Perinatal deaths in Australia 1993–2012

Summary The loss of a baby who was either stillborn or died in the first weeks of life is a tragic event that affects around 3,000 families every year in Australia. Perinatal mortality is widely recognised as an important indicator of population health. While Australia is one of the safest places in the world to give birth, almost 1 in 100 pregnancies will end in a perinatal death. Perinatal deaths in Australia 1993–2012 represents the first comprehensive national report on perinatal mortality in Australia and includes a detailed analysis of data relating to stillbirths and neonatal deaths for the period 2011-2012 and an analysis of trends for 1993–2012. The aim of this report is to gain a better understanding of the causes of perinatal deaths at a population level and identify changes in perinatal mortality over time. Data used for this report come from information recorded in jurisdictional perinatal data collections and information collated by state and territory perinatal mortality review committees. For the 2 years 2011 and 2012, just over 6,000 babies died during the perinatal period: a rate of 9.9 deaths per 1,000 births. Approximately three-quarters of those deaths were stillbirths (4,485) with the remaining 1,580 deaths being neonatal deaths. The rate of perinatal mortality varied by the state or territory in which babies were born, with the highest perinatal mortality rate recorded in Victoria (12.2 deaths per 1,000 births) and the lowest in New South Wales (8.3 deaths per 1,000 births). The rates also varied considerably between different subgroups including those based on mothers\u27 level of remoteness, socioeconomic status, age, smoking status, body mass index (BMI) and Indigenous status. The perinatal mortality rate of babies born to mothers who identified as Aboriginal or Torres Strait Islander was almost double that of babies of non-Indigenous mothers (17.1 versus 9.6 deaths per 1,000 births). Similarly, the perinatal mortality rate was almost 50% higher among babies whose mothers smoked compared with those who did not smoke (13.3 versus 8.9 deaths per 1,000 births). The stillbirth rate for babies of teenage mothers and mothers older than 45 was more than double that for mothers aged 30–34 (13.9 and 17.1 versus 6.4 deaths per 1,000 births). Over the 20-year period 1993–2012, the overall perinatal mortality rate was stable at around 10 deaths per 1,000 live births. There was a decrease in the rate of neonatal death (3.2 to 2.4 deaths per 1,000 live births) and an increase in the stillbirth rate (6.4 to 7.2 deaths per 1,000 births). Although remaining high, the report shows a decrease of 20% in the perinatal mortality rate among babies of Aboriginal and Torres Strait Islander mothers. During 2011 and 2012, congenital abnormality was the leading condition in the fetus classified by the PSANZ Perinatal Death Classification as the cause of stillbirths (26.3% of stillbirths) and neonatal deaths (33.1%). An additional PSANZ Neonatal Death Classification of extreme prematurity was the leading condition contributing to deaths in the neonatal period (33.5%). When examined by Indigenous status, however, the leading cause of perinatal death among babies of Aboriginal and Torres Strait Islander mothers was spontaneous pre-term birth (26.8% of stillbirths and 48.0% of neonatal deaths). This report provides insight into the trends in perinatal mortality in Australia, and highlights variations in some of Australia\u27s most vulnerable and disadvantaged population subgroups. This indicates areas that warrant further investigation and attention by clinicians, researchers and health policy makers

Grief and loss during childbearing : the crying times

Today the public expectation in developed countries is that pregnancy leads to the birth of a live and healthy baby. There is also the perception that with the advances in medical technology very little should and can go wrong during the childbearing experience. The reality is that this is not always the case—miscarriage, genetic abnormalities, premature birth, stillbirth and neonatal death still occur; the reality is they probably will always occur even in the future we can't imagine yet. In Australia, despite rapid advances in medical technology and high rates of intervention, the perinatal mortality rate has not changed in over a decade. So, on the one hand we have a perception that perfect outcomes during childbirth are increasing, yet this is not the reality we see in the perinatal statistics. Each situation where a women and her partner experience loss creates ripples that impact significantly on family, friends and community. As De Frain et al. (1991, p 165) said ‘the death of a baby is like a stone cast into the stillness of a quiet pool; the concentric ripples of despair sweep out in all directions, affecting many, many people’. As midwives we witness the despair, we wipe the tears, we hold those shaking shoulders and we learn to walk through the fog that grief and loss creates in lives. However, knowing what to do and say, and more importantly what not to do and say, is not always so intuitive to midwives. It is beyond the scope of this chapter to discuss all of the events where bereavement can occur during pregnancy and childbirth. We have also not reviewed the physical care associated with different experiences of loss. This can be found in other areas of this textbook. It is our intention in this chapter to take you by the hand and show you the ripples of despair that sweep out in all directions when a baby dies and how you as midwives can make such an important contribution to the journey families who experience perinatal loss will go on

