Report of the Queensland Maternal and Perinatal Quality Council, … · 2016. 11. 10. · 4 Recommendations Recommendation1 Recommendation2 Recommendation3 Recommendation4 Recommendation5

Report of the Queensland Maternaland Perinatal Quality Council

MATERNAL AND PERINATALMORBIDITY AND MORTALITYIN QUEENSLAND

2002

MATERNAL AND PERINATAL MORBIDITY AND MORTALITY IN

QUEENSLAND -2000

Contact details for further information

All correspondence should be addressed to:

The Secretariat

Queensland Maternal & Perinatal Quality Council

Office of the Chief Health Officer

Queensland Health

PO Box 48

BRISBANE QLD 4001

Ph: (07) 323 40607

Fax: (07) 322 17535

Email: [email protected]

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Preface

This is the first report of the Queensland Maternal and Perinatal Quality Council (the Council) and provides an

overview of the activities of the Council since its inception in August 2001. The Council will build on the work

that was undertaken by the former Queensland Council on Obstetric and Paediatric Morbidity and Mortality

(QCOPMM).

The Council was established pursuant to the quality assurance provisions of the

which provides members with legislative protection and enables the Council to undertake confidential

enquiries into perinatal and maternal mortality and morbidity.

The Council considers patterns and trends of mortality and morbidity in Queensland, to enable benchmarking

and comparisons across regions and populations which can be monitored and provide opportunities to

improve health outcomes.

This report contains data sourced from the Perinatal Data Collection Unit of Queensland Health, which largely

underpins the activities of the Council.

Gathering data about maternal mortality remains challenging, as, due to the low incidence of maternal

mortality, a dedicated maternal mortality collection does not exist. However, Council seeks to report on direct,

indirect and incidental deaths and is thankful for the support of colleagues throughout Queensland who

contribute to this effort.

I would like to thank the members of the Council, and those who support them, for their commitment to

improving obstetric and perinatal outcomes. I trust that clinicians throughout Queensland will find this report

helpful and give careful consideration to the Council's recommendations.

Dr Gerry FitzGerald

Chief Health Officer

October 2003

Health Services Act 1991,

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Chairman's report

This is the first report of the Queensland Maternal and Perinatal Quality Council (QMPQC) and I would like to

thank the Council members for their participation and enthusiasm. The inaugural meeting of the Council was

held on 8 August 2001, and since then the Council has met on nine occasions and discussed a range of topics,

including linkages with local perinatal mortality committees, classification issues and endorsement of the

classification guidelines and specific maternal morbidities.

In addition, Council has continued to pursue and refine strategies to encourage clinicians to undertake

perinatal mortality reviews and determine and report on the clinical classification, in accordance with the

Australia and New Zealand Antecedent Classification of Perinatal Mortality (ANZACPM), and the Australia and

New Zealand Neonatal Death Classification (ANZNDC).

The Council has established two subcommittees:

1. The Perinatal Morbidity and Mortality Subcommittee which is chaired by Dr David Cartwright and has

two discrete working parties:

Mortality Working Party

Morbidity Working Party

2. The Maternal Morbidity and Mortality Subcommittee, which was chaired by Professor Michael

Humphrey from January 2002 until December 2002.

In 2000, 434 (80%) of 542 perinatal deaths were classified by hospital or regional perinatal mortality

committees with access to relevant data. Council applauds the support of clinicians in regional committees in

auditing perinatal deaths.

While the subcommittees continue to review and analyse mortality data, both subcommittees have taken up

the challenge of analysing morbidity data in an effort to identify opportunities for benchmarking and improving

clinical practice.

I would like to acknowledge and thank Mrs Wendy Rogash (Administration Officer), Mrs Joan Kennedy

(Principal Policy Officer), Mrs Susan Jenkins (Manager-Clinical Audit) and Mr Philip Baker (Epidemiologist)

from the Office of the Chief Health Officer for providing secretariat and epidemiological support.

Professor David Tudehope

Chairman, QMPQC

October 2003

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Table of Contents

Preface ................................................................................................................................................ii

Chairman’s Report..............................................................................................................................iii

1 Introduction.........................................................................................................................................1

2 Membership........................................................................................................................................2

3 Executive Summary .............................................................................................................................3

4 Recommendations ..............................................................................................................................4

5 Maternal mortality ...............................................................................................................................5

5.1 Introduction................................................................................................................................5

5.2 Maternal Morbidity & Mortality Subcommittee Terms of Reference..............................................5

5.3 Definition of maternal mortality...................................................................................................5

5.4 Classification of maternal deaths ................................................................................................5

5.5 Classification of maternal deaths 2000.......................................................................................6

5.6 Maternal mortality ratios and trends ...........................................................................................6

5.7 Avoidable factors - maternal deaths 2000...................................................................................8

6 Maternal morbidity..............................................................................................................................9

7 Perinatal mortality .............................................................................................................................10

7.1 Modus operandi........................................................................................................................10

7.2 Clinical classification.................................................................................................................10

7.3 Data collection ..........................................................................................................................10

7.4 Definitions.................................................................................................................................11

7.5 Perinatal mortality rates and trends ...........................................................................................11

7.6 Comparison with Australian data...............................................................................................12

7.7 Cause specific perinatal mortality..............................................................................................13

7.8 Cause of neonatal death by ANZNDC .........................................................................................15

7.9 Multiple pregnancy ...................................................................................................................16

7.10 Indigenous perinatal mortality ..................................................................................................18

7.11 Gestational age and birth weight specific perinatal mortality rates............................................20

7.12 Perinatal autopsies ...................................................................................................................22

8 References ........................................................................................................................................32

9 Appendices .......................................................................................................................................33

9.1 Appendix 1: Perinatal Mortality and Morbidity Subcommittee ....................................................33

9.2 Appendix 2: Maternal Mortality and Morbidity Subcommittee....................................................33

9.3 Appendix 3: Australia and New Zealand Antecedent Classification of Perinatal Mortality

(ANZACPM) ...............................................................................................................................34

9.4 Appendix 4: Australia and New Zealand Neonatal Death Classification......................................36

9.5 Appendix 5: Perinatal Substance Use Special Interest Group .....................................................37

9.6 Appendix 6: Australia and New Zealand Perinatal Mortality Classification Special Interest

Group .......................................................................................................................................39

9.7 Perinatal Indigenous Network ...................................................................................................40

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ist of Figures

ist of Tables

Figure 1: Comparative maternal mortality ratios since 1988....................................................................6

Figure 2: Fetal, neonatal and perinatal mortality rates corrected for late terminations,

Queensland 1987 - 2000.........................................................................................................12

Figure 3: Perinatal mortality rates by usual residence of mother, Queensland and Australia,

1983 - 2000 ............................................................................................................................12

Figure 4: Perinatal mortality rate by plurality, Queensland 2000............................................................17

Table 1: Maternal mortality, Queensland 1988-2000 ............................................................................7

Table 2: Maternal mortality avoidable factors by classification .............................................................8

Table 3: Fetal, neonatal and perinatal deaths, Queensland 2000 ........................................................11

Table 4: Perinatal deaths by cause and type, Queensland 2000..........................................................13

Table 5: Neonatal deaths by cause (ANZNDC) and gestational age, Queensland 2000.........................15

Table 6: Neonatal deaths by cause (ANZNDC) and birth weight, Queensland 2000..............................16

Table 7: Perinatal deaths by plurality, Queensland 2000 ....................................................................16

Table 8: Perinatal deaths by cause and plurality, Queensland 2000 ....................................................17

Table 9: Fetal, neonatal and perinatal deaths, Queensland 2000........................................................18

Table 10: Perinatal deaths by cause and Indigenous status, Queensland 2000.....................................19

Table 11: Perinatal deaths by cause and gestational age, Queensland 2000 ........................................20

Table 12: Perinatal deaths by cause and birth weight, Queensland 2000 ..............................................21

Table 13: Perinatal autopsies by cause and type of death, Queensland 2000 .......................................22

Table 14: Perinatal mortality rates by gestational age, Queensland 2000..............................................23

Table 15: Perinatal mortality rates by birth weight, Queensland 2000...................................................24

Table 16: Perinatal deaths by cause, Queensland 2000........................................................................25

Table 17: Neonatal deaths by cause (ANZNDC), Queensland 2000 .......................................................30

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1 Introduction

Purpose of the Council

Terms of Reference

The Queensland Maternal and Perinatal Quality Council was established following a review of the Queensland

Council on Obstetric and Paediatric Morbidity and Mortality (QCOPMM). The review found that the scope of

QCOPMM was too broad to enable appropriate consideration of maternal, perinatal and paediatric morbidity

and mortality. The establishment of a separate Maternal and Perinatal Quality Council with suitably focussed

Terms of Reference will provide greater opportunities to review and evaluate morbidity and mortality.

To provide advice to the Minister for Health and Director-General, Queensland Health, through the Chief Health

Officer, on matters relating to maternal and perinatal morbidity and mortality in Queensland.

Utilise the data from the Health Information Centre (HIC), national health guidelines, literature

reviews and members' expertise.

Identify appropriate indicators of quality.

Consider patterns and causation of morbidity and mortality in Queensland so that recommendations

may be made to reduce preventable death and disability.

Provide direction that will assist health providers in Queensland to develop policies that positively

impact on morbidity and mortality.

Identify avoidable factors associated with morbidity and mortality and advise on the implementation

of measures that could assist with the prevention of such deaths, including improvements in health

services.

Provide information and guidance required for members of the health professions and for the

community generally, in order to assist in the reduction of morbidity and mortality.

Co-opt relevant experts to advise the Council on issues related to their functions.

Advise on standards and quality of clinical care and assist with the extension of such standards in both

public and private sectors.

Advise on research directions.

Provide an annual report to the Minister and Director-General through the Chief Health Officer.

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2 Membership

Membership of the Queensland Maternal and Perinatal Quality Council (QMPQC)

Ex-officio

Secretariat

Professor David Tudehope Director-Division of Neonatology, Mater Mothers’ Hospital

(Chairman)

Dr David Cartwright Director-Neonatology, Royal Women's Hospital

Dr Yogesh Chadha Director-Obstetrics and Gynaecology, Toowoomba Hospital and Health

Service District

Ms Rowena Chapman Member of SANDS (Consumer)

Professor Paul Colditz Neonatologist, Director-Perinatal Research Centre, Royal Women's

Hospital

Ms Sue Cornes Deputy Manager, Health Information Centre

Ms Lynne Dunne Vice-President, Queensland Branch, Australian College of Midwives

Dr John Evans General Practitioner, Emerald

Ms Vicki Flenady Perinatal Researcher, Centre for Clinical Studies, Women and Children's

Health, Mater Hospital

Professor Michael Humphrey Director-Obstetrics and Gynaecology, Cairns Base Hospital

(resigned 8/1/2003)

Ms Christian McClelland Women's Health Adviser, Queensland Health

Ms Heather McCosker Lecturer, School of Nursing, QUT

Dr Robyn McDermott Medical Epidemiologist, Tropical Public Health Unit, (Cairns), Queensland

Health

Professor Jeremy Oats Director - Obstetrics and Gynaecology, Mater Mothers’ Hospital

(resigned 25/9/2001)

Dr Diane Payton Staff Pathologist, QHPSS, Royal Brisbane and Royal Women’s Hospital and

Health Service District

Dr Nikki Whelan Obstetrician and Gynaecologist, Private Practice and VMO Royal Women's

Hospital

Dr John Wilson Senior Obstetrician, Royal Women's Hospital

(appointed 21/11/2001)

Professor Jennifer Batch Chairman, Queensland Paediatric Quality Council

Professor Bryan Campbell Chief Health Officer

Mr Philip Baker Clinical Audit Information Manager, Office of the Chief Health Officer

Mrs Susan Jenkins Clinical Audit Manager, Office of the Chief Health Officer

Ms Joan Kennedy Principal Policy Officer, Office of the Chief Health Officer

Ms Wendy Rogash Administration Officer, Office of the Chief Health Officer

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3 Executive Summary

The overall maternal mortality rate in Queensland was 14.4 per 100,000 mothers, comprised of 2 direct deaths,

3 indirect deaths and 2 incidental deaths.

