The 13th Annual PAN EUROPE PACIFIC MEDICAL & LEGAL CONFERENCE PARIS, FRANCE Monday 1 April 2013 - Monday 8 April 2013 Perinatal Mortality and Morbidity . Charles P. McCusker Associate Professor Department of Obstetrics and Gynaecology School of Medicine University of Western Sydney.
The 13th Annual PAN EUROPE PACIFIC MEDICAL & LEGAL CONFERENCE
Monday 1 April 2013 - Monday 8 April 2013
Perinatal Mortality and Morbidity
Charles P. McCusker
Department of Obstetrics and Gynaecology
School of Medicine
University of Western Sydney
"The birth of a baby is an occasion for weaving hopeful dreams about the future."
Aung San Suu Kyi, 1997
Pre-natal fetal death
Neonatal fetal death
Neonatal fetal morbidity
What is Stillbirth?
In Australia and New Zealand, stillbirth is the death of a baby before or during birth, from the 20th week of pregnancy onwards, or 400 grams birthweight.
• Stillbirth remains unexplained in 60% of stillbirths occurring at term.
pathologists is an important factor in achieving better rates of high
• Unexplained stillbirth is nearly 10 times more common than
Sudden Infant Death Syndrome (SIDS). It compounds the tragedy
of the loss to parents left wondering why and does not give any
clues for how to care for the woman in a subsequent pregnancy or
for prevention strategies to reduce the number of these tragic
In Australia and New Zealand the most common conditions of stillbirth are spontaneous preterm birth (often associated with infection) and congenital abnormalities.
Growth restriction is also a common finding which is due to placental dysfunction. It is estimated that around one-third of stillbirths are associated with factors relating to care –largely around delays in detecting and responding to emerging complications and undetected fetal growth restriction.
A number of risk factors have been found to increase the risk of stillbirth.
The most important potentially modifiable factors are: advancing
maternal age, obesity and smoking. There is a concerning number of
women with multiple risk factors.
• Maternal age: The proportion of mothers aged 35 years or older in
Australia has been increasing from 16.3% in 1999 to 22.9% in
• Obesity: There are similar levels of overweight and obesity in
Australia and other high income countries. It is estimated that
about a third of pregnant women in Australia and the United
Kingdom are overweight or obese7, 8. In the US, up to 38% and
40% of pregnant women are overweight and obese8, respectively.
• Smoking: 16% of women smoke during pregnancy in Australia and
New Zealand (16%)1, 3 similar to other high income countries such
as USA (12%)9, and England (17%)10. Sweden has reduced
smoking rates to 7% from 30% in 1983.
• Higher rates of smoking occurred in disadvantaged groups:
Indigenous Australians have rates more than double that of non-
Indigenous Australians (50.9% vs 14.4%)1, 40% of teenage
mothers smoke during pregnancy.
• Alcohol. A recent concerning report indicates that around 50% of
women in Australia consume alcohol during pregnancy.
The Lancet series reports a survey of communities around the globe showing some surprising findings about perceptions of stillbirth in such a progressive setting including:
“Whilst many women may not be in a position, or want, to become
pregnant when younger, the best advice we can give at the moment to
anyone who is pregnant or who is planning it, is to lose weight and stop
• We need to improve the quality of data on stillbirths to guide
prevention strategies –unexplained stillbirth may be
underestimated by 50%
• Develop effective approaches to investigation of all stillbirths
• Improve approaches to stillbirth classification to enable valid
comparisons across regions to identify areas for prevention
• Raise awareness of modifiable risk factors and undertake research
into ways to reduce this risk.
• Undertake research into placental causes of stillbirth and detection
of women at risk early enough to intervene to prevent stillbirth
• Undertake research into interventions to reduce stillbirths
associated with modifiable risk factors such as obesity and
• Address health inequalities for Indigenous Australians and other
disadvantaged groups by implementing programs which address
their needs and promote a healthy lifestyle for women of child
• Implement bereavement care linked from hospital to community
Each year in Australia approximately 58,000 couples experience reproductive loss:About 55,000 experience early pregnancy loss, 1,750 babies are stillborn
and about 900 babies die in the first twenty-eight days after birth…....
Preterm Birth is the most common cause of perinatal mortality, causing almost 30 percent of neonatal deaths. Birth defects cause about 21 percent of neonatal death.
What is the common feature?
Maternal deaths continues to plague under-developed countries, especially in Africa and south Asia. They also continue to occur in small but significant numbers in the developed world. The death of a young, healthy women because of complications of pregnancy and childbirth is an overwhelming catastrophe
for the individual, the family, and not least, the doctors and midwives who were involved in her care. It is especially distressing if the outcome is potentially preventable.
In June 1854, Charlotte Brontë married Arthur Bell Nicholls, her father's curate and, in the opinion of many scholars, the model for several of her literary characters such as Jane Eyre's Rochester and St. John. She became pregnant soon after the marriage. Her health declined rapidly during this time, and according to Gaskell, her earliest biographer, she was attacked by "sensations of perpetual nausea and ever-recurring faintness.“Charlotte died, along with her unborn child, on 31 March 1855, at the young age of 38. Her death certificate gives the cause of death as phthisis (tuberculosis), but many biographers suggest she may have died from dehydration and malnourishment, caused by excessive vomiting from severe morning sickness or hyperemesis gravidarum.
Mr Dreyer says it was not until after she aborted in the toilet that a bed was found for her and doctors called, but even then it was another hour before she was cleaned up.
