pmmrc 10th report 2016 - health quality & safety commission...perinatal related mortality risk...
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PMMRC 10th report
2016
Lynn Sadler
The 10th report of the PMMRC June 2016
Online and navigable In entirety Tables adjacent
to relevant sections Active links
http://www.hqsc.govt.nz/our-programmes/mrc/pmmrc/
Perinatal mortality 2007-2014 (8 years) 656 perinatal related deaths in 2014
= 1:89 births
Maternal mortality 2006-2014 (9 years) 4 maternal deaths in 2014
Neonatal encephalopathy 2010-2014 (5 years) 55 babies with neonatal encephalopathy 2014
Perinatal Mortality
Perinatal related mortality 2007–14 (rolling three-year rates)
0
2
4
6
8
10
12
2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014
Dea
th ra
te/1
000
birt
hs
Year of death
Perinatal related mortalities StillbirthsNeonatal deaths Terminations of pregnancy
Figure 1.12 Page 29
Perinatal related mortality NZ 2007–14
0
2
4
6
8
10
12
TOP Stillbirth Neonatal death Perinatal relatedmortality
2007-2010 2011-2014
0
1
2
3
4
5
6
7
TOP Stillbirth Neonatal death
2007-2010 2011-2014
Perinatal related mortality NZ 2007–14
0
1
2
3
4
5
6
7
TOP Stillbirth Neonatal death
2007-2010 2011-2014
Perinatal related mortality NZ 2007–14
0
1
2
3
4
5
6
7
TOP Stillbirth Neonatal death
2007-2010 2011-2014
Perinatal related mortality NZ 2007–14
DHB specific perinatal related mortality
International definition: >=28weeks/1000g (rolling 3yr rates)
0
1
2
3
4
5
6
2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014
Dea
th ra
te/1
000
birt
hs
Year of death
Perinatal related mortalities StillbirthsNeonatal deaths Terminations of pregnancy
Figure 1.13 Page 29
p=0.0013
p=0.0002
International comparisons
0 2 4 6 8 10
Perinatal mortality
Stillbirth
Neonatal death
Rate (/1000)
England and Wales 2014 New Zealand 2014
International comparisons
0 2 4 6 8 10
Perinatal mortality
Stillbirth
Neonatal death
Rate (/1000)
England and Wales 2014 New Zealand 2014
Perinatal related mortality risk by gestation 2007–14
0
0.5
1
1.5
2
2.5
3
3.5
2007 2008 2009 2010 2011 2012 2013 2014
Perin
atal
rela
ted
mor
talit
y ris
k/10
00
ongo
ing
preg
nanc
ies
Year of death
≥41 weeks
Figure 1.22 Page 44
p=0.0003
Perinatal related mortality risk by gestation 2007–14
0
0.5
1
1.5
2
2.5
3
3.5
2007 2008 2009 2010 2011 2012 2013 2014
Perin
atal
rela
ted
mor
talit
y ris
k/10
00
ongo
ing
preg
nanc
ies
Year of death
37–40 ≥41 weeks
Figure 1.22 Page 44
p=0.0003
p=0.017
Perinatal related mortality risk by gestation 2007–14
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
2007 2008 2009 2010 2011 2012 2013 2014
Perin
atal
rela
ted
mor
talit
y ris
k/10
00
ongo
ing
preg
nanc
ies
Year of death
20–22 37–40 ≥41 weeks
p=0.0003
p=0.017
p=0.002
Figure 1.22 Page 44
Perinatal related mortality risk by gestation 2007–14
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
2007 2008 2009 2010 2011 2012 2013 2014
Perin
atal
rela
ted
mor
talit
y ris
k/10
00
ongo
ing
preg
nanc
ies
Year of death
20–22 23–24 37–40 ≥41 weeks
Figure 1.22 Page 44
Perinatal related mortality risk by gestation 2007–14
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
2007 2008 2009 2010 2011 2012 2013 2014
Perin
atal
rela
ted
mor
talit
y ris
k/10
00
ongo
ing
preg
nanc
ies
Year of death
20–22 23–24 25–27 37–40 ≥41 weeks
Figure 1.22 Page 44
Perinatal related mortality risk by gestation 2007–14
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
2007 2008 2009 2010 2011 2012 2013 2014
Perin
atal
rela
ted
mor
talit
y ris
k/10
00
ongo
ing
preg
nanc
ies
Year of death
20–22 23–24 25–27 28–31 37–40 ≥41 weeks
Figure 1.22 Page 44
Perinatal related mortality risk by gestation 2007–14
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
2007 2008 2009 2010 2011 2012 2013 2014
Perin
atal
rela
ted
mor
talit
y ris
k/10
00
ongo
ing
preg
nanc
ies
Year of death
20–22 23–24 25–27 28–31 32–36 37–40 ≥41 weeks
Figure 1.22 Page 44
Intrapartum stillbirth rolling three-year rates
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 Still
birt
h ris
k/10
00 o
ngoi
ng p
regn
anci
es
Year of death
≥37 weeks
Figure 1.24 Page 46
p=0.00002
Intrapartum stillbirth rolling three-year rates
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 Still
birt
h ris
k/10
00 o
ngoi
ng p
regn
anci
es
Year of death
23–27 28–36 ≥37 weeks
Figure 1.24 Page 46
p=0.00002
p=0.16
p=0.65
Gestation at birth (all births) 2007–14: NZ
0
5
10
15
20
25
30
2007 2008 2009 2010 2011 2012 2013 2014
Birt
hs (%
)
Year of registration
36 37 38 39
Figure 1.3 Page 22
Gestation at birth (all births) 2007–14: NZ
0
5
10
15
20
25
30
35
2007 2008 2009 2010 2011 2012 2013 2014
Birt
hs (%
)
Year of registration
36 37 38 39 40 ≥41 weeks
Figure 1.3 Page 22
Demography and perinatal related mortality 2007–12
Crude Independent
Stillbirth Neonatal death 20-27 weeks
Age Yes
Ethnicity Māori, Pacific, Indian
Socioeconomic status Yes
Demography and perinatal related mortality 2007–12
Crude Independent
Stillbirth Neonatal death 20-27 weeks
Age Yes No No
Ethnicity Māori, Pacific, Indian Indian Māori, Pacific
Socioeconomic status Yes No Yes
Cause (PSANZ-PDC) of perinatal related deaths 2014
0
20
40
60
80
100
120
140
160
180
200
Congenitalabnormality
Perinatalinfection
Hypertension Antepartumhaemorrhage
Maternalconditions
Specificperinatal
conditions
Hypoxicperipartum
death
Fetal growthrestriction
Spontaneouspreterm
Unexplainedantepartum
death
No obstetricantecedent
Deat
hs
Cause (PSANZ-PDC) of stillbirth 2014
0
10
20
30
40
50
60
70
80
90
100
Congenitalabnormality
Perinatalinfection
Hypertension Antepartumhaemorrhage
Maternalconditions
Specificperinatal
conditions
Hypoxicperipartum
death
Fetal growthrestriction
Spontaneouspreterm
Unexplainedantepartum
death
Still
birt
hs
Misclassification of unexplained perinatal related deaths
Unexplained antepartum death with placental
pathology N=177
Reclassified “explained death” N=30
Another PDC N=7
Significant placental pathology explains
death N=23
Unexplained antepartum death with placental
pathology N=177
Reclassified “explained death” N=30
Another PDC N=7
Significant placental pathology explains
death N=23
Reclassified No significant
pathology N=106
Remain unexplained N=147
No significant pathology
N=41
2017: PMMRC will change the classification
Bartlett K, Sadler L, Masson V, Zuccollo J. "Rethinking placental pathology in the
PSANZ classification of unexplained stillbirth at term."
ANZJOG 2016 (accepted)
PSANZ-NDC by gestation (excluding congenital abnormalities) 2007–14
0102030405060708090
100
20–22 n=344
23–24 n=252
25–27 n=126
28–36 n=124
≥37 n=232
Dea
ths (
%)
Gestation at birth (weeks)
Extreme prematurity Cardio-respiratory disorders InfectionNeurological Gastrointestinal Other
Figure 1.26 Page 50
Neonatal death rate* by gestation and ethnicity 2007–14
0.0
0.5
1.0
1.5
2.0
2.5
20-22 23-24 25-27 28-36 ≥ 37
Neo
nata
l dea
th r
ate/
1000
live
birt
hs (
all g
esta
tions
)
Gestation at birth (weeks)
Māori Pacific peoples Indian NZ European
Figure 1.25 Page 49 * Excludes congenital abnormalities
Screening for diabetes among mothers of stillbirths and neonatal
deaths
0102030405060708090
100
2007 2008 2009 2010 2011 2012 2013 2014
%
screened not screened unknown declined
Table 1.19 Page 55
Potentially avoidable perinatal related death and ethnicity (2009–14)
0
10
20
30
40
50
60
70
80
90
100
Māori Pacific peoples Indian Other Asian Other (includingunknown)
NZ European
Perin
atal
rela
ted
deat
hs (%
)
Maternal prioritised ethnicity
UnknownNo contributory factorsContributory factors BUT NOT or unknown if potentially avoidableContributory factors and potentially avoidable
Figure 1.31 Page 62
Main contributory factor in potentially avoidable deaths (2009–14)
0
5
10
15
20
25
30
Māori Pacific peoples Indian Other Asian Other (includingunknown)
NZ European
Perin
atal
rela
ted
deat
hs (
%)
Maternal ethnicity (prioritised)
Organisation/management Personnel Barriers Specific contributory factor not identified
Figure 1.32 Page 62
Postmortem investigations
0
10
20
30
40
50
60
70
Māori Pacificpeoples
Indian Other Asian Other NZEuropean
%
Optimal investigation Partial investigation No investigation
Table 1.2 Page 58
Postmortem investigations
0
10
20
30
40
50
60
70
Māori Pacificpeoples
Indian Other Asian Other NZEuropean
%
Optimal investigation Partial investigation No investigation
Table 1.2 Page 58
Partial investigations
Partial investigations
MATERNAL MORTALITY
Maternal mortality 2006–14
0
5
10
15
20
25
30
2006 2007 2008 2009 2010 2011 2012 2013 2014
Mat
erna
l mor
talit
y ra
tio/1
00,0
00
mat
erni
ties
Year of death
3-year rolling direct MMR 3-year rolling indirect MMR3-year rolling MMR 1-year MMR
Figure 2.2 Page 106
Maternal mortality 2006–14
0
5
10
15
20
25
30
2006 2007 2008 2009 2010 2011 2012 2013 2014
Mat
erna
l mor
talit
y ra
tio/1
00,0
00
mat
erni
ties
Year of death
3-year rolling direct MMR 3-year rolling indirect MMR3-year rolling MMR 1-year MMR
Figure 2.2 Page 106
12
6
4
5
4 1
9
9 8
22
8 6
SUICIDE
PRE-EXISTING NEURO
NON-OBSTETRIC SEPSIS AFE
OBSTETRIC SEPSIS
PRE-ECLAMPSIA
HAEMORRHAGE
VTE OTHER DIRECT
UNCLASSIFIABLE
PRE-EXISTING CARDIAC OTHER PRE-EXISTING
DIRECT DEATHS
INDIRECT DEATHS Table 2.1 Page 105
Demography of maternal mortality in New Zealand
0
10
20
30
40
50
60
70
80
90
100
<20 20–24 25–29 30–34 35–39 ≥40
Mat
erna
l mor
talit
y ra
tio/1
00,0
00
mat
erni
ties
Maternal age (years)
Figure 2.2 Page 106
Demography of maternal mortality in New Zealand
0
5
10
15
20
25
30
35
40
45
50
Māori Pacific peoples Indian Other Asian Other (includingunknown)
NZ European
Mat
erna
l mor
talit
y ra
tio/1
00,0
00 m
ater
nitie
s
Prioritised ethnicity
Figure 2.2 Page 106
Demography of maternal mortality in New Zealand
0
5
10
15
20
25
30
35
40
1 (least deprived) 2 3 4 5 (most deprived)
Mat
erna
l mor
talit
y ra
tio/1
00,0
00
mat
erni
ties
Deprivation quintile
Figure 2.2 Page 106
Maternal demography contd
Maternal deaths 2006-2014
NZ Mothers 2014
% % Nulliparous 27 40 1-3 births 48 55 4+ births 23 5
Maternal demography contd
Maternal deaths 2006-2014
NZ Mothers 2014
% % Nulliparous 27 40 1-3 births 48 55 4+ births 23 5 BMI>=30 44 25 Current smoker 34 16 Alcohol/substance use 25
Cause specific MMR: Direct deaths NZ v UK
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
MM
R /1
00,0
00 m
ater
nitie
s
Direct cause of death
NZ2006-2013 UK2006-2011
Figure 2.2 Page 106
Cause specific MMR: Indirect deaths NZ v UK
0
1
2
3
4
5
6
7
Pre-existing medical* Psychiatric Other indirect#
MM
R/10
0,00
0 m
ater
nitie
s
Indirect cause of death
NZ2006-2013 UK2006-2011
Figure 2.2 Page 106
Neonatal encephalopathy in NZ
Neonatal encephalopathy rates /1000 term births (2010–14)
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
2010 2011 2012 2013 2014
NE/
1000
term
birt
hs
Neonatal encephalopathy by gestation at birth
0.0
0.5
1.0
1.5
2.0
2.5
3.0
37 38 39 40 41 ≥42
NE
rate
/100
0 te
rm b
irths
Gestation at birth (weeks)
NE care improvements
Cord gases performed
0
20
40
60
80
100
2010 2011 2012 2013 2014
%
NE care improvements
Cord gases performed Induced cooling
0
20
40
60
80
100
2010 2011 2012 2013 2014
%
0
20
40
60
80
100
2010 2011 2012 2013 2014
%
NE care improvements
Cord gases performed
Cooled within 6 hours
Induced cooling
0
20
40
60
80
100
2010 2011 2012 2013 2014
%
0
20
40
60
80
100
2010 2011 2012 2013 2014
0
20
40
60
80
100
2010 2011 2012 2013 2014
%
NE care improvements
Cord gases performed
MRI among survivors Cooled within 6 hours
Induced cooling
0
20
40
60
80
100
2010 2011 2012 2013 2014
%
0
20
40
60
80
100
2010 2011 2012 2013 2014
%
0
20
40
60
80
100
2010 2011 2012 2013 2014
0
20
40
60
80
100
2010 2011 2012 2013 2014
%
Acknowledgements
• To you…. • Families • PMMRC members • PMMRC Local Coordinators • LMCs and DHB staff • Otago Data Group • National coordination service • HQSC
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