There were 49,138 births and 542 perinatal deaths in Queensland for 2000, giving a crude perinatal mortality

rate (PMR) of 11 per 1,000 total births. This was comprised of a fetal death rate of 7.3 per 1,000 total births and a

neonatal mortality rate (NMR) of 3.8 per 1,000 live births.

Since 1983, the rate of perinatal deaths in Queensland has been similar to that observed for Australia.

Preterm births (<37 weeks) accounted for 8.5% of infant and 81% of perinatal deaths. Very preterm births (<28

weeks) accounted for 0.9% of infant and 55% of perinatal deaths.

Twins and higher order multiple births accounted for 3.2% of births and 13% of all perinatal deaths. The rates

for multiple births are 5 times that of singleton births (48.2% v 9.8 per 1,000)

The main causes of death according to the ANZACPM were Congenital abnormality (22%), Unexplained

antepartum death (17.9%) and Spontaneous preterm (17.3%). The overall rate of Unexplained antepartum

death was 2.0 per 1,000 births, which is four times greater than the rate of SIDS.

Of all fetal deaths, 13% were attributed to voluntary interruption of pregnancy at 20 weeks gestation. Late

terminations of pregnancy have contributed to a 10% increase in the fetal death rate for the years 1994 to 2000.

In 2000, 6% of births were to Indigenous women, whilst 12% of perinatal deaths were in babies of Indigenous

women. The Indigenous perinatal mortality rate is 2.2 times higher than the non-Indigenous perinatal mortality

rate. The perinatal mortality rates for the Indigenous population were higher in most cause of death categories.

The cause of perinatal death accounting for most of the increased perinatal mortality in the Indigenous

population was Spontaneous preterm, which was more than three times more frequent than in the non-

Indigenous population. The categories of Unexplained antepartum death and Specific perinatal conditions

were more than twice as frequent in the Indigenous population.

The rate of perinatal autopsies for Queensland in 2000 was 39% which compares unfavourably with rates

observed elsewhere in Australia and overseas, and is well below the rate of 75% recommended by the Royal

College of Obstetricians and Gynaecologists and the Royal College of Pathologists.

4 Recommendations

Recommendation 1

Recommendation 2

Recommendation 3

Recommendation 4

Recommendation 5

Recommendation 6

Recommendation 7

Recommendation 8

Recommendation 9

Health professionals should be made aware that pregnancy could be the cause of symptomatic hypertension

in a young woman. If such a woman is found to be pregnant, referral to a specialist obstetrician is appropriate

for investigation, treatment and, if necessary, admission to hospital for monitoring.

Every perinatal death should be reviewed by a local or regional multi-disciplinary clinical committee (including

a pathologist), with direct access to all relevant information. The committee should classify cause of death

according to the Australia and New Zealand Antecedent Classification of Perinatal Mortality (ANZACPM) and

the Australia and New Zealand Neonatal Death Classification (ANZNDC).

To assist clinicians in ANZACPM and ANZNDC classification of perinatal mortality, education programs should

be provided to enable clinicians to ensure accurate completion of the MR63d, confidential perinatal mortality

summary form, perinatal death certificate (Form T) and MR66.

Clinicians should consider the potential value of an autopsy examination in every instance of perinatal death,

and should discuss this with the parents. Clinicians are reminded that when perinatal autopsies are

requested, placental pathology must be included to ensure that the report is complete.

When determining the clinical classification of Specific Perinatal Conditions Antepartum Cord Complications

(Category 6.3), there must be evidence of some or all of the following:

Petechiae distant to the site of complications

Clotting in the cord vessels at site of complications

Distinct indentation around infant or persisting indentations of cord when knot is untied

Differential congestion on either side of the complications

Comprehensive guidelines for review and investigation of fetal deaths should be developed. Further research

and strategies aimed at reducing the risk of unexplained antepartum death should be supported.

A comprehensive congenital abnormality register should be established, which includes notification of

congenital abnormalities resulting in early termination of pregnancy and those detected within the first two

years of life.

The higher rates of perinatal mortality in the Indigenous population highlight the need for continued focussed

research and strategies to reduce this imbalance.

Comprehensive clinical guidelines should be developed for investigation of unexplained antepartum deaths,

which should include an epidemiological analysis on a complete cohort of unexplained antepartum deaths.

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5 Maternal mortality

5.1 Introduction

5.2 Maternal Morbidity & Mortality Subcommittee Terms of Reference

5.3 Definition of maternal mortality

5.4 Classification of maternal deaths

Maternal mortality survey is one of the oldest recorded forms of medical care audit. The Maternal Mortality and

Morbidity Sub-Committee of the Queensland Maternal and Perinatal Quality Council, enquired confidentially

into all known maternal deaths in Queensland in 2000. This report contains a review of seven maternal deaths

from 2000, along with a previously unclassified death from 1999.

Contribute to the reduction of preventable maternal mortality and morbidity in Queensland.

Identify and review all maternal deaths in Queensland.

Classify all maternal deaths as to cause and presence of avoidable factors.

Collaborate with the clinical audit managers in the identification and review of all maternal deaths.

Report on patterns and trends of maternal mortality and morbidity in Queensland.

Report information and recommendations to the Queensland Maternal & Perinatal Council.

Identify areas for research into various aspects pertaining to maternal mortality and morbidity.

Liaise with other state and national bodies to monitor maternal mortality and morbidity.

Revise the terms of reference and activities of the subcommittee in response to changing trends and

circumstances.

A maternal death is defined by the World Health Organisation (WHO) as:

The definition used in this report includes, in addition to the WHO definition, incidental deaths and deaths

occurring more than 42 days after termination of pregnancy, when their origin and illness related to the

pregnancy.

It is noted that the most recent 'Report on Maternal Deaths in Australia', for the period 1994 to 1996, used the

definition of 'death of a woman while pregnant or within 42 days of termination of pregnancy'.

are those that result from obstetric complications of the pregnant state (pregnancy, labour and

puerperium) including deaths from interventions, omissions, inappropriate treatment or from a chain of events

resulting from any of the above. They are complications of pregnancy itself.

are those which result from pre-existing disease or disease that developed during pregnancy

and were not due to direct obstetric causes, but which may have been aggravated by physiological effects of

pregnancy.

are those due to conditions occurring during pregnancy, where the pregnancy is unlikely to

have contributed significantly to the death, although it is sometimes possible to postulate a distant

association.

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'the death of a woman while pregnant or within 42 days of termination of pregnancy,

irrespective of the duration and the site of the pregnancy, from any cause related to

or aggravated by the pregnancy or its management.'

Direct deaths

Indirect deaths

Incidental deaths

5.5 Classification of maternal deaths 2000

5.6 Maternal mortality ratios and trends

There were seven maternal deaths in Queensland in the year 2000. This report also notes a maternal death

from 1999, which was not able to be classified at the time of publication of the 1999 report of the Queensland

Council on Obstetric and Paediatric Morbidity and Mortality.

Of the two direct maternal deaths in 2000, one was due to intracerebral haemorrhage secondary to severe pre-

eclampsia and the other was due to a massive intra-abdominal haemorrhage of unknown source.

Three deaths were classified as indirect maternal deaths and were due to: congestive cardiac failure secondary

to mitral valve disease; subdural haemorrhage secondary to domestic violence; intracerebral haemorrhage:

renal failure secondary to sporadic thrombotic thrombocytopaenic purpura of unknown cause. The previously

unreported death from 1999 was also classified as an indirect maternal death and, although the cause of death

was not clearly identified, it was thought likely to be associated with hypoglycaemia secondary to treatment for

diabetes mellitus.

There were two incidental maternal deaths, one of which was due to homicide. The cause in the second death

was not apparent.

In situations where numerators are small and denominators are large, as with maternal mortality ratios,

interpretation is difficult as small numerator variations lead to large alterations in such ratios. The overall

maternal mortality ratio for Queensland for 2000 was 14.4 per 100,000 mothers (Table 1). This is similar to the

national ratio of 13.0 per 100,000 for the triennium 1994-1996 (Figure 1).

1. Queensland Council on Obstetric and Paediatric Morbidity and Mortality. 1999 Report. Brisbane:

Queensland Health.

2. Advisory Committee on Maternal Mortality and Morbidity, NHMRC. Report on Maternal Deaths in

Australia, 1994-1996. Canberra: NHMRC.

Figure 1:Comparative maternal mortality ratios since 1988

Data sources:

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25

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1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

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Queensland annual reports

Queensland triennia reports

Australian triennia reports

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Table 1: Maternal mortality, Queensland 1988-2000

Data sources:

Deaths

Year Total Direct Indirect Incidental All deaths

Mothers n ratio n ratio n ratio n ratio

1988 40,628 1 2.5 1 2.5 3 7.4 5 12.3

1989 42,296 3 7.1 0 0.0 1 2.4 4 9.5

1990 44,467 2 4.5 0 0.0 1 2.2 3 6.7

1991 44,131 2 4.5 2 4.5 3 6.8 7 15.9

1992 46,073 0 0.0 3 6.5 3 6.5 6 13.0

1993 46,765 3 6.4 1 2.1 6 12.8 10 21.4

1994 47,356 5 10.6 2 4.2 3 6.3 10 21.1

1995 47,864 5 10.4 3 6.3 2 4.2 10 20.9

1996 47,302 1 2.1 0 0.0 5 10.6 6 12.7

1997 47,163 4 8.5 2 4.2 3 6.4 9 19.1

1998 47,450 0 0.0 0 0.0 4 8.4 4 8.4

1999 48,044 4 8.3 3 6.2 6 12.5 13 27.1

2000 48,524 2 4.1 3 6.2 2 4.1 7 14.4

1. Queensland Council on Obstetric and Paediatric Morbidity and Mortality.

2. Queensland Maternal & Perinatal Quality Council & Perinatal Data Collection, Data Services Unit,

Queensland Health

1 1 1 1

1 per 100,000 mothers

5.7 Avoidable factors - maternal deaths 2000

Avoidable factors

These are defined as departures from the accepted standard of satisfactory care that may have played a part in

the death. It is not suggested that in cases in which avoidable factors are considered present (Table 2), death

could certainly have been averted; such judgements indicate that the subcommittee considered that the risk of

death could have been reduced had the management been different. Avoidable factors were thought to be

related to clinical care, to the setting in which the treatment was provided, to factors associated with the

woman not complying with treatment, or to the social setting within which the pregnancy occurred.

The Maternal Morbidity and Mortality Sub-Committee of the QMPQC agreed that avoidable factors were

present when departures from accepted standards of care occurred and, if such departure had not occurred,

the outcome may have been different. In four of the eight cases reviewed in this report (50%), avoidable factors

were thought to be present. However, please note that more than one factor was noted to be present in one

case.

Whilst these numbers are small, and conclusions from small numbers are unreliable, this incidence of

potentially avoidable factors is similar to that reported in the most recently available Australian report (42% in

the 1994 1996 triennium).

Factor Direct Indirect Incidental Total

n=2 n=3 n=2 n=7

Clinical care Failure to diagnose Significant proteinuria - 2

severe pre-eclampsia. not effectively investigated

immediately.

Clinical setting Lack of continuous access - - 1

to appropriately trained

health professionals.

Woman Concealment of pregnancy Non-compliance with - 2

treatment

Social setting Inability to manage - 1

adequate contraception in

a setting where domestic

violence prevailed.

Total factors 3 factors in 2 deaths 3 factors in 3 deaths 6

Total deaths 2 3 2 7

7 maternal deaths from the year 2000 and 1 maternal death from 1999.

(More than one factor was recognised in some deaths)

Table 2: Maternal mortality avoidable factors by classification

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6 Maternal morbidity

Recognising that maternal death is a rare complication of pregnancy in Queensland, the subcommittee

considered the possibility of examining the incidence of serious episodes of maternal morbidity. Surprisingly,

the subcommittee members were unable to find significant state or national maternal mortality and morbidity

bodies with experience in these matters, due to the perceived difficulties of reliable data collection and review.

In considering topics for initial investigation, the subcommittee took particular note of frequent causes of

maternal death and of causes of maternal morbidity, where evidence exists that such morbidity is potentially

preventable in some cases. The subcommittee has undertaken a co-operative review of data sources and their

reliability, with staff of the Office of the Chief Health Officer and of the Health Information Centre of Queensland

Health.

Topics under consideration for future reporting include:

Wound infection, hysterectomy, unintended damage to urinary or gastro-intestinal tract, the need for

blood transfusion and re-admission to hospital in association with birth via caesarean section.

