Council of Obstetric & Paediatric Mortality & Morbidity · Alcohol Consumption and Pregnancy 5 ... Sex of Infants 34. Page ii Birthweight 35 ... Table 14: Presentation at Delivery

Depar tment o f Hea l th and Human Serv ices

Council of Obstetric & Paediatric Mortality & Morbidity Annual Report 2009

Published by Care Reform, Department of Health & Human Services, Tasmania.

Copyright State of Tasmania, Department of Health & Human Services, 2011.

This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968.

Published on www.dhhs.tas.gov.au

July 2011

http://www.dhhs.tas.gov.au/

Page i

Table of Contents Index of Tables iii

Index of Figures v

Executive Summary 1

Babies in 2009 1

Mothers in 2009 1

Perinatal and Paediatric Deaths at a Glance 2

Perinatal Deaths 2

Maternal Deaths 3

Paediatric Deaths 4

Smoking and Pregnancy 5

Alcohol Consumption and Pregnancy 5

Data Collection and Reporting 6

Acknowledgments 8

Amendment of the Perinatal Registry Act 1994 9

Definitions Used by the Council 10

Supplementary Definitions 11

Members of the Council of Obstetric & Paediatric Mortality & Morbidity 12

Members of Sub-Committees & Support Services 13

Committee Reports 14

Perinatal Mortality & Morbidity Sub-Committee 14

Basic Information on Stillbirths for 2009 15

Basic Information on Neonatal Deaths for 2009 20

Paediatric Mortality & Morbidity Sub-Committee 23

Paediatric Deaths for 2009 23

Maternal Mortality & Morbidity Sub-Committee 28

Maternal Deaths for 2009 28

Data Management Sub-Committee 30

Perinatal Statistics 31

Births and Birth Rates 31

Sex of Infants 34

Page ii

Birthweight 35

Low Birthweight 35

Apgar Scores 37

Resuscitation 38

Presentation at Delivery 39

Perinatal Mortality 39

Neonatal Mortality 41

Autopsy Rates 44

Age of Mothers 45

Parity Status 48

Indigenous Status 49

Breastfeeding 49

Mode of Delivery 51

Caesarean Section 55

Induction of Labour 60

Augmentation of labour 62

Multiple Pregnancy 62

Maternal Hypertension 64

Postpartum Haemorrhage 65

Antepartum Haemorrhage 65

Smoking and Pregnancy 66

Alcohol Consumption and Pregnancy 71

Attachment A: Guidelines for Investigation of “Unexplained” Stillbirths 76

Attachment B: Perinatal Data Collection Form 78

Feedback Form 82

Notes 83

Page iii

Index of Tables Table 1: Perinatal Deaths for 2009 14

Table 2: Paediatric Deaths for 2009 23

Table 3: Type of Injury leading to Paediatric Death in year 2009 23

Table 4: Livebirths and Birth Rates for Tasmania 2000-2009 31

Table 5: Livebirths by Region 2000-2009 32

Table 6: Livebirths by Hospital 2000-2009 32

Table 7: Proportion of Public and Private Patients 2000-2009 33

Table 8: Sex of all Infants Born Live in Tasmania 2000-2009 34

Table 9: Incidence of Low and Very Low Birthweight for all Births 2000-2009 35

Table 10: Survival to Hospital Discharge by Gestation 1996-2009 36

Table 11: Apgar Score for all Births at Five Minutes 2000-2009 37

Table 12: Intubation Rate 2000-2009 38

Table 13: Resuscitation Rate 2000-2009 38

Table 14: Presentation at Delivery for all Births 2000-2009 39

Table 15: Perinatal Outcome 2000-2009 39

Table 16: Perinatal Mortality Rates 2000-2009 40

Table 17: Neonatal Mortality, per 1 000 Births, in Infants over 28 weeks Gestation 2000-2009 41

Table 18: Neonatal Mortality, per 1 000 Births, in Infants over 1 000 Grams Birthweight 2000-2009 42

Table 19: Foetal, Neonatal and Perinatal Death Rate per 1 000 Births by State and Territory 2000-2008 43

Table 20: Rate of Autopsies on Perinatal Deaths 2000-2009 44

Table 21: Proportion of Births by Maternal Age Groups 2000-2009 45

Table 22: Rates of Birth per 1 000 Female Population by Maternal Age 2000-2009 47

Table 23: Percentage of Births by Parity 2000-2009 48

Table 24: Mother's Indigenous Status 2000-2009 49

Table 25: Live Births by Breastfeeding at Discharge 2000-2009 50

Table 26: Breastfeeding at Discharge by Public / Private Hospital 2000-2009 50

Table 27: Breastfeeding at Discharge by Parity 2000-2009 50

Table 28: Mode of Delivery 2000-2009 51

Table 29: Mode of Delivery by Gestation 2000-2009 54

Table 30: Emergency / Elective Caesarean Section Proportion 2000-2009 55

Table 31: Emergency / Elective Caesarean Section Proportion by Public / Private Hospitals 2000-2009 55

Table 32: Primary / Repeat Caesarean Section Proportion 2000-2009 55

Page iv

Table 33: Primary / Repeat Caesarean Section Proportion by Public / Private Hospitals 2000-2009 56

Table 34: Adverse Outcomes in Overweight and Obese Women 57

Table 35: All Births by Caesarean Section following Augmentation of Labour 2000-2009 59

Table 36: Induction Rate 2000-2009 60

Table 37: Caesarean Section Rate following Induction of Labour 2000-2009 60

Table 38: Induction Rate by Public / Private Hospitals 2000-2009 61

Table 39: Augmentation of Labour 2000-2009 62

Table 40: All Births by Multiple Pregnancies 2000-2009 62

Table 41: Perinatal Mortality in Multiple Pregnancies 2000-2009 63

Table 42: Perinatal Mortality in Multiple Pregnancies by Birth Order 2005-2009 64

Table 43: Number of cases of Maternal Hypertension for all Births 2000-2009 64

Table 44: Incidence of Postpartum Haemorrhage 2000-2009 65

Table 45: Type of Antepartum Haemorrhage 2000-2009 65

Table 46: Smoking Comparison 2009 and 1982 66

Table 47: Proportion of Women Smoking Tobacco during Pregnancy by State and Territory, 2008 67

Table 48: Alcohol Consumption in 2009 72

Page v

Index of Figures Figure 1: Birth Rate for Tasmania per 1 000 Head of Population 1992-2009 31

Figure 2: Proportion of Public and Private Patients 1992-2009 33

Figure 3: Number of Infants Born by Sex 1997-2009 34

Figure 4: Percentage of all Births by Birthweight Groups 2000-2009 35

Figure 5: Survival to hospital discharge by Gestation 1996-2009 36

Figure 6: Number of Births with Apgar Score less than 6 at Five Minutes 1997-2009 37

Figure 7: Stillbirths & Neonatal Deaths 1997-2009 40

Figure 8: Perinatal Mortality Rate per 1 000 Births in Tasmania 1998-2009 and Australia 1998-2008 41

Figure 9: Proportion of Births by Maternal Age Groups 1992-2009 46

Figure 10: Proportion of Births by Maternal Age in Tasmania 2009 and Australia 2008 46

Figure 11: Mode of Delivery in Tasmania 1998-2009 51

Figure 12: Mode of Delivery in Public Hospitals in Tasmania 2009 and Australia 2008 52

Figure 13: Mode of Delivery for Private and Public Patients in Tasmania 2009 52

Figure 14: Caesarean Section and Assisted Vaginal Rates 1992-2009 56

Figure 15: Incidence of Postpartum Haemorrhage 1992-2009 65

Figure 16: Self-reported Tobacco Smoking Status during Pregnancy in Tasmania 2009 66

Figure 17: Self-Reported Tobacco Smoking Status during Pregnancy by Age, Tasmania 2009 67

Figure 18: Self-Reported Smoking Status by Public / Private Patients, Tasmania 2009 68

Figure 19: Self-Reported Tobacco Smoking Status during Pregnancy by Hospital, Tasmania 2009 69

Figure 20: Self-Reported Smoking Status during Pregnancy and Birthweight, Tasmania 2009 69

Figure 21: Self-reported Alcohol Consumption Status during Pregnancy in Tasmania 2009 72

Figure 22: Self-Reported Alcohol Consumption Status during Pregnancy by Age, Tasmania 2009 73

Figure 23: Self-Reported Alcohol Consumption Status by Public / Private Patients, Tasmania 2009 73

Figure 24: Self-Reported Alcohol Consumption Status during Pregnancy by Hospital, Tasmania 2009 74

Figure 25: Self-Reported Alcohol Consumption Status during Pregnancy by Birthweight, Tasmania 2009 75

Executive Summary

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Executive Summary The members of the Council of Obstetric & Paediatric Mortality & Morbidity are pleased to present the Annual Report for the calendar year 2009.

A key aim of the Council’s Annual Report is to provide epidemiological information on the women who gave birth to liveborn or stillborn babies in 2009, and on their children. Data are derived from the Perinatal Data System with the source of data being the Perinatal Data Collection Form that is completed by all maternity service providers in Tasmania.

The Annual Report includes the reports submitted by each subcommittee detailing relevant key trends arising during this year and recommendations based upon committee investigations and findings. Trends in reported perinatal and maternal statistics have been reported in Tasmania and compared with latest available national findings.

Key findings in the Annual Report for 2009 include:

Babies in 2009 • The number of livebirths recorded on the Perinatal Data System in 2009 was 6 317, a decrease of

86 (1.3 per cent) since 2008 (6 403). The total number of births including stillbirths was 6 369.

• Males accounted for 51.1 per cent of births and females 48.9 per cent.

• There were 86 episodes of multiple births, including 83 sets of twins and 3 sets of triplets.

• The proportion of low birth weight babies (less than 2 500 grams) in Tasmania was 6.9 per cent, which is comparable to national figures reported in 2008 (i.e., 6.1per cent).

• 9 per cent of deliveries were preterm (less than 37 weeks gestation).

Mothers in 2009 • 71.0 per cent of mothers were public patients and 28.1 per cent were private patients.

• 45.0 per cent of mothers were aged over 30 years; 7.0 per cent of mothers were under the age of 20 years, a higher proportion than the national average of 4.2 per cent in 2008.

• 40 per cent of mothers had their first baby and 33 per cent had their second baby.

• 4.5 per cent of mothers were identified as Aboriginal, Torres Strait Islands or Aboriginal & Torres Strait Islanders.

• 64.1 per cent of mothers had an unassisted vaginal delivery and 6.6 per cent had an instrumental delivery.

• 29.3 per cent of mothers gave birth by caesarean section (compared to 22.1 per cent in 2000).

• Of the caesarean section deliveries, 52.0 per cent were elective and 48.0 per cent were emergencies.

• 79.7 per cent of mothers were breastfeeding at discharge.

• 23.9 per cent of mothers reported smoking during pregnancy with the rate for teenage mothers being 34.9 per cent.

• 11.2 per cent of mothers reported that they had consumed alcohol during pregnancy with the rate being greatest for mothers aged between 35-39 years (16.1 per cent) and for mothers who were reported as private patients (15.0 per cent) compared to public patients (9.7 per cent).

Executive Summary

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Perinatal and Paediatric Deaths at a Glance

Classification Total No. for 2009

(n = 6 369) Rate per

1 000 Births

Perinatal Mortality 67 10.5

Stillbirths 52 8.2

Neonatal Mortality 15 2.4

Total Infant Mortality (from 20 weeks gestation to 1 year)

23 3.6

Non-Neonatal Infant Mortality (>28 days post delivery to 1 year)

8 1.3

Paediatric Mortality 36 0.3*

* ABS figure for total no. of children <18 yrs for 2009 in Tasmania is estimated at 118, 397(ABS Cat no. 3201.0 Population by Age and Sex, Australian States

and Territories, June 2009). T Thus Paediatric Mortality is calculated by total deaths divided by estimated total no. of children in Tasmania under 18 years of

age.

Perinatal Deaths The Perinatal Mortality and Morbidity Sub-Committee reviewed 67 deaths in 2009. The perinatal autopsy rate was 37.3 per cent, which is higher than reported in the previous year. As noted in 2008, Council believed that a post mortem examination would have been of benefit in many more of the perinatal deaths that occurred in 2009. The process of giving consent for an autopsy is recognised to be challenging for parents who have lost a baby in pregnancy. Thus, a senior member of the obstetric staff best handles such a request. The Council expects that all perinatal deaths will be reviewed by an obstetric audit in the relevant unit once all relevant investigations have been completed.

Foetal growth restriction (FGR) remains a significant and preventable cause of foetal loss. All foetal deaths from FGR in 2009 occurred at more than 30 weeks where foetal survival beyond 30 weeks for normal babies delivered is almost 100 per cent. Council encourages all maternity service providers to establish protocols for the detection of growth-restricted foetuses from 30 weeks gestation and for timely, and appropriate management.

Congenital anomalies continue to account for about a quarter of foetal losses, usually planned pregnancy termination. The current level of 25+per cent reflects the increasing involvement of ultrasound scanning for foetal anomalies (now at about 20 week’s gestation) with pregnancy termination after 20 weeks. As such, this results in a stillbirth (rather than a miscarriage) that is included in the perinatal mortality statistics. Previously foetal scanning was undertaken at earlier gestations, 16-18 weeks, resulting in termination being performed before 20 weeks gestation. Whilst Tasmania’s legislation related to termination of pregnancy does not specify gestational age, discussion by providers of care and the community may be appropriate to consider whether it is preferable that such diagnoses, and therefore terminations if requested, are undertaken prior to 20 weeks.

Executive Summary

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Unexplained stillbirths remain a frustrating group for both doctors and the family involved. A recent study1 has investigated the possible role of sleeping position on the incidence of unexplained late pregnancy stillbirth. If results are confirmed by other studies, maternity care providers may be able to provide advice on sleeping habits in late pregnancy to improve outcomes.

The neonatal death rate in Tasmania remains low compared to national figures reported in 2008 (rate of 2.8 per 1 000 births), pointing to continued advances in obstetric and neonatal care. Clinicians should be aware of the recommendations outlined in the Tasmanian Neonatal Care Guidelines for care of women in whom delivery is threatening at 23 weeks gestation, the option of not offering resuscitation at this gestation should be carefully discussed given the poor survival and high risk of long term neurodevelopmental disability. At 24 weeks gestation, mortality in Tasmania remains relatively high (47 per cent) of those managed in the RHH NPICU), and the estimated incidence of significant disability in the long term is 25-33 per cent. It is thus appropriate to consider and discuss with prospective parents whether resuscitation and intensive care should be offered to an infant born at this gestation. Survival at 24 weeks is poor for infants born outside a tertiary centre, and every effort should be made for such infants to be inborn if full intensive care is to be offered.

Clinicians should be aware of the potential for viral infection to cause significant compromise to a neonate and the features that should raise suspicion of such an infection (known or suspected maternal viral disease, onset of symptoms later in the first week, liver dysfunction, coagulation disturbances and signs of myocarditis).

