Charles P. McCusker Associate Professor Department of Obstetrics and Gynaecology

1. 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

2. "The birth of a baby is an occasion for weaving hopeful dreams about the future." Aung San Suu Kyi, 1997

3. Pre-natal fetal death Neonatal fetal death Neonatal fetal morbidity Maternal death Maternal morbidity

4. [Pre] - Pre-natal fetal deathSome terms! • Chemical pregnancy v Clinical pregnancy • Miscarriage v Abortion • Clinical and Psychological management of various types of abortion • The concept of Viability

5. Pre-natal fetal death 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.

6. Unexplained stillbirth • Stillbirth remains unexplained in 60% of stillbirths occurring at term. • However most are not comprehensively investigated and important causes may be missed. • Autopsy rates are low in many regions and lack of qualified pathologists is an important factor in achieving better rates of high quality autopsy • 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 deaths.

7. What causes stillbirth? 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.

8. Risk FactorsAustralia and New Zealand 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 2008. • 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.

9. How do we care for families whose baby is stillborn? 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: • perceptions that a stillborn baby was never meant to live; • that the stillbirth was part of natural selection; • and was the mothers’ fault. • Responses also indicated that a woman’s public grieving for her loss is not acceptable. • Support for mothers, fathers and also for care providers is less than optimal in Australia

10. What can be done? “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 smoking” • 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 smoking • 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 bearing age • Implement bereavement care linked from hospital to community

11. Neonatal fetal death 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….... Causes 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.

12. The main cause of perinatal loss in The United State, The United Kingdom and Australia is smoking. • 20% of the Australian population smoke and 15% of pregnant women smoke at some time during their pregnancy. • There is a move (Byron's law) to prosecute those who kill an unborn child. • How far are we from prosecution of “unborn” child abuse.

14. Neonatal fetal morbidity • What is the quality of life of a baby born at 24 weeks gestation? • United Kingdom experience • The Netherlands experience

15. What is the common feature?

16. Maternal death

17. 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.

19. Maternal Deaths due to early pregnancy problems Spontaneous abortion Septic abortion Trophoblastic disease Ectopic Pregnancy Eclampsia Hyperemesis gravidarum Suicide

21. 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.

22. Updated September 26, 2007 16:16:00 [from ABC.net.au] Toilet miscarriage 'the latest in a string of problems' 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.“ xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 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 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx 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”.

27. The number of maternal deaths in Australia each year………………………………………… • Equals the number of young children drowned in domestic swimming pools [30]

28. Tenerife 583 fatalities

30. Worldmapper 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.

32. How may maternal mortality change in your Professional lifetime? Increased Obesity Plus Increased Caesarean Section rate Leads to Increased rate of Placenta Accreta / Increta / Percreta

34. The ‘elephant in the room’ is the consistent under-registration of maternal deaths. 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%

35. 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.

36. 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.

37. Preventable deaths 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.

38. Maternal morbidity

41. 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.

42. Perinatal Morbidity • NEW YORK (Reuters Health) Aug 03 - Tougher hospital policies can go a long way toward curbing the practice of scheduling a birth as soon as the fetus is considered full-term, a new study shows. • Despite the fact that elective delivery in the 37th or 38th week is considered to carry needless risks, the practice still accounts for an estimated 10% to 15% of all deliveries in the U.S. -- because the absolute risk of complications for any one baby are low, • The researchers estimate that if the drop in elective deliveries achieved in the hard-stop policy hospitals could be accomplished nationally, a half-million NICU days could be avoided and close to $1 billion saved each year.

43. Charlie’s law of relativity

48. What group in our society is currently under persecution / genocide / ethnic cleansing?