Thrombo-embolic complications of pregnancy, including deep vein thrombosis and pulmonary

embolism.

Significant anaemia associated with pregnancy and birth.

Antepartum and postpartum haemorrhage.

Major complications of pre-eclampsia.

New admissions to intensive care, coronary care and renal dialysis units relating to pregnancy and

birth.

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7 Perinatal mortality

7.1 Modus operandi

7.2 Clinical classification

7.3 Data collection

All perinatal deaths in Queensland are subject to a systematic review. Perinatal mortality data have been

obtained from the Perinatal Data Collection (PDC - Queensland Health), the Registrar General for Births Deaths

and Marriages and case summaries from hospital and regional perinatal mortality committees in Queensland.

During 2000, a number of local mortality committees collaborated with the Council in the perinatal mortality

review process. The working party of the Perinatal Morbidity & Mortality Subcommittee received case

summaries and cause of death classifications assigned by these committees for 80% of perinatal deaths

occurring in 2000.

The Terms of Reference for the subcommittee are:

Review and report on patterns and trends of perinatal morbidity and mortality.

Support and guide clinicians in clinical audit activities, including classification of perinatal deaths

and important perinatal morbidity.

Determine and report on preventable factors.

Liaise with appropriate national and local bodies in the identification of clinical indicators.

Identify evidence-based health care interventions which may reduce morbidity and mortality.

Identify strategies for dissemination of information to clinicians.

Identify research priorities into perinatal morbidity and mortality.

All perinatal deaths in the year 2000 were classified according to the primary cause of death using the new

Australia and New Zealand clinical classification systems - the Australia and New Zealand Antecedent

Classification of Perinatal Death (ANZACPM) and in addition for neonatal deaths, the Australia and New

Zealand Neonatal Death Classification (ANZNDC). These classifications replace the clinical classification

systems used by the Council in previous years: the obstetric antecedent classification Queensland Council

Perinatal Mortality Classification (QCPMC) for all perinatal deaths and the Neonatal Mortality Classification for

all neonatal deaths. The main difference between the current obstetric antecedent classification (ANZACPM)

and the previous QCPMC, is the removal of a specific category for multiple pregnancy. Perinatal deaths in

multiple pregnancies are now classified according to the condition causing the death (eg Twin-twin

transfusion, Hypertension etc). There is very little difference between the previous neonatal death

classification and the current ANZNDC.

The Council acknowledges and thanks the clinicians who have participated in local mortality review and

classification.

The Council has established a perinatal mortality working party. Two of the functions of this working party are to

classify those deaths not classified at the local level and to conduct a quality review of classifications applied

to perinatal deaths at facility/local committee level.

The purpose of classifying deaths according to the ANZACPM and ANZNDC systems is to focus on aetiology, to

enable consideration of preventable factors associated with perinatal deaths through the systematic

application of clinically relevant categories to large populations. (Further information about the classification

systems is to be found in Appendices 3 and 4).

Perinatal mortality data have been obtained from the Perinatal Data Collection (PDC) Queensland Health, the

Registrar General for Births Deaths and Marriages and from hospital and regional perinatal mortality

committees in Queensland. The major data sources are the Perinatal Data Collection Forms (MR63d), the

Medical Certificate of Cause of Perinatal Death (Form T), the Council's Confidential Perinatal Mortality Case

Summary Form and the autopsy and placental pathology report when available.

Perinatal deaths are notified by the Registrar General’s Office to the Perinatal Data Collection (PDC), Data

Services Unit of Queensland Health. The Chief Health Officer then requests that a copy of the autopsy and other

relevant material be sent to the PDC to facilitate classification by the Perinatal Mortality Working Group. The

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Council secretariat collates and makes available all information on the deaths for review by the Perinatal

Mortality Working Group

During 2000, a number of regional/facility committees collaborated with the Council in the perinatal mortality

review process. The Council received case summaries and cause of death classifications assigned by these

Committees for 80% of perinatal deaths occurring in 2000.

Defined in the as:

Defined in the as:

The death of an infant within 28 days of birth.

The death of an infant under one year of age and includes neonatal deaths and postneonatal deaths up to 1

year.

The number of fetal and neonatal deaths per 1,000 total births.

The number of fetal deaths per 1,000 total births.

The number of deaths of live born infants under 28 days of age per 1,000 live births.

The number of deaths of infants under one year of age per 1,000 live births.

The crude perinatal mortality rate (PMR) for Queensland for the year 2000 was 11.0 per 1,000 total births (Table 3)

comprised of a fetal death rate of 7.3 per 1,000 total births and a neonatal mortality rate (NMR) of 3.8 per 1,000

live births. The total number of births in Queensland increased by 569, from 48,749 in 1999 to 49,318 in 2000.

The small reduction in PMR experienced in 1999 compared with 1994-1998 was sustained in 2000. The fetal

death component of 65.4% of perinatal deaths was similar to previous years. Data on late terminations of

pregnancy (>20 weeks gestation) as a result of voluntary interruption of pregnancy, have been collected since

1994. In the year 2000, voluntary interruption pregnancy contributed 19.4% (37) to the total fetal deaths. It

should be noted, as in previous years, many of the deaths in this category can be attributed to women whose

place of usual residence was outside Queensland. When these fetal deaths are removed from annual

statistics, there is no increase in the fetal death rate. (Figure 2)

Total Live Fetal deaths Neonatal deaths Perinatal deathsbirths births n rate n rate n rate

All Queensland 49,318 48,960 358 7.3 184 3.8 542 11.0

(CI 6.5-8.0) (CI 3.3-4.4) (CI 10.1-11.9)

Perinatal Data Collection, Data Services Unit, Queensland Health

Registration of Births, Deaths, and Marriages Act, 1962

'a child whose heart has not beaten after it has been completely expelled or extracted from its mother and

who is either of not less than 20 weeks gestation or of not less than 400g by weight at birth'.

Registration of Births, Deaths and Marriages Act, 1962

'a child whose heart has beaten after it has been completely expelled or extracted from its mother'.

Table 3: Fetal, neonatal and perinatal deaths, Queensland 2000

Data source:

1 2

1

1

2

per 1,000 births (95% confidence interval)

per 1,000 live births (95% confidence interval)

7.4 Definitions

7.5 Perinatal mortality rates and trends

Fetal death

Live birth

Neonatal death

Infant death

Perinatal mortality rate

Fetal death rate

Neonatal mortality rate

Infant mortality rate

Figure 2: Fetal, neonatal and perinatal mortality rates corrected for late terminations, Queensland1987-2000

Data source:

Figure 3: Perinatal mortality rates by usual residence of mother, Queensland and Australia, 1983-2000


Differences exist in definitions and reporting practices between the Australian Bureau of Statistics (ABS) and

the Perinatal Data Collection (PDC), making interstate and national comparisons difficult. For example, the

ABS reports deaths of infants according to the place of usual residence, whereas PDC reports deaths of all

infants born in Queensland. The ABS includes fetal deaths where the birth weight was at least 400g the

gestational age was 20 weeks, whereas PDC uses the definition found in the

(birth weight at least 400g the gestational age was 20 weeks).

Figure 3 compares the PMR for Queensland and Australian residents using ABS definitions and data.

Between 1983 and 2000, the Australian PMR declined from 12.6 to 8.3 deaths per 1,000 births and similarly,

the Queensland PMR declined from 12.8 to 8.9 deaths per 1,000 births. Analysis of perinatal mortality by usual

residence of the mother (ABS definition), shows Queensland rates are much closer to the Australian rate (8.9

deaths per 1,000 births vs 8.3 deaths per 1,000 births) than the PDC Queensland rate (of 11.0 deaths per 1,000)

which includes perinatal deaths of mothers from other states. Small year-to-year fluctuations exist between

the Queensland state rate and the Australian rate which should be interpreted with caution. There was no

statistical difference between Queensland and Australian perinatal, fetal and neonatal death rates for the year

2000 (p > 0.05; binomial exact test).

Data source: ABS Causes of deaths, Australia 2000

and

�

�

Registration of Birth, Deaths and

Marriages Act, 1962 or

1rates per 1,000 births (based on 400 grams/20 weeks definition)

7.6 Comparison with Australian data

12

0

2

4

6

8

10

12

14

16

1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Year

pe

r1

00

0b

irth

s

Fetal deaths

Neonatal deaths

Perinatal deaths

FD - TOP

PND - TOP

13

7.7 Cause specific perinatal mortality

Cause of perinatal deaths by ANZACPM

Congenital abnormalities (Category 1)

The main causes of death using the Australia and New Zealand Antecedent Classification of Perinatal Mortality

(ANZACPM) clinical classification system, are illustrated in Table 4. The three leading causes of perinatal

deaths were Congenital abnormalities (22.4%), Unexplained antepartum death (17.9%) and Spontaneous

preterm (17.3%) which cumulatively account for 57.8% of all deaths.

Other significant contributions were Specific perinatal conditions (9.8%), Antepartum haemorrhage (8.3%)

and Hypertension (5.4%). The main causes for neonatal deaths were Congenital abnormality (33.2%) and

Spontaneous preterm (28.8%). The main causes of fetal death were Unexplained antepartum death (27.1%)

and Congenital abnormality (16.8%).

Type of Perinatal death

Cause of death Fetal death Neonatal death Total

(ANZACPM) n % rate n % rate n % rate

1. Congenital abnormality 60 16.8 1.2 61 33.2 1.2 121 22.3 2.5

2. Perinatal infection 7 2 0.1 5 2.7 0.1 12 2.2 0.2

3. Hypertension 16 4.5 0.3 13 7.1 0.3 29 5.4 0.6

4. Antepartum haemorrhage 27 7.5 0.5 18 9.8 0.4 45 8.3 0.9

5. Maternal conditions 45 12.6 0.9 4 2.2 0.1 49 9 1

6. Specific perinatal conditions 37 10.3 0.8 16 8.7 0.3 53 9.8 1.1

7. Hypoxic peripartum deaths 9 2.5 0.2 6 3.3 0.1 15 2.8 0.3

8. Fetal growth restriction 16 4.5 0.3 4 2.2 0.1 20 3.7 0.4

9. Spontaneous preterm 41 11.5 0.9 53 28.8 1.1 94 17.3 1.9

10. Unexplained antepartum death 97 27.1 2 0 0 0 97 17.9 2

11. No obstetric antecedent 2 0.6 0 4 2.2 0.1 6 1.1 0.1

Not classified 1 0.3 0 0 0 0 1 0.2 0

Total 358 100 7.3 184 100 3.8 542 100 11.0


Of the 121 perinatal deaths classified as Congenital abnormalities, there were 60 fetal deaths and 61 neonatal

deaths.

The most frequent Congenital abnormalities were central nervous system (28), cardiovascular system (24),

chromosomal (18), and other multiple congenital abnormality (30) (Table 16).

Overall, 71 of the 121 deaths (59%) were the result of a single system defect.

Overall, Congenital abnormalities contributed to 22.3% of all perinatal deaths in 2000, (2.5 per 1,000 total

births). This rate has not changed in Queensland since cause specific analyses were conducted in 1994.

These rates are considerably higher than those reported for Australia, where Congenital abnormalities

accounted for 18% of perinatal deaths in 1996 at a rate of 1.6 per 1,000 total births. (Source: Australian Institute

for Health and Welfare)

Table 4: Perinatal deaths by cause and type, Queensland 2000

Data source:

1 2 1

1

2

rate per 1,000 births

rate per 1,000 live births

Central nervous system (CNS)

Congenital cardiovascular system abnormalities

Hypertension (Category 3)

Antepartum haemorrhage (Category 4)

Maternal conditions (Category 5)

Specific perinatal conditions (Category 6)

Spontaneous preterm (<37 weeks gestation) (Category 9)

Unexplained antepartum death (Category 10)

The majority of the 28 deaths from CNS abnormalities were due to neural tube defects. No data are available

on terminations of pregnancy prior to 20 weeks gestation for neural tube defects. Data are also lacking on

folate ingestion for the 28 women whose babies had lethal CNS malformations. This lack of information is a

major barrier to monitoring the rate of central nervous system congenital malformations, and renders it

impossible to gauge the effectiveness, or otherwise, of the public health program of peri-conceptual folate

supplementation.

