for Health and Care Excellence guidelines since 2016. In 2019, NHS England announced the roll-out of PIGF testing through the rapid uptake programme in order to help rule out pre-eclampsia, which was a welcome step forward in England. The use of PIGF has been shown to reduce demand on maternity services, improve patient safety and patient experience, reduce admissions and reduce unnecessary in-patient monitoring services.

A previous trial called the PARROT trial—“Placental growth factor testing to assess women with suspected pre-eclampsia: a multicentre, pragmatic, stepped-wedge cluster-randomised controlled trial”—demonstrated that, compared to traditional methods, the PIGF test, alongside blood pressure and urine checks, reduced the average time to diagnosis from 4.1 days to 1.9 days. It also significantly cut the rate of serious maternal complications and maternal death, with no increased risk to babies and no increase in premature deliveries or neonatal unit admissions.

As things stand, that test is not routinely available in Scotland and many mothers-to-be and families here think that that disparity in care between women in England and women in Scotland is unfair, and I share their concerns. The Scottish Government’s position to date—I hope that the minister will clarify this during the debate—is that ministers need to wait until the results of a second trial—PARROT-2—are known, before adopting routine PIGF tests. However, that trial might take up to five years to report and there is already strong clinical evidence to recommend using the PIGF test. In addition, it is supported in national clinical guidelines, including NICE diagnostic evidence 23—DG23—which states that the test,

“used with standard clinical assessment”

is

“recommended to help rule-out pre-eclampsia in women presenting with suspected pre-eclampsia between 20 weeks and 34 weeks plus 6 days of gestation.”

Furthermore, the PARROT-2 trial, the results of which ministers have said they want to wait for, will look only at the effectiveness of repeat PIGF testing. However, given that no PIGF testing is taking place in Scotland, I do not think that the trial will add the value that ministers have suggested that they are waiting to see.

What campaigners and I want to emphasise is that, although the PIGF test is a powerful tool in ruling out pre-eclampsia, it is not a certain diagnosis of the condition. However, the tests are highly accurate in ruling out the chances of a woman developing pre-eclampsia requiring delivery in the next 14 days. Care can therefore be targeted and unnecessary admissions reduced, while women who are at greater risk can receive the appropriate surveillance to reduce possible complications. NICE’s economic evaluation of the test suggests a potential cost reduction of between £2,488 and £2,896 per patient, compared to standard clinical assessment, depending on the test used. The potential saving and investment for the NHS is therefore significant.

I believe strongly that mums-to-be in Scotland who might be at risk of pre-eclampsia need as much support as possible and should be able to access the best possible ways of ruling out the condition. PIGF testing is working highly successfully in England and is helping many pregnant women and reducing pressure and costs on the English NHS. It is unacceptable that pregnant women in Scotland cannot access those tests routinely and that there appears to be no clear path identifying their adoption here.

I hope that the debate presents an opportunity for ministers to consider the success of the testing elsewhere and the clear NICE guidelines, to review their current position and to introduce the tests so that women in Scotland can have the same level of treatment as those in England—anything else will not be acceptable.

17:09  

I congratulate Miles Briggs on securing the debate and I thank him for his kind words at its commencement. As I proceed, Miles will find that I agree completely with his speech.

I also thank Action on Pre-eclampsia for its campaign to secure the adoption of placental growth factor testing in Scotland, a matter that Patricia Gibson MP has actively pursued at Westminster and in meetings with the minister and the cabinet secretary for health. The blood test has been proven to improve patient safety and experience through faster and more accurate diagnosis, easing anxiety and hospital admissions; it also reduces unnecessary in-patient monitoring tests and demand on maternity services; and it could potentially decrease admissions for suspected pre-eclampsia in lower-risk women. An economic evaluation carried out by the National Institute for Health and Care Excellence showed a potential cost reduction of between £2,488 and £2,896 per patient, compared with standard clinical assessment. As a result, in England, the test has become almost routine, as we have heard.

With pre-eclampsia affecting around 6 per cent of pregnancies, it is necessary to have proactive testing and appropriate treatment integrated in our maternity healthcare system. Pre-eclampsia can lead to the serious injury and even death of both baby and mother. In the 30 per cent of cases in which a mother suffers from a severe form called HELLP syndrome, the mother loses her life.

My wife Patricia and I endured our own personal nightmare with NHS Greater Glasgow and Clyde when the entirely preventable loss of our son at full term occurred due to a failure to diagnose pre-eclampsia in Patricia, who was 41 years old at the time, pregnant with her first baby and therefore known to be at increased risk. Patricia nearly lost her life, too, and spent 19 days in intensive care and high dependency after her liver ruptured.

We sought only an apology and an assurance that steps would be taken to ensure that such a circumstance did not happen to anyone else. That was fought tooth and nail by NHS Greater Glasgow and Clyde’s lawyers, no doubt at great public expense, for seven years. Health boards surely have a duty of care to patients and their families in such circumstances. The sad truth is that pre-eclampsia is not always diagnosed properly or treated effectively. When it occurs, the patient, her child and family should be treated appropriately and with respect.

The 2020 programme for government commits to establishing a women’s health plan and, on 18 September, I asked the health secretary when the women’s health group would be convened and whether it would prioritise the diagnosis of pre-eclampsia. The response was positive. Apart from the obvious fact that pre-eclampsia only happens to women, we must look at economic inequalities based on living in deprived areas, which is a high-risk factor for many of my constituents. Inequalities also exist in some ethnic minorities and age groups, with women aged 40 and older more likely to suffer from pre-eclampsia. A family history of the condition can also play a part.

The health secretary assured me that the group would be convened shortly and that testing for and treatment of the condition would be prioritised in its work plan. With several months having since elapsed, I would appreciate an update from the minister as to what steps have been taken so far by the women’s health team to improve the diagnosis, prevention and treatment of pre-eclampsia.

I understand, as Miles Briggs discussed, that it was decided to wait for the outcome of the so-called PARROT-2 research into repeat testing, but NICE guidance does not suggest that further evidence is needed before the routine adoption of placental growth factor testing. It seems that that will only kick things further down the road and delay the day when Scottish women can benefit from the test, as women south of the border can.

I welcome Scottish Government funding for the maternal newborn and infant clinical outcome review programme run by MBRRACE-UK, which stands for “mothers and babies: reducing risk through audits and confidential enquiries across the UK”.

We must ensure that women are aware of how to reduce risk factors such as obesity, smoking or drinking in pregnancy that are associated with an increased risk of serious adverse outcomes, including miscarriage, birth defects, thromboembolism, gestational diabetes, postpartum haemorrhage, dysfunctional labour, wound infections, stillbirth and, indeed, pre-eclampsia. We must help mothers to minimise such factors wherever possible.

17:14  

I remind the chamber that one of my daughters is a midwife in the Scottish NHS, and I add my thanks to my colleague Miles Briggs for bringing the debate to the chamber.

Pre-eclampsia is a condition of which I became aware through a constituent of mine, Fraser Morton, who first came to my surgery early in my political career after he and his partner had quite recently lost their son in childbirth—an unimaginable situation for any of us to contemplate.

Since that tragedy, however, through consistent campaigning he has changed things for the better for parents, and he continues to push for more change. I know that his partner, during the later stages of her pregnancy, suffered with pre-eclampsia; or, to be more accurate, the misdiagnosis of June’s condition was eventually accepted as a major contributory factor in the death of their son.

Listening to Kenny Gibson, I thought that it was fantastic that he was able to come to the chamber and speak as he did of the tragedy that he and Patricia Gibson experienced. They have been fighting for change, and I hear that echoed in Mr Morton’s experience. That should make us all stand up and take note. When such tragedies occur, we always say that we need to learn from those occurrences, and that we want to create a system in which we do that. However, listening to Kenny Gibson, and knowing what Mr Morton went through, it seems that we have a long way to go before the system allows that to happen. In Mr Morton’s case, it was a death that should not have happened—that, in real stark terms, is what we are discussing. It is about preventing parents from having to go through the unimaginable trauma of losing a child in childbirth or in the later stages of pregnancy.

I want to mention the misreading of cardiotocography scans, which is a major contributor to baby deaths. Through Mr Morton’s considerable efforts, it is now mandatory for all neo-natal staff to undergo CTG scan training twice a year. Let me tell you, it was—as I have already said—quite a journey. We had to lobby two cabinet secretaries for health and sit in front of the Health Improvement Scotland board and the NHS Ayrshire and Arran health board to eventually effect the change that would address an obvious weak spot in the system.

The reason why I tell that story, and that of the on-going efforts of Mr Morton, is to highlight that raising such issues in this place can lead to change—change that can save babies’ lives and prevent the pain and trauma of losing a son or daughter.

In the motion, Miles Briggs calls for placental growth factor testing to be routinely available to tackle the misdiagnosis of pre-eclampsia and the serious ramifications of that. The reality is that Scotland’s pregnant women are being denied PIGF testing. Following the PARROT study and the publication of the NICE guidelines—which recommended that it should be adopted—PIGF testing has been adopted in England. As Miles Briggs said in his opening speech, it leads to reduced demand on maternity services, improved patient safety through a more accurate and faster diagnosis; reduced anxiety, and has the potential to reduce admissions. However, most importantly, using that test alongside blood pressure and urine tests cuts the rate of serious maternal complications before birth, such as pre-eclampsia, stroke and maternal death.

The Scottish Government, rightly, looks for an evidence-based approach to policy. I say to the Scottish Government that the evidence here is pretty solid and that, by introducing PIGF testing alongside other changes such as CTG scan training, it is possible to reduce mortality in childbirth for both parent and child. It should not take someone such as Mr Morton to force that kind of change. The test should be available in Scotland, and I ask the Scottish Government to make that change.

17:18  

I join colleagues in thanking Miles Briggs for bringing the motion to the chamber this evening. Like colleagues, I am heartened that many members are here for the debate and have been asking parliamentary questions. I know that Alex Cole-Hamilton has done so and Kenny Gibson has been—I do not have the words for Kenny Gibson right now. Both he and Patricia Gibson have been so courageous and relentless in their campaigning, and we all admire how much they have put into the issue.

Even if you have not gone through it, we all understand that pre-eclampsia is a frightening and life-threatening condition for too many pregnant women and their babies. I thank Action on Pre-eclampsia for its helpful briefing, for all the support that it provides to families, and for all its campaigning work over the decades.

Miles Briggs’s motion is very straightforward. In it, he highlights a glaring inequality whereby women and their babies over the border in England can get those tests—the benefits of which are well evidenced and clear—while women and their babies here in Scotland do not have that benefit.

I understand that the tests are not that expensive—it is possible that the cost is below £100—so I hope that, by the time that we get to the end of the debate, we can find a way forward. I do not see why there needs to be further research. Kenneth Gibson is right that it is welcome that we have a focus on women’s health; the Scottish Government has done positive work, but we need to bring it forward.

As others have done, I pay tribute to Kenneth and Patricia Gibson for speaking out about the loss of their baby son, Ken. That is not easy to do and I know that, by speaking out about their experience and their loss, they will have helped not just people in the constituency but thousands of people across Scotland and beyond. That is important when we bring personal stories to the chamber.

I do not think that there is a lot more that we can add. It seems to me that the issue is really simple. I know that ministers have a lot of issues on their desks that are complicated and need more research and investment, but for this issue there is a solution on the shelf—it is ready made and we can learn from colleagues elsewhere. I admit that I did not know a lot about the issue, so I am grateful to Miles Briggs for introducing the debate. These debates raise awareness. I read The Sunday Post articles last year, in which professionals were quoted, and I also read about the family impact and the trauma that can stay with families for many years. I pay tribute to Fraser Morton, as Brian Whittle has done.

I hope that this is an issue on which we can all agree. This is a short debate, but we do not have to re-invent the wheel. There is a solution, and I would welcome hearing from the minister that he will take on board what Kenneth and Patricia Gibson have said. Miles Briggs’s motion has not a word that can be criticised. Action on Pre-eclampsia has been very clear. If we have to have further trials in Scotland, how long will that take? If the issue is about resources, are ministers looking at that?

We can all agree on the issue. It would be a really positive outcome if we could get an update from the minister that the work will go ahead and that tests will be available to women and babies in Scotland very soon.

17:22  

I thank Miles Briggs for securing this important debate.

I think that we are in agreement that it is essential for pre-eclampsia to be diagnosed and treated as soon as possible. Every maternity health professional in Scotland is trained to recognise the signs and symptoms of pre-eclampsia in their patients. They are also trained in how to manage the condition effectively, so that women across Scotland receive the highest-quality care that is tailored to their needs.

I will touch on Brian Whittle’s points about learning lessons from adverse events. It is important that we learn from adverse outcomes in the maternity setting and we are clear that systematic, multidisciplinary, high-quality reviews into death in maternity settings are hugely important. That is why we commissioned the development of the perinatal mortality review tool, which supports our professionals to undertake robust reviews. The reviews highlight learnings so that boards can continue to improve outcomes for the women and their families in their areas. All health boards in Scotland are registered to use the perinatal mortality review tool.

The UK has the lowest incidence of maternal mortality from pre-eclampsia in the world. Out of all the women who give birth here, the number who die from pre-eclampsia is now fewer than one in every million. That is testament to the skills, knowledge and dedication of the incredible staff in our NHS in Scotland and elsewhere in the UK.

The latest MBRRACE-UK “Saving Lives, Improving Mothers’ Care” report was published in December last year. It tells us that, thankfully, pre-eclampsia accounted for just 2 per cent of all maternal deaths—5 deaths—between 2015 and 2017 across the UK. Nevertheless, it is important that we remember the huge impact of such loss. I add my thanks to Kenneth Gibson for speaking out today and sharing his and his wife’s personal experience.

Around 50,000 babies are born each year in the NHS in Scotland, and we know that hypertensive disorders, including pre-eclampsia, affect around eight to 10 per cent of pregnant women. Health boards throughout Scotland also return information to the Information Services Division of the NHS in Scotland on the number of babies delivered by mothers with pre-eclampsia. In Scotland in 2019, fewer than 1.5 per cent of babies who were reported to ISD Scotland were delivered because of pre-eclampsia. That has been the case in each of the past five years, and that illustrates the impact and importance of the great work that has been done to date across maternity services in Scotland, which are delivered by our excellent NHS care staff. Nevertheless, it is important that we remember the individual impact of that, that we are not complacent and that we continue to look at what more we can do to ensure that Scotland is a fantastic place for women to give birth and start their families in.

There has been talk across the chamber about access. I will come to that in a minute; I am minding the time.

Miles Briggs talked about PARROT, or placental growth factor to assess and diagnose hypertensive pregnant women: a stepped wedge trial. The results of PARROT on placental growth factor testing were encouraging, as we have heard. They suggested that testing could reduce the time that is taken for doctors to diagnose pre-eclampsia. However, only single testing was looked at, and negative results using the test are valid for only 14 days. Further research is needed to ensure that we act on robust evidence in the best interests of patients and their families.

Monica Lennon asked how that testing would go forward. Scotland is directly participating in that work. NHS Lothian is taking part in PARROT-2, which is an independent research study into repeated placental growth factor testing. Therefore, PARROT is available for women involved in the area.

The NICE guidelines are pretty clear. What is it about them that the minister disagrees with?

I was just about to come on to the NICE guidelines.

We recognise that placental growth factor testing shows promise in improving the detection and diagnosis of pre-eclampsia. It is vital that any such testing is robust and evidence based. The NICE diagnostics guidance, as it stands, takes the view that there is currently insufficient evidence to recommend the routine adoption of placental growth factor testing.

There has been some talk of an inequality between Scotland and the rest of the UK. However, as I have said, the PARROT test is taking place in Lothian. It has been suggested that there is universal access to the test in other parts of the UK, but we understand that that is not the case. By the end of last year, we were aware of only 33 of 223 trusts in England that had implemented the testing.

To return to Scotland, I cannot thank Kenneth Gibson enough for the work that he has put into the issue. That is never easy, because such things always bring back memories. However, his personal experience and that of his wife are very powerful.

The Cabinet Secretary for Health and Sport and I met Patricia Gibson MP in September last year, and we explained that we were committed to developing a women’s health plan in our programme for government, which was launched on 3 September last year. The expert women’s health group met for the first time on 5 February this year, and it was agreed then that testing for pre-eclampsia would be part of the group’s work plan. The group will consider recent and emerging evidence as part of that work. The group is scheduled to meet again in May, and placental growth factor testing is a confirmed agenda item for that meeting. It is absolutely on the agenda for the next meeting.

At the end of August last year, my officials spoke with the chief executive officer of Action on Pre-eclampsia. It was really positive to hear about that charity’s great work in maintaining public awareness of pre-eclampsia. We know that it also runs training events for professionals, and I am delighted to hear that a study day event is scheduled in Scotland for 11 March, which is next week.

We are continuing to look at the evidence and to work with officials, and our officials continue to engage with officials in NHS England on placental growth factor testing to really understand the emerging evidence from the experience in the 33 trusts in which that has been rolled out. The majority of boards south of the border have not yet rolled it out.

I assure members that the issue is very much on the Scottish Government’s agenda, and I look forward to being able to report back on the output from the women’s health group as we move forward.

Meeting closed at 17:29.