In view of the relatively high percentage of mothers of the neonatal deaths reported as having been smokers, clinicians should continue to encourage smoking cessation at antenatal visits and reinforce that nicotine replacement therapy in pregnancy is safer than ongoing smoking.

Maternal Deaths In 2009, one late maternal death was reported in Tasmania which was classified as a non maternal (incidental) death the cause of which was due to mixed drug toxicity and aspiration pneumonia. It is recommended that referral to complex care team and drug support services is undertaken following identification of “at risk” women and that this service be accessible as an outreach service for women who fail to be compliant with attendance. It is also important to ensure that appropriate education is provided to drug misusing patients regarding the dangers of mixing prescribed and illicit drugs.

The Maternal Mortality & Morbidity Subcommittee also believed that cases of “near misses” were important to consider especially in terms of maternal morbidity issues. The establishment of the Australian Maternity Outcomes Surveillance System (AMOSS): Improving the Safety and Quality of Maternity Care in Australia has provided a significant step in initiating a comprehensive study of serious maternal morbidity events considered to contribute significantly to maternal morbidity in Australia. The System undertakes active surveillance and epidemiological research of selected obstetric conditions with the aim of improving the knowledge of rare obstetric disorders and their management in Australia. While the NH&MRC will support this project for the first five years, it is hoped that hospitals/states will, in the future, continue to support this system as part of their normal risk management framework.

1 Stacey, T., Thompson, J., Mitchell, E., Ekeroma, A., Zuccollo, J., McCowan, L. (2011). Association between maternal sleep practices and risk of late stillbirth: a case-control study. BMJ 2011;342:doi:10.1136/bmj.d3403 (Published 14 June 2011).

Executive Summary

Page 4 of 83

plained infant deaths (n=3, 8

more,

sleeping

e effective scene examination be undertaken to establish whether the cause of

t be

at all

ist

al should always be taken seriously and appropriate support and interventions be

t a bsequent children of mothers of children who

have died where neglect or abuse have been identified.

Paediatric Deaths The Paediatric Mortality and Morbidity Sub-Committee noted that the number of paediatric deaths in Tasmania in 2009 was 36 (estimated at 0.3 per 1 000 persons aged 0-17 years). While the national paediatric mortality rate was slightly higher compared to Tasmania in 2009 (estimated at 0.412 per 1 000 persons aged 0-17 years), the national rate was not statistically significantly higher than the equivalent Tasmanian rate.

The major cause of death was injuries (n=14, 39 per cent) and conditions determined at birth (n=11, 31 per cent) followed by other acquired conditions (n=8, 22 per cent), and unexper cent) where two cases were associated with risk factors.

It is recommended that the community be alerted to risks associated with unsatisfactory restraint of children as passengers in moving vehicles and encouraged to ensure that all children are safely restrained with seatbelts when travelling in motor vehicles and preferably seated in the rear of the car. Furtherchildren whilst travelling as passengers in a motor vehicle should not wear lap belts. As reported in previous years, the benefits of wearing harnesses in relation to young children have been highlighted.

In view of cases continuing to be reported as Unexplained Infant Deaths in 2009, the issue of safe practices continues to remain an important issue for the Tasmanian community and the universal distribution of educational material concerning safe sleeping practices would benefit all new parents. It is also recommended that mordeath is due to overlying3.

In view of potential hazards located around the home, it is encouraged that all children’s play equipmenpositioned safely around the home and well-clear from potential hazards such as overhead wiring; and access to parked cars is restricted. As highlighted in previous reports, it is important to ensure thchildren be provided with levels of supervision appropriate to the child’s level of development4.

It is recommended that the dangers of aerosol inhalation and its link to fatalities should be highlighted.

The issue of youth suicide in Tasmania continues to be a concern particularly in light of the reported hanging of an adolescent in 2009. It is recommended that increased awareness of available services to assin the prevention of youth suicide in Tasmania be encouraged. In particular, warnings from young people who are potentially suicidfollow-up without delay.

Children who have been previously notified to child protection services and who have been reported to have died continue to remain a concern to Council. In response to these concerns, Council proposes thasystemic alert system be established for the young and su

2 Australian Bureau of Statistics (2009), Deaths, cat. no. 3302.0, ABS, Canberra.

3 Li, L., Zhang, Y., Zielke, R.R., Ping,Y., and Fowler, D.R. (2009). Observations on Increased Accidental Asphyxia Deaths in Infancy while Co-sleeping in the State of Maryland. American Journal of Forensic Medical Pathology. Vol.30, No.4, pp. 318-321.

4 This issue is discussed in detail in Lawrence, R. and Irvine, P. (2004). Redefining fatal neglect, Issues Paper No.21, Australian Institute of Family Studies, Melbourne.

Executive Summary

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Smoking and Pregnancy The proportion of mothers smoking during pregnancy in 2009 in Tasmania was 24 per cent which is higher than the reported rates from most other States in 2008 but lower than the rate reported in Tasmania in 2008. Maternal smoking continues to be more prevalent among younger women; particularly those aged less than 20 years (35 per cent) and between 20-24 years (40 per cent). It is encouraging to note however that there is a statistically significant reduction in mothers smoking during pregnancy who are aged less than 20 years. This group in fact has been reported to undertake smoking practices less during pregnancy than the women aged between 20 to 24 years, a difference that is statistically significant. It is also encouraging to find that the percentage reported in 2009 for public patients who smoked during pregnancy is lower than the percentage reported in the previous year.

The data have also confirmed the statistically significant (p<0.001) association between birth weight and smoking status during pregnancy, with a higher proportion of low birth weight babies born to mothers who smoked (12 per cent) compared to non-smoking mothers (5 per cent). Given the association between intrauterine growth restriction and stillbirth, methods to reduce maternal smoking need to particularly target our youngest mothers and, if effective, may reduce the stillbirth rate.

Alcohol Consumption and Pregnancy The Perinatal Data Collection Form continues to collect data regarding alcohol consumption during pregnancy. From the data available in 2009, the overall proportion of mothers consuming alcohol during pregnancy in Tasmania was 11 per cent, which was statistically significantly (p=0.015) lower than the percentage reported in 2008 (12.6 per cent). Maternal alcohol consumption continues to appear to be more prevalent among older women, particularly those aged between 35-39 years (16 per cent) and greater than 39 years (~12 per cent). It also appeared that alcohol consumption was more prevalent among private patients (15 per cent) compared to public patients (10 per cent). Alcohol consumption amongst public patients was significantly reduced compared to 2008 (p=0.002).

The data showed that 9.3 per cent of babies born to mothers who consumed alcohol during pregnancy were of low birth weight, compared to 6.5 per cent for mothers who did not consume alcohol during pregnancy. This difference was statistically significant (p=0.006). NH&MRC has recently recommended that women should not consume alcohol during pregnancy, as there has been no safe level of alcohol consumption identified. Alcohol has been associated with intrauterine growth restriction, stillbirth and the foetus is susceptible to Foetal Alcohol Spectrum Disorders (FASD)5. In particular, Foetal Alcohol Syndrome (FAS) is known to produce deleterious effects during foetal development resulting in characteristic facial abnormalities, impaired growth and abnormal function or structure of the central nervous system. High level and/or frequent intake of alcohol in pregnancy increases the risk of miscarriage, stillbirth and premature birth.

5 National Health and Medical Research Council (NHMRC) (2009), Australian Guidelines to Reduce Health Risks from Drinking Alcohol, Canberra.

Executive Summary

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Data Collection and Reporting The statewide Electronic Perinatal Database known as ObstetrixTas was implemented in all public maternity hospitals throughout Tasmania commencing in 2010. This system aims to provide users with a more streamlined process of data entry and extraction. The Council has continued to maintain a running list for consideration and discussion during the development and refinement of the Electronic Perinatal Database system. The Council’s Data Management Committee had recently undertaken detailed analysis of the EPD (ObstetrixTas) system to assist in the process of future improvement of the system. It also continues to discuss key issues regarding the preparation and structure of this and future Annual Reports. Membership on this subcommittee includes representatives from the areas of obstetrics, paediatrics, midwifery, Chair of COPMM and representatives from the Clinical Data Services Unit, DHHS and Epidemiology Unit, Population Health DHHS.

Associate Professor Peter Dargaville

Chairperson – Council of Obstetric and Paediatric Mortality and Morbidity

Executive Summary

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Disclaimer:

During the production of this report data anomalies may have arisen, however processes such as the undertaking of regular data audits have been established to minimise these anomalies.

Feedback:

A Feedback Form is provided at the end of this report inviting comments from readers on information presented. Please forward to the Executive, Care Reform, Safety & Quality Unit, DHHS, Ground Floor, 34 Davey St. Hobart 7000. (Phone: 6216 4366).

Acknowledgments

Page 8 of 83

Acknowledgments The production of this Report relies on the assistance, willing co-operation and on-going support of numerous individuals and professional groups, which include:

• Members of the Council of Obstetric and Paediatric Mortality and Morbidity, and its sub-committees (Paediatric Mortality & Morbidity, Maternal Mortality & Morbidity, Perinatal Mortality & Morbidity and Data Management);

• Epidemiology Unit, Population Health;

• Obstetricians, Paediatricians and Midwives working in all parts of Tasmania;

• The Department of Health and Human Services Tasmania (DHHS) for its commitment to and funding of COPMM and its activities;

• The State Coroner’s Office and Staff;

• Statewide Forensic Medical Services;

• The Australian Bureau of Statistics;

• Births, Deaths and Marriages;

• Information Services, Purchasing and Performance Management Unit;

• Medical Record Departments and Staff in all Tasmanian hospitals;

• Launceston General Hospital;

• Northwest Private Hospital;

• North West Regional Hospital - Mersey Campus;

• North Eastern Soldiers Memorial Hospital (Scottsdale);

• Smithton District Hospital;

• Calvary Healthcare - Lenah Valley Campus;

• Royal Hobart Hospital; and

• The Hobart Private Hospital.

Amendment of the Perinatal Registry Act 1994

Page 9 of 83

Amendment of the Perinatal Registry Act 1994 The Perinatal Registry Act 1994 (the Act) establishes the Council of Obstetric and Paediatric Mortality and Morbidity (the Council). The functions of the Council include the maintenance of a perinatal data collection system, investigating the circumstances surrounding maternal deaths, perinatal deaths and the deaths of children up to 17 years; and investigating and reporting on matters relating to obstetric and paediatric mortality and morbidity referred to it by the Minister or Secretary.

The Act contains very strict confidentiality provisions such that the Council and its members are precluded from providing information to other persons except in very limited circumstances.

In 2009, as part of a coronial inquiry into the death of a child, the coroner called for urgent amendment of the Perinatal Registry Act to enable relevant information held by the Council to be provided to the coroner.

The Council undertook a review of the Act and determined that there was merit in the coroner’s recommendation. It also identified some other deficiencies in the Act.

The Perinatal Registry Amendment Act 2010 commenced on Royal Assent on 4 November 2010. The amendments -

• enable the Council to communicate to a coroner information relevant to a coronial inquiry or possible coronial inquiry into the death of a child or woman, of its own motion or at the request of the coroner;

• enable the Council to investigate and report to the Secretary or Minister (or any other relevant Minister) on any matter relating to obstetric and paediatric mortality and morbidity of its own motion without a reference from the Secretary or Minister;

• enable the Council to communicate information regarding identified deaths or morbidities to the Secretary, a relevant Minister or a prescribed body;

• provide that the Council has the power to place a restriction upon the subsequent use of any information or reports provided by the Council to a coroner, the Secretary, a Minister or a prescribed body;

• enable a Council member to communicate information that comes into its possession to the Secretary where there is a belief or suspicion, on reasonable grounds, that a child has been or is being abused or neglected or is at risk of being abused or neglected;

• allow the Council to report information about possible criminal offences to the Commissioner of Police; and

• clarify the annual reporting requirements of the Council.

At the same time, the Act was renamed as the Obstetric and Paediatric Mortality and Morbidity Act 1994 to better reflect its purpose.


Page 10 of 83

Definitions Used by the Council Abortion / Miscarriage: Spontaneous or medically induced termination of pregnancy before the foetus is viable (before 20 weeks gestation)

Low birthweight: An infant born weighing less than 2 500 grams

Very low birthweight: An infant born weighing less than 1 500 grams

Extremely low birthweight: An infant born weighing less than 1 000 grams

Infant death: A death, occurring within 1 year of birth in a liveborn infant whose birthweight was at least 400 grams, or at least of 20 weeks gestation if the birthweight was not known.

Paediatric death: A death, occurring in the age group from 29 days to 17 years (inclusive).

Late maternal death: means the death of a woman more than 42 days but less than one year after the cessation of pregnancy:

(a) resulting from an obstetric cause or another cause aggravated by an obstetric cause; and

(b) Irrespective of the duration of the pregnancy and the location of the foetus within the woman’s body.

Maternal death: means the death of a woman while pregnant, or within 42 days after the cessation of pregnancy:

(a) from any cause related to, or aggravated by, the pregnancy or its management; and

(b) Irrespective of the duration of the pregnancy and the location of the foetus within the woman’s body.

Neonatal death: A death occurring within 28 days of birth in an infant whose birthweight was at least 400 grams, or if the weight was not known, an infant born after at least 20 weeks of gestation.

Preterm: An infant with a gestational age of less than 37 completed weeks.

Sudden Infant Death Syndrome (SIDS): Sudden death of an infant under 1 year of age, which remains unexplained after a thorough case investigation including performance of a complete autopsy, examination of the death scene, and a review of the clinical history.6 The term Sudden Unexplained Death of an Infant (SUDI) is now often used instead of Sudden Infant Death Syndrome (SIDS) because some coroners prefer to use the term 'undetermined' for a death previously considered to be SIDS.

Stillbirth: A foetal death prior to the complete expulsion or extraction from its mother of a product of conception of 20 or more completed weeks of gestation or 400 grams or more birthweight; the death is indicated by the fact that after such separation the foetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.7

6 Willinger, M., James, L.S. & Catz, C (1991), Defining the Sudden Infant death Syndrome (SIDS): Deliberations of an Expert Panel convened by the National Institute of Child Health & Human Development. Paediatric Pathology 11:667-684, 1991.

7 Australian Institute of Health and Welfare (2005), Stillbirth (fetal death), Canberra, viewed August 2008, <http://meteor.aihw.gov.au/content/index.phtml/itemId/327266>.

http://meteor.aihw.gov.au/content/index.phtml/itemId/327266


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Perinatal Death: A death fulfilling the definition of either a stillbirth or neonatal death.

Supplementary Definitions8 Direct maternal death: This includes death of the mother resulting from obstetrical complications of pregnancy, labour, or the puerperium, and from interventions, omissions, incorrect treatment, or a chain of events resulting from any of these factors. An example is maternal death from exsanguination resulting from rupture of the uterus.

Indirect maternal death: This includes a maternal death not directly due to obstetrical causes, but resulting from previously existing disease, or a disease that developed during pregnancy, labour, or the puerperium, but which was aggravated by maternal physiological adaptation to pregnancy. An example is maternal death from complications of mitral stenosis.