There were 24 (4.4%) perinatal deaths attributed to this category in 2000, which is similar to 1998 and 1999

(4.2%).

In the year 2000, there were 28 perinatal deaths (5.2% of all perinatal deaths) attributed to hypertension,

compared to 16 in 1998 and 9 in 1999. Whether this represents a genuine increase in deaths due to

hypertension, or a change in classification is difficult to assess.

There were 45 perinatal deaths attributed to Antepartum haemorrhage (8.3% of all perinatal deaths), the

majority being due to placental abruption (32) and 11 of undetermined origin. There were two deaths

attributed to placenta praevia and none to vasa praevia.

In the year 2000, there were 49 perinatal deaths (6.8% of all perinatal deaths). Thirty-seven (37) perinatal

deaths were assigned to the category of Voluntary interruption of pregnancy. This category specifically

excludes termination of pregnancy relating to major Congenital abnormalities. There appears to be a

progressive increase in this category, with 30 in 1998, 35 in 1999 and 37 in 2000.

This group contributed 53 (9.3%) to all perinatal deaths. The main contributing conditions were Twin/twin

transfusion (23), and Uterine abnormalities (13). In 1998, there were 16 perinatal deaths attributed to

Twin/twin transfusion (2.9% of all perinatal deaths), and only 8 (1.5%) in 1999. The increase in 2000 may have

resulted from elective referral patterns to maternal fetal medicine units, improved accuracy with diagnosis

and/or changes in the classification system used. The 13 deaths due to Uterine abnormalities include deaths

resulting from bi-cornuate uterus and cervical incompetence.

Preterm birth accounted for 8.5% of all births and 81% of perinatal deaths, of which 44% were fetal deaths and

56% neonatal deaths. Of the 437 preterm deaths, 94 (17.3%) of all perintal deaths were assigned to the

category of Spontaneous preterm as there were no other identified antecedents. There has been no reduction

in the rate of preterm birth over the past 10 years in Queensland.

There were 97 perinatal deaths attributed to unexplained antepartum death, accounting for 27.1% of fetal

deaths and 17.9% of all perinatal deaths. In only 61 of 97 cases (62.9%) was there an autopsy and in 4 cases

there was not a formal examination of placenta.

The overall rate of unexplained fetal death is 2.0 per 1,000 births, which is greater than the rate of Sudden

Infant Death Syndrome. (Reference Paediatric Council Report.)

Of the 97 Unexplained antepartum deaths, 27 (28%) occurred at <28 weeks gestation, 29 (30%) at 28-36 weeks

gestation and 41 (42%) at 37 weeks. For the first time, systematic information was collected on placental

pathology (Table 16) for this category. This revealed evidence of utero-placental insufficiency in 16%-18% of

cases, the relevance of which is uncertain.

Analysis is currently underway in Queensland Health to identify the epidemiological factors associated with

Unexplained antepartum deaths for the years 1994 to 2000.

�

14

15

7.8 Cause of neonatal death by ANZNDC

Extreme prematurity (Category 2)

Cardio-respiratory (Category 3)

Infection (Category 4)

Neurological (Category 5)

Gastrointestinal (Category 6)

Of the 184 neonatal deaths (Tables 5 & 17), 65 (35.3%) were due to Congenital abnormality, 48 (26.1%), to

Extreme prematurity and 29 (15.8%) to Cardio-respiratory disorders. Other causes were Neurological (16

deaths - 8.7%) and Infection (12 deaths - 6.5%). There were four more neonatal deaths attributed to Congenital

abnormality in the ANZNDC classification than in the obstetric antecedent classification of ANZACPM. The

purpose of the neonatal death classification is to identify the most important factor occurring at, or after, the

birth of the baby, which triggers the cascade of events leading to eventual neonatal death. For this reason,

there may be differences in the congenital abnormality numbers between ANZACPM and ANZNDC

classifications.

Gestational age (weeks)

Cause of death <28 28-36 37+ Total

(Neonatal classification) n % n % n % n %

1. Congenital abnormality 15 15 27 56.2 23 64.9 65 35.3

2. Extreme prematurity 46 46.0 2 4.2 0 0.0 48 26.1

Not resuscitated 43 43.0 2 4.2

Unsuccessful resuscitation 3 3.0 0 0.0

3. Cardio-respiratory disorders 23 23.0 5 10.4 2 2.8 29 15.8

4. Infection 6 6.0 3 6.2 3 8.3 12 6.5

5. Neurological 5 5.0 5 10.4 6 16.7 16 8.7

6. Gastrointestinal 2 2.0 2 4.2 1 2.8 5 2.8

7. Other 3 3.0 4 8.3 2 5.6 9 4.9

Total 100 100 48 100 36 100 184 100


Deaths from extreme prematurity (typically infants <24 weeks gestation of <600g birth weight) were reported in

48 cases (Table 6), predominantly in infants who were considered to be pre-viable and not resuscitated (45),

with only three infants having an unsuccessful resuscitation.

Cardio-respiratory disorders contributed to 29 neonatal deaths, with 20 babies dying as a result of hyaline

membrane disease. The single death attributed to chronic neonatal lung disease highlights the difficulty with

definition of this sub-category because this diagnosis is usually restricted to babies beyond 28 days of age.

The low rate of acquired bacterial (nosocomial) infections occurring in only eight babies does not fully

represent the contribution to neonatal deaths by this complication. There were two neonatal deaths due to

congenital bacterial infection. Unlike the ANZACPM classification, the neonatal classification does not identify

causative organism.

There were 16 neonatal deaths assigned to this category, of which 11 were due to hypoxic ischaemic

encephalopathy and 5 to intracranial haemorrhage.

There were five deaths attributed to necrotising enterocolitis, four of which were low birth weight babies.

Table 5: Neonatal deaths by cause (ANZNDC) and gestational age, Queensland 2000

Data source:

Other (Category 7)

7.9 Multiple pregnancy

In 2000, there was one neonatal death attributed to SIDS (at <day 28 of life), compared to four in 1999.

However, there were seven deaths attributed to other causes (Category 7.8 see Appendix 4). Of these, four

were of <28 weeks gestation. The obstetric antecedent classification (ANZACPM) categories assigned to these

deaths are as follows: Twin/twin transfusion in three deaths; Idiopathic hydrops in a further two deaths;

Spontaneous preterm in one death; and No obstetric antecedent-other, for the remaining death which was

ascribed to a sleeping accident.

Birth weight (g)


(Neonatal classification) n % n % n % n %

1. Congenital abnormality 16 15.7 25 53.2 24 64.9 65 35.3

2. Extreme prematurity 46 45.1 2 4.3 0 0.0 48 26.1

Not resuscitated 44 43.1 1 2.1 0 0.0 45 24.5

Unsuccessful resuscitation 2 2.0 1 2.1 0 0.0 3 1.6

3. Cardio-respiratory disorders 23 22.5 5 10.6 1 2.7 29 15.8

4. Infection 7 6.9 3 6.4 2 5.4 12 6.5

5. Neurological 4 3.9 5 10.6 7 18.9 16 8.7

6. Gastrointestinal 2 2.0 2 4.3 1 2.7 5 2.7

7. Other 4 3.9 3 6.4 2 5.4 9 4.9

Total 102 100 47 100 37 100 184 100


In the year 2000, there were 1,556 births from multiple pregnancies, contributing to 3.16% of all births. The

incidence of twins in 2000 was 2.9% with a PMR of 47.1 per 1,000 births (Table 7, Figure 4). The incidence of

triplets and higher order multiples was 0.18% with a PMR of 67 per 1,000 births. Overall, multiple births

contributed to 75 of the 542 perinatal deaths (13%) with a PMR of 66.7.

The main causes of perinatal deaths in singleton births were Congenital abnormality, Unexplained antepartum

deaths and Spontaneous preterm. The main causes of perinatal deaths in multiple births were Specific

perinatal conditions, Spontaneous preterm and Congenital abnormalities.

Total Live Fetal deaths Neonatal deaths Perinatal deaths

Plurality births births n rate n rate n rate

Singleton 47,762 47,436 326 6.8 141 3.0 467 9.8

Twins 1,466 1,438 28 19.1 41 28.5 69 47.1

Triplets or higher 90 86 4 44.4 2 23.3 6 66.7

Total multiple 1,556 1,524 32 20.6 43 28.2 75 48.2

Total 49,318 48,960 358 7.3 184 3.8 542 11.0


Table 6: Neonatal deaths by cause (ANZNDC) and birth weight, Queensland 2000

Data source:

Table 7: Perinatal deaths by plurality, Queensland 2000

Data Source:

1 2 1

1

2


rate per 1,000 live births

16

17

Figure 4: Perinatal mortality rate by plurality, Queensland 2000

Data source:

Table 8: Perinatal deaths by cause and plurality, Queensland 2000

Data source:

.


Cause of death Singleton Multiple

(ANZACPM) n % rate n % rate RR (95% CI)

1. Congenital abnormality † 109 23.3 2.3 12 16.0 7.7 3.34 (1.7-6.1)

2. Perinatal infection 12 2.6 0.3 0 0.0 0.0 0.00 (0.0-11.0)

3. Hypertension † 17 3.6 0.4 12 16.0 7.7 21.7 (9.4-48.1)

4. Antepartum haemorrhage 42 9.0 0.9 3 4.0 1.9 2.2 (0.4-6.9)

5. Maternal conditions 49 10.5 1.0 0 0.0 0.0 0.0 (0.0-2.4)

6. Specific perinatal conditions † 31 6.6 0.6 22 29.3 14.1 21.8 (12.0-38.9)

7. Hypoxic peripartum deaths 14 3.0 0.3 1 1.3 0.6 2.2 (0.1-14.4)

8. Fetal growth restriction 19 4.1 0.4 1 1.3 0.6 1.6 (0.1-10.2)

9. Spontaneous preterm † 72 15.4 1.5 22 29.3 14.1 9.4 (5.5-15.3)

10. Unexplained antepartum death 95 20.3 2.0 2 2.7 1.3 0.6 (0.1-2.4)

11. No obstetric antecedent 6 1.3 0.1 0 0.0 0.0 0.0 (0.0-26.1)

Not classified 1 0.2 0.0 0 0.0 0.0 0.0

Total † 467 100.0 9.8 75 100.0 48.2 4.9 (3.8-6.3)


1 1 2

1

2

per 1,000 births

RR relative risk with 95% confidence intervals

† mortality rates for singleton and multiple birth statistically different using Fisher's Exact (P < 0.05)

total includes one unclassified death

9.8

47.1

66.7

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Singleton Twins Triplets or higher

Plurality

pe

r1

00

0b

irth

s

7.10 Indigenous perinatal mortality

In the year 2000, there were 2,843 births to Indigenous women, contributing to 5.8% of total births. The term

Indigenous refers to an Aboriginal or Torres Strait Islander person. The definition of an Aboriginal or Torres

Strait Islander person, as accepted by Queensland Health and other agencies including the Commonwealth

Government, is: “a person of Aboriginal/Torres Strait Islander descent who identifies as an Aboriginal or Torres

Strait Islander, and is accepted as such by the community in which he or she lives.” In this report, an

Indigenous birth is one that occurs to an Indigenous woman as defined above. Although there are differences

between the two groups that should be considered for health policy, they are grouped together for statistical

purposes. There were 65 perinatal deaths, with an overall PMR of 22.9 per 1,000 total births comprising 46 fetal

deaths (16.2 per 1,000 total births) and 19 neonatal deaths (6.8 per 1,000 live births).

From the period 1994 to 1996, the overall PMR was 24.2, comprised of a fetal death rate of 15.4 and an NMR of

8.9 per 1,000; in 1998, the comparable figures were 21.4, 12.3 and 9.2 respectively, and in 1999, 16.6, 9.7 and

7.0 respectively. Overall, there has been no improvement in the closure of the gap between Indigenous women

and non Indigenous women. The relative risk for perinatal mortality in the Indigenous population in

comparison with non Indigenous women is 2.2 (95% confidence intervals, 1.7 to 2.9). The absolute risk

difference is 12.6 per 1,000. This absolute risk difference estimates 179 deaths over a 5 year period (95% CI 99-

258)(see Table 9). These rates may be low as they are based only on the mother's status.

