the 2010 pmmrc report · the pmmrc 7th report perinatal mortality 2007-2011 maternal mortality...

The PMMRC 7th Report Perinatal mortality 2007-2011

Maternal mortality 2006-2011

Neonatal encephalopathy 2010-2011

Maternal Morbidity 2010-2011

• The data presented here are a review of the new findings in the 2013 report

• Many important findings, presented in previous years, are not repeated but are still important

• Some new findings and PMMRC recommendations will be presented by later speakers

Methodology: mortality

Perinatal Maternal

Ascertainment of cases Clinicians; LMCs; Local coordinators

BDM; NMDS; Coronial services; media

Data sources LMCs; hospitals; GPs; Coroners; Police

Review of cases, classification of cause, contributory factors, and potentially avoidable death

Local

multidisciplinary

National

multidisciplinary

Denominator data Registered births - BDM

Definitions: perinatal mortality

Perinatal mortality

NZ > 20wks

/1000 fetal + neonatal deaths to 1week

Definitions: perinatal mortality

Perinatal mortality

NZ > 20wks

/1000 fetal + neonatal deaths to 1week

Perinatal related mortality

NZ > 20wks

/1000 fetal + neonatal deaths to 1month

Definitions: perinatal mortality

Perinatal mortality

NZ > 20wks

/1000 fetal + neonatal deaths to 1week WHO > 1000g /28wks

Perinatal related mortality

NZ > 20wks

/1000 fetal + neonatal deaths to 1month WHO > 1000g /28wks

Definitions: perinatal and maternal mortality

Perinatal mortality

NZ > 20wks

/1000 fetal + neonatal deaths to 1week WHO > 1000g /28wks

Perinatal related mortality

NZ > 20wks

/1000 fetal + neonatal deaths to 1month WHO > 1000g /28wks

Maternal mortality ratio

In pregnancy to 6wks post

Direct+indirect

/100,000 births > 20weeks

Definitions

• Ethnicity – prioritised maternal

• DHB of maternal residence at birth registration

• Deprivation quintile (NZDep 2006)

Perinatal mortality New Zealand 2007-2011

Figure 12, page 34

Perinatal mortality 2007-2011: WHO international definition

Figure 13, Page 35

Perinatal related mortality 2007-2011: WHO international definition

Figure 13, Page 35

Perinatal death classification (PDC) 2007-2011

Figure 15, Page 38

Perinatal death classification (PDC) 2007-2011

Figure 15, Page 38

Intrapartum stillbirth rate (excluding congenital abnormalities) 2007-2011

Figure 16, page 40

Perinatal related death risk (per 1000 babies remaining in utero) 2007-2011

Figure 31, page 67

**

**

Perinatal related mortality in multiple pregnancies 2007-2011

Perinatal related death rates in multiple pregnancies 2007 – 2011

0

10

20

30

40

50

60

2007 2008 2009 2010 2011

Mo

rtal

ity

rate

/1

00

0 m

ult

iple

bir

ths

Year of death

Termination of pregnancy Stillbirths Neonatal deaths Total perinatal related deaths

PDC specific perinatal related death rates for multiple v singleton pregnancies 2007 – 2011

Figure 29, page 59

Spontaneous preterm deaths 2007-2011

Spontaneous Preterm birth

• ...contributed to 709 (20%) of perinatal related deaths in 2007-2011

• …40% of all neonatal deaths

• …54% of cases were associated with bleeding at 20 weeks or beyond (APH)

• …and 40% of cases were associated with prolonged rupture of membranes

• …associated with smoking, alcohol, marijuana use

Relative risk of spontaneous preterm death by ethnicity

Relative risk

Maori 2.31

Pacific 1.81

Indian 1.78

Other Asian 0.99

Other 1.10

NZ European 1.00

Gestation at birth of spontaneous preterm deaths

Figure 39, page 96

• In 2013, the PMMRC will be reviewing specifically

– Unexplained stillbirths at term

– Term intrapartum deaths

Contributory factors and potentially avoidable perinatal related mortality

2009-2011

• Contributory factors - including organisation and management, personnel, and barriers to access/engagement factors that contributed to the death

• Potentially avoidable death – defined when the absence of a factor may have prevented the death

Contributory factors and potentially avoidable perinatal related deaths 2011

Table 38, page 80

Contributory factors in potentially avoidable deaths 2011

Figure 33, page 84

Contributory factors and potentially avoidable perinatal related death 2009-2011

Figure 34, page 85

Contributory factor(s) in potentially avoidable perinatal related deaths 2011

Figure 35, page 86

Contributory factors and potentially avoidable perinatal related death 2009-2011

p<0.0001

Figure 36, page 87

Maternal Mortality 2006-2011

Maternal mortality ratio (/100,000 maternities) 2006-2011

Figure 40, page 102

Maternal mortality ratio (/100,000 maternities) 2006-2011

Figure 40, page 102

MMR and international ratios 2003-2011

Figure 41, page 103

Causes of maternal death

Recommendation

•Women with pre-existing medical conditions should have individualised pre-conceptual counselling about their condition and the medication they are taking

•Health professionals…need to communicate the importance of continuing medication in pregnancy (if appropriate) and advise women to seek early medical advice

Role of postmortem in maternal mortality 2006-2011

Postmortem N=47

Clinical diagnosis confirmed 64%

Clinical diagnosis changed or determined 19%

Additional findings 11%

Inconclusive 6%

Where a coroner declines jurisdiction, postmortem should be offered as part of full investigation of cause of death

Contributory factors and potentially avoidable maternal mortality 2006-2011

• Contributory factors 55% of maternal deaths

– 32% Organisation and/or management

– 32% Personnel

– 40% Barriers to access or engagement with care

• Potentially avoidable 35%

Contributory factors and potentially avoidable maternal mortality 2006-2011

• Contributory factors 55% of maternal deaths

– 32% Organisation and/or management

• Lack of policies protocols guidelines

– 32% Personnel

• Lack of recognition of complexity or seriousness of condition

– 40% Barriers to access or engagement with care

• Lack of recognition of complexity or seriousness of condition

• Late or infrequent access to antenatal care

• Potentially avoidable 35%

Neonatal encephalopathy 2010-2011

Definitions: neonatal encephalopathy

•A syndrome of disturbed neurological function within the first week of life in term infants, predominantly resulting from lack of oxygen to the brain around the time of birth.

•Includes term neonatal deaths due to hypoxia (PDC7) and/or neonatal death due to hypoxic ischaemic encephalopathy (NDC5.1)

•2010-2011

Neonatal Encephalopathy

1.27/1000 term births

NE clinical characteristics

NE N=149

Died 36 24

Resuscitation

Intubated and ventilated 90 67

Cardiac massage 72 53

Abnormal cord gases 102 69

Apgar score <5 @ 1min 119 80

Apgar score <7 @10min 77 52

Induced cooling 107 72

NE clinical characteristics

NE N=149

Acute peripartum event 37 25

Induction of labour 35 24

Mode of birth

Normal vaginal 63 42

Vaginal breech 3 2

Operative vaginal 22 15

Caesarean section 61 41

NE rate Stillbirth rate at term

Ethnicity and NE

NE rates and DHB of residence 2010-2011

Figure 49, page 121

Other recommendations

• Continual improvement of the standard of neonatal resuscitation by all health professionals involved in intrapartum care

• All babies with NE undergo investigation prior to discharge to inform prognosis ie formal neurological exam, MRI and, if available, EEG

• …and this be included in a formal discussion with the parents on prognosis and ongoing care for their child

Thank you for careful collection, and sharing, of data which allow analyses such as presented today to occur