Non maternal (incidental) death: Death of the mother resulting from accidental or incidental causes in no way related to the pregnancy may be classified as a non maternal death. An example is death from an automobile accident.

Maternal hypertension: Maternal blood pressure of > 140/90 mmHg.

Postpartum haemorrhage (PPH): Estimated blood loss of ≥ 500 ml after vaginal birth or ≥1 000 ml after caesarean delivery.

Antepartum haemorrhage (APH): Refers to uterine bleeding after 20 weeks of gestation unrelated to labour and delivery.

.

8 Definitions derived from ‘Williams Obstetrics – 20th edition’ by Cunningham MacDonald Gant Leveno Gilstrap Hankins Clark; Copyright 1997

& www.uptodate.com, viewed August 2008

http://www.uptodate.com/

Members of the Council of Obstetric & Paediatric Mortality & Morbidity

Page 12 of 83


Organisation Membership 2009 Current Membership

as of June 2011 Nominees of the University of Tasmania (2)

Professor Allan Carmichael Associate Professor Bipin Gupta

Professor Allan Carmichael Associate Professor Amanda Dennis

Person nominated by the Secretary employed in delivery of Neonatal Services

Associate Professor Peter Dargaville (Chair)

Associate Prof Peter Dargaville (Chair)

Person nominated by the Secretary employed in the Department of Health & Human Services

Dr Helen McArdle Ms Gina Butler

Nominee of the Tasmanian Regional Committee of the Royal Australian & NZ College of Obstetricians and Gynaecologists

Dr James Brodribb Dr James Brodribb

Nominee of the Tasmanian Branch of the Paediatric Health Division of the Royal Australian College of Physicians

Dr Michelle Williams Dr Michelle Williams

Nominee of the Tasmanian Branch of the Royal Australian College of General Practitioners

Dr Thomas (Geoff) Shannon Dr Thomas (Geoff) Shannon

Nominee of the Tasmanian Branch of the Australian College of Midwives Inc.

Ms Elaine (Flo) Jensen Ms Elaine (Flo) Jensen

Additional Member Nominated by Council to Represent Community interests

Ms Ros Escott Mr Paul Mason, (Commissioner for Children)

Ms Ros Escott Mr Paul Mason


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Members of Sub-Committees & Support Services

Name of Subcommittee Membership in 2009 Current Membership

as of June 2011 Maternal Mortality & Morbidity Subcommittee

A/Professor Bipin Gupta (Chair) Dr James Brodribb Ms Elaine (Flo) Jensen) Dr Amanda Dennis

Associate Prof. Amanda Dennis (Chair) Dr James Brodribb Ms Elaine (Flo) Jensen

Paediatric Mortality & Morbidity Subcommittee

Dr Michelle Williams (Chair) Dr Chris Lawrence Dr Thomas (Geoff) Shannon Dr Anita Cornelius Dr Bert Shugg Mr Paul Mason

Dr Michelle Williams Dr Chris Lawrence Dr Thomas (Geoff) Shannon Dr Chris Williams Dr Bert Shugg Mr Paul Mason Ms Aileen Ashford Ms Liz O’Malley

Perinatal Mortality & Morbidity Subcommittee

Assoc/Prof Peter Dargaville (Chair) Dr Tony DePaoli Dr James Brodribb Assoc/Prof Amanda Dennis Ms Elaine (Flo) Jensen

Assoc/Prof Peter Dargaville (Chair) Dr Tony De Paoli Dr James Brodribb Assoc/Prof Amanda Dennis Ms Elaine (Flo) Jensen

Data Management Subcommittee

Activities undertaken by the Council

Assoc/Prof Peter Dargaville (Chair) Dr Jamie Brodribb (RANZCOG rep) Dr Michelle Williams (RACP-Paediatric

Rep) Mr Peter Mansfield (Clinical Data Services) Mr Michael Long (Epidemiology Unit,

Population Health) Ms Peggy Tsang (Clinical Data Services) Dr Jo Jordan (Manager, COPMM)

National Perinatal Data Development Committee-Tasmanian Representative

Mr Peter Mansfield Mr Peter Mansfield

Executive Dr Jo Jordan Dr Jo Jordan

Support Staff Ms Helen Galea (CDS) Ms Diane Hickie (CDS)

Mr Peter Mansfield (DS&IU)) Ms Peggy Tsang (DS&IU) Ms Diane Hickie (DS&IU)) Ms Cynthia Rogers (DS&IU)

Compilation of this 2009 Annual Report by: Executive: Dr Jo Jordan (Care Reform, Safety & Quality Unit) Support Staff: Mr Peter Mansfield (Data Standards & Integrity Unit) Ms Peggy Tsang (Data Standards & Integrity Unit) Mrs Diane Hickie (Data Standards & Integrity Unit) Ms Cynthia Rogers (Data Standards & Integrity Unit)

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Committee Reports

Perinatal Mortality & Morbidity Sub-Committee The ABS definition of perinatal deaths includes all infants (both live and stillborn) who had a birth weight of at least 400 grams or where birth weight is unknown, a gestational age of at least 20 weeks.

There were 67 perinatal deaths in Tasmania who died in 2009. Fifteen of these deaths were neonatal deaths (live born infants who did not live beyond 28 days of age) and 52 were stillbirths. The overall perinatal mortality rate was 10.5 per 1 000 births. The neonatal mortality rate was 2.4 per 1 000 births, with a stillbirth rate of 8.2 per 1 000 births.

The Australia and New Zealand Perinatal Mortality Classification was used to classify the Perinatal Deaths.

Table 1: Perinatal Deaths for 2009

Cause of Death Number of deaths

2001 2002 2003 2004 2005 2006∗ 2007∗ 2008* 2009*

Congenital Anomalies 16 12 15 8 6 5+8 15+6 17+3 12+3

Perinatal Infection 1 0 2 3 1 2 2+1 1+1 1+ 2

Hypertension 2 2 0 0 0 0+2 0 2+3 3

Antepartum Haemorrhage 5 6 8 8 4 1+5 1+2 3+2 6+4

Maternal Conditions 3 2 4 5 1 0+1 2 1 2

Specific Perinatal Conditions 0 7 4 3 9 1+6 6 4 7

Hypoxic Peripartum Death 0 5 1 4 3 0+4 2+2 3+2 1

Foetal Growth Restriction (FGR) 1 1 3 9 9 0+4 6 12 8

Spontaneous Pre-Term 8 19 19 10 10 4+6 3+6 6+3 2+6

Unexplained Antepartum Deaths 16 16 15 1 5 6 3 11 10

No Obstetric Antecedent 0 2 2 0 0 0 4 0 0

Birth Trauma 0 1 0 0 0 0 0 1 0

Overlying - - - - - - 1 - -

TOTALS 57 73 73 51 48 55 62 75 67

* The + symbol indicates neonatal deaths plus stillbirths

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Basic Information on Stillbirths for 2009

There were 52 stillbirths for 2009 which is the second lowest number since 2000. The tables below show the breakdown by 1) gestation, 2) according to the Perinatal Society of Australia and New Zealand (PSANZ) classification used nationally, and 3) by gestation and PSANZ classification together.

Gestation of stillbirth (N=52)

Gestation (weeks)

2005 %

2006 %

2007 %

2008 %

2009 % No. Births S/B Rate*

20-24 48.8 38.1 63.7 45.8 46.2 24 34 705.9

25-29 7.7 11.9 6.8 16.3 5.8 3 29 103.4

30-34 17.9 23.8 6.8 11.5 13.5 7 181 38.7

35-39 17.9 21.4 15.9 21.6 34.6 18 3 374 5.3

40+ 7.7 4.8 6.8 3.2 1.9 0 2 751 0.0

* Stillbirth rate is per 1 000 births at that gestation

Classification according to the Perinatal Society of Australia and New Zealand

2009 STILLBIRTHS BY CATEGORY

Category 2005

% 2006

% 2007

% 2008

% 2009

% No. 1 Congenital anomalies 12.8 19 31.8 27.8 23.1 12 2 Perinatal infection 0.0 0.0 0.6 1.6 1.9 1 3 Hypertension 0.0 4.7 0.0 3.2 5.8 3 4 Antepartum haemorrhage 10.3 11.9 2.3 4.9 11.5 6 5 Maternal conditions 2.3 2.4 6.8 1.6 3.8 2 6 Specific perinatal conditions 21.5 14.4 13.6 6.5 13.5 7 7 Hypoxic peripartum death 2.3 9.4 6.8 4.9 1.9 1 8 Foetal growth restriction (FGR) 23.1 9.4 13.6 19.6 15.4 8 9 Spontaneous preterm labour 13.4 14.4 6.8 9.8 3.8 2 10 Unexplained antepartum deaths 12.8 14.4 6.8 18.0 19.2 10 11 No obstetric antecedent 0.0 0.0 0.0 0.0 0.0 0 12 Birth trauma 0.0 0.0 6.8 1.6 0.0 0

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Classification by gestation period and PSANZ (2009) classification

20 to 24 weeks gestation (24)

Category Causes of stillbirth

1 One baby with anencephaly, one baby with Dandy-Walker syndrome and XXY, one baby with acrania, one baby with XYY, gastrointestinal abnormalities, one with hypoplastic left heart, one with hypoplastic right heart and tricuspid atresia, one with hypoplastic left heart and 3q duplication and 9q deletion, one with multiple abnormalities-cardiac and sacral,, one with multiple abnormalities- urinary and musculoskeletal, one with double outlet right ventricle and right sided heart and cerebral ventricular abnormalities

3 One with severe pre-eclampsia/eclampsia, one with severe hypertension pre-existing and placental infarction, one with severe pre-eclampsia

4 One with essential hypertension and intraplacental haemorrhage, one with placental abruption (? drug related), one with placental abruption and foetal growth restriction (FGR) (? drug related), one with placental abruption.

6 One with cervical incompetence, unbooked (previous 34 week preterm labour), one monochorionic diamniotic (MC/DA) twin (90gm) and other MC/DA twin (84gm) with amniotic rupture and cord entanglement

7 One intrapartum asphyxia (had premature pre-labour rupture of membranes (PPROM) and antepartum haemorrhage (APH) 5 days before, labour induced)

9 One with PPROM (PH of LLETZ), one (90gm) PPROM and chorioamnionitis

10 One unexplained



1 One with a sacrococcygeal teratoma.

4 One with severe pre-eclampsia.

6 One with twin-to-twin transfusion in MC/DA twin component of a triplet pregnancy. Other foetuses survived.



1 One with posterior urethral valves and foetal urinary ascites.

2 One with intra-uterine E coli pneumonia due to PROM following APH.

4 One with placental abruption with amphetamine use.

8 One with FGR 3rd centile weight, one FGR<3rd centile for weight, one FGR <3rd centile for weight, one FGR<3rd centile for weight.

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4 One with abruption and 10th centile for weight and amphetamine use.

5 One with poorly controlled insulin treated gestational diabetes mellitus (GDM).

6 One with in utero cord haemorrhage, one with extra long cord and loops x5 around foetal neck, one in DC/DA twin pregnancy with unexplained foetal hydrops.

8 One with FGR and weight <3rd centile, one with FGR in DC/DA twins and weight <3rd centile, one at 35 weeks and 945gm<1st centile, one with FGR and weight < 3rd centile.

10 One at 10-25th weight centile, one at 75th centile for weight and meconium grade 3 suggesting late placental insufficiency, one at 10-25th centile for weight, one at 10-25th centile for weight with cytomegalovirus (CMV) IgG and IgM positive, one with weight 10-25th centile, one at 50th centile for weight, one at 75-90th centile with meconium grade 3 suggesting late placental insufficiency, one at 75-90th centile for weight, one >97th centile with meconium grade 3 suggesting late placental insufficiency and poor attender with anti-c/anti-K/anti-E antibodies.

40+ weeks gestation (0)

Discussion and Recommendations on Stillbirths

1) There were 52 stillbirths reported in 2009 where “stillbirths” refers to the expulsion of a foetus beyond 20 weeks gestation (irrespective of whether foetal death had occurred before or after 20 weeks), or > 400gms weight.

2) Three of the stillbirths were derived from pregnancies that finished prior to 20 weeks, twins weighing 84 and 96gms, and a twin weighing 100gms at 37 weeks – hydrops noted at 21 weeks.

3) The number of stillbirths occurring since 1997 are outlined below:

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

52 37 46 45 43 49 48 37 39 42 44 61 52

4) Almost 1 in 5 stillbirths are unexplained and unfortunately, the investigations for stillbirth continue to be incomplete. Council recommends that practitioners follow the Perinatal Society of Australia and New Zealand Recommendations (2009) for the investigation of stillbirth.9

9 Flenady, V., King, .J, Charles, A., Gardener, G., Ellwood, D., Day, K., McCowan, L., Kent, A., Tudehope, D., Richardson, R., Conway, L., Chan, A., Haslam, R., Khong, Y. for the Perinatal Society of Australia and New Zealand (PSANZ) Perinatal Mortality Group (2009), PSANZ Clinical Practice Guideline for Perinatal Mortality version 2.2 April 2009, PSANZ, Australia, viewed 31 May 2011, <http://www.PSANZ.COM.AU/files/Section_5_Version_2.2_April_2009.pdf>.

http://www.psanz.com.au/files/Section_5_Version_2.2_April_2009.pdf

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5) Foetal growth restriction (FGR) remains an area of considerable concern particularly since it accounts for 15 per cent of foetal losses. All foetal deaths from FGR in 2009 occurred at >30 weeks. This is similar to previous years. These foetuses are significantly restricted, many being <3rd centile for gestation. As indicated in the 2008 Council Annual Report, the foetal survival beyond 30 weeks for normal babies delivered is almost 100 per cent. Council encourages all maternity service providers to establish protocols for the detection of growth-restricted foetuses from 30 weeks gestation and for timely, and appropriate, management. An aid to this process is the use of customised growth charts10, allowing growth assessment by either ultrasound or symphysis-fundus height measurements.

6) Congenital anomalies continue to account for about a quarter of foetal losses, usually as planned pregnancy termination. In the past, the contribution has been low, 1996 (5/53 = 9 per cent) and 1997 (11/60 = 18 per cent).

The current level of 25+ per cent reflects the increasing involvement of ultrasound scanning for foetal anomalies (now at about 20 weeks gestation) with pregnancy termination after 20 weeks. Previously, foetal scanning was done at earlier gestations, 16-18 weeks, resulting in terminations being performed before 20 weeks gestation. The completeness and sensitivity of such screening is superior at 18-20 weeks rather than at 16-18 weeks especially in more difficult patients (for example obese women). However, this means that the diagnosis of foetal abnormalities is not made until 20 weeks and if further investigations (such as amniocentesis) are required, termination of pregnancy may not be undertaken until after 20 weeks gestation. This results in a stillbirth (rather than a miscarriage), which is included in the perinatal mortality statistics. Whilst Tasmania’s legislation related to termination of pregnancy does not specify gestational age, discussion by providers of care and the community may be appropriate to consider whether it is preferable that such diagnoses, and therefore terminations if requested, are undertaken prior to 20 weeks.