Table 9 illustrates the number of Indigenous deaths that could potentially be avoided if the Indigenous

mortality rate were the same as the non Indigenous mortality rate over 5 years.

Total Live Fetal deaths Neonatal deaths Perinatal deathsbirths births n rate n rate n rate

Indigenous 2,843 2,797 46 16.2 19 6.8 65 22.9

(11.9-21.5) (4.1-10.6) (17.7-29.0)

Not Indigenous 46,465 46,154 311 6.7 165 3.6 476 10.2

(6.0-7.5) (3.0-4.2) (9.3-11.2)

Relative risk for 2.4 1.9 2.2

Indigenous (1.8-3.3) (1.2-3.1) (1.7-2.9)

Absolute risk 9.5 3.2 12.6

difference for (4.8-14.2) (0.1-6.3) (7.0-18.2)

Indigenous

5-year 134 (68-201) 45 (1-88) 179 (99-258)

potentially avoidable

Indigenous deaths


Table 9: Fetal, neonatal and perinatal deaths, Queensland 2000

Data source:

4

1 2 1

3

5

1

2

3

4

5

rate per 1,000 births (95% confidence interval)

rate per 1,000 births (95% confidence interval)

Neither Australian Aboriginal nor Torres Strait Islander, total births excludes 10 live births where the Indigenous status was not stated

Indigenous and not Indigenous death figures exclude one fetal death where the Indigenous status was not stated

The number of Indigenous deaths that could potentially be avoided if the Indigenous mortality rate were the same as the not

Indigenous mortality rate for 5 years. Does not refer to a specific condition or intervention that could reduce the rates for Indigenous

people.

18

19

Table 10: Perinatal deaths by cause and Indigenous status, Queensland 2000

Data source:

Cause of death Indigenous Not Indigenous

(2,843 births) (46,465 births)

(ANZACPM) n % rate n % rate RR (95% CI)

1. Congenital abnormality 9 13.8 3.2 112 23.5 2.4 1.31(0.58-2.58)

2. Perinatal infection 1 1.5 0.4 11 2.3 0.2 1.49 (0.03-10.2)

3. Hypertension 10 15.4 3.5 19 4.0 0.4 8.6 (3.5-19.4)

4. Antepartum haemorrhage 2 3.1 0.7 43 9.0 0.9 0.76 (0.89-2.92)

5. Maternal conditions 2 3.1 0.7 47 9.9 1.0 0.70 (0.08-2.66)

6. Specific perinatal conditions 9 13.8 3.2 44 9.2 0.9 3.34 (1.43-6.94)

7. Hypoxic peripartum deaths 0 0.0 0.0 15 3.2 0.3 0.00 (0-4.56)

8. Fetal growth restriction 2 3.1 0.7 18 3.8 0.4 1.82 (0.2-7.58)

9. Spontaneous preterm 16 24.6 5.6 78 16.4 1.7 3.35 (1.83-5.79)

10. Unexplained antepartum 12 18.5 4.2 84 17.6 1.8 2.33 (1.16-4.30)

death

11. No obstetric antecedent 1 1.5 0.4 5 1.1 0.1 3.27 (0.07-29.2)

Not classified 1 1.5 0.4 0 0.0 0.0

Total 65 100.0 22.9 476 100.0 10.2 2.23 (1.69-2.89)


2 3

1 1 5

4

1

2

3

4

5


Indigenous status: Australian Aboriginal, Torres Strait Islander or Australian Aboriginal and Torres Strait Islander

Neither Australian Aboriginal nor Torres Strait Islander, total births excludes 10 live births where the Indigenous status was not stated

excludes 1 stillbirth where Indigenous status was not stated

RR relative risk for Indigenous vs not Indigenous with 95% confidence intervals

7.11 Gestational age and birth weight specific perinatal mortality rates

Analyses of perinatal mortality rate by gestational age and birth weight are displayed in Tables 11, 12 and 15 as

crude rates and rates corrected for deaths from congenital abnormalities. Preterm births (<37 weeks)

accounted for 8.5% of all births, and 81% of perinatal deaths. Very preterm births (<28 weeks gestation),

contributed to 0.9% of all births and 300 (55.4%) perinatal deaths. For infants born at term, the risk of perinatal

death is 1.6 per 1,000 total births, comprised of a fetal death rate of 1.4 per 1,000 total births, and neonatal

death rate of 0.2 per 1,000 live births. The rate of post-term birth (>42 weeks) was 1.9% of total births, with a

PMR corrected for congenital abnormality of 4.3 per 1,000. Once again, this increased risk for post-term

women supports the widely-disseminated results of randomised trials for post-term deliveries, indicating the

benefit of induction of labour for women at >42 completed weeks of gestation (Crowley, 2003).

The corrected PMR for babies with birth weights between 3000-4499 grams was 1.3 per 1,000. The corrected

PMR for infants 500 to 999 grams was 485 in 1998, 461 per 1,000 in 1999 and 409 in 2000 representing a

gradual improvement.

The clinical classification systems for perinatal mortality are also used to analyse fetal and neonatal mortality

by gestational age and birth weight.

Cause of death Gestational age (weeks)

<28 28-36 37+ Total

(ANZACPM) n % n % n % n %


2. Perinatal infection 8 2.7 4 2.9 0 0 12 2.2

3. Hypertension 14 4.7 12 8.8 3 2.8 29 5.4

4. Antepartum haemorrhage 32 10.7 11 8.0 2 1.9 45 8.3

5. Maternal conditions 43 14.3 3 2.2 3 2.9 49 9.0

6. Specific perinatal conditions 31 10.3 16 11.7 6 5.7 53 9.8

7. Hypoxic peripartum deaths 1 0.3 5 3.6 9 8.6 15 2.8

8. Fetal growth restriction 6 2.0 8 5.8 6 5.7 20 3.7

9. Spontaneous preterm 84 28.0 10 7.3 0 0.0 94 17.3

10. Unexplained antepartum 27 9.0 29 21.2 41 39 97 17.9

death

11. No obstetric antecedent 0 0.0 0 0.0 6 5.7 6 1.1

Not classified 1 0.3 0 0.0 0 0 1 0.2

Total 300 100 137 100 105 100.0 542 100.0

Rate per 1,000 births 681.8 36.8 2.3 11.0


Note: Babies born at <28 weeks contributed 55.4% of perinatal deaths, babies born at 28-36 weeks

contributed 25.2% of perinatal deaths, babies born 37+ weeks contributed 19.3% of perinatal deaths

The main causes of deaths in babies of <28 weeks were Spontaneous preterm (28%), Congenital abnormalities

(17.7%) and Maternal conditions (14.3%).

The main causes of deaths in babies from 28-36 weeks were Congenital abnormalities (28.5%), Unexplained

antepartum deaths (21.2%) and Specific perinatal conditions (11.7%).

The main causes of deaths in babies at 37+ weeks were Unexplained antepartum deaths (39%) and Congenital

abnormalities (27.6%).

Table 11: Perinatal deaths by cause and gestational age, Queensland 2000

Data source:

20

21

Table 12: Perinatal deaths by cause and birth weight, Queensland 2000

Data source:

Birth weight (g)


(ANZACPM) n % n % n % n %


2. Perinatal infection 7 2.3 3 2.6 2 1.7 12 2.2

3. Hypertension 17 5.5 9 7.8 3 2.6 29 5.4

4. Antepartum haemorrhage 31 10.0 10 8.6 4 3.4 45 8.3

5. Maternal conditions 43 13.9 2 1.7 4 3.4 49 9.0

6. Specific perinatal conditions 30 9.7 11 9.5 12 10.3 53 9.8

7. Hypoxic peripartum deaths 2 0.6 2 1.7 11 9.4 15 2.8

8. Fetal growth restriction 9 2.9 7 6.0 4 3.4 20 3.7

9. Spontaneous preterm 82 26.5 11 9.5 1 0.9 94 17.3

10. Unexplained antepartum 33 10.7 23 19.8 41 35.0 97 17.9

death

11. No obstetric antecedent 0 0.0 2 1.7 4 3.4 6 1.1

Not classified 0 0.0 1 0.9 0 0.0 1 0.2

Total 309 100.0 116 100.0 117 100.0 542 100.0


Low birth weight babies (<2500g) contributed to 7.1% of all births and accounted for 78.5% of all perinatal

deaths.

The major causes of perinatal deaths in extremely low birth weight infants were Spontaneous preterm (26.5%)

and Congenital abnormalities (17.8%).

The major causes of perinatal deaths for those babies 1000g-2499g were Congenital abnormalities (30.2%)

and Unexplained antepartum deaths (19.8%).

The major causes of perinatal deaths for those babies >2500g were Unexplained antepartum deaths and

Congenital abnormalities.

7.12 Perinatal autopsies

The rate of autopsy for all 542 perinatal deaths in 2000 was 213 (39.3%), with autopsies being performed in

44.1% of fetal deaths and only 29.9% of neonatal deaths (Table 13). This compares unfavourably with autopsy

rates of 45.2% in 1999 and 43.5% in 1998. The autopsy rate in this state falls considerably short of the 75%

recommended by the Royal College of Obstetricians and Gynaecologists and the Royal College of Pathologists,

and is lower than that achieved elsewhere in Australia and overseas. Of particular concern is the autopsy rate

of only 62.9% for deaths attributed to the category Unexplained antepartum fetal deaths.

Type of perinatal death

Cause of death Fetal Neonatal Total

(ANZACPM) n Autopsy n Autopsy n Autopsy

rate rate rate

1. Congenital abnormality 35 58.3 25 41.0 60 49.6

2. Perinatal infection 5 71.4 0 0.0 5 41.7

3. Hypertension 8 50.0 5 38.5 13 44.8

4. Antepartum haemorrhage 4 14.8 5 27.8 9 20.5

5. Maternal conditions 3 6.7 0 0.0 3 6.7

6. Specific perinatal conditions 13 35.1 3 18.8 16 30.2

7. Hypoxic peripartum deaths 4 44.4 1 16.7 5 33.3

8. Fetal growth restriction 8 50.0 2 50.0 10 50.0

9. Spontaneous preterm 16 39.0 12 22.6 28 29.8

10. Unexplained antepartum 61 62.9 0 0.0 61 62.9

death

11. No obstetric antecedent 1 50.0 2 50.0 3 50.0

Total 158 44.1 55 29.9 213 39.3


Autopsy rate: number of autopsies per 100 deaths

Table 13: Perinatal autopsies by cause and type of death, Queensland 2000

Data Source:

1 1 1

1

Note: The autopsy status was unknown in 6 cases.

Total includes 1 unclassified death

22

23

Tab

le14

:P

eri

na

tal

mo

rtal

ity

rate

sb

yg

est

ati

on

ala

ge

,Q

ue

en

sla

nd

20

00

Da

taso

urc

e:

Ge

sta

tio

na

l ag

e(w

ee

ks)

<22

22

-2

42

5-

27

28

-2

93

0-

31

32

-3

43

5-

36

37

-4

14

2+

Tota

l

Tota

l bir

ths

89

176

175

181

29

51,

04

62

,20

34

4,2

09

93

34

9,3

18

%o

fto

tal b

irth

s0

.20

.40

.40

.40

.62

.14

.58

9.6

1.9

100

.0

Tota

l liv

eb

irth

s16

7015

416

22

78

1,0

172

,179

44

,14

69

27

48

,96

0

Tota

l fe

tal d

ea

ths

73

106

21

1917

29

24

63

63

58

%o

fto

tal f

eta

l de

ath

s2

0.4

29

.65

.95

.34

.78

.16

.717

.61.

710

0.0

Feta

l de

ath

rate

82

0.2

60

2.3

120

.010

5.0

57.6

27.

710

.91.

46

.47.

3

Tota

l ne

on

ata

l de

ath

s16

55

29

910

1217

35

118

4

%o

fto

tal n

eo

na

tal d

ea

ths

8.7

29

.915

.84

.95

.46

.59

.219

.00

.510

0.0

Ne

on

ata

l de

ath

rate

1,0

00

.07

85

.718

8.3

55

.63

6.0

11.8

7.8

0.8

1.1

3.8

Tota

l pe

rin

ata

l de

ath

s8

916

15

02

82

74

14

19

87

54

2

%o

fto

tal d

ea

ths

16.4

29

.79

.25

.25

.07.

67.

618

.11.