Grief and loss during childbearing : the crying times

Today the public expectation in developed countries is that pregnancy leads to the birth of a live and healthy baby. There is also the perception that with the advances in medical technology very little should and can go wrong during the childbearing experience. The reality is that this is not always the case – miscarriage, genetic abnormalities, premature birth, stillbirth and neonatal death still occur, the reality is they probably will always occur, even in the future we can’t imagine yet. In Australia, despite rapid advances in medical technology and high rates of intervention, the perinatal mortality rate has changed little in over two decades (AIHW, 2021). So, on the one hand we have a perception that perfect baby outcomes during childbirth are increasing, yet this is not the reality we see in the perinatal statistics. Each situation where a woman and her partner experience loss creates ripples that impact significantly on family, friends and community. As De Frain et al. (1991) said, ‘the death of a baby is like a stone cast into the stillness of a quiet pool; the concentric ripples of despair sweep out in all directions, affecting many, many people’. As midwives we witness the despair, we wipe the tears, we hold those shaking shoulders, and we learn to walk through the fog that grief and loss creates in lives. However, knowing what to do and say, and more importantly what not to do and say, is not always so intuitive to midwives. It is beyond the scope of this chapter to discuss all of the events where bereavement can occur during pregnancy and childbirth. We have also not reviewed the physical care associated with different experiences of loss. This can be found in other areas of this textbook. It is our intention in the chapter to take you by the hand and show you the ripples of despair that sweep out in all directions when a baby dies and how you as midwives can make such an important contribution to the journey that families who experience perinatal loss will go on

A validation study of the Maternity Care Classification System (MaCCS)

The provision of maternity care has become a complex healthcare intervention involving multiple care providers, locations and many interconnecting components packaged as ‘models of care’. There is mounting evidence that some models of care result in better maternal and perinatal outcomes, however translating such evidence into practice has been hampered by a lack of standardised terminology for defining models of care. The Australian Maternity Care Classification System (MaCCS) is a world-first system for classifying models of maternity care based on 15 model characteristics including an over-arching Major Model Category. The aim of this doctoral research program was to externally validate the MaCCS to inform a successful implementation in Australia. This research project used a quasi-experimental mixed-methods research design involving two separate studies. One quantitative study at 69 public hospitals across New South Wales (NSW), Australia addressed two of the research objectives: 1. Assess the level of heterogeneity of models of care of the same type and whether they can be classified using the Major Model Category alone. 2. Evaluate whether the MaCCS is accurate, repeatable and reproducible at classifying models of maternity care.The second mixed-methods study at four hospitals in NSW addressed the third objective: 3. Evaluate whether the MaCCS classifications are more accurate when completed by a team of staff or an individual staff member working in the models of care, and which method is preferred.The findings showed the MaCCS can detect variations in models of care that potentially impact on maternal and perinatal outcomes that would otherwise be masked when classified by their Major Model Category alone. Further, the MaCCS is accurate, repeatable and reproducible at classifying models of care. The results indicate that classifications should be completed by a team of staff rather than an individual, including the Manager. Using several measures of validity, this doctoral research has demonstrated the MaCCS is a valid system for classifying models of maternity care. The findings from this thesis have already been applied to the implementation of the MaCCS, as well as contributing to maternity services strategy and policy in Australia and the UK

Improving, but could do better: Trends in gestation-specific stillbirth in Australia, 1994-2015

Background: Stillbirth remains a public health concern in high-income countries. Over the past 20\ua0years, stillbirth rates globally have shown little improvement and large disparities. The overall stillbirth rate, which measures risk among births at all gestations, masks diverging trends at different gestations. This study investigates trends over time in gestation-specific risk of stillbirth in Australia. Methods: Analytical epidemiological study using nationally reported gestational age data for births in Australia, 1994-2015. Average annual change in gestation-specific prospective risk of stillbirth (per 1000 fetuses at risk [FAR]) was calculated among births in 1994-2009 and 2010-2015 at term (37-41\ua0weeks) and for preterm gestational age subgroups: 28-36, 24-27, and 20-23\ua0weeks. Results: The decline in risk of stillbirth at term from 2010 to 2015 from 1.43 to 1.16 per 1000 FAR was more rapid than from 1994 to 2009; for preterm gestations from 24 to 27\ua0weeks, there were no discernible trends; from 28 to 36\ua0weeks, the decline between 1994 and 2009 was not sustained; among births from 20 to 23\ua0weeks, the risk of stillbirth plateaued in 2010-2015, fluctuating around 3.3 per 1000 FAR. Conclusions: Improvement in the stillbirth rate from 28\ua0weeks’ gestation aligns with changes in other high-income countries, but more work is needed in Australia to achieve the levels of reduction seen elsewhere. Gestation-specific risk of stillbirth is more informative than the overall stillbirth rate. The message that the overall risk of stillbirth is not changing disregards gains at different stages of pregnancy