7) Antepartum haemorrhages account for approximately 10 per cent of losses, often associated with premature membrane rupture. In many instances, chorioamnionitis has supervened, often because of the conservative management of extreme prematurity of many of these pregnancies and the understandable desire to extend the period of gestation to one at which survival is likely to occur. In such situations, surveillance for and treatment of infection is of paramount importance.

8) It has been noted for some time that surgery for cervical dysplastic disease, either cold knife conisation, laser conisation or LLETZ procedures has been linked with increased perinatal morbidity and mortality due to PROM/preterm delivery11. Therefore, close observation of such women during pregnancy for evidence of cervical incompetence after 14 weeks gestation is required when there is evidence of previous cervical surgery for cervical dysplastic disease treatment. Risks are even greater when there has been more than one such procedure performed.

9) Surprisingly, true preterm labour alone has accounted for very few stillbirths.

10 Gestation Network (2007), Perinatal Institute, Birmingham, United Kingdom, viewed 31 May 2011, <http://www.gestation.net/fetal_growth/fetal_growth.htm>.

11 Arbyn M, Kyrgiou M, Simoens C, Raifu AO, Koliopoulos G, Martin-Hirsch P, Prendiville W, Paraskevaidis E. (2008) Perinatal mortality and other severe adverse pregnancy outcomes associated with treatment of cervical intraepithelial neoplasia: meta-analysis. BMJ. Sep 18;337.

http://www.gestation.net/fetal_growth/fetal_growth.htm

http://www.ncbi.nlm.nih.gov/pubmed?term=%2522Arbyn%20M%2522%255BAuthor%255D

http://www.ncbi.nlm.nih.gov/pubmed?term=%2522Kyrgiou%20M%2522%255BAuthor%255D

http://www.ncbi.nlm.nih.gov/pubmed?term=%2522Simoens%20C%2522%255BAuthor%255D

http://www.ncbi.nlm.nih.gov/pubmed?term=%2522Raifu%20AO%2522%255BAuthor%255D

http://www.ncbi.nlm.nih.gov/pubmed?term=%2522Koliopoulos%20G%2522%255BAuthor%255D

http://www.ncbi.nlm.nih.gov/pubmed?term=%2522Martin-Hirsch%20P%2522%255BAuthor%255D

http://www.ncbi.nlm.nih.gov/pubmed?term=%2522Prendiville%20W%2522%255BAuthor%255D

http://www.ncbi.nlm.nih.gov/pubmed?term=%2522Paraskevaidis%20E%2522%255BAuthor%255D

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10) It is noted that unexplained stillbirths account for about 20 per cent of all stillbirths. This remains a frustrating group for both doctors and the family involved. A recent paper12 from Auckland in the BMJ in 2011 which was case-controlled, explored the role of maternal sleeping position in the pregnancy and particularly late pregnancy. In this paper the following was noted: Stillbirth is significantly more common if-

a. Sleeping position on the last night of pregnancy was non left sided - 2.54 (1.04 to 6.18) b. Regular daytime sleep occurred in the last month of pregnancy - 2.04 (1.26 to 3.30) c. Greater than 8 hours of night-time sleep in the last month of pregnancy - 1.71 (0.99 to

2.95) d. “The absolute risk of late stillbirth for women who went to sleep on their left side was 1.96/1 000

and was 3.93/1 000 for women who did not go to sleep on their left”. This is the first study to investigate the possible role of sleeping position on the incidence of unexplained late pregnancy stillbirth. It is possible that, if this is confirmed by other studies, maternity care providers might be able to offer advice about sleeping habits in late pregnancy to improve outcomes.

11) Recent ANZSA statements have concentrated on the significance of reduced foetal movements13. All jurisdictions and practitioners should ensure that their policies reflect evidence based guidelines regarding the review and further investigations of this group of women.

12) Birth trauma has been a cause of only one foetal death since 2000, and that was in 2002.

12 Stacey, T., Thompson, J., Mitchell, E., Ekeroma, A., Zuccollo, J., McCowan, L. (2011), ‘Association between maternal sleep practices and risk of late stillbirth: a case-control study’, British Medical Journal, 2011;342:doi:10.1136/bmj.d3403 (Published 14 June 2011).

13 Preston S, Mahomed K, Chadha Y, Flenady V, Gardener G, MacPhail J, Conway L, Koopmans L, Stacey T, Heazell A, Fretts R and Frøen F for the Australian and New Zealand Stillbirth Alliance (ANZSA), Clinical Practice Guideline for the Management of Women who Report Decreased Foetal Movements First Edition, Version 1.1, July 2010, Brisbane, Queensland, viewed 2010, <http://www.stillbirthaliiance.org.au/guideline.htm>.

http://www.stillbirthaliiance.org.au/guideline.htm

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Basic Information on Neonatal Deaths for 2009

There were a total of 15 neonatal deaths.

Classification of Neonatal Deaths according to the Perinatal Society of Australia and New Zealand

2009 NEONATAL DEATHS

Category 2006

% 2007

% 2008

%

2009

% No.

1 Congenital anomalies 38.5 33.3 21.4 20.0 3

2 Perinatal infection 15.4 5.6 7.1 13.3 2

3 Hypertension 0.0 0.0 21.4 0.0 0

4 Antepartum haemorrhage 7.7 11.1 14.3 26.7 4

5 Maternal conditions 0.0 0.0 0.0 0.0 0

6 Specific perinatal conditions 7.7 0.0 0.0 0.0 0

7 Hypoxic peripartum death 0.0 11.1 14.3 0.0 0

8 Foetal growth restriction 0.0 0.0 0.0 0.0 0

9 Spontaneous preterm labour 30.8 33.3 21.4 40.0 6

10 Unexplained antepartum deaths 0.0 0.0 0.0 0.0 0

11 No obstetric antecedent 0.0 0.0 0.0 0.0 0

12 Birth trauma 0.0 0.0 0.0 0.0 0

CONGENITAL ABNORMALITIES

There were 3 neonatal deaths in Tasmania associated with a congenital abnormality:

• Bilateral renal dysplasia associated with posterior urethral valves;

• Congenital cardiac defect with pulmonary atresia and hypoplastic R ventricle; and

• Anencephaly.

PERINATAL INFECTION

There were 2 neonatal deaths relating to a perinatally-acquired viral infection, in both cases cytomegalovirus infection:

• 25 week infant delivered because of severe intrauterine growth restriction, with post-natal multiorgan failure; and

• 27 week infants delivered because of foetal hydrops, with severe renal failure post-natally.

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ANTEPARTUM HAEMORRHAGE

There were 4 neonatal deaths preceded by antepartum haemorrhage:

• 2 infants born after placental abruption at 24 weeks, both of whom died shortly after birth;

• 1 infant born at 28 weeks after placental abruption, who had an uncomplicated course until the onset of fulminant necrotising enterocolitis on day 8 of life; and

• 1 infant born at 27 weeks gestation, who died at 1 month of life of necrotising enterocolitis.

SPONTANEOUS PRE-TERM

There were 6 neonatal deaths associated with spontaneous preterm labour, including 4 at a previable gestation:

• 20 weeks gestation;

• 22 weeks gestation;

• Twins at 22 weeks gestation;

• 25 weeks gestation (ultimate cause of death pulmonary interstitial emphysema / evolving chronic lung disease and respiratory failure); and

• 30 weeks gestation (ultimate cause of death fungal sepsis).

Issues:

The review of neonatal mortality identified the following issues:

• Tasmania’s current neonatal mortality rate of 2.2 per 1 000 remains very low. This has been contributed to by improvements in obstetric care, as evidenced by the low rate of hypoxic-ischaemic encephalopathy and birth trauma, as well as advances in neonatal intensive care. Survival for infants born prematurely is now on par with, or above, national averages at all gestations above 24 weeks.

• Survival for babies at 23 weeks gestation in Tasmania remains low (20 per cent), and there is a high risk of long term disability. These factors need to be taken into consideration in dealing with infants (in or ex utero) at 23 weeks, as outlined in the Tasmanian Neonatal Care Guidelines. The option of not offering resuscitation at this gestation should be carefully discussed given the poor survival and high risk of neurodevelopmental disability.

• At 24 weeks gestation, mortality in Tasmania remains relatively high (47 per cent of those managed in the RHH NPICU), and the estimated incidence of significant disability in the long term is 25-33 per cent. It is thus appropriate to consider and discuss with prospective parents whether resuscitation and intensive care should be offered to an infant born at this gestation. Survival at 24 weeks is poor for infants born outside a tertiary centre, and every effort should be made for such infants to be inborn if full intensive care is to be offered.

• There have been no neonatal deaths directly related to bacterial sepsis in the past 4 years. The paucity of cases of group B streptococcal infection reflects the trend elsewhere, and can be attributed at least in part to the antenatal screening program, and appropriate use of intrapartum antibiotics.

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Recommendations on Neonatal Deaths:

1. For infants less than 30 weeks, early in utero transfer of women threatening to deliver prematurely is much preferred over delivery in a regional centre. The opportunity to expedite transfer as soon as possible should not be missed. Especially at gestations <28 weeks, birth at a tertiary centre without the need to post-natal transfer improves the chance of survival, and reduces the risk of intraventricular haemorrhage.

2. All obstetric and paediatric staff should maintain vigilance for the signs of neonatal viral infection. Viral disease of the newborn is now a more prevalent cause of neonatal mortality in Tasmania than bacterial disease. Causative organisms include cytomegalovirus, adenovirus, enteroviruses (Coxsackie and Echoviruses), as well as herpes simplex virus types I and II. Features to alert the clinician include maternal history of flu-like illness, maternal herpetic lesions (oral or genital), a neonatal disease of onset later in the first week of life, significant liver dysfunction, coagulopathy with or without thrombocytopenia, and evidence of myocarditis (with enterovirus).

3. In view of at least 6 (40 per cent) of the mothers of the neonatal deaths were documented as smokers (tobacco +/- marijuana), clinicians should continue to encourage smoking cessation at antenatal visits and reinforce that nicotine replacement therapy in pregnancy is safer than ongoing smoking.

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Paediatric Mortality & Morbidity Sub-Committee

Paediatric Deaths for 2009

The Council’s Terms of Reference in relation to paediatric mortality and as specified under the updated Obstetric and Paediatric Mortality and Morbidity Act 1994 are:

To investigate the circumstances surrounding, and the conditions that may have caused deaths of children in Tasmania in the age group from 29 days to 17 years.

The total number of paediatric deaths in Tasmania during 2009 was 36, with an estimated paediatric mortality rate of 0.30 per 1 000 persons aged 0-17 years. Due to the relatively small number of paediatric deaths, paediatric mortality is classified using a broad four category classification system. Deaths are classified as being due to a condition determined at birth, an acquired condition, a sudden unexplained infant death (SUDI) or due to an injury. An increase in the total number of deaths due to injury and a decrease in the total number of sudden unexplained infant deaths were noted in 2009. Child protection status this year has been refined to reflect the following factors: whether a notification to child protection services had been made; whether the notification had been substantiated in the last 3 years and/or whether the case had been placed on orders prior to death. This more comprehensive information is now tracked for paediatric death cases reported for Tasmania. The total number of children who had been notified to child protection services prior to the death of the reported child in 2009 for all categories was six. Noting the child protection status in this report does not necessarily imply that protective concerns were implicated in the cause of death. Only one case had been substantiated in the last 3 years. Paediatric deaths for the years 2001 to 2009 have been classified below.

Table 2: Paediatric Deaths for 2009

Cause of Death 2001 2002 2003 2004 2005 2006 2007 2008 2009 Conditions determined at birth 3 3 7 1 5 4 7 8 11

Acquired conditions 8 8 5 3 7 5 6 3 8

Unexplained Infant Deaths 8 2 2 4 4 5 3 5 3

Injuries 4 12 4 10 8 20 7 7 14

Unknown/Indeterminate 2 1 1 0 1 1 0 1 0

TOTAL 26 27 21 18 25 35 25 24 36

Table 3: Type of Injury leading to Paediatric Death in year 2009

Type of Injury No.

Motor Vehicle Accident (MVA) 9

Drowning 2

Hanging 2

Inhalation of Aerosols 1

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1. CONDITIONS DETERMINED AT BIRTH

In 2009, there were 11 reported paediatric death cases in this category, the causes of which were:

• One case with necrotising enterocolitis due to extreme prematurity and heart disease (age 1 month); and two cases with necrotising enterocolitis due to extreme prematurity and extreme short gut syndrome (ages 2 months and 11 months).

• Acute aspiration pneumonia and cerebral palsy, marked scoliosis and history of epilepsy (age 9 years).

• Pneumonia due to complications of epilepsy and severe cerebral palsy (age 15 years).

• Pneumonia on a background of metabolic disorder and seizures (age 2 years).

• Chromosomal abnormality (age 2 months).

• Heart failure and pulmonary atresia (age 16 years).

• Hypertrophic cardiomyopathy (age 8 years).

• Severe kyphoscoliosis and short stature and dysmorphism (age 7 years).

• Dilated cardiomyopathy and possible lung infection (age 16 years).

2. ACQUIRED CONDITIONS

In 2009 there were 8 deaths in children ranging from 2 months to 17 years. These included:

• Three cases due to complications from a pontine glioma (age 7 years); metastatic neuroblastoma (age 1.5 years); astrocytoma (age 1 year).

• Two cases due to complications from either leukaemia (age 17 years) or T-cell leukaemia and lymphoma and Intracranial bleed (age 13 years).

• One case with complications from H1N1 09 viral pneumonia on a background of Klippel-Feil Syndrome (age 12 years).

• One case due to viral pneumonia (Picornavirus) (age 2 months).

• One case of hypoxic brain injury following dural venous thrombosis on a background of congenital adrenal hypoplasia (steroid and mineral corticoid dependent) (age 17 years).

3. UNEXPLAINED INFANT DEATH

In 2009, three paediatric ‘unexplained infant deaths’ were reported in infants aged between 2 months to 6 months with two of the deaths having been associated with risk factors. As was found in recent years, these particular 2009 death cases had been primarily attributed to risk factors such as an unsafe sleeping environment, especially co-sleeping (bed sharing) with a parent or unsafe bedding.

Investigation of these cases found that a:

• 6 month old female died as a result of sudden unexplained infant death in infancy where no risk factors had been identified.

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• 3 month old male died where risk factors had been identified including an unsafe sleeping environment with the identification of a pillow placed within the cot and infant assuming a face down position. Despite this infant having a history of a consistent cough and suggested gastric aspiration with an inflammatory reaction, there was no evidence of having a convincing pneumonia in this infant.

• 2 month old male died where risk factors had been identified including unsafe sleeping position of face down on a pillow in association with a prone positioning of infant.

A more detailed comparison of Tasmania’s number and rate of unexplained deaths of infants with other jurisdictions (QLD, NSW, SA & VIC) in 2008 showed that the rate of death per 100 000 infants was the highest of any of the jurisdictions considered, followed by Queensland14. Overall, the number of infant (less than 1 year old) deaths in Australia in 2009 where the cause of death was ill-defined or unknown was 123 or a rate of 0.4 deaths per 1 000 livebirths where this number/rate includes deaths due to Sudden Infant Death Syndrome15.