310

0.0

Pe

rin

ata

l mo

rta

lity

rate

1,0

00

.09

14.8

28

5.7

154

.79

1.5

39

.218

.62

.27.

511

.0

Co

rre

cte

dp

eri

na

tal m

ort

ali

ty

Feta

l de

ath

wit

hC

A2

416

23

26

23

26

0

Feta

l de

ath

rate

753

.856

2.5

109

.88

9.9

51.2

22

.110

.01.

44

.36

.0

Ne

on

ata

l de

ath

wit

hC

A5

42

14

912

23

16

1

Ne

on

ata

l de

ath

rate

1,0

00

.07

72.7

177.

64

9.7

21.

93

.02

.30

.30

.02

.5

Pe

rin

ata

l de

ath

sw

ith

CA

29

20

44

615

142

63

121

Pe

rin

ata

l de

ath

sw

ith

ou

tC

A6

014

14

62

42

12

62

772

44

21

Co

rre

cte

dp

eri

na

tal m

ort

ali

tyra

te10

00

.09

03

.82

69

.013

5.6

72.7

25

.212

.31.

64

.38

.6

Pe

rin

ata

l Da

taC

oll

ect

ion

,D

ata

Se

rvic

es

Un

it,

Qu

ee

nsl

an

dH

ea

lth

1

2

3

2

4

5

2

5

3

5

5

2

12

3

45

incl

ud

es

“no

tst

ate

d”

-11

live

bir

ths.

rate

pe

r1,

00

0b

irth

sra

tep

er

1,0

00

live

bir

ths

corr

ect

edfo

rco

ng

en

ita

lab

no

rma

lity

con

ge

nit

ala

bn

orm

ali

ty

24

Tab

le15

:P

eri

na

tal

mo

rtal

ity

rate

sb

yb

irth

we

igh

t,Q

ue

en

sla

nd

20

00

Da

taso

urc

e:

Bir

thw

eig

ht

(g)

<50

05

00

-74

975

0-

100

0-

125

0-

150

0-

175

0-

20

00

-2

25

0-

25

00

-3

00

0-

35

00

-4

00

0-

99

912

49

149

917

49

199

92

24

92

49

92

99

93

49

93

99

94

49

9>4

50

0To

tal

Tota

l bir

ths

182

142

143

152

187

27

14

45

68

21,

28

16

,92

617

,00

315

,43

95

,50

59

55

49

,318

%o

fto

tal b

irth

s0

.40

.30

.30

.30

.40

.50

.91.

42

.614

.03

4.5

31.

311

.21.

910

0.0

Tota

l liv

eb

irth

s3

69

612

813

617

32

66

42

86

741,

270

6,8

93

16,9

83

15,4

24

5,4

97

951

48

,96

0

Tota

l fe

tal d

ea

ths

146

46

1516

145

178

113

32

015

84

35

8

%o

fto

tal f

eta

l de

ath

s4

0.8

12.8

4.2

4.5

3.9

1.4

4.7

2.2

3.1

9.2

5.6

4.2

2.2

1.1

100

.0

Feta

l de

ath

rate

80

2.2

32

3.9

104

.910

5.3

74.9

18.5

38

.211

.78

.64

.81.

21.

01.

54

.27.

3

Tota

l ne

on

ata

l de

ath

s3

44

919

73

88

109

1214

92

018

4

%o

fto

tal n

eo

na

tal d

ea

ths

18.5

26

.610

.33

.81.

64

.34

.35

.44

.96

.57.

64

.91.

10

.010

0.0

Ne

on

ata

l de

ath

rate

94

4.4

510

.414

8.4

51.5

17.3

30

.118

.714

.87.

11.

70

.80

.60

.40

.03

.8

Tota

l pe

rin

ata

l de

ath

s18

09

53

42

317

132

518

20

45

34

24

104

54

2

%o

fto

tal d

ea

ths

33

.217

.56

.34

.23

.12

.44

.63

.33

.78

.36

.34

.41.

80

.710

0.0

Pe

rin

ata

l mo

rta

lity

rate

98

9.0

66

9.0

23

7.8

151.

39

0.9

48

.056

.22

6.4

15.6

6.5

2.0

1.6

1.8

4.2

11.0

Co

rre

cte

dp

eri

na

tal m

ort

ali

ty

Feta

l de

ath

wit

hC

A2

912

31

30

41

15

01

00

60

Feta

l de

ath

rate

764

.72

61.

58

5.7

99

.359

.818

.52

9.5

10.3

7.8

4.0

1.2

0.9

1.5

4.2

6.0

Ne

on

ata

l de

ath

wit

hC

A5

42

21

63

94

710

71

06

1

Ne

on

ata

l de

ath

rate

93

5.5

48

9.1

134

.93

7.3

11.6

7.7

11.8

1.5

3.9

0.7

0.2

0.1

0.2

0.0

2.5

Pe

rin

ata

l de

ath

sw

ith

CA

34

165

34

67

105

1210

81

012

1

Pe

rin

ata

l de

ath

sw

ith

ou

tC

A14

679

29

20

137

188

153

32

416

94

42

1

Co

rre

cte

dp

eri

na

tal m

ort

ali

tyra

te9

86

.56

27.

02

10.1

134

.27

1.0

26

.44

1.1

11.9

11.8

4.8

1.4

1.0

1.6

4.2

8.6

Pe

rin

ata

l Da

taC

oll

ect

ion

,D

ata

Se

rvic

es

Un

it,

Qu

ee

nsl

an

dH

ea

lth

1

2

3

2

4

5

2

5

3

5

5

2

1 2 3 4 5

incl

ud

es

“no

tst

ate

d”

-5

live

bir

ths.

rate

pe

r1,

00

0b

irth

s

rate

pe

r1,

00

0li

veb

irth

s

corr

ect

edfo

rco

ng

en

ita

lan

om

aly

con

ge

nit

ala

no

ma

ly

25

Tab

le16

:P

eri

na

tal

dea

ths

by

cau

se,

Qu

ee

nsl

an

d2

00

0

Cla

ssif

ica

tio

nD

ea

thty

pe

Feta

l de

ath

Ne

on

ata

l de

ath

Pe

rin

ata

l de

ath

n%

n%

n%

1.C

ON

GE

NIT

AL

AB

NO

RM

ALI

TY(i

ncl

ud

ing

term

ina

tio

ns

wh

ere

the

fetu

sh

as

con

ge

nit

al a

bn

orm

ali

tie

s)6

016

.86

13

3.2

121

22

.4

1.1

Ce

ntr

al n

erv

ou

ssy

ste

m17

4.8

116

.02

85

.2

1.2

Ca

rdio

vasc

ula

rsy

ste

m7

2.0

179

.22

44

.4

1.3

Uri

na

rytr

act

41.

13

1.6

71.

3

1.4

Ga

stro

inte

stin

al t

ract

20

.62

1.1

40

.7

1.5

Ch

rom

oso

ma

l14

3.9

42

.218

3.3

1.6

Me

tab

oli

c3

0.8

52

.78

1.5

1.7

Mu

ltip

le9

2.5

63

.315

2.8

1.8

Oth

er

con

ge

nit

al a

bn

orm

ali

ty2

0.6

137.

115

2.8

1.9

Un

spe

cifi

ed

con

ge

nit

al a

bn

orm

ali

ty2

0.6

10

.52

0.4

2.

PE

RIN

ATA

LIN

FEC

TIO

N7

2.0

52

.712

2.2

2.1

Ba

cte

ria

l-

-1

0.5

10

.2

2.1

1G

rou

pB

Str

ep

toco

ccu

s2

0.6

10

.53

0.6

2.1

2E

.co

li-

-1

0.5

10

.2

2.1

3Li

ste

ria

mo

no

cyto

ge

ne

s1

0.3

--

10

.2

2.1

8O

the

rb

act

eri

al

--

10

.51

0.2

2.1

9U

nsp

eci

fie

db

act

eri

al

--

--

--

2.2

Vir

al

--

--

--

2.2

1C

yto

me

ga

lovi

rus

10

.31

0.5

20

.4

2.2

2P

arv

ovi

rus

--

--

--

2.2

3H

erp

es

sim

ple

xvi

rus

--

--

--

26

Cla

ssif

ica

tio

nD

ea

thty

pe

Feta

l de

ath

Ne

on

ata

l de

ath

Pe

rin

ata

l de

ath

n%

n%

n%

2.2

4R

ub

ell

avi

rus

--

--

--

2.2

8O

the

rvi

ral

--

--

--

2.2

9U

nsp

eci

fie

dvi

ral

10

.3-

-1

0.2

2.3

Pro

tozo

al e

gto

xop

lasm

a-

--

--

-

2.4

Sp

iro

cha

eta

l eg

syp

hil

is-

--

--

-

2.5

Fun

ga

l-

--

--

-

2.8

Oth

er

20

.6-

-2

0.4

3.

HY

PE

RTE

NS

ION

164

.713

7.1

29

5.4

3.1

Ch

ron

ich

ype

rte

nsi

on

:e

sse

nti

al

30

.86

3.3

91.

7

3.2

Ch

ron

ich

ype

rte

nsi

on

:se

con

da

ry,

eg

ren

al d

ise

ase

10

.32

1.1

30

.6

3.3

Ch

ron

ich

ype

rte

nsi

on

:u

nsp

eci

fie

d-

--

--

-

3.4

Ge

sta

tio

na

l hyp

ert

en

sio

n-

--

--

-

3.5

Pre

-ecl

am

psi

a11

3.1

42

.215

2.8

3.6

Pre

-ecl

am

psi

asu

pe

rim

po

sed

on

chro

nic

hyp

ert

en

sio

n-

-1

0.5

10

.2

3.9

Un

spe

cifi

ed

hyp

ert

en

sio

n1

0.3

--

10

.2

4.

AN

TEP

AR

TUM

HA

EM

OR

RH

AG

E(A

PH

)2

77.

618

9.8

45

8.3

4.1

Pla

cen

tal a

bru

pti

on

21

5.9

116

.03

25

.9

4.2

Pla

cen

tap

rae

via

10

.31

0.5

20

.4

4.3

Va

sap

rae

via

--

--

--

4.8

Oth

er

AP

H-

--

--

-

4.9

AP

Ho

fu

nd

ete

rmin

ed

ori

gin

51.

46

3.3

112

.0

27

Cla

ssif

ica

tio

nD

ea

thty

pe

Feta

l de

ath

Ne

on

ata

l de

ath

Pe

rin

ata

l de

ath

n%

n%

n%

5.

MA

TER

NA

LC

ON

DIT

ION

S4

512

.64

2.2

49

9.1

5.1

Term

ina

tio

no

fp

reg

na

ncy

37

10.4

--

37

6.8

such

as

rup

ture

of

me

mb

ran

es

(RO

M)

aft

er

am

nio

cen

tesi

s)

5.2

Dia

be

tes/

ge

sta

tio

na

l dia

be

tes

30

.81

0.5

40

.7

5.3

Ma

tern

al i

nju

ry-

--

--

-

5.3

1A

ccid

en

tal

--

--

---

5.3

2N

on

-acc

ide

nta

l-

--

--

-

5.4

Ma

tern

al s

ep

sis

20

.6-

-2

0.4

5.8

Oth

er

ma

tern

al c

on

dit

ion

s,e

gLu

pu

so

bst

etr

icsy

nd

rom

e3

0.8

31.

66

1.1

6.

SP

ECIF

ICP

ER

INA

TAL

CO

ND

ITIO

NS

37

10.4

168

.753

9.8

6.1

Twin

-to

-tw

intr

an

sfu

sio

n16

4.5

73

.82

34

.2

6.2

Feto

ma

tern

al h

ae

mo

rrh

ag

e5

1.4

--

50

.9

6.3

An

tep

art

um

cord

com

pli

cati

on

s(e

gco

rdh

ae

mo

rrh

ag

e;

tru

ek

no

tw

ith

evi

de

nce

of

occ

lusi

on

)4

1.1

--

40

.7

6.4

Ute

rin

ea

bn

orm

ali

tie

s,e

gb

ico

rnu

ate

ute

rus,

cerv

ica

l in

com

pe

ten

ce.

61.

77

3.8

132

.4

6.5

Bir

thtr

au

ma

(typ

ica

lly

infa

nts

of

>24

we

ek

sg

est

ati

on

or

>60

0g

bir

thw

eig

ht)

--

--

--

6.6

Ha

em

oly

tic

dis

ea

se-

--

--

-

6.7

Idio

pa

thic

hyd

rop

s2

0.6

21.

