Neonatal deaths in New Zealand

Dr David KnightDirector of NeonatologyMater Mothers’ Hospital

BrisbaneAustralia

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

• Headings1. Congenital anomaly2. Infection3. Hypertension4. Antepartum haemorrhage5. Maternal conditions6. Perinatal conditions7. Hypoxic8. Growth restriction9. Spontaneous preterm10.Unexplained11.No factors

• Neonatal death classification– 7 headings– 36 sub-headings

• Headings1. Congenital anomaly2. Extreme prematurity3. Cardiorespiratory4. Infection5. Neurological6. Gastrointestinal7. Other

Why do babies die (PSANZ)?

PN Death classification1. Congenital anomaly

181

2. Spontaneous preterm108

3. Unexplained102

4. Antepartum haemorrhage 77

5. Perinatal conditions 75

6. Growth restriction 53

7. Maternal conditions 37

8. Hypertension 28

9. Hypoxic 28

10. Infection 24

11. No factors 7

Neonatal death classification1. Extreme prematurity 57

2. Congenital anomaly 43

3. Neurological 40

4. Infection 12

5. Cardiorespiratory 11

6. Other 11

7. Gastrointestinal 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%– Lethal/untreatable– Potentially survivable

• Extreme preterm ≤24weeks 155 30%– Few survivors

• Very preterm 24-27 weeks 92 18%– Potentially survivable

• Preterm 28-36 weeks 48 9%– Should survive

• Term and post term 106 20%– Should survive

Very preterm 24-27 weeks(numbers for 2007-9)

• Cardiorespiratory 22 24%

• Extreme preterm 20 22%

• Infection 18 20%

• Neurological 17 18%

• Other 8 9%

• Gastrointestinal 7 8%

• Total 92

Preterm 28-31 weeks(numbers for 2007-9)

• Neurological 21 44%

• Infection 13 27%

• Other 7 15%

• Cardiorespiratory 3 6%

• Gastrointestinal 3 6%

• Extreme preterm 1 2%

• Total 48

Term and post-term neonatal deaths(numbers for 2007-9)

• Neurological 64 60%

• Other 27 25%

• Infection 14 13%

• Cardiorespiratory 1 1%

• Total 106

How does NZ compare?

Neonatal death rate per 1000 live-births

Gestation NZ 2007-9

UK 2007

Australia 2008

20-23 ?  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 rateNZ 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 rateper 1000 total births

Gestation NZ2007-9

Australia2008

28-31 113 106

32-36 22 19

37-41 3 2

42+ 2.8 3.8

Perinatal death and multiple birth

• Stillbirth rate 3 greater than that of singletons• Neonatal rate 7 greater • Perinatal rate 3.7 greater • One in 25 perinatal loss

  Births TOP Stillbirth Neonatal Perinatal

Singleton 61862 2.1 6 2.4 10.5

Multiple 1803 3.3 17.8 18.1 38.8

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 IQNZ perinatal and maternal mortality report 2009Pharoah POD, Clin Perinatol 2006;33:301– 313Cooke 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

  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 related death rates by deprivation quintile

Perinatal death rate by maternal age

<20 20-24 25-29 30-34 35-39 >40

TOP Stillbirth Neonatal death Total perinatal

18

14

12

10

8

6

4

2

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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 34

• Health personnel 50

• Technology or equipment 6

• Environmental 12

• Access/engagement 111– Acces– Cultural aspects– Social issues– Communication

Contributory factors to perinatal deaths

• Organisational 34

• Health personnel 50

– Inadequate education and training 9– Lack of policies or guidelines 10– Failure to follow recommended best practice24– Knowledge/skill lacking 16

Clinical Guidelines• NZ Guidelines Group:

– 1 perinatal guideline, 2004, 106 pages

• Professional groups

27 guidelines, succinct, 1-2 pages

65+ guidelines

254 neonatal guidelines, short practical guides

• Individual hospitals

• 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 

• 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

Neonatal Guidelines

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