4. INJURY

An increase in the number of children dying as a result of injury was reported in 2009 compared to 2008 figures with a total of 14 paediatric death cases having been reviewed.

The majority of these deaths (nine of the fourteen) were as a result of injuries sustained in road trauma. Two adolescents died from head injuries sustained in single vehicle accidents where they were unrestrained passengers. One adolescent rear passenger died from severe head and chest injuries (including laceration of the heart and brain injury) following a single vehicle MVA. Two adolescents died due to multiple blunt traumatic injuries sustained in a MVA with severe internal chest and abdominal injuries and internal bleeding. One young child died as a consequence of head and chest injuries following a collision with a truck caused by the vehicular suicide of a driver of a third vehicle. One adolescent died from diffuse axonal brain injury and blunt trauma of head sustained in a MVA where he had been the sole occupant and driver and had collided head on with another vehicle. One toddler died as a consequence of cervical and abdominal injuries due to ejection following a single vehicle collision and rollover. The toddler had been unrestrained in their booster seat. This particular child had previously been notified to child protection services.

One young adolescent died as a result of blunt trauma of the head when crushed by a car within which this individual had been playing with the handbrake.

One toddler died as a consequence of the combined effects of asphyxia and drowning following evidence of an assault with obvious bruising and abrasions on head, face, neck and body. This child had been notified to child protection services which had also been substantiated in the last 3 years.

One death involved a young child sustaining accidental hanging due to a trampoline accident. This death highlighted the risks associated with placement of play equipment around the home.

One death of an adolescent was due to asphyxia and hanging.

14 Commission for Children and Young People and Child Guardian Queensland (2010), Annual Report: Deaths of children and young people,

Queensland, 2009-10, Part VII: National child death statistics: An interstate comparison, 2008 calendar year, Chapter 10, pp. 155-164, Commission for Children and Young People and Child Guardian Queensland, Brisbane.

15 Australian Bureau of Statistics (2009), Causes of Deaths, cat. no. 3303.0, ABS, Canberra.

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One adolescent died as a consequence of volatile chemical (butane, isobutane and propane) toxicology and inhalation of aerosol contents.

One adolescent died as a result of drowning in a river.

5. CASES STILL UNDER INVESTIGATION

Three of the adolescent cases at the time of reporting were still under coronial investigation. The cause of death for two of the cases had been classified above as a result of injury (either due to road trauma or drowning).

6. UNKNOWN/INDETERMINATE

There were no deaths reviewed in 2009 that were classified in this category.

The number of paediatric deaths in Tasmania reported in 2009 was the highest reported in the last decade with the number of deaths reported as a result of injury, particularly associated with road trauma having doubled in this year. One case had been reported to be a consequence of death through suicide while one death had been associated with a drowning incident.

In view of the increased number of paediatric deaths resulting from road/traffic trauma, it is important to encourage and implement measures to improve road and traffic safety to help prevent such unnecessary paediatric deaths in Tasmania. Enforcement of wearing seatbelts should also be strengthened in view of a number of cases found to have been unrestrained passengers in motor vehicle accidents.

Encouragingly, the number of deaths listed as ‘unexplained infant death’ reported in 2009 was lower than the number of cases reported in the previous year with the primary risk factors having been identified as positional (e.g. prone) or inclusion of unsafe bedding such as pillows in the infant’s sleeping environment. Despite these risk factors, it is heartening to observe that unsafe sleeping practices of co-sleeping with adults had not been factored in the deaths reported in this year.

Recommendations:

1. It is recommended that the community be alerted to risks associated with unsatisfactory restraint of children as passengers in moving vehicles and encouraged to ensure that all children are safely restrained with seatbelts when travelling in motor vehicles and preferably seated in the rear of the car. (It is noted that age, height and weight restrictions for children sitting in the front of a motor vehicle should be better defined and that children should not ride in motor vehicles as front seat passengers based on height/weight guidelines as well as age restrictions). Furthermore, it is recommended that children should not wear lap belts whilst travelling as passengers in a motor vehicle. As reported in previous years, the benefits of wearing harnesses in relation to young children have been highlighted.

Committee Reports

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2. In view of cases continuing to be reported as Unexplained Infant Deaths in 2009, the issue of safe sleeping practices continues to remain an important issue for the Tasmanian community and the universal distribution of educational material concerning safe sleeping practices would benefit all new parents. It is also recommended that more effective scene examinations be undertaken to establish whether the cause of death is due to overlying16.

3. In view of potential hazards located around the home, it is encouraged that all children’s play equipment be positioned safely around the home and well clear from potential hazards such as overhead wiring; and accessibility to parked cars is restricted. As highlighted in previous reports, it is important to ensure that all children be provided with levels of supervision appropriate to the child’s level of development.

4. It is recommended that the dangers of aerosol inhalation and its link to fatalities should be highlighted.

5. The issue of youth suicide in Tasmania continues to be a concern and is highlighted by the reported hanging of an adolescent in 2009. Nationally, the rate of suicide reported in the 15-24 year age category in 2009 was 8.3 deaths per 100 00017. It is recommended that increased awareness of available services to assist in the prevention of youth suicide in Tasmania be encouraged. In particular, warnings from young people who are potentially suicidal should always be taken seriously and appropriate support and interventions be followed-up without delay.

6. Children who have been previously notified to child protection services and who have been reported to have died continues to remain a concern to Council. In response to these concerns, Council proposes that a systemic alert system be established for the young and subsequent children of mothers of children who have died where neglect or abuse has been identified. The proposal to establish a Child Death Review and Serious Injury Council for Tasmania is welcomed to undertake formal review of contentious cases and assist in highlighting the need for rigorous follow-up of child protection cases, in particular siblings of these cases.

7. Guidelines have been developed by the Paediatric Mortality & Morbidity Subcommittee to assist in the process of review of paediatric death cases. These guidelines have been established to ensure that all relevant practitioners are provided with an opportunity to review subcommittee opinions and recommendations and have the ability to engage in a right of reply as required. This process ensures that accurate information is provided to the Coroner to assist in the development of Coronial Findings.

16 Li, L., Zhang, Y., Zielke, R.R., Ping,Y., and Fowler, D.R. (2009), ‘Observations on increased accidental asphyxia deaths in infancy while co-sleeping in the state of Maryland’, American Journal of Forensic Medical Pathology. vol.30, no.4, pp. 318-321.

17 Australian Bureau of Statistics (2009), Causes of Deaths, cat. no. 3303.0, ABS, Canberra.

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Maternal Mortality & Morbidity Sub-Committee

Maternal Deaths for 2009

In terms of classification of maternal deaths there are three distinct classifications utilised and recognised by the World Health Organisation (WHO). These include direct, indirect and non-maternal (incidental) death. These classifications have been specified earlier in the Report.

One late maternal death was reported in Tasmania in 2009 where this case represented a non maternal (incidental) death due to a drug overdose. Details are as follows:

Case summary A 34 year old woman who had given birth approximately 3 months prior to her death had been unexpectedly found deceased at her home. Police investigating the scene found intravenous drug paraphernalia. The autopsy revealed recent needle puncture injuries and aspiration pneumonia that occurred shortly prior to death. Forensic Pathologists found no anatomical cause of death but toxicology reports revealed the presence of multiple prescription and illicit drugs. The Forensic Pathology Report stated that this woman had died as a result of mixed drug toxicity (methamphetamine, venlafaxine, morphine and diazepam) and aspiration pneumonia. The woman had been known to have a history of intravenous drug use. Classification: Late maternal death, non maternal (incidental) death. Cause: Mixed drug toxicity (methamphetamine, venlafaxine, morphine and diazepam) and aspiration pneumonia. Avoidable factors: Antenatal intravenous drug misuse had been noted in the antenatal period. This patient had been referred to the complex care clinic at the institution providing antenatal care. The drug misuse Social Worker had also been involved. However, the woman had been a very poor attendee at the Antenatal Care and admitted and had a number of presentations with drug use during the pregnancy. She had presented at 34 weeks gestation in spontaneous labour and delivered a premature infant that required admission to the nursery. She was discharged on Day 6 postnatal to undergo detoxification. Contraception had been administered prior to her discharge (Implanon). In summary, avoidable factors intrauterine drug use. Poor attendance at antenatal care.

Recommendations:

It is recommended that upon identification of “at risk” women appropriate referral to complex care team and drug support services is undertaken. It is also recommended that this service be accessible as an outreach service for women who fail to be compliant with attendance. It is also important to provide appropriate education to drug misusing patients regarding the dangers of mixing prescribed and illicit drugs.

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SS

It is important to remember that significant maternal morbidity issues will continue to arise however, and that these need to be managed appropriately. The establishment of the Australian Maternity Outcomes Surveillance System (AMOSS): Improving the Safety and Quality of Maternity Care in Australia has provided a significant step in initiating a comprehensive study of serious maternal morbidity events considered to contribute significantly to maternal morbidity in Australia. The System undertakes active surveillance and epidemiological research of selected obstetric conditions with the aim of improving the knowledge of rare obstetric disorders and their management in Australia, providing evidence-based data for; clinical guideline development, educational resources and ongoing national perinatal research. While the NH&MRC will support this project for the first five years, it is hoped that hospitals/states will, in the future, continue to support this system as part of their normal risk management framework.

All six main providers of birthing services in Tasmania (i.e., RHH, HPH, Calvary Health, LGH, Mersey Community and North West-Burnie) are participating in AMOSS with data collection being initially based on six morbid events. Additional maternal morbid events as determined by an Advisory Group will be included as part of future data collections. The AMOSS website became operational at the end of July 2009 http://www.npsu.unsw.edu.au/NPSUweb.nsf/page/AMO .

While the NH&MRC will support this project for the first five years, it is hoped that hospitals/states will, in the future, continue to support this system as part of their normal risk management framework.

http://www.npsu.unsw.edu.au/NPSUweb.nsf/page/AMOSS

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Data Management Sub-Committee Membership of the Data Management Sub-Committee includes representatives derived from obstetric, paediatric, midwifery, Clinical Data Services and Epidemiology Unit, Population Health areas with the Chair of Council also agreeing to Chair this subcommittee. The subcommittee continues to meet regularly to progress discussions around formatting and preparation of future Annual Reports as well as the Electronic Perinatal Database (ObstetrixTas System).

While no official report is available for 2009, the following advances have continued to be progressed:

Data collection form:

The revised Perinatal Data Collection Form was implemented in 2005, with continued collection of data regarding smoking status of mothers during pregnancy, as well as self-reported use of drugs and alcohol by mothers during pregnancy.

National interest in the development of a national database for congenital anomalies has previously been reported, but the Council has deferred taking on this task in Tasmania for now due to lack of resources.

Progress in database:

The development and establishment of a statewide Electronic Perinatal Database known as ObstetrixTas has been implemented in all statewide public maternity hospitals to provide obstetric units with access to clinical information for management, planning, teaching and research purposes. Implementation has progressed since March 2010. The database is the repository of information for the perinatal data system, eliminating the need for a hand written perinatal data form and improving the timeliness, completeness and accuracy of information reported from the system. Council continues to maintain a running list of recommendations for revision of the Perinatal Data Collection Form to be considered and implemented during refinement of the Electronic Perinatal Database.

Review the structure of the Annual Report

The 2009 report format continues to be refined as required to ensure a more effective format for clearer presentation of data. The role of the Data Management subcommittee provides opportunities to discuss and revise formatting issues as required.

Perinatal Statistics


Births and Birth Rates Table 4: Livebirths and Birth Rates for Tasmania 2000-2009

Year No. of Births Birth Rate

Per 1 000 Population 2000 5 975 12.7

2001 5 726 12.1

2002 5 714 12.0

2003 5 545 11.5

2004 5 540 11.5

2005 5 916 12.1

2006 6 144 12.5

2007* 6 289 12.7

2008 6 403 12.8

2009 6 317 12.5

NB: Australian Bureau of Statistics estimates Tasmania’s population 505 360 in December 2009 (Australian Bureau of Statistics June 2010, 3101.0 -

Australian Demographic Statistics). Please note this estimation of population is a preliminary figure only and is subject to change.

* Livebirths - Births as per Perinatal Data Forms provided by maternity units and maternity service providers. Also 2007 figure has been updated in this

report to reflect just livebirths.

The number of births recorded in 2009 showed a slight decreased trend compared to the previous year.

Figure 1: Birth Rate for Tasmania per 1 000 Head of Population 1992-2009

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Table 5: Livebirths by Region 2000-2009

Year South North Northwest 2000 2 922 1 692 1 357

2001 2 904 1 573 1 238

2002 2 873 1 600 1 230

2003 2 762 1 557 1 193

2004 2 753 1 567 1 161

2005 2 983 1 638 1 295

2006 3 060 1 713 1 369

2007 3 177 1 708 1 398

2008 3 203 1 769 1 420

2009 3 148 1 710 1 405

Note: Some interstate not included

The decrease in the number of births in Tasmania reported in 2009 is varied across Tasmania with the Northern region reporting the greatest decrease in this year (3.3 per cent) since 2008 followed by the Southern region (1.7 per cent) and finally the Northwest region (1.1 per cent).

Table 6: Livebirths by Hospital 2000-2009

Year

Royal Hobart (QAH)

Launceston General (QVH)

District Hospitals

NWRH Mersey Campus

Private Hospitals†

Others (includes

homebirths) TOTAL 2000 2 007 1 587 119 NA* 2 216 46 5 975 2001 1 823 1 512 101 NA* 2 250 40 5 726 2002 1 831 1 493 78 NA* 2 230 82 5 714 2003 1 633 1 482 61 NA* 2 284 85 5 545 2004 1 688 1 505 60 NA* 2 193 94 5 540 2005 1 836 1 583 37 492 1 901 67 5 916 2006 1 912 1 638 47 551 1 947 49 6 144 2007 2 015 1 605 44 537 2 034 54 6 289 2008 2 032 1 673 46 500 2 089 63 6 403 2009 1 965 1 667 26 476 2 128 55 6 317

* Not available - included in private hospitals

† includes for some years public patients at the North West Private Hospital


Table 7: Proportion of Public and Private Patients 2000-2009

Year Public % Private % 2000 70.6 28.8

2001 65.0 34.6

2002 62.7 36.6

2003 65.2 34.3

2004 66.9 33.0

2005 70.2 29.3

2006 71.5 27.8

2007 71.6 27.5

2008 73.3 25.4

2009 71.0 28.1

* Allocation unknown in some cases

Figure 2: Proportion of Public and Private Patients 1992-2009

Note: “Public” and “Private” is classified by the mother’s elected accommodation chargeable status upon admission to hospital - thus a patient in a public

hospital can elect to be treated as a private patient.

In Tasmania, the proportion of private patients (28.1 per cent) and public patients (71.0 per cent) in 2009 was higher than reported in 2008 and comparable to national figures reported in 2008 (i.e., proportion of public patients was 69.8 per cent and 30.2 per cent for private patients).