14

0.7

6.8

Oth

er

spe

cifi

cp

eri

na

tal c

on

dit

ion

s(i

ncl

ud

es

ute

rin

eru

ptu

re,

iatr

og

en

icco

nd

itio

ns

41.

1-

-4

0.7

7.H

YP

OX

ICP

ER

IPA

RTU

MD

EA

TH(t

ypic

all

yin

fan

tso

f>2

4w

ee

ks

ge

sta

tio

no

r>

60

0g

bir

thw

eig

ht)

92

.56

3.3

152

.8

7.1

Wit

hin

tra

pa

rtu

mco

mp

lica

tio

ns

82

.22

1.1

101.

8

7.2

No

intr

ap

art

um

com

pli

cati

on

s-

--

--

-

7.9

Un

spe

cifi

ed

hyp

oxi

cp

eri

pa

rtu

md

ea

th1

0.3

42

.25

0.9

28

Cla

ssif

ica

tio

nD

ea

thty

pe

Feta

l de

ath

Ne

on

ata

l de

ath

Pe

rin

ata

l de

ath

n%

n%

n%

acu

tea

the

rosi

s,m

ate

rna

l va

scu

lar

thro

mb

osi

so

rm

ate

rna

l flo

or

infa

rcti

on

<24

ho

urs

be

fore

de

live

ry

--

--

--

9.3

9U

nsp

eci

fie

do

rn

ot

kn

ow

nw

he

the

rp

lace

nta

exa

min

ed

30

.89

4.9

122

.2

8.

FETA

LG

RO

WTH

RE

STR

ICTI

ON

(FG

R)

164

.54

2.2

20

3.7

8.1

Wit

he

vid

en

ceo

fu

tero

pla

cen

tal i

nsu

ffic

ien

cye

gsi

gn

ific

an

tin

farc

tio

n8

2.2

31.

611

2.0

8.2

Wit

hch

ron

icvi

llit

is-

--

--

-

8.3

Wit

ho

ut

the

ab

ove

pla

cen

tal p

ath

olo

gy

61.

71

0.5

71.

3

8.4

No

exa

min

ati

on

of

pla

cen

ta-

--

--

-

8.9

Un

spe

cifi

ed

FGR

or

no

tk

no

wn

wh

eth

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8 References

Advisory Committee on Maternal Mortality and Morbidity, NHMRC. Report on Maternal Deaths in Australia,

1994-1996. Canberra: NH & MRC

Crowley P. Interventions for preventing or improving the outcome of delivery at or beyond term (Cochrane

Review). In: The Cochrane Library, Issue 1, 2003. Oxford: Update Software.

Maternal Deaths in Australia 1994-1996. Perinatal Data Collection, Data Services Unit, Queensland Health.

Report of the Queensland Council on Obstetric and Paediatric Morbidity and Mortality, 1999. Queensland

Health.

33

9 Appendices

9.1 Appendix 1: Perinatal Mortality and Morbidity Subcommittee

9.2 Appendix 2: Maternal Mortality and Morbidity Subcommittee

Members

Members

Dr David Cartwright (Chair) Director-Neonatology, Royal Women's Hospital

Mr Philip Baker Clinical Information Manager, Clinical Audit Program

Ms Rowena Chapman Member of SANDS (Consumer)

Dr Paul Colditz Director-Perinatal Research Centre, Royal Women's Hospital

Ms Sue Cornes Deputy Manager-Health Information Centre

Ms Lynne Dunne Vice President-Queensland Branch, Australian College of Midwives

Dr John Evans General Practitioner, Emerald

Ms Vicki Flenady Perinatal Researcher-Centre for Clinical Studies, Women & Children's

Health, Mater Hospital

Professor Michael Humphrey Director-Obstetrics and Gynaecology, Cairns Base Hospital (to December

2002)

Mrs Joan Kennedy Principal Policy Officer, Office of the Chief Health Officer

Dr Guan Koh Senior Staff Specialist, NICU, The Townsville Hospital

Dr Lucinda Pallis Obstetrician & Gynaecologist, Gold Coast Hospital

Dr Diane Payton Staff Pathologist, QHPSS, Royal Brisbane and Royal Women’s

Hospital and Health Service District

Professor David Tudehope Director, Division of Neonatology, Mater Mothers' Hospital

Mrs Wendy Rogash Administration Officer, Office of the Chief Health Officer

Dr Nikki Whelan Obstetrician & Gynaecologist (Private Practice)

Professor Michael Humphrey Director-Obstetrics and Gynaecology, Cairns Base Hospital (Chairman) (to

December 2002)

Ms Rowena Chapman Member SANDS (Consumer)

Ms Vicki Flenady Perinatal Researcher-Centre for Clinical Studies Women's and Children's

Health, Mater Misericordiae Hospital

Dr Karen Lust Obstetric Physician, Royal Women's Hospital

Mrs Heather McCosker Lecturer, Queensland University of Technology

Dr Diane Payton Staff Pathologist, QHPSS, Royal Brisbane and Royal Women’s

Hospital and Health Service District

Dr David Watson Consultant Obstetrician, The Townsville Hospital

Dr Nikki Whelan Obstetrician & Gynaecologist (Private Practice) and VMO Royal Women's

Hospital

Dr John Wilson Senior Staff Specialist, Royal Womens Hospital

34

9.3 Appendix 3: Australia and New Zealand Antecedent Classification of Perinatal

Mortality (ANZACPM)

Australia and New Zealand Antecedent Classification of Perinatal Mortality (ANZACPM)

1. CONGENITAL ABNORMALITY (including terminations where the fetus has congenital

abnormalities)

1.1 Central nervous system

1.2 Cardiovascular system

1.3 Urinary tract

1.4 Gastrointestinal tract

1.5 Chromosomal

1.6 Metabolic

1.7 Multiple

1.8 Other congenital abnormality

1.9 Unspecified congenital abnormality

2. PERINATAL INFECTION

2.1 Bacterial

2.11 Group B Streptococcus

2.12 E coli

2.13 Listeria monocytogenes

2.18 Other bacterial

2.19 Unspecified bacterial

2.2 Viral

2.21 Cytomegalovirus

2.22 Parvovirus

2.23 Herpes simplex virus

2.24 Rubella virus

2.28 Other viral

2.29 Unspecified viral

2.3 Protozoal eg Toxoplasma

2.4 Spirochaetal eg Syphilis

2.5 Fungal

2.8 Other

2.9 Unspecified organism

3. HYPERTENSION

3.1 Chronic hypertension: essential

3.2 Chronic hypertension: secondary, eg renal disease

3.3 Chronic hypertension: unspecified

3.4 Gestational hypertension

3.5 Pre-eclampsia

3.6 Pre-eclampsia superimposed on chronic hypertension

3.9 Unspecified hypertension

4. ANTEPARTUM HAEMORRHAGE (APH)

4.1 Placental abruption

4.2 Placenta praevia

4.3 Vasa praevia

4.8 Other APH

4.9 APH of undetermined origin

5. MATERNAL CONDITIONS

5.1 Termination of pregnancy

5.2 Diabetes/gestational diabetes

35


5.3 Maternal injury

5.31 Accidental

5.32 Non-accidental

5.4 Maternal sepsis

5.8 Other maternal conditions, eg Lupus obstetric syndrome

6. SPECIFIC PERINATAL CONDITIONS

6.1 Twin-to-twin transfusion

6.2 Fetomaternal haemorrhage

6.3 Antepartum cord complications (eg cord haemorrhage; true knot with evidence of occlusion)

6.4 Uterine abnormalities, eg bicornuate uterus, cervical incompetence.

6.5 Birth trauma (typically infants of >24 weeks gestation or >600g birth weight)

6.6 Haemolytic disease

6.7 Idiopathic hydrops

6.8 Other specific perinatal conditions (includes uterine rupture, iatrogenic conditions such as

rupture of membranes (ROM) after amniocentesis)

7. HYPOXIC PERIPARTUM DEATH (typically infants of >24 weeks gestation or >600g birthweight)

7.1 With intrapartum complications

7.2 No intrapartum complications

7.9 Unspecified hypoxic peripartum death

8. FETAL GROWTH RESTRICTION (FGR)

8.1 With evidence of uteroplacental insufficiency eg significant infarction, acute atherosis,

maternal vascular thrombosis or maternal floor infarction

8.2 With chronic villitis

8.3 Without the above placental pathology

8.4 No examination of placenta

8.9 Unspecified FGR or not known whether placenta examined

9. SPONTANEOUS PRETERM (<37 weeks gestation)

9.1 Spontaneous preterm labour with intact membranes, or membrane rupture <24 hours before

delivery

9.11 with chorioamnionitis

9.12 without chorioamnionitis

9.13 no examination of placenta

9.19 unspecified or not known whether placenta examined

9.2 Spontaneous preterm labour with membrane rupture 24 hours before delivery

9.21 with chorioamnionitis,

9.22 without chorioamnionitis,



9.3 Spontaneous preterm labour with membrane rupture of unknown duration before

delivery,

9.31 with chorioamnionitis,

9.32 without chorioamnionitis,



10. UNEXPLAINED ANTEPARTUM DEATH

10.1 With evidence of uteroplacental insufficiency, eg significant infarction, acute atherosis,

maternal vascular thrombosis or maternal floor infarction

10.2 With chronic villitis

10.3 Without the above placental pathology

36


10.4 No examination of placenta

10.9 Unspecified unexplained antepartum death or not known whether placenta examined

11 NO OBSTETRIC ANTECEDENT

11.1 SIDS

11.11 Consistent with SIDS

11.12 Possible SIDS

11.2 Postnatally acquired infection

11.3 Accidental asphyxiation

11.4 Other accident, poisoning or violence (postnatal)

11.8 Other

11.9 Unknown/unexplained

Australia and New Zealand Neonatal Death Classification

1 CONGENITAL ABNORMALITY

1.1 Central nervous system

1.2 Cardiovascular system

1.3 Urinary tract

1.4 Gastrointestinal tract

1.5 Chromosomal

1.6 Metabolic

1.7 Multiple

1.8 Other congenital abnormality

1.9 Unspecified congenital abnormality

2 EXTREME PREMATURITY (Typically infants of <24 weeks gestation or <600g birth weight)

2.1 Not resuscitated

2.2 Unsuccessful resuscitation

2.9 Unspecified or not known whether resuscitation attempted

3 CARDIO-RESPIRATORY DISORDERS

3.1 Hyaline membrane disease/Respiratory distress syndrome (RDS)

3.2 Meconium aspiration syndrome

3.3 Primary persistent pulmonary hypertension

3.4 Pulmonary hypoplasia

3.5 Chronic neonatal lung disease (typically, bronchopulmonary dysplasia)

3.8 Other

4 INFECTION

4.1 Bacterial

4.11 Congenital bacterial

4.12 Acquired bacterial

4.2 Viral

4.21 Congenital viral

4.22 Acquired viral

4.3 Protozoal eg toxoplasma

4.4 Spirochaetal eg syphilis

4.5 Fungal

4.8 Other

4.9 Unspecified organism

5. NEUROLOGICAL

5.1 Hypoxic ischaemic encephalopathy/perinatal asphyxia (typically infants of >24 weeks gestation

or >600g birth weight)

9.4 Appendix 4: Australia and New Zealand Neonatal Death Classification

37

Australia and New Zealand Neonatal Death Classification

5.2 Intracranial haemorrhage

5.8 Other

6. GASTROINTESTINAL

6.1 Necrotising enterocolitis

6.8 Other

7. OTHER

7.1 SIDS

7.11 Consistent with SIDS

7.12 Possible SIDS

7.2 Multi-system failure-only if unknown primary cause or trigger event

7.3 Trauma

7.8 Other

7.9 Undetermined/unknown

B

PSANZ Council has endorsed the interest group on Substance Use in Pregnancy as a Special Interest Group

affiliated with the Perinatal Society of Australia and New Zealand, at its council meeting in March 2003.

A special meeting was held in March 2000 to discuss Perinatal Substance Use issues. Attending this meeting

were two hundred and sixty registrants from across Australia and New Zealand and representing all

disciplines. During this meeting, extreme interest was expressed in ongoing commitment to this topic by

promoting communication via a special forum.

