lynn sadler epidemiologist pmmrc...management of obstetric emergencies •16 dhbs provide mdt; 10...
TRANSCRIPT
June 201711th annual report of the PMMRC:
Reporting mortality and morbidity 2015
Lynn SadlerEpidemiologist PMMRC
Significant changes to the report 2017
• The MAT (New Zealand Maternity) dataset has been substituted for the birth registration dataset (BDM) as the denominator for all analyses
– Parity
– BMI
– Smoking
• Māori perinatal and maternal mortality
• Maternal Morbidity Working Group
Significant changes to the report 2017
• Presentation of contemporaneous (2011-2015) data in tables and figures
• Grouping of 2 yearly data
Significant changes to the report 2017
Rates 2007-2015
Perinatal related mortality rolling 3-year rates: New Zealand definitions 2007–2015
0
2
4
6
8
10
12
2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015
De
ath
rat
e/1
00
0 b
irth
s
Year of death
Perinatal related mortalities Neonatal deaths Stillbirths Terminations of pregnancy 2015
Perinatal related mortality rolling 3-year rates: international definitions 2007–2015
0
1
2
3
4
5
6
2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015
De
ath
rat
e/1
00
0 b
irth
s
Year of death
Perinatal related mortalities Neonatal deaths Stillbirths Terminations of pregnancy
Perinatal related mortality risk by gestational age at birth and year (per 1000 ongoing
pregnancies) 2007–2015
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 ≥41
Pe
rin
atal
re
late
d m
ort
alit
y ri
sk/1
00
0
on
goin
g p
regn
anci
es
Gestation at birth (weeks)
2007–2009 2010–2012 2013–2015
Perinatal related mortality risk by gestational age at birth and year (per 1000 ongoing
pregnancies) 2007–2015
22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 ≥41
Gestation at birth (weeks)
2007–2009 2010–2012 2013–2015
Why has the stillbirth rate reduced?
• Fewer births at 40+ weeks
• More iatrogenic births
• Reduced smoking, fewer mothers <20 years
• Reduced hypoxic peripartum deaths
• Maternity quality improvement (MQSP, Perinatal mortality review)
• Education around detection and management of SGA
• Sleep position
Trends in gestation at birth (36 weeks and beyond) among births in New Zealand 2007–2015
0
5
10
15
20
25
30
35
2007 2008 2009 2010 2011 2012 2013 2014 2015
Bir
ths
(%)
Year of birth
36 37 38 39 40 ≥41 weeks
Neonatal death rates 2007-2015
0
0.5
1
1.5
2
2.5
3
3.5
2007 2008 2009 2010 2011 2012 2013 2014 2015
rate
/10
00
live
bir
ths
neonatal deaths (NZ definition) neonatal deaths (international definition)
0
0.5
1
1.5
2
2.5
3
3.5
2007 2008 2009 2010 2011 2012 2013 2014
UK: NND/1000 live births from 24 weeks excluding TOPs
MBRRACE 2014 ONS data
What has happened to the neonatal death rate in other countries?
0
0.5
1
1.5
2
2.5
3
3.5
2007 2008 2009 2010 2011 2012 2013 2014
Australian neonatal death rate/1000 live births
What has happened to the neonatal death rate in other countries?
AIHW perinatal data 2014 portal
What has happened to the neonatal death rate in other countries?
Perinatal statistics in the Nordic countries 2014Neonatal deaths >=22 weeks
0
0.5
1
1.5
2
2.5
2007 2008 2009 2010 2011 2012 2013 2014
Neonatal mortality rates Scandinavia 2007-2014
Finland Iceland Norway Sweden
Recommendation
The PMMRC investigate why there has been no reduction in neonatal mortality in New Zealand
Neonatal encephalopathy rates (per 1000 term births) (three-year rolling) 2010–2015
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
2010–2012 2011–2013 2012–2014 2013–2015
NE
rate
/10
00
te
rm b
irth
s
Year of birth
Maternal mortality ratios (MMR) (per 100,000 maternities) (one-year and three-
year rolling) 2006–2015
0
5
10
15
20
25
30
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Mat
ern
al m
ort
alit
y ra
tio
/10
0,0
00
m
ate
rnit
ies
Year of death
3-year rolling MMR 1-year MMR
The MAT dataset as a denominator Contemporaneous
accurate number of births /year
Extra variables(BMI, parity, smoking)
Maternity data
Missing data Ethnicity issues
Perinatal related death rates by maternal parity 2011-2015
0
2
4
6
8
10
12
14
16
18
20
22
24
Termination of pregnancy Stillbirths Neonatal deaths Perinatal related deaths
De
ath
rat
e/1
00
0 b
irth
s
Parity 0 1 2 3 4 ≥5
Perinatal related death rates by maternal body mass index (BMI) 2011-2015
0
2
4
6
8
10
12
14
Termination of pregnancy Stillbirths Neonatal deaths Perinatal related deaths
De
ath
rat
e/1
00
0 b
irth
s
<18.50 18.50–25.49 25.50–30.49 30.50–35.49 35.50–40.49 ≥40.50
BMI (kg/m2)
Perinatal related mortality rates by smoking at registration with maternity care 2011–2015
0
2
4
6
8
10
12
14
Termination ofpregnancy
Stillbirths Neonatal deaths Perinatal relateddeaths
De
ath
rat
e/1
00
0 b
irth
s
Smoker Non-smoker
Missing registration data
• LMC, parity, BMI, smoking at registration are required data from an LMC for payment
• DHBs are bulk funded and NOT required to provide data for payment but are required to provide these data as part of service specifications
Perinatal related mortality rate by missing smoking, parity, or BMI (2008-2015)
21.09
8.92
0
5
10
15
20
25
Smoking, parity or BMI missing Smoking, parity, BMI all present
rate
/1
00
0
perinatal related mortality rate
Missing parity, smoking or BMI by ethnicity (2008-2015)
18.09
11.015.84 7.54
11.97
24.31
0
5
10
15
20
25
30
Indian Maori NZE Other OtherAsian
Pacific
% m
issi
ng
dat
a
Missing parity, BMI, or smoking by LMC at registration (2008-2015)
45.99
0.08 0.05
99.99
0.04 2.010
10
20
30
40
50
60
70
80
90
100
DHB GP MWF No LMC OBS OTHER
% m
issi
ng
dat
a
0
5
10
15
20
25
30
1 2 3 No LMC 4 5
Pe
rin
atal
re
late
d m
ort
alit
y ra
te (
/10
00
)
LMC at registration
Perinatal related mortality rate by LMC at registration (2008-2015)
Missing parity, smoking or BMI by DHB of residence (2008-2015)
0
10
20
30
40
50
60
70
% m
issi
ng
dat
a
Can we determine what the adjusted perinatal related mortality rate is for DHBs?
For ethnicity?
10.61 11.89
25.09
8.86
0
5
10
15
20
25
30
1all deaths/all births
2deaths with
missing data/births with missing
data
3all deaths/
births with nomissing data
4deaths with nomissing data/births with nomissing data
Pe
rin
atal
re
late
d m
ort
alit
y ra
te
Increased risk group
MVA with all deaths
MVA restricted to
women with data
Unadjusted analysis
What is the impact of missing data on multivariable analysis (2008-2015)?
Recommendation
The Ministry of Health urgently require DHBs to provide complete and accurate registration data to the MAT dataset (as required of LMCs providing services to pregnant women in order to receive funding…)
Missing any of smoking, parity or BMI by DHB of residence 2015
0
2
4
6
8
10
12
14
16
18
20
% m
issi
ng
dat
a
Ethnicity
• Ethnicity definition
– Registration data = parent defined at birth
– MAT = compiled from hospital discharge, LMC, NHI using prioritisation
• Numerator denominator bias
– Numerator = registration data or LMC data
– Denominator (2007-2014) = registration data
– Denominator (2015) = MAT
Perinatal related mortality rates by maternal prioritised ethnicity (with 95% CIs) 2011–2015
(MAT denominator)
0
2
4
6
8
10
12
14
16
18
20
Termination of pregnancy Stillbirths Neonatal deaths Perinatal related deaths
De
ath
rat
e/1
00
0 b
irth
s
Māori Pacific peoples Indian Other Asian Other (including unknown) NZ European
Perinatal related mortality rates by maternal prioritised ethnicity (with 95% CIs) 2011–2014
(BDM denominator)
0
2
4
6
8
10
12
14
16
18
Termination of pregnancy Stillbirths Neonatal deaths Perinatal related deaths
De
ath
rat
e/1
00
0 b
irth
s
Māori Pacific peoples Indian Other Asian Other (including unknown) NZ European
Perinatal related mortality 3year rolling rates (Māori and NZ European 2007-2015) using BDM
denominator data
0
2
4
6
8
10
12
14
2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015
Rat
e (
/10
00
)
Year of death
Total perinatal death - Māori - BDM denominator
Total perinatal death - NZ European - BDM denominator
Perinatal related mortality 3year rolling rates (Māori and NZ European 2007-2015) using MAT and
BDM denominator data
0
2
4
6
8
10
12
14
2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015
Rat
e (
/10
00
)
Year of death
Total perinatal death - Māori - MAT denominator Total perinatal death - NZ European - MAT denominator
Total perinatal death - Māori - BDM denominator Total perinatal death - NZ European - BDM denominator
Recommendation
As a matter of urgency the Ministry of Health update the MAT including ethnicity data as identified by the parents in the birth registration process (PMMRC 9th report 2015)
41 week losses 2015
41 week losses in 2015
• There were 29 perinatal losses at or beyond 41 weeks in 2015
• Of the 17 stillbirths at 41 weeks or beyond in 2015, excluding those from congenital abnormality, no antenatal risk factors were identified in 11
• Among the remaining 6, care did not follow recommended best practice
The PMMRC supports the development of a national interdisciplinary clinical practice guideline on the indications and timing for induction of labour, to guide clinicians to offer induction when appropriate (that is, where evidence shows that benefit to mother and/or baby outweighs risk) and to avoid induction when not appropriate.
Recommendation
MAORI PERINATAL AND
MATERNAL MORTALITY
“He matenga ohorere, he wairua uiui, wairua mutunga-kore.
MAORI PERINATAL MORTALITY
Unadjusted and adjusted* perinatal related mortality rates Māori and NZE 2008–2015
0
2
4
6
8
10
12
OR unadjusted OR adjusted
rate
/1
00
0
Maori-perinatal related mortality NZE-perinatal related mortality
*Adjusted for age, deprivation score, sex, multiple pregnancy, year of birth
Unadjusted and adjusted* neonatal mortality rates by Māori and NZE 2008–2015
0
0.5
1
1.5
2
2.5
OR unadjusted OR adjusted
rate
/1
00
0
Maori-NND <28 weeks NZE-NND <28 weeks
*Adjusted for age, deprivation score, sex, multiple pregnancy, year of birth
Neonatal death rate by gestation and ethnicity (Māori and New Zealand European) 2011–2015
(excluding congenital abnormalities)
Maternal mortality ratios by ethnicity (Māori and New Zealand European) 2006–2015
0
10
20
30
40
50
60
70
2006–2008 2007–2009 2008–2010 2009–2011 2010–2012 2011–2013 2012–2014 2013–2015
Rat
io (
/10
0,0
00
)
Year of death
Māori - BDM denominator NZ European - BDM denominator
MATERNAL MORTALITY
Maternal mortalities 2015
• 11 maternal mortalities 2015
– 1 AFE
– 2 VTE
– 3 pre-existing medical conditions
– 5 suicide
Recommendations for the prevention of pregnancy-associated venous thromboembolism. McLintock et al 2012:ANZJOG 52(1):3-13
Survey of multidisciplinary training in management of obstetric emergencies
• 16 DHBs provide MDT; 10 DHBs holding training in primary units
• A full day of in-house training in all but 1 unit
• 3 DHBs it is mandatory for obstetric, midwifery (core and LMC) and anaesthetics; 1 mandatory for DHB clinicians
• Cost and backfill were listed most often as barriers to attendance
Cause specific maternal mortality ratios in New Zealand 2006–2015 and the UK 2006–
2014 (with 95% CIs)
0
1
2
3
4
5
6
7
Mat
ern
al m
ort
alit
y ra
tio
/10
0,0
00
mat
ern
itie
s
NZ2006-2015 UK2006-2014
RECOMMENDATION
The PMMRC recommend the HQSC establish a permanent Suicide Review Committee
NEONATAL ENCEPHALOPATHY
NE rates by parity (2010-2015)
0.0
0.5
1.0
1.5
2.0
2.5
0 1 2 3 ≥4
NE
rate
/10
00
te
rm b
irth
s
Parity
NE audits in the 11th report
• Babies not cooled 2011-14
– 54 babies (22 severe; 32 moderate)
– 2 severe and 9 moderate babies may have benefited from cooling
• Late recognition, late consultation, late transfer
NE audits in the 11th report
• Babies not resuscitated at birth 2011-14
– 18 babies
– In 10 of these, HIE was recognised at birth on clinical grounds or cord pH
– In 7 babies, there was later presentation with NE from other causes
– One baby presented late with a diagnosis of HIE
Management of Umbilical Cord Blood Results Management of umbilical cord lactate results
Cord lactates should be taken and processed within 10 minutes of cord clamping.
Umbilical cord lactate result Action
Less than 6.0 Document results
6.0 or above Send paired umbilical cord gases
Management of umbilical cord gas results Umbilical cord gases can be analysed within one hour of birth if clamped immediately after delivery. Both umbilical cord arterial and venous gases should be analysed.
Umbilical cord gas result Action
pH less than 7.0 or base excess less than or equal to −12 mmol/L
Call paediatrician for review.
pH 7.0–7.15 or base excess −11 to −7 mmol/L Or umbilical cord gas result not available and cord lactate greater than or equal to 6.0 mmol/L
Monitor baby for signs of neonatal encephalopathy (hypotonia, poor feeding, lethargy, weak or absent suck/gag or Moro reflex, seizures). Call paediatrician if any concerns.
pH above 7.15 and base excess above −7 mmol/L
Document results.
(Auckland District Health Board 2017)
Interdisciplinary review 2016-2017
• 47 babies
• NE following an acute intrapartum event
• 2013-2015
• Reporting this year
Maternal Morbidity Working Group
ACKNOWLEDGEMENTS
• To you….
• LMCs
• DHB local coordinators
• Otago Data Group
• PMMRC and working groups
• National coordination service
• Families
• HQSC