pmmrc 10th report 2016 - health quality & safety commission...perinatal related mortality risk...

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

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

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


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


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


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


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


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


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

)


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


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

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

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


0

5

10

15

20

25

30

35

40

45

50


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


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


NE care improvements

Cord gases performed

0

20

40

60

80

100

2010 2011 2012 2013 2014

%


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

%



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

%



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

pmmrc 10th report 2016 - health quality & safety commission...perinatal related mortality risk...

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