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Sex of Infants Table 8: Sex of all Infants Born Live in Tasmania 2000-2009

Year Male Female Indeterminate Total

No. % No. % No. % No. 2000 3 211 53.7 2 762 46.2 2 ^ 5 975

2001 3 073 53.7 2 650 46.3 3 ^ 5 726

2002 2 930 51.3 2 782 48.7 2 ^ 5 714

2003 2 909 52.5 2 635 47.5 1 ^ 5 545

2004 2 904 52.5 2 632 47.5 0 ^ 5 540

2005 3 036 51.3 2 880 48.7 0 ^ 5 916

2006 3 180 51.8 2 964 48.2 0 ^ 6 144

2007 3 216 51.1 3 073 48.9 0 ^ 6 289

2008 3 280 51.2 3 121 48.7 2 ^ 6 403

2009 3 230 51.1 3 087 48.9 0 ^ 6 317

^ Less than 0.1 per cent.

Figure 3: Number of Infants Born by Sex 1997-2009

Male births continue to exceed female births, accounting for 51.1 per cent of all Tasmanian births in 2009. This is comparable to national trends reported in 2008 with male births reported as higher (51.4 per cent) than female births (48.6 per cent). The 2008 national sex ratio for singleton livebirths was 105.9 male liveborn babies per 100 female liveborn babies.

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Birthweight Figure 4: Percentage of all Births by Birthweight Groups 2000-2009

Low Birthweight

Low birthweight is defined as weight less than 2 500 grams and includes babies that are small for gestational age as well as those who are premature. Very low birthweight is defined as weight less than 1 500 grams.

Table 9: Incidence of Low and Very Low Birthweight for all Births 2000-2009

Year

Very Low Birthweight

(< 1 500 grams) Proportion of all births

Low Birthweight

(< 2 500 grams) Proportion of all births

No. % No. % 2000 104 1.7 413 6.8

2001 74 1.3 399 7.0

2002 102 1.8 430 7.6

2003 104 1.9 460 8.4

2004 91 1.6 425 7.5

2005 76 1.3 389 6.7

2006 67 1.1 423 6.9

2007 107 1.7 462 7.3

2008 94 1.5 492 7.6

2009 84 1.3 439 6.9

* Note that number - low birthweight (< 2 500 grams) figures have been adjusted in this report to enable consistency in reporting of these figures that also

includes very low birthweight babies.

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The percentage of very low birthweight infants reported in Tasmania for 2009 was lower (although not significantly) than reported in 2008. The percentage of low birthweight infants reported in Tasmania in 2009 was also lower than reported in the previous couple of years, although was slightly higher than reported national figures. In 2008, the national percentage of very low birthweight infants was 1.0 per cent of all births (including stillbirths) and the percentage of low birthweight infants was 6.1 per cent of all births.

Table 10: Survival to Hospital Discharge by Gestation 1996-2009

Year

% Survival 23

wks 24

wks 25

wks 26

wks 27

wks 24-27 wks

28 wks

29 wks

30 wks

1996-1999 29 67 50 72 87 73 94 93 98

2000-2003 0 30 43 69 93 67 94 94 98

2004-2009 20 53 68 81 93 79 91 100 97

* Outcomes are for infants admitted to the Tasmanian Neonatal and Paediatric Intensive Care Unit at the Royal Hobart Hospital.

Figure 5: Survival to hospital discharge by Gestation 1996-2009

The substantial majority of preterm infants born at or beyond 28 weeks gestation now survive, most with few complications of prematurity. Survival for infants less than 28 weeks has continued to improve in Tasmania, with around 80 per cent of infants between 24 and 27 weeks now surviving. This observation reflects the ongoing improvement in neonatal care provided to such infants in Tasmania, as well as an improvement in antenatal care, including better interhospital communication and more timely interhospital transfer.

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Apgar Scores The Apgar Score is routinely recorded shortly after birth, (usually at one minute and again at five minutes after birth) for all infants. It is a general measure of an infant’s well-being immediately after birth based on assessment of the heart rate, breathing, colour, muscle tone, and reflex irritability. An Apgar Score at five minutes is a good indication of the infant’s overall health and well-being. An Apgar Score of less than 6 at five minutes is indicative of an unwell infant.

Table 11: Apgar Score for all Births at Five Minutes 2000-2009

Apgar Score

2000 %

2001 %

2002 %

2003 %

2004 %

2005 %

2006 %

2007 %

2008 %

2009 %

1 0.1 ^ 0.1 ^ ^ ^ ^ ^ ^ 0.1

2 0.0 0.0 0.1 0.1 ^ ^ ^ ^ ^ ^

3 0.2 0.1 0.1 ^ ^ ^ ^ ^ ^ ^

4 0.2 0.2 0.2 0.2 0.1 0.2 0.1 0.1 0.1 0.2

5 0.3 0.2 0.5 0.3 0.3 0.3 0.3 0.3 0.3 0.2

6 0.5 0.7 0.8 0.8 0.8 0.5 0.6 0.5 0.5 0.5

7 1.8 1.8 2.0 1.6 1.3 1.2 1.5 1.5 1.6 1.1

8 5.0 4.2 4.4 4.3 3.9 4.3 3.7 4.0 4.2 3.5

9 60.0 60.0 58.7 58.7 59.3 63.6 62.2 63.3 63.6 66.8

10 30.7 31.0 31.9 32.4 32.8 28.9 30.5 29.2 28.4 26.3

^ Less than 0.1 per cent

Figure 6: Number of Births with Apgar Score less than 6 at Five Minutes 1997-2009

Figure 6 above reflects a positive outcome in that the number of births associated with low Apgar Scores at five minutes has overall declined over the years since the late-1990s.

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Resuscitation The following table shows all intubations in the delivery room, including those done in conjunction with other methods of resuscitation as specified on the perinatal data collection form. The percentage of livebirths requiring intubation reported in 2009 remains steady with recently reported figures.

Table 12: Intubation Rate 2000-2009

Year Intubations

No. Live Births

No. Live Births Requiring Intubation

% 2000 42 5 975 0.7

2001 19 5 726 0.3

2002 30 5 714 0.5

2003 22 5 545 0.4

2004 14 5 540 0.3

2005 33 5 916 0.5

2006 35 6 144 0.6

2007 34 6 289 0.5

2008 31 6 403 0.5

2009 30 6 317 0.5

Table 13: Resuscitation Rate 2000-2009

Year Resuscitations

No. Live Births

No. Live Births Requiring Resuscitation

% 2000 662 5 975 11.0

2001 568 5 726 9.9

2002 339 5 714 5.9

2003 297 5 545 5.4

2004 243 5 540 4.4

2005 379 5 916 6.4

2006 433 6 144 7.0

2007 440 6 289 7.0

2008 473 6 403 7.4

2009 481 6 317 7.6


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Presentation at Delivery Table 14: Presentation at Delivery for all Births 2000-2009

Year Vertex No. (%)

Face & Brow No. (%)

Breech No. (%)

Other No. (%)

Not Stated No. (%)

2000 5 388 (90) 21 (^) 256 (4) 66 (1) 243 (4)

2001 5 340 (93) 22 (^) 225 (4) 78 (1) 67 (1)

2002 5 374 (94) 23 (^) 250 (4) 61 (1) 8 (^)

2003 5 219 (94) 24 (^) 246 (4) 50 (1) 6 (^)

2004 5 204 (94) 18 (^) 256 (5) 57 (1) 5 (^)

2005 4 336 (76) 12 (^) 5 (^) 13 (^) 1 595 (27)

2006 4 464 (72) 10 (^) 5 (^) 14 (^) 1 688 (27)

2007 4 504 (71) 3 (^) 5 (^) 6 (^) 1 805 (29)

2008 4 533 (70) 11 (^) 4 (^) 16 (^) 1 900 (29)

2009 4 485 (70) 2 (^) 3 (^) 15 (^) 1 864 (29)

^ Less than 1 per cent; “not-stated” corresponds to C-Section delivery only which is not currently included in Perinatal Data Collection Form

Since 2005, if a Caesarean delivery is performed for breech presentation, the presentation at delivery is not recorded in the Perinatal Data Collection Form (i.e., not stated). Only vaginal breech presentations are included in the Table for 2005-2009.

Perinatal Mortality The Tasmanian Perinatal Mortality rate per 1 000 births in 2009 was found to be lower (10.5 deaths per 1000 births) than reported in 2008 and consistent with the national figure of 10.2 deaths per 1 000 births reported in 2008. Causes of Perinatal Mortality are outlined in Table 1.

Table 15: Perinatal Outcome 2000-2009

Outcome Stillbirth Liveborn and

survived* Neonatal

death Unknown Total 2000 39 5 914 18 4 5 975

2001 44 5 666 14 2 5 726

2002 49 5 641 24 0 5 714

2003 48 5 472 25 0 5 545

2004 37 5 490 13 0 5 540

2005 39 5 868 9 0 5 916

2006 42 6 089 13 0 6 144

2007 44 6 251 19 0 6 314

2008 61 6 388 15 0 6 464

2009 52 6 302 15 0 6 369

* Survived to first hospital discharge.


Figure 7: Stillbirths & Neonatal Deaths 1997-2009

Table 16: Perinatal Mortality Rates 2000-2009

Year Perinatal deaths*

No. Total Births

No. Rate of Perinatal Mortality

Per 1 000 Births 2000 61 5 975 10.2

2001 57 5 726 10.0

2002 68 5 714 11.9

2003 73 5 545 13.2

2004 51 5 540 9.2

2005 48 5 916 8.1

2006 55 6 144 9.0

2007 63 6 314 9.9

2008 76 6 464 11.8

2009 67 6 369 10.5

* Includes neonatal deaths occurring following first hospital discharge. The number of births from 2000 to 2006 reflects figures for livebirths but has been

altered to reflect total birth figures since 2007.

It is evident that for Tasmania, perinatal mortality rate in 2009 decreased from the rate reported in 2008 and was comparable with the national rate of perinatal deaths (10.2 rate per 1 000 births). In 2008, the national stillbirth rate was 7.4 per 1 000 births; the neonatal death rate was 2.8 per 1 000 live births; and the perinatal death rate was 10.2 per 1 000 births.

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Figure 8: Perinatal Mortality Rate per 1 000 Births in Tasmania 1998-2009 and Australia 1998-2008

Source of Australian Perinatal Mortality Rate: Australia’s mothers & babies, published annually by the Australian Institute of Health & Welfare.

Neonatal Mortality

Neonatal mortality includes all deaths of liveborn babies born after 20 weeks gestation or with a birthweight greater than 400 grams, and the rate is expressed as deaths per 1 000 births.

The neonatal mortality rate per 1 000 births reported in Tasmania in 2009 remains steady (2.4 per 1 000 births) with the rate recorded in 2008 (2.3 per 1 000 births) but lower than the national neonatal mortality rate reported in 2008 (i.e. 2.8 per 1 000 births). The majority of improvements continue to be associated with infants < 28 weeks gestation (see Table 17) or < 1 000 grams (see Table 18).

Table 17: Neonatal Mortality, per 1 000 Births, in Infants over 28 weeks Gestation 2000-2009

Year Neonatal Mortality

No. Neonatal Mortality

Rate 2000 6 1.0

2001 6 1.1

2002 6 1.1

2003 4 0.7

2004 6 1.1

2005 3 0.5

2006 3 0.5

2007 8 1.3

2008 1 0.2

2009 2 0.3

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Table 18: Neonatal Mortality, per 1 000 Births, in Infants over 1 000 Grams Birthweight 2000-2009

Year Neonatal Mortality

No. Neonatal Mortality

Rate 2000 7 1.2

2001 6 1.1

2002 3 0.5

2003 4 0.7

2004 5 0.9

2005 4 0.7

2006 6 0.9

2007 8 1.3

2008 2 0.3

2009 3 0.5

^ Less than 0.1 per cent.


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Table 19: Foetal, Neonatal and Perinatal Death Rate per 1 000 Births by State and Territory 2000-2008

Year Aus TAS NT ACT NSW VIC QLD SA WA Foetal

2000 5.2 7.0 8.1 5.4 4.6 5.3 5.1 5.3 6.2 2001 6.9 8.2 6.9 7.8 6.3 7.4 7.3 6.8 6.7 2002 6.7 8.6 8.1 7.3 6.0 7.2 6.7 6.9 7.1 2003 7.1 8.7 11.2 11.3 6.1 8.4 6.1 7.5 7.5 2004 7.5 6.7 6.3 6.7 6.6 9.7 6.8 6.4 7.4 2005 7.3 6.4 11.4 9.2 5.9 9.2 6.8 7.1 7.4 2006 7.4 6.8 11.0 9.1 6.4 9.0 6.9 7.4 7.3 2007 7.4 7.0 8.9 7.2 6.6 9.6 6.9 6.6 6.3

2008 7.4 9.0 7.3 9.6 6.1 9.7 6.3 7.6 7.3

Neonatal

2000 3.1 3.7 6.5 3.0 3.2 2.6 3.7 2.9 2.2 2001 3.2 2.5 n.a. 4.4 2.9 3.3 4.0 3.6 2.9 2002 3.1 3.2 n.a. 5.2 2.7 3.6 3.6 3.1 2.2 2003 3.0 3.8 n.a. 5.4 2.6 3.8 3.5 2.4 2.2 2004 3.1 2.2 5.5 4.7 2.5 3.3 3.9 2.9 2.4 2005 3.2 1.4 6.6 4.0 2.9 3.7 3.4 3.4 2.7 2006 3.0 2.1 n.a. 5.2 2.4 3.3 4.0 2.0 2.2

2007 2.9 2.7 3.7 4.4 2.5 3.4 3.4 2.6 2.0

2008 2.8 1.9 3.9 4.4 2.6 3.0 3.3 2.5 1.9

Perinatal

2000 8.3 10.6 14.5 8.3 7.7 7.9 8.9 8.2 8.4 2001 10.1 10.7 n.a. 12.2 9.2 10.7 11.3 10.4 9.6 2002 9.8 11.7 n.a. 12.5 8.7 10.7 10.3 9.9 9.2 2003 10.1 12.5 n.a. 16.6 8.6 12.1 9.6 9.9 9.6 2004 10.5 8.9 11.8 11.4 9.0 13.0 10.7 9.4 9.8 2005 10.5 7.8 17.8 13.2 8.7 12.9 10.1 10.5 10.1 2006 10.3 9.0 n.a. 14.2 8.8 12.2 10.8 9.4 9.5 2007 10.3 9.7 12.6 11.6 9.0 12.9 10.3 9.2 8.2

2008 10.2 10.8 11.2 14.0 8.7 12.7 9.6 10.1 9.2

Source: Australia’s mothers and babies 2000- 2008 National Perinatal Statistics Unit. Includes perinatal & neonatal deaths of infants less than 28 days and

foetal deaths at least 20 weeks or 400 grams (table 6.1, p.91, 2008)


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Autopsy Rates

In view of the repeated recommendation from the Council of Obstetric & Paediatric Mortality & Morbidity on the value of autopsy as an investigative tool in cases of perinatal death, especially in cases of unexplained intrauterine death, it is positive to find that the autopsy rate increased in 2009 and remains overall higher in recent times. It is important to note that the Australia and New Zealand Stillbirth Alliance is seeking to improve and conduct research into stillbirth in the Australia and New Zealand region. In particular, it aims to identify factors contributing to low autopsy consent rate for stillbirths and will provide robust information to develop information and educational materials that address the needs of parents and clinicians and improve overall autopsy rates in the future.