He says it should not happen in a hospital in Australia.
"I reckon you get better care in a third-world country," he said. He’s wrong
"Pregnant women should be confident that they can go to a public hospital facility and get taken care of.
"This is not a backwater. It's Royal North Shore Hospital.“
The Premier, Morris Iemma, and his Health Minister, Reba Meagher, say an independent investigation has been set up to find out exactly what happened.
"Those circumstances do not indicate that the best level of care has been provided," Mr Iemma said.
"This is a distressing and deeply concerning incident in which we owe it to the family to get to why it happened and the circumstances surrounding that.“
Ms Meagher says she wants to ensure such a case never happens again. It will
Mr Iemma has told Parliament the Opposition is welcome to go to the Healthcare Complaints Commission if it wants a wider inquiry into the hospital. He said:
"It has wide-ranging independent investigative powers to investigate and to hold people accountable. In Translation this means:….”name, shame and blame some healthcare worker”.
The number of maternal deaths in Australia each year…………………………………………
Tenerife 583 fatalities
Population.In Spring 2000 world population estimates reached 6 billion; that is 6 thousand million. The distribution of the earth's population is shown in this map.
India, China and Japan appear large on the map because they have large populations. Panama, Namibia and Guinea-Bissau have small populations so are barely visible on the map.
Population is very weakly related to land area. However, Sudan which is geographically the largest country in Africa, has a smaller population than Nigeria, Egypt, Ethiopia, Democratic Republic of Congo, South Africa and Tanzania.
Maternal Deaths per annum. In the year 2000, more than 513 thousand women died due to pregnancy-related causes. The map shows that most of these maternal deaths were in Southern Asian and African territories. The fewest maternal deaths were in Western Europe and Japan.
The highest rate of maternal deaths was in Sierra Leone, where 2 mothers die per 100 births. At the other extreme, Malta and Iceland reported no maternal deaths in 2000. The world average is 386 maternal deaths for every 100,000 births.
Increased Caesarean Section rate
Increased rate of Placenta Accreta / Increta / Percreta
This leads to much uncertainty and cynicism about national maternal mortality figures. According to the World Health Organization, in their estimates for 2010, two Mediterranean countries had very impressive results - Greece had an MMR of 3, and Italy 4. However, an in-depth review of maternal mortality in Italy by Donati et al. reported that the official Italian registration system only identified 37% of all maternal deaths.
Such under-reporting is prevalent in most developed countries. An in-depth review of death records in two U.S states (Massachusetts and North Carolina) and two European countries (France and Finland) found under-reporting of maternal deaths varying from 22% in France to 93% in Massachusetts. In Maryland, a study found that 38 percent of maternal deaths were not reported on death certificates as such. A review of maternal deaths in the Netherlands between 1983 -1992 found the level of under-reporting to be 26%
An Australian midwife [indirect personal communication] working in the Ethiopian town of Motta in western Ethiopia reported ……..that in 2009, during a time where there was no-one available to perform caesarean sections, approximately 70 out of 750 pregnant women died .In Afghanistan, Bartlett et al. reported on the remote and mountainous district of Ragh, where their estimate for MMR between 1999 – 2002 was 6,507 deaths per 100,000 births.
It is interesting to compare the maternal mortality estimates in the two countries with populations over one billion – India and China. In 2008, India’s MMR was reported as 230 by WHO and 254 by IHME; by contrast, China’s rates were 38 and 40 respectively .It is suggested that China has a much higher incidence of deliveries at hospitals and health care facilities than India. In 2007-2008, an Indian Government Report indicated that 53% of the approximately 25 million births each year in that country took place at home, many of which were not attended by a health worker In addition, contraception is more widely available in China, because of its one-child policy.
Unicef says that several countries in South Asia are responsible for the bulk of these mostly preventable deaths.
India has the largest number of annual maternal deaths (117,000), then Afghanistan (26,000), Bangladesh (21,000), and Pakistan (15,000). In many countries, the majority of births occur at home in rural areas without qualified medical help.
Ines Ramírez Pérez is a peasant living in rural Mexico. She had no medical training, but nevertheless performed a successful Caesarean section on herself: both she and her baby survived.
Ramírez was alone in her cabin in Southern Mexico, when her labour started. The nearest midwife was more than 50 miles away over rough terrain and rough roads. Her husband, who had assisted her through her previous labours, was drinking at a cantina. Rio Talea has 500 people and only one phone, but it was not nearby. Ramírez had given birth to eight children, seven living, at the time of the pregnancy in question. The last pregnancy, three years prior, had ended in fetal death during labour. Rather than experience the loss of another child in the same way, Ramírez decided to operate on herself.
At midnight, on 5 March 2000 — after 12 hours of continual pain, Ramírez sat down on a bench and drank three small glasses of hard liquor. She then used a 15 centimetres (5.9 in)kitchen knife to cut open her abdomen in a total of three attempts. Ramírez cut through her skin in a 17 centimetres (6.7 in) vertical line several centimetres to the right of her navel, starting near the bottom of the ribs and ending near the pubic area. After operating on herself for an hour, she reached inside her uterus and pulled out her baby boy. She then severed the umbilical cord with a pair of scissors and became unconscious. She used clothes to bandage her wound after regaining consciousness, and sent her son to find help.
Several hours later, the village health assistant and a second man found Ramírez conscious and alert, along with her live baby. He sewed her incision with an available needle and thread.
Ramírez is believed to be the only person known to have performed a successful caesarean section on herself.