Many of these interested persons are PSANZ members; others work within the field of alcohol and drug

treatment services or associated health services. It is imperative that any proposed special interest group

attracts health professionals in all relevant disciplines.

A national group of interested health professionals has been formed and has held two tele-conferences (in

November 2001 and February 2002) as well as a breakfast meeting in Christchurch in March 2003.

Development of a networking and communication system for stakeholders in the area of perinatal substance

use.

Currently there is a lack of state-wide and national epidemiological data on the prevalence of substance use

(illicit and licit) in pregnancy and the effect on the family and neonate.

This impacts on clinical management issues in the areas of: -

antenatal management

neonatal abstinence syndrome

family and social outcomes

intellectual, developmental and behavioural outcomes for the infant.

There is a lack of Australian and New Zealand research in this area to support evidence-base practice for

clinical management and prevention strategies.

To establish and maintain a forum of stakeholders in perinatal substance use.

y David Tudehope and Kei Lui (Co-chairpersons Perinatal Substance Use Special Interest Group)

�

�

�

�

9.5 Appendix 5: Perinatal Substance Use Special Interest Group

Background to the formation of this special interest group

Project Definition

Problem being addressed

Goal

38

Objectives

Outcomes

Scope

The objectives of the interest forum are: -

Advance members' knowledge and skills in managing perinatal substance use.

Promote research and data collection in perinatal substance use.

Provide expert advice to government and other bodies on matters pertaining to perinatal substance

use.

To develop best practice models in prevention and management.

Examine the feasibility of establishment of clinical indicators and/or national database for

benchmarking purposes.

Maintain liaison with international bodies in perinatal substance use through the promotion of this

interest forum.

Improved clinical management (evidence-based) specifically for antenatal, neonatal abstinence syndrome,

long term outcomes for the infant, and family and social outcomes

Increased education and information for health care professionals

Increased networking between community and hospital based agencies and other related services

Improved outcomes for mother, infants and families

Increased opportunities for research in this field.

Networking and communication of stakeholders (within Australia and New Zealand) through the

establishment of an Executive, including secretariat, a register of members, newsletters and web-site.

Stakeholders will represent the following disciplines:

Paediatricians

Neonatal nurses

Midwives

Obstetricians

Allied Health, Physiotherapist, Social Workers, Pharmacist, Nutritionists

General Practitioners

Alcohol and Drug Case Managers and Counsellors

There will be representation from other services, including:

Mental Health services

Child Health services

Non-Government Organisations (eg. Queensland Intravenous AIDS Association, Alcohol & Drug

Foundation of Australia, Hepatitis C Council)

Any enquiries regarding membership to this special interest group, please provide your mailing address

/contact details to one of the persons listed below:

Ann Kingsbury (Acting secretariat)

David Tudehope*

Kei Lui*

*Co-chairpersons Perinatal Substance Use Special Interest Group

�

�

�

�

�

�

�

�

�

�

�

�

�

�

�

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�

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[email protected]

[email protected]

[email protected]

39

9.6 Appendix 6: Australia and New Zealand Perinatal Mortality Classification Special

Interest Group

Introduction

Terms of reference

The Perinatal Classification System

THE PERINATAL SOCIETY of

AUSTRALIA & NEW ZEALAND

The Perinatal Society of Australia and New Zealand (PSANZ) Perinatal Mortality Classification Group (PMC-SIG)

has been established from foundations laid by a group of PSANZ members who had met informally over a

number of years to develop a systematic approach to the review and classification of perinatal deaths. The

main objective of this activity was to accurately identify the main contributing factors of perinatal mortality to

enable the development, implementation and ongoing monitoring of strategies to reduce the risk of perinatal

death.

The importance of a clinically orientated classification system, which could be easily and consistently applied

to all perinatal deaths across ANZ to allow the assembly of a large epidemiological dataset to inform

prevention strategies, was recognised. To this end, a clinical classification system (ANZ Antecedent

Classification of Perinatal Mortality and the ANZ Neonatal Death Classification) was developed and piloted and

is now implemented in most States and Territories in Australia and in some regions of New Zealand.

The classifications have been endorsed by the National Perinatal Data Development Committee and accepted

for future publication in the National Perinatal Statistics Unit publication Australia's Mothers and Babies.

Following endorsement of this activity as a SIG of the PSANZ in March 2003, the classifications have been

renamed to the Perinatal Society of Australia and New Zealand - Antecedent Classification for Perinatal

Mortality (PSANZ-ACPM) and the Perinatal Society of Australia and New Zealand Neonatal Death Classification

(PSANZ-NDC).

To develop, implement and manage a clinical classification system for perinatal mortality for use

across Australia and New Zealand

To review the classification annually in terms of required amendments

To develop guidelines for perinatal mortality audit and reporting

To provide advice for Colleges and other bodies on perinatal mortality review

Membership

All PSANZ members with an interest in perinatal mortality classification are welcome to join the SIG. The aim is

to have multidisciplinary membership with geographic representation from across ANZ and to also have

representation from the following:

State and Territory Perinatal Committees; the National Perinatal Statistics Unit; and the Perinatal Data

Collections within ANZ.

The perinatal mortality classification is known as the Australian and New Zealand Antecedent Classification

System for Perinatal Mortality (ANZACPM) and the neonatal system is called the Australian and New Zealand

Neonatal Death Classification (ANZNDC) .

�

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2,3

40

The purpose of the classification is to focus on aetiology thereby enabling consideration of preventable factors

associated with perinatal death through the systematic application of clinically relevant categories to large

populations.

The two systems have been endorsed by the (Australian) National Perinatal Data Development Committee and

are presently being submitted to the (Australian) National Centre for the Classification of Health. Endorsement

by NCCH will give the classifications official status so that they may be accepted for publication in AIHW reports

such as Australia's Mothers and Babies. The classifications are now being applied in States and Territories

across Australia and some Hospitals in New Zealand.

The Perinatal Indigenous Network was founded in response to the poor state of Indigenous perinatal health as

a formally constituted special interest group of the Perinatal Society of Australia and New Zealand. It

recognises that there is much expertise both among Society members, but also that there is a large workforce

involved in perinatal Indigenous health care outside of the 1000+ current membership of PSANZ. As

Australia's and New Zealand's premier perinatal multidisciplinary group, it is fitting that this initiative be within

PSANZ It has received funding from 2000 by PSANZ in the form of a special initiative grant. The broad aim of PIN

is to both promote awareness and opportunities for Indigenous perinatal health advancement within and

beyond PSANZ.

A PIN web page is accessible from the PSANZ Home Page. A major focus has been highlighting perinatal

Indigenous health issues within the PSANZ Annual Congress. Issues addressed include epidemiological and

cultural issues and the need to incorporate structural and managerial change to deal with issues that tend to be

fragmented by current structures.

Key areas identified by PIN workshop participants as in need of change to improve Indigenous health outcomes

included housing (overcrowding); immunization; alcohol and drugs; knowledge; education and training;

antenatal protocols; breastfeeding; recognition and respect; supporting clients; funding; strategies to address

problems; length of programs; accessing health providers; role of men; supporting decentralized models;

supporting local services; partnerships; networking support, building community capacity and maintaining a

positive focus.

This year has seen several activities.

1. Efforts have been made to establish whether Indigenous Health Workers could be attracted to the

annual PIN meeting. These efforts have identified that the IHW workforce is loosely organised,

fragmented and has very limited funding for conference attendance.

2. In light of the above, and in an environment where PIN was unable to immediately identify sources of

funding, a restructure of how PIN conducts its core business of being a network of PSANZ members and

other interested people who can provide a structure within PSANZ to highlight and deal with perinatal

Indigenous health matters was undertaken. The direct outcome of this has been a reformatting of PIN

involvement at the PSANZ Congress so that:

There be a dedicated session on Indigenous Health (as opposed to a satellite meeting) at every PSANZ ASM

from and including Hobart 2003.

The Indigenous abstracts be assessed along with all abstracts and 4 selected for presentation in the dedicated

session.

The dedicated Indigenous Health session be constituted as 4 papers (total 1 hour) with 30 minutes for an

invited Indigenous speaker and questions.

A complex set of issues underpins poor Indigenous Perinatal health outcomes. PIN, by its multidisciplinary

nature may have an important role in drawing together those involved in the various policy issues,

jurisdictions, service providers, researchers, epidemiologists, statisticians and most importantly the

Indigenous people involved in perinatal health.

1. Whitfield CR, Smith NC, Cockburn F, Gibson AAM. Perinatally related wastage a proposed classification of primary obstetric factors. Br J Obstet Gynaecol 1986;93:694-703.

2. King J, Chan A, Haslam R, Flenady V, Tudehope D, Hockey R. ANZACPM and ANZNDC classifications for perinatal mortality: an analysis of agreement between clinicians. Proceedings Perinatal Society of Australia and

New Zealand 4th Annual Congress, Canberra, March 2001.

3. Flenady V, King J, Hockey R, Tudehope D, Woodgate P. Trends in cause specific perinatal mortality in a tertiary maternity hospital using a new clinical classification (ANZACPM). Proceedings Perinatal Society of

Australia and New Zealand 5th Annual Congress, Christchurch, March 2002.

9.7 Perinatal Indigenous Network (PIN)

41

10 Glossary of terms

Avoidable factor Some departure from the accepted standard of satisfactory care which

may have played a part in the death, injury or complication resulting

from the delivery of a health service.

Child Section 5 (2) The Registration of Births, Deaths and Marriages Act 1962

defines a child as follows:

For the purposes of the Act

(a) a child born alive is one whose heart has beaten after it has been

completely expelled or extracted from its mother; and

(b) a child not born alive is one whose heart has not beaten after it has

been completely expelled or extracted from its mother and who is

either-

(i) of not less than 20 weeks gestation; or

(ii) of not less than 400g by weight at birth

Fetal Death Commonly known as stillbirth, is a child of less than 20 weeks gestation

or 400grams and who shows no signs of life after birth.

Fetal Death Rate The number of fetal deaths per 1,000 total births.

Five-year avoidable excess The absolute difference in the mortality rates of Indigenous and non-

Indigenous status Indigenous populations, multiplied by the number of Indigenous births

in 2000, multiplied by five years, and truncated to an integer value. Does

not refer to a specific condition or intervention to reduce the rates for

Indigenous populations.

Indigenous Status Mother’s ethnicity indicated as Australian Aboriginal, Torres Strait

Islander or both Australian Aboriginal and Torres Strait Islander.

Although there are differences between the two groups that should be

considered for health policy, they are grouped together for statistical

purposes.

Live Birth A child whose heart has beaten after it has been extracted from its

mother.

Maternal Death Direct deaths are those that result from obstetric complications of the

pregnant state (pregnancy, labour and puerperium) including deaths

from interventions, omissions, inappropriate treatment, or from a chain

of events resulting from any of the above. They are complications of

pregnancy itself.

Indirect deaths are those which result from pre-existing disease or

disease that developed during pregnancy and was not due to direct

obstetric causes, but which may have been aggravated by physiological

effects of pregnancy.

Incidental deaths are those due to conditions occurring during

pregnancy, where the pregnancy is unlikely to have contributed

significantly to the death, although it is sometimes possible to postulate

a distant association.

Maternal Mortality Rate Maternal Mortality rate is:

Number of maternal deaths X 100,000

Number of births (live births and still births)

Neonatal Death The death of a child within twenty-eight days of its birth.

Neonatal Mortality Rate The number of deaths of live born infants under 28 days of age per 1,000

live births.

Perinatal Mortality Rate The number of fetal and neonatal deaths for 1,000 total births.

Still Birth See fetal death.

Acknowledgments

The Queensland Maternal & Perinatal Quality Council would like to thank the following people and

organisations for their assistance and hard work in preparing this report

Australian Bureau of Statistics

Client Services, Health Information Centre, Queensland Health

Health Statistics Unit, Australian Bureau of Statistics

Members of the Council

Office of the Government Statistician, Queensland

Queensland Coroners

Registrar General of Births, Death and Marriages, Queensland

Notes

Documents

Report of the Queensland Maternal and Perinatal Quality Council, … · 2016. 11. 10. · 4 Recommendations Recommendation1 Recommendation2 Recommendation3 Recommendation4 Recommendation5