Table 20: Rate of Autopsies on Perinatal Deaths 2000-2009

Year Autopsy Rate % 2000 46.0

2001 23.0

2002 7.4

2003 7.8

2004 2.0

2005 33.0

2006 38.5

2007 26.8

2008 33.8

2009 37.3


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Age of Mothers Table 21: Proportion of Births by Maternal Age Groups 2000-2009

Year

Under 20 years of age

%

20 – 24 years of age

%


%


%


%

40 and over years of age

% 2000 8 21 30 27 11 2

2001 8 19 30 28 12 2

2002 8 21 29 28 12 3

2003 8 19 28 31 13 2

2004 7 19 28 29 13 2

2005 7 20 27 30 14 2

2006 7 20 27 28 14 3

2007 7 20 27 27 14 3

2008 7 20 28 28 15 3

2009 7 20 28 27 15 3

In Tasmania, the age of mothers in the various groups reported in 2009 is consistent with those reported in 2008 with a slight decrease in the 30-34 year age group. In general, the 25-29 year old and the 30-34 year old groups continue to remain higher than the other age groups included in assessment in 2009, a trend consistent with national reports from 2008 and consistent with an upward trend in maternal age in recent years. The average age of women at the time of birth has increased gradually in recent years where nationally in 2008, the mean age was 29.9 years compared with 29.0 years in 1999 and the median age in 2008 was 30.0 years. The proportion of older mothers in Tasmania aged 35 years or more has continued to show an overall increase in recent times which corresponds to national figures reporting an increase from 16.3 per cent in 1999 to 22.9 per cent in 2008. Furthermore, national figures has shown evidence for an increase in the proportion of first-time mothers in the older age groups between 1999 and 2008 (of women aged 35-39 years, 26.6 per cent were first-time mothers compared with 24.0 per cent in 1999; of women aged 40 years and over, 25.3 per cent had their first baby in 2008, compared with 22.4 per cent in 1999.

The trend in delayed childbearing has been attributed to a number of factors including social, educational and economic and increased access to assisted reproduction technology18.

18 Laws, P.J. & Hilder, L (2008), Australia’s mothers and babies 2006, Perinatal statistics series, No. 22, Cat. no. PER 46, Sydney: AIHW National Perinatal Statistics Unit.


Figure 9: Proportion of Births by Maternal Age Groups 1992-2009

Figure 10: Proportion of Births by Maternal Age in Tasmania 2009 and Australia 2008

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Table 22: Rates of Birth per 1 000 Female Population by Maternal Age 2000-2009

Maternal Age In Years Year

Estimated Tasmanian Female Population *

Rate of Births Per 1 000

15 – 19

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

17 112 16 626 16 591 16 639 16 689 16 557 16 467 16 676 16 698 16 833

29.3 28.7 27.9 26.3 24.5 26.1 26.6 25.2 21.1 26.5

20 – 24

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

14 484 14 022 14 175 14 105 14 287 14 905 15 443 15 217 15 322 15 374

86.0 78.2 84.1 73.0 73.9 77.9 80.4 84.0 79.5 81.2

25 – 29

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

15 619 14 712 14 028 13 970 13 568 13 406 13 893 14 256 14 250 14 520

114.2 115.9 116.2 109.6 114.7 118.6 120.3 118.7 122.7 124.5

30 – 34

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

16 058 16 390 16 304 16 314 16 393 15 842 15 485 14 535 14 573 14 574

99.6 98.4 96.9 104.4 97.6 110.7 112.9 119.0 125.4 117.1

35 – 39

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

18 059 17 620 16 987 16 992 16 690 16 575 17 052 17 377 17 424 17 232

37.6 38.9 40.1 41.0 44.0 49.5 51.5 52.4 60.9 55.5


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Maternal Age In Years Year

Estimated Tasmanian Female Population *

Rate of Births Per 1 000

40 – 44

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

18 108 18 511 18 589 18 600 18 820 18 533 17 927 17 180 17 207 17 146

6.9 7.0 9.1 6.5 7.2 7.6 8.7 10.9 13.8 11.1

45 – 49

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

16 915 17 135 17 282 17 258 17 568 18 297 17 568 19 122 19 107 19 198

0.3 0.1 0.3 0.6 0.2 0.4 0.6 0.2 0.5 0.5

* Australian Bureau of Statistics 2000-2001, 3311.6 - Demography, Tasmania; Australian Bureau of Statistics June 2002-2008, 3201.0 - Population by Age &

Sex.

Parity Status

Parity refers to the condition of having given birth to an infant or infants, alive or deceased. A multiple birth (giving birth to >1 infant in a delivery) is considered as a single parity.

Table 23: Percentage of Births by Parity 2000-2009

Year Para 1

% Para 2

% Para 3

% Para 4

% Para 5 and

over % 2000 39 33 17 6 4

2001 39 33 17 6 4

2002 40 33 17 6 4

2003 41 33 16 6 4

2004 42 33 15 6 5

2005 41 34 15 6 4

2006 41 33 16 6 4

2007 39 33 17 6 5

2008 38 33 16 6 5

2009 40 33 15 7 4

In Tasmania, 40 per cent of mothers gave birth for the first time and 33 per cent had their second baby. This trend is similar to those reported nationally in 2008, where 41.6 per cent of mothers gave birth for the first time and 33.4 per cent had their second baby. One in six mothers (15.2 per cent) nationally had given birth twice previously and 9.7 per cent had given birth three or more times.


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Indigenous Status

Reporting of indigenous status is by self-identification and patients are asked if they are of Aboriginal or Torres Strait Island origin when commencing antenatal care. Low community acceptance of the need to ask the question, and a lack of confidence in how an affirmative response will be treated has possibly resulted in some under reporting of indigenous status. As a result of a targeted project to improve the quality of indigenous status data, the number of mothers identifying as Aboriginal has increased markedly since 2003 and remains relatively steady in 2009. In 2009, the “not stated” data remains consistent with figures reported in recent years where origin was not stated as a result of improvement in the data collection process.

Nationally in 2008, 11 188 women identified as being Aboriginal or Torres Strait Islander gave birth in Australia, representing 3.8 per cent of all women who gave birth.

Table 24: Mother's Indigenous Status 2000-2009

Year Aboriginal Torres Strait

Islander

Aboriginal & Torres Strait

Islander Other Not Stated 2000 11 1 46 1 444 4 473

2001 15 3 30 1 081 4 597

2002 12 3 25 756 4 918

2003 122 4 22 2 980 2 417

2004 118 7 7 5 368 36

2005 183 15 24 5 694 0

2006 175 14 30 5 928 0

2007 201 15 20 6 078 0

2008 255 22 26 6 161 0

2009 242 19 28 6 079 0

Breastfeeding

Trends reported in Tasmania (see tables below) indicate that the percentage of public hospital patients’ breastfeeding at discharge has particularly increased since year 2000. In 2009, the percentage of public hospital patients’ breastfeeding at discharge is equivalent to the percentage reported for private hospital patients.


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Table 25: Live Births by Breastfeeding at Discharge 2000-2009

Year Yes No % Yes

2000 4 430 1 545 74.1

2001 4 281 1 445 74.8

2002 4 346 1 368 76.1

2003 4 257 1 288 76.8

2004 4 209 1 331 76.0

2005 4 789 1 127 81.0

2006 5 039 1 099 82.0

2007 5 145 1 144 81.8

2008 5 072 1 331 79.2

2009 5 035 1 282 79.7

Table 26: Breastfeeding at Discharge by Public / Private Hospital 2000-2009

Year Public % Yes

Private % Yes

2000 71 78

2001 68 84

2002 71 73

2003 73 82

2004 73 80

2005 78 86

2006 79 87

2007 79 85

2008 76 82

2009 79 79

* Note that figures reported between 2005 and 2008 in this report differs from previous reports since data needed to reflect public/private patients rather than

hospital

Table 27: Breastfeeding at Discharge by Parity 2000-2009

Year Primiparae

% Yes Multiparae

% Yes 2000 76 73

2001 78 73

2002 79 74

2003 81 74

2004 77 75

2005 83 80

2006 84 80

2007 83 80

2008 80 77

2009 81 78


Mode of Delivery Table 28: Mode of Delivery 2000-2009

Year Total Births

Unassisted Vaginal Instrumental* Deliveries Caesarean Sections

Number % Number % Number %

2000 5 970 4 038 67.6 564 9.4 1 322 22.1

2001 5 735 3 797 66.2 571 10.0 1 335 23.3

2002 5 718 3 849 67.3 583 10.2 1 249 21.8

2003 5 552 3 507 63.2 573 10.3 1 449 26.1

2004 5 531 3 412 61.7 582 10.5 1 508 27.3

2005 5 916 3 815 64.5 520 8.8 1 581 26.7

2006 6 144 4 024 65.5 446 7.3 1 677 27.3

2007 6 314 3 837 60.8 670 10.6 1 807 28.6

2008 6 462 4 099 63.4 465 7.2 1 898 29.4

2009 6 369 4 083 64.1 422 6.6 1 864 29.3

* Instrumental Deliveries includes forceps, forceps rotation & vacuum extraction.

Vaginal Breech deliveries were less than 0.1 per cent in 2005 (not included here).

Note that 2 stillbirth records were not recorded in the system in 2008 thus reflecting the reduced total birth figure quoted in this table.

Figure 11: Mode of Delivery in Tasmania 1998-2009

* Instrumental Delivery includes Forceps, Forceps Rotation & Vacuum Extraction.

Vaginal Breech Deliveries were very limited in previous years and less than 0.1 per cent in 2005 and subsequently not graphed.

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Figure 12: Mode of Delivery in Public Hospitals in Tasmania 2009 and Australia 2008

Note: It should be highlighted that Tasmania public hospital rates reported here may be skewed since all babies that are both public and private are born at the Launceston General Hospital thus inflating the public hospital rate via the private patient contribution. Moreover, the North West Private Hospital at Burnie is a private hospital contracted to accommodate public patients.

Mode of delivery has remained relatively unchanged over the last five years with Tasmania recording 73.0 per cent and Australia recording 73.5 per cent for vaginal deliveries in 2004 compared to 72.7 per cent for Tasmania in 2009 and 71.9 per cent nationally in 2008. Furthermore in 2004, caesarean sections (CS) were reported at 27 per cent for Tasmania and 26.5 per cent nationally in 2004 and 27.3 per cent for Tasmania in 2009 compared to 28.1 per cent nationally in 2008.

Figure 13: Mode of Delivery for Private and Public Patients in Tasmania 2009

Note: There were 55 births where the mother had not declared insurance status undertook all non-instrumental vaginal deliveries.

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Private patients in Tasmania in 2009 continued to undergo more caesarean sections and instrumental vaginal deliveries than public patients (see Figure 13), a trend which was consistent with last year’s figures. Conversely, more non-instrumental deliveries continued to be performed for public patients compared to private patients during 2009. In each case, the difference between public and private patients was statistically significant. Overall in Tasmania in 2009, the total LSCS rate was 29.3 per cent; the total unassisted vaginal delivery rate was 64 .1per cent and the total instrumental delivery rate was 6.6 per cent.

In further detail:

• The higher caesarean section rates reported in 2009 in Tasmanian private hospitals is a trend consistent with national findings reported in 2008. National figures derived from 2008 have shown caesarean section rates to be higher in private hospitals (41.3 per cent) compared with public hospitals (28.1 per cent) across all age groups;

• Of the vaginal deliveries nationally reported in public hospitals in 2008, 61.8 per cent were spontaneous, 3.3 per cent were forceps deliveries and 6.9 per cent were vacuum extraction; and

• Of the vaginal deliveries nationally reported in private hospitals in 2008, 43.3 per cent were spontaneous, 4.9 per cent were forceps deliveries and 10.4 per cent were vacuum extraction.


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Table 29: Mode of Delivery by Gestation 2000-2009

Gestation in weeks Year

Vaginal Delivery Caesarean Section Total No. (%) No. (%) No.

20 – 24

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

25 (89) 23 (100) 20 (87) 26 (87) 24 (89) 23 (96) 21 (95) 37 (95) 31 (89) 30 (88)

3 (11) 0

3 (13) 4 (13) 3 (11) 1 (4) 1 (5) 2 (5) 4 (11) 4 (12)

28 23 23 30 27 24 22 39 35 34

25 – 29

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

20 (43) 13 (48) 25 (53) 24 (55) 13 (36) 17 (59) 16 (59) 13 (38) 24 (57) 7 (24)

27 (57) 14 (52) 22 (47) 20 (45) 23 (64) 12 (41) 11 (49) 21 (62) 18 (43) 22 (76)

47 27 47 44 36 29 27 34 42 29

30 - 34

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

88 (57) 81 (54) 72 (48) 80 (52) 73 (46) 60 (50) 87 (52) 61 (42) 85 (45) 92 (51)

66 (43) 70 (46) 77 (52) 74 (48) 84 (54) 60 (50) 79 (48) 86 (58) 105 (55) 89 (49)

154 151 149 154 157 120 166 147 190 181

35 - 39

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

1 898 (70) 1 819 (68) 1 816 (70) 1 760 (65) 1 754 (64) 1 898 (65) 1 929 (63) 1 965 (62) 2 109 (63) 2 130 (63)

794 (30) 853 (32) 767 (30) 937 (35) 969 (36)

1 038 (35) 1 144 (37) 1 186 (38) 1 236 (37) 1 244 (37)

2 629 2 672 2 583 2 697 2 723 2 936 3 073 3 151 3 345 3 374

40 and over

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

2 590 (86) 2 426 (86) 2 521 (87) 2 197 (84) 2 157 (83) 2 337 (83) 2 417 (84) 2 431 (83) 2 315 (81) 2 246 (82)

429 (14) 389 (14) 376 (13) 414 (16) 428 (17) 470 (17) 442 (16) 512 (17) 535 (19) 505 (18)

3 019 2 815 2 897 2 611 2 585 2 807 2 859 2 943 2 850 2 751

* Note: Due to 2 missing stillbirths within the system for 2008, the total number figure is slightly under-reported in this table.


