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