Neonatal deaths in
New Zealand
Dr David Knight
Director of Neonatology
Mater Mothers’ Hospital
Brisbane
Australia
Queensland Maternal and Perinatal
Quality Council
• Chequered history: 3rd iteration
• Resurrected 3 years ago
• Produces report sent to Minister and Director
General of Health
• Sub-committees for Perinatal Mortality, Maternal
Mortality, Congenital Anomalies and Indigenous
Health
• Data from QH Perinatal Data Collection
– No separate perinatal mortality data source
– No mandatory reporting of details of perinatal deaths
Perinatal and Maternal Mortality
Review Committee
• Set up by legislation
• Mandatory reporting
• Maternal deaths have to be reported to
coroner
– Almost all have autopsies
• Setting up reviews of major maternal and
neonatal morbidity
Why do babies die (PSANZ)?
•
PN death classification
•
– 11 headings
– 66 sub-headings
•
Headings
1. Congenital anomaly
2. Infection
3. Hypertension
4. Antepartum haemorrhage
5. Maternal conditions
6. Perinatal conditions
7. Hypoxic
8. Growth restriction
9. Spontaneous preterm
10. Unexplained
11. No factors
Neonatal death classification
– 7 headings
– 36 sub-headings
•
Headings
1.
2.
3.
4.
5.
6.
7.
Congenital anomaly
Extreme prematurity
Cardiorespiratory
Infection
Neurological
Gastrointestinal
Other
Why do babies die (PSANZ)?
PN Death classification
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Congenital anomaly
Spontaneous preterm
Unexplained
Antepartum haemorrhage
Perinatal conditions
Growth restriction
Maternal conditions
Hypertension
Hypoxic
Infection
11. No factors
Neonatal death classification
181
108
102
77
75
53
37
28
28
24
7
1. Extreme prematurity
2. Congenital anomaly
3. Neurological
4. Infection
5. Cardiorespiratory
6. Other
7. Gastrointestinal
57
43
40
12
11
11
8
Very preterm babies
• PSANZ defines extreme prematurity as
– Typically ≤24 weeks or ≤600g and either
• Not resuscitated or
• Unsuccessful resuscitation or
• Unspecified or not known whether resuscitation attempted
• Deaths in babies 24-27 weeks (other than
“extreme prematurity”) classified as:
–
–
–
–
–
Cardiorespiratory
Infection
Neurological
Gastrointestinal
Other
Why do live-born babies die?
• Congenital anomaly
– Lethal/untreatable
– Potentially survivable
• Extreme preterm <24weeks
– Few survivors
• Very preterm 24-27 weeks
– Potentially survivable
• Preterm 28-36 weeks
– Should survive
• Term and post term
– Should survive
Scottish Perinatal Mortality Report
• Includes tables on “normally-formed birth
weight and gestation specific mortality”
• Separate for stillbirths and neonatal
deaths
• Tables are for singletons only
Why live-born do babies die?
(numbers for 2007-9)
• Congenital anomaly
124
25%
155
30%
92
18%
48
9%
106
20%
– Lethal/untreatable
– Potentially survivable
• Extreme preterm ≤24weeks
– Few survivors
• Very preterm 24-27 weeks
– Potentially survivable
• Preterm 28-36 weeks
– Should survive
• Term and post term
– Should survive
Very preterm 24-27 weeks
(numbers for 2007-9)
•
•
•
•
•
•
•
Cardiorespiratory
Extreme preterm
Infection
Neurological
Other
Gastrointestinal
Total
22
20
18
17
8
7
92
24%
22%
20%
18%
9%
8%
Preterm 28-31 weeks
(numbers for 2007-9)
•
•
•
•
•
•
•
Neurological
Infection
Other
Cardiorespiratory
Gastrointestinal
Extreme preterm
Total
21
13
7
3
3
1
48
44%
27%
15%
6%
6%
2%
Term and post-term neonatal deaths
(numbers for 2007-9)
•
•
•
•
Neurological
Other
Infection
Cardiorespiratory
• Total
64
27
14
1
106
60%
25%
13%
1%
How does NZ compare?
Neonatal death rate
per 1000 live-births
Gestation
20-23
NZ
UK
Australia
2007-9
2007
2008
?
409
24-27
147
204
28-31
29
34
27
32-36
6
6
4
37-41
0.8
0.9
0.5
42+
1.2
0.7
1.2
Neonatal death rate
NZ 2007-9
excluding deaths from anomalies
Live-births* Deaths
Rate
Rate
including
anomalies
24-27
643
92
143
147
28-31
1474
20
14
29
32-36
11686
28
2.4
6
37-41
143018
78
0.5
0.8
42+
36363
28
0.8
1.2
* Live-births less those with lethal anomalies
How does NZ compare?
Perinatal related death rate
per 1000 total births
NZ
Australia
2007-9
2008
28-31
113
106
32-36
22
19
37-41
3
2
2.8
3.8
Gestation
42+
Perinatal death and multiple birth
Births
TOP
Singleton
61862
2.1
6
2.4
10.5
Multiple
1803
3.3
17.8
18.1
38.8
•
•
•
•
Stillbirth Neonatal Perinatal
Stillbirth rate
3 greater than that of singletons
Neonatal rate
7 greater
Perinatal rate
3.7 greater
One in 25 perinatal loss
Perinatal Mortality of singletons
and multiples in Queensland
1995-2007
Queensland Maternal and Perinatal Quality Council. 2010
Birth weight of singletons and multiples
Pharoah POD, Clin Perinatol 2006;33:301– 313
Multiple pregnancy rate over time
Black M, Bhattacharya S. Seminars in Fetal & Neonatal Medicine 2010;15:306-312
Multiple births and perinatal deaths
• Strongly associated with fertility treatment
• 7 of 70 perinatal deaths in multiples
conceived with IVF, FSH or clomiphene
Percentage of multiple births in pregnancies conceived with and without the use of fertility techniques
Queensland 1995-2007
Multiple births by maternal age
Black M, Bhattacharya S. Seminars in Fetal & Neonatal Medicine 2010;15:306-312
Outlook for multiple pregnancies
•
•
•
•
•
•
•
Stillbirth rate 3 greater than that of singletons
Neonatal death rate 7 greater
Perinatal death rate 3.7 greater
One in 25 perinatal loss
Five time rate of cerebral palsy
1% cerebral palsy
Six point reduction in IQ
NZ perinatal and maternal mortality report 2009
Pharoah POD, Clin Perinatol 2006;33:301– 313
Cooke RWI, Seminars in Fetal & Neonatal Medicine 2010;15:362-366
Maternal Ethnicity and Neonatal
Deaths
Births
Deaths
n
%
n
%
rate
Māori
14646
23%
68
37%
4.69
Pacific
6823
11%
29
16%
4.30
Indian
2190
3%
11
6%
5.07
Other Asian
4590
7%
9
5%
1.97
Other
5732
9%
8
4%
1.14
NZ European
29684
47%
57
31%
1.94
Maternal Ethnicity and Perinatal
Deaths
2008
2009
Neonatal Perinatal
Neonatal Perinatal
Māori
3.8
10.9
4.7
14.1
Pacific
3.5
13.9
4.3
15.4
Indian
3.6
13.3
5.1
15.1
Other Asian
1.6
8.9
2
9.2
Other
0.9
9.8
1.4
8.7
NZ European
2.4
9.9
1.9
9.5
Socio-economic disadvantage
Perinatal related death rates by deprivation quintile
Births
TOP
Stillbirth Neonatal Perinatal
1
10,177
2.5
4.3
1.4
8.2
2
11,225
1.8
4.7
1.8
8.3
3
12,088
2.1
5.5
2.3
9.8
4
13,342
2.3
7.1
3
12.4
5
16,530
2.1
8.1
4.9
15
Perinatal death rate by maternal age
<20
20-24
25-29
30-34
35-39
18
Death rate (/1000)
16
14
12
10
8
6
4
2
0
TOP
Stillbirth
Neonatal death
Total perinatal
>40
Perinatal death rate by maternal age
• Mothers <20 years of age
– Increased stillbirth, neonatal and perinatal
deaths
– Related to smoking (50%) and
– SE deprivation (50% in highest quintile)
– Ethnicity distribution similar to that of all
perinatal deaths
• Mothers >40 years of age
– Increased TOP, stillbirths and perinatal deaths
– Congenital anomalies 5/1000 vs. 3/1000 in
younger women
“100 babies died needlessly – report”
“The deaths of nearly 100 late term
and newborn babies could have been
prevented in 2009, new figures show.”
Contributory factors to perinatal deaths
n = 169
•
•
•
•
•
Organisational
Health personnel
Technology or equipment
Environmental
Access/engagement
– Acces
– Cultural aspects
– Social issues
– Communication
34
50
6
12
111
Contributory factors to perinatal
deaths
• Organisational
• Health personnel
34
50
– Inadequate education and training
– Lack of policies or guidelines
– Failure to follow recommended best practice
– Knowledge/skill lacking
9
10
24
16
Clinical Guidelines
• NZ Guidelines Group:
– 1 perinatal guideline, 2004, 106 pages
• Professional groups
27 guidelines, succinct, 1-2 pages
65+ guidelines
• Individual hospitals
254 neonatal guidelines, short practical guides
• Formed in 2009
• Evidence informed consensus guidelines
• Produce guidelines
– Clinical lead
– Volunteer members from interested lay and health groups
• Published on the web
• Education and audit project
• Financial reward to institutions for implementing
guidelines
• 18 published guidelines
– 9 Maternity
– 9 Neonatal
– 13 to 31 pages long
– All have a flow sheet designed for display in
clinical units
Maternity guidelines
• Published
–
–
–
–
–
–
–
–
–
Stillbirth care
Early onset Group B streptococcal disease
Intrapartum fetal surveillance
Hypertensive disorders
Obesity
Vaginal birth after caesarean section
Primary post partum haemorrhage
Venous thromboembolism prophylaxis
Preterm labour
• In preparation
–
–
–
–
–
–
Non-urgent referral for antenatal care Consultation
Maternity shared care
Early pregnancy loss
Normal birth
Perineal care
Review: Postpartum haemorrhage
Neonatal Guidelines
• Published
–
–
–
–
–
–
–
–
–
Breastfeeding initiation
Examination of the newborn
Neonatal hypoglycaemia
Hypoxic ischaemic encephalopathy
Neonatal jaundice
Neonatal abstinence syndrome
Respiratory distress and CPAP
Neonatal resuscitation
Term small for gestational age baby
• In preparation
–
–
–
–
Neonatal stabilisation for retrieval
Neonatal pain
Neonatal seizures
Review – neonatal resuscitation
Controlled trials: is this the first?
Holy Roman Emperor Frederick II
1194-1250
• Aim:
– Does exercise influence
digestion?
• Designed a controlled clinical
trial
• 2 Knights ate a meal
– 1 exercised
– 1 slept
• Killed both Knights and
looked at stomach contents
• Conclusion:
– Exercise inhibits gastric
emptying
Controlled trials
• Bill Silverman and
retinopathy of prematurity
• Mont Liggins, Ross Howie
and antenatal steroids
• Brian Darlow and the
Boost II studies
– Oxygen saturation targeting
in preterm infants
Epidemiology:
Florence Nightingale
• Educated woman
– Latin, Greek, History,
Mathematics
• Used statistics to prove her
hypotheses
• 1st female member of Royal
Statistical Society in 1858
• Honorary member of
American Statistical Society
Epidemiology
• Richard Doll, Austin
Bradford and smoking
• NZ Perinatal and Maternal
Mortality Review
Committee
Conclusions
• NZ has an impressive setup for gathering
data
• The report in comprehensive and timely
• The report contains detailed analysis of
deaths, not just raw data
• Needs more data on all births so that
denominator known in subgroups
Suggestion
• Separate reporting of congenital
anomalies
• Data on gestational age and birth weight
specific mortality in babies without
anomalies
Conclusion
• NZ outcomes compare well with UK and
Australia
• Outcomes for multiple pregnancies significantly
worse than for singletons
• Worse outcome for youngest and oldest mothers
• Noteworthy that there is an uneven risk related
to ethnicity, deprivation decile and DHB of birth
– DHB outcomes likely to related to the other two
factors
– This is seen in all countries
Thank you for the invitation to
comment on this impressive report
and these excellent results