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Caesarean Section Table 30: Emergency / Elective Caesarean Section Proportion 2000-2009

Year Emergency Elective

No. % No. % 2000 649 50.3 642 49.7

2001 675 51.1 645 48.9

2002 600 48.2 646 51.8

2003 707 48.7 733 51.0

2004 754 49.9 741 49.1

2005 766 48.4 816 51.6

2006 797 47.5 879 52.5

2007 846 46.8 962 53.2

2008 882 46.5 1 015 53.5

2009 895 48.0 970 52.0

Table 31: Emergency / Elective Caesarean Section Proportion by Public / Private Hospitals 2000-2009

Year Emergency % Elective %

Public Private Public Private 2000 56 41 44 59

2001 57 45 43 55

2002 54 41 46 59

2003 49 47 51 53

2004 56 42 44 58

2005 51 45 49 55

2006 52 39 48 61

2007 52 37 48 63

2008 52 39 48 61

2009 53 40 47 60

Table 32: Primary / Repeat Caesarean Section Proportion 2000-2009

Year Primary Repeat

No. % No. % 2000 832 62.8 492 37.2

2001 811 60.8 523 39.2

2002 754 60.5 492 39.5

2003 912 62.9 539 37.1

2004 951 63.0 559 37.0

2005 971 61.3 611 38.6

2006 968 57.8 708 42.2

2007 1 018 56.3 790 43.6

2008 1 100 58.0 797 42.0

2009 1 084 58.1 781 41.9


Table 33: Primary / Repeat Caesarean Section Proportion by Public / Private Hospitals 2000-2009

Year Primary % Repeat %

Public Private Public Private 2000 66 59 34 41

2001 64 57 36 43

2002 61 60 39 40

2003 62 64 38 36

2004 65 60 35 40

2005 61 62 39 38

2006 58 57 42 43

2007 56 57 44 43

2008 58 58 42 42

2009 59 57 41 43

Figure 14: Caesarean Section and Assisted Vaginal Rates 1992-2009

The incidence of CS has risen progressively since the 1970s. This has been a trend in all countries, although the degree of rise has varied. In Tasmania, the rate is 29 per cent in year 2009, which is still below the Australian national rate reported in 2008 (31.1 per cent).

As outlined in recent reports, multiple factors that are likely to contribute to this trend include the following:

1. Maternal age. This has been known to be an independent variable ever since perinatal outcomes were recorded by the late Professor Joe Correy when he started the first data collection in a state population in Australian in the 1970s. In general, here has been a steady trend for a reduction in births in women in the 20-29 age group, with an equally steady trend for an increase in the 30-39 year age group and over. The CS rate for the 40+ group is approximately double the rate reported for the 20-29 age group and as a demographic change alone it would be expected that the CS rate should rise without any change in background rates changing.

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2. Obstetric medical disorders. One of the consequences of an increasing maternal age in the obstetric population is that providers are now experiencing a significant increase in the incidence of medical disorders in pregnancy. Hypertension, diabetes mellitus, renal disease, connective tissue and autoimmune diseases, etc all have significant potential implications for the well-being of mother and foetus. As these disorders, per se, are associated with increased CS rates, then a move to an older obstetric population will inevitably lead to a rise in CS rates as a method of managing more complex pregnancies.

3. Change in parity. Whereas in the 1970s and before it was not unusual for women to have more than 3 babies, the rate per woman is now less than 2 babies. As has been well documented, the CS rate for primigravidae is much higher than for multipara. This concentration of primigravidae, who are also older, concentrate the numbers likely to have CS delivery as a demographic change alone, without any actual increase in rates in each age group.

4. Maternal weight. The problems of obesity in pregnancy and the issues in relation to pregnancy have been highlighted in recent times particularly with obesity becoming a modern health epidemic. In developed countries this has reached proportions that have a significant consequence for health services. In recent years much attention has rested on smoking and its effects on health. There is emerging evidence of a similar effect and magnitude related to obesity. Even being overweight has been shown to increase morbidity and health costs. In the last decade attention has been directed to maternal body weight and its effects on pregnancy outcome. Although no obstetric weight data from Tasmania are available, it has been shown that the rate of obesity in the general population in Tasmania has increased significantly – as in other states in Australia. Research has shown that a BMI >30 is associated with a significant increase in CS rates. Thus, it is reasonable to assume, though it is not proven in Tasmania, that part of the increase stems from an increase in maternal obesity rates.

Table 34: Adverse Outcomes in Overweight and Obese Women

BMI 25-30 - overweight BMI >30 - obese

Gestational diabetes 1.68 (1.53 - 1.84) 3.6 (3.25 - 3.98)

Pre-eclampsia 1.44 (1.28 - 1.62) 2.14 (1.85 - 2.47)

Induction of labour 2.14 (1.85 - 2.47) 1.70 (1.64 - 1.76)

Emergency CS 1.30 (1.25 - 1.34) 1.83 (1.74 - 1.93)

PPH 1.16 (1.12 - 1.21) 1.39 (1.32 - 1.46)

Wound infection 1.27 (1.09 - 1.48) 2.24 (1.91 - 2.64)

Birthweight> 90% 1.57 (1.50 - 1.64) 2.36 (2.23 - 2.50)

Intra-uterine death 1.10 (0.94 - 1.28) 1.40 (1.14 - 1.71)

Breast feeding at discharge 0.86 (0.84 - 0.88) 0.58 (0.56 - 0.60)

5. A change in method of delivery from the early 1980s. Instrumental delivery rates have fallen from above 20 per cent to under 10 per cent. This is in recognition that traumatic instrumental delivery, particularly from high in the birth canal, is attended by significant morbidity both for the baby and the mother. Few breech babies are born vaginally now Australia-wide and an increasing number of twins undergo CS delivery for all of the reasons postulated with the addition of the complications of twin pregnancy including malpresentation and discrepancy in foetal growth and condition.


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6. Altered delivery of pre-term babies. Table 30 shows data from year 2000 until current. There has been an increasing trend to deliver babies by CS at gestations 30-39 weeks.

This reflects the increasing neonatal support, and survival rates, available now, where babies born very preterm from conditions such as IUGR, pre-eclampsia etc, who were managed longer in utero, are now born earlier and in better condition by CS. Those delivered by CS at very early gestations are now expected to have very high survival rates in NICU.

7. The use of cardiotocography (CTG). Although it is known that the introduction and widespread use of CTG in the 1970s to monitor foetuses in labour has been associated with a significant rise in CS rates, it is questionable whether CTG use is still responsible for ongoing rising rates. The institution of the RANZCOG CTG guidelines has yet to be evaluated with regard to its impact on the rate of CS since the widespread Australian use of the guidelines began.

8. Concern regarding Pelvic Floor function. The Colorectal and Urological literature has focused on the burden of both faecal and urinary incontinence in the female population highlighting the effects of childbirth. In practice this has led to a more liberal offer of CS to women perceived to be at higher risk of subsequent bowel or urinary incontinence e.g. those who experienced anal sphincter damage (a third or fourth degree tear with a prior delivery) or who have undergone surgery for prolapse or urinary incontinence.

9. Debate in Obstetric Academic Circles and literature with regard to the safety of Vaginal Birth after Caesarean Section (VBAC) and the low acceptance of any foetal risk within the pregnant population and their families.

10. Empowerment of women as the consumer of maternity care and a preference among some groups of women to request CS. Although elective CS in a primigravida with no medical indication is still relatively rare practitioners face difficulty in the current practising climate to refuse such requests. Once minor risk factors are added – VBAC, multiple pregnancy, difficult previous vaginal delivery, IVF pregnancy, predicted larger than average baby the practitioner has limited grounds for refusal of a request for CS.

11. Induction of labour. Whilst overall the effect of increasing induction of labour rates is associated with increased CS rates, research19 shows that women carefully selected have no increase in CS rates. The practice of delaying induction of labour to term plus 10 days, in the absence of contra-indications to waiting, means labour is more likely to occur spontaneously.

19 Patterson, J. A., Roberts, C. L., Ford, J. B. and Morris, J. M. (2011), Trends and outcomes of induction of labour among nullipara at term.

Australian and New Zealand Journal of Obstetrics and Gynaecology. doi: 10.1111/j.1479-828X.2011.01339.


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Table 35: All Births by Caesarean Section following Augmentation of Labour 2000-2009

Type of Augmentation Year Primary Repeat

% of all Augmentations

ARM* only

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

25 35 34 37 44 73 96 97 74 91

5 2 5 7 9 6 14 17 16 17

5.4 6.5 5.8 6.6 8.6 10.2 11.2 12.5 10.2 11.3

Oxytocin only

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

34 35 38 57 60 82 96 91 113 98

3 0 1 1 5 3 2 6 3 4

19.1 17.6 18.5 22.6 26.5 23.2 21.6 21.3 24.6 23.2

Oxytocin & ARM*

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

18 22 19 25 24 66 66 103 93 125

1 3 2 1 4 5 2 4 5 4

16.2 17.1 16.0 19.7 21.0 20.7 24.5 24.6 24.9 29.8

Other

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

0 0 1 1 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0

0.0 0.0 25.0 33.3 0.0 0.0 0.0 0.0 0.0 0.0

* ARM = Artificial Rupture of Membranes


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Induction of Labour

Table 36: Induction Rate 2000-2009

Deliveries following Induction of Labour

Year Vaginal Deliveries

Caesarean Section Deliveries Total Induction Induction Rate

No. (%) No. (%) No. % 2000 1 159 (85) 211 (15) 1 370 22.9

2001 1 157 (83) 235 (17) 1 392 24.3

2002 1 267 (87) 189 (13) 1 456 25.5

2003 1 192 (84) 235 (16) 1 427 25.7

2004 1 195 (81) 279 (19) 1 474 26.6

2005 1 433 (80) 349 (20) 1 782 30.1

2006 1 375 (80) 335 (20) 1 710 27.8

2007 1 315 (79) 350 (21) 1 665 26.4

2008 1 300 (79) 353 (21) 1 653 25.6

2009 1 347 (78) 380 (22) 1 727 27.1

The rate of induction of labour has shown an overall increase from 22.9 per cent in 2000 to 27.1 per cent in 2009 (see Table 36) compared to national figures of 25.7 per cent in 2000 to 24.8 percent in 2008. The percentage of CS deliveries has significantly increased since 2000 to 2009 (see Table 36). The consequences of increasing maternal age are the concomitant increase in complex maternal obstetric conditions such as hypertension, diabetes mellitus, renal disease etc. As these medical conditions are known to potentially impact on the pregnancy and the well-being of the baby it is not surprising that rates of induction of labour have increased.

The true reasons for increased induction of labour and caesarean section in Tasmania remain to be elucidated. Prospective data are necessary to meaningfully analyse these trends and propose interventions that may reverse these trends. It is hoped that the statewide Electronic Perinatal Database (ObstetrixTas) will enable the facilitation of the collection of such information for formal assessment.

Table 37: Caesarean Section Rate following Induction of Labour 2000-2009

Year Caesarean Sections

No. Inductions of Labour with Caesarean Section Delivery

No. % 2000 1 324 211 15.9

2001 1 334 235 17.6

2002 1 246 189 15.2

2003 1 451 235 16.2

2004 1 510 279 18.5

2005 1 582 349 22.1

2006 1 676 335 20.0

2007 1 808 350 19.4

2008 1 898 353 18.6

2009 1 864 380 20.4


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Table 38: Induction Rate by Public / Private Hospitals 2000-2009

Year

Deliveries following Induction of Labour

Vaginal deliveries No. (%)

Caesarean Section No. (%)

Induction Rate %

Public Private Public Private Public Private

2000 593 (81) 503 (88) 139 (19) 66 (12) 20.4 25.7

2001 608 (83) 502 (83) 127 (17) 103 (17) 22.0 26.9

2002 669 (87) 563 (86) 99 (13) 90 (14) 23.9 29.3

2003 670 (84) 558 (81) 125 (16) 133 (19) 26.5 30.3

2004 634 (80) 540 (82) 158 (20) 118 (18) 24.4 30.1

2005 912 (81) 531 (80) 215 (19) 136 (20) 28.2 34.4

2006 860 (78) 528 (85) 242 (22) 96 (15) 26.3 31.7

2007 784 (78) 538 (81) 226 (22) 125 (19) 23.7 32.5

2008 787 (79) 513 (79) 214 (21) 139 (21) 23.1 31.0

2009 815 (78) 533 (79) 235 (22) 145 (21) 25.0 31.6

*Note that figures reported between 2005 and 2008 in this report differs from previous reports since data needed to reflect public/private patients rather than

hospital

Nationally in 2008, of women who gave birth, 57.0 per cent had a spontaneous onset of labour; 18.2 per cent of mothers had no labour; and 24.8 per cent of mothers had induced labour while labour was augmented for 19.9 per cent of all mothers, representing 35.0 per cent of mothers with spontaneous onset of labour. Of all women who gave birth in 2008, 57.5 per cent had a non-instrumental vaginal birth; forceps delivery accounted for 3.7 per cent of mothers while vacuum extraction accounted for 7.7 per cent of women who gave birth nationally. Induced labour continues to be more likely in the private sector in Tasmania (31.6 per cent). While inductions are higher in the private sector, induction in both private and public hospitals has increased by the same relative proportion in the last decade.

There has been a continued increase in caesarean sections reported nationally over the last 10 years with 31.1 per cent of mothers undergoing caesarean section deliveries in 2008. Again in 2008, national data have shown that caesarean section rates increase with maternal age and continue to be higher among older mothers (aged 35 and over) and those who gave birth in private hospitals.


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Augmentation of labour

Table 39: Augmentation of Labour 2000-2009

Year

Artificial Rupture of Membranes Oxytocin Other None

Total Augmentation

Augmentation Rate

No. No. No. No. No. % 2000 498 165 64 2 958 684 20.4

2001 541 179 133 2 559 721 25.0

2002 667 210 136 2 377 727 29.9

2003 671 257 135 2 104 853 33.6

2004 618 245 138 2 217 1 013 31.1

2005 772 366 343 4 435 1 063 25.0

2006 985 454 277 4 431 1 001 27.9

2007 920 455 435 4 504 1 481 28.6

2008 885 471 394 4 712 1 716 27.1

2009 956 439 433 4 540 1 810 28.7

In Tasmania, 28.7 per cent of mothers were reported in 2009 to have undertaken augmentation of spontaneous labour. In contrast, 19.9 per cent of all mothers nationally (2008) were reported to have their labour augmented. Furthermore, in 2008 nationally, the onset of labour was spontaneous for 57.0 per cent of all mothers giving birth and 24.8 per cent of mothers had their labour induced.

Multiple Pregnancy Table 40: All Births by Multiple Pregnancies 2000-2009

Year

Infants Born from a Twin Pregnancy

No.

Infants Born from a Triplet* Pregnancy

No. 2000 180 3

2001 180 3

2002 164 3

2003 184 3

2004 197 9

2005 176 3

2006 172 6

2007 188 3

2008 209 3

2009 166 9

* All birth orders >1 are multiple.

Please note that infants who do not survive beyond 20 weeks of gestation, or who do not weigh more than 400 grams are not recorded as a birth, hence some

odd numbers in the figures above.


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The proportion of multiple births in Tasmania continues to be higher than the national average with 27.5 multiple pregnancies per 1 000 mothers recorded in Tasmania in 2009. There were 16.1 multiple pregnancies per 1 000 mothers in 2008 nationally. Multiple pregnancies in 2008 accounted for 1.6 per cent of all pregnancies: 4 639 twin pregnancies, 62 triplet pregnancies and two quadruplet pregnancies were reported in this year. It has been reported20 that the number of multiple births has increased in the last two decades where this increasing national trend being most likely attