Potentially Avoidable Deaths – What Could Neonatologists Do Better ?

Malcolm Battin

Chair NE Working Group

Neonatologist’s role

Neonatologist’s role

Might include :

• Clinical Practice • Advocacy• Research or clinical review • Education

• Aim to improve mortality

Primary Neonatal Death Classification (PSANZ-NDC) 2009

Top 3 causes account for 77 % of neonatal deaths

NND classification (Page 32)

Extreme prematurity 31.3%

• 1.5 % births < 32 wks GA• 0.4% births 24-27 wks GA

• Lower range GA 20 wks (T. 17) • 114/165 (87%) deaths <24/40 (T. 21)

• 20/165 deaths (12.1%) 24-27/40 (T. 21)• Plus respiratory, neurological, gastro (NEC)

01020

3040506070

8090

100

1959

1961

1963

1965

1967

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2008

%501-1000 g 1001-1500 g

Survival of NW inborn babies by BW

01020

3040506070

8090

100

1959

1961

1963

1965

1967

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

2008

%501-1000 g 1001-1500 g

Survival of NW inborn babies by BW

Liggins & Howie

1st surfactant report

OSIRIS in NZ HFOV/CPAP/Trigger

A progressive ceiling on potential developmental outcomes ?

Wolke (Lagercrantz 2008)

When Does Neonatal Death Occur ? Time of death

0

10

20

30

40

50

60

70

80

90

100

<1 2-7 8-14 15-21 22-28

Days

Perc

en

tag

e

20-23

24-27

>28/40

Data from Table 6

Prematurity

• Concept of borderline in viability

• Individualised approach < 24 weeks

• Audit of neurodevelopmental outcomes

• Publication of results for scrutiny !

• Spontaneous preterm birth & APH as antecedent causes associated with deprivation

• Prematurity associated neonatal death risk highest in teenage mothers

Teenage mothers• Half of teenage mothers whose babies died

were Maori • risk increased across ethnicities

• Half of teenage mothers whose babies died in highest deprivation quintile.

• 45 % of teenage mothers whose babies died were smokers

• More contact health system after birth• NICU nurses support

Maternal age (Figure 18)

Canadian studies what people know about risk associated with maternal age

• 1,044 women, after first live-born, aware link with conception difficulties – 85.%

• * Multiple birth 24%, c.section 18.8%, preterm delivery 22% and LBW 11%

• Further survey 20-45 yrs without children• > 70% recognized link to conception • < 50 % knew that advanced maternal age

increased the risk of stillbirth, c. section, *multiple birth and preterm delivery

Tough 2002 and 2007

NND classification Page 32

• Congenital abnormality 23.6%• Potentially avoidable – complex issue• Some benefit scale or special service

• Neurological 22% • NE Working Group

• Infection 6.6% • Cardio-respiratory 6% • Gastrointestinal 4.4%

Neonatal Encephalopathy or Hypoxic Ischemic Death 2010 data collection

• Thank you for completing forms• Please keep it up for 2011

• 5 % of babies had 1 min Apgar ≥ 9• 23 % of babies had 5 min Apgar ≥ 7• 15 % either no resus or oxygen only • Cooling – not all babies• Investigation, counseling for family

Contributory Factors (T33)

  Neonatal deaths

n=182

Contributory factors

n %

Yes 61 34

No 103 57

Not stated 18 10

Potentially avoidable

35 19

Organisation/people/skills

Perinatal Mortality 2009

• Neonatal deaths with no obstetric antecedent are considerably more frequent in babies of Maori mothers

• Seven cases of SUDI deaths• Four had a mother who smoked• 6 were co-sleeping • 10 cases in 2008

Conclusion

Some contribution clinical practice

Major benefit is working across disciplines

Communication, best practice, lack of skills and knowledge