1. Neonatal deaths in New Zealand Dr David Knight Director of Neonatology Mater Mothers’ Hospital Brisbane Australia

2. Queensland Maternal and Perinatal Quality Council Chequered history: 3 rd 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

3. 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

4. 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.Congenital anomaly 2.Extreme prematurity 3.Cardiorespiratory 4.Infection 5.Neurological 6.Gastrointestinal 7.Other

5. Why do babies die (PSANZ)? PN Death classification 1.Congenital anomaly181 2.Spontaneous preterm108 3.Unexplained102 4.Antepartum haemorrhage77 5.Perinatal conditions75 6.Growth restriction53 7.Maternal conditions37 8.Hypertension28 9.Hypoxic28 10.Infection24 11.No factors 7 Neonatal death classification 1.Extreme prematurity57 2.Congenital anomaly43 3.Neurological40 4.Infection12 5.Cardiorespiratory11 6.Other11 7.Gastrointestinal8

6. 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

7. 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

8. 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

9. Why live-born do babies die? (numbers for 2007-9) Congenital anomaly12425% –Lethal/untreatable –Potentially survivable Extreme preterm ≤24weeks15530% –Few survivors Very preterm 24-27 weeks 9218% –Potentially survivable Preterm 28-36 weeks489% –Should survive Term and post term10620% –Should survive

10. Very preterm 24-27 weeks (numbers for 2007-9) Cardiorespiratory2224% Extreme preterm 2022% Infection1820% Neurological1718% Other89% Gastrointestinal78% Total92

11. Preterm 28-31 weeks (numbers for 2007-9) Neurological2144% Infection 1327% Other715% Cardiorespiratory36% Gastrointestinal36% Extreme preterm12% Total48

12. Term and post-term neonatal deaths (numbers for 2007-9) Neurological6460% Other2725% Infection1413% Cardiorespiratory11% Total106

13. How does NZ compare? Neonatal death rate per 1000 live-births Gestation NZ 2007-9 UK 2007 Australia 2008 20-23? 409 24-27147204 28-31293427 32-36664 37-410.80.90.5 42+1.20.71.2

14. Neonatal death rate NZ 2007-9 excluding deaths from anomalies Live-births*DeathsRate including anomalies 24-2764392143147 28-311474201429 32-3611686282.46 37-41143018780.50.8 42+36363280.81.2 * Live-births less those with lethal anomalies

15. How does NZ compare? Perinatal related death rate per 1000 total births Gestation NZ 2007-9 Australia 2008 28-31113106 32-362219 37-4132 42+2.83.8

16. 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 BirthsTOPStillbirthNeonatalPerinatal Singleton618622.162.410.5 Multiple18033.317.818.138.8

17. Perinatal Mortality of singletons and multiples in Queensland 1995-2007 Queensland Maternal and Perinatal Quality Council. 2010

18. Birth weight of singletons and multiples Pharoah POD, Clin Perinatol 2006;33:301– 313

19. Multiple pregnancy rate over time Black M, Bhattacharya S. Seminars in Fetal & Neonatal Medicine 2010;15:306-312

20. 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

21. Multiple births by maternal age Black M, Bhattacharya S. Seminars in Fetal & Neonatal Medicine 2010;15:306-312

22. 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

23. Maternal Ethnicity and Neonatal Deaths BirthsDeaths n%n%rate Māori1464623%6837%4.69 Pacific682311%2916%4.30 Indian21903%116%5.07 Other Asian45907%95%1.97 Other57329%84%1.14 NZ European2968447%5731%1.94

24. Maternal Ethnicity and Perinatal Deaths 2008 2009 NeonatalPerinatal NeonatalPerinatal Māori3.810.9 4.714.1 Pacific3.513.9 4.315.4 Indian3.613.3 5.115.1 Other Asian1.68.9 29.2 Other0.99.8 1.48.7 NZ European2.49.9 1.99.5

25. Socio-economic disadvantage BirthsTOPStillbirthNeonatalPerinatal 110,1772.54.31.48.2 211,2251.84.71.88.3 312,0882.15.52.39.8 413,3422.37.1312.4 516,5302.18.14.915 Perinatal related death rates by deprivation quintile

26. Perinatal death rate by maternal age <2020-2425-2930-3435-39>40 TOP Stillbirth Neonatal death Total perinatal 18 14 12 10 8 6 4 2 0 16 Death rate (/1000)

27. 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

28. “100 babies died needlessly – report” “The deaths of nearly 100 late term and newborn babies could have been prevented in 2009, new figures show.”

29. Contributory factors to perinatal deaths n = 169 Organisational34 Health personnel50 Technology or equipment6 Environmental12 Access/engagement111 –Acces –Cultural aspects –Social issues –Communication

30. Contributory factors to perinatal deaths Organisational34 Health personnel50 –Inadequate education and training9 –Lack of policies or guidelines10 –Failure to follow recommended best practice24 –Knowledge/skill lacking16

31. 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

32. 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

33. 18 published guidelines –9 Maternity –9 Neonatal –13 to 31 pages long –All have a flow sheet designed for display in clinical units

34. 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

35. 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

36. 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

37. 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

38. Epidemiology: Florence Nightingale Educated woman –Latin, Greek, History, Mathematics Used statistics to prove her hypotheses 1 st female member of Royal Statistical Society in 1858 Honorary member of American Statistical Society

39. Epidemiology Richard Doll, Austin Bradford and smoking NZ Perinatal and Maternal Mortality Review Committee

40. 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

41. Suggestion Separate reporting of congenital anomalies Data on gestational age and birth weight specific mortality in babies without anomalies

42. 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

43. Thank you for the invitation to comment on this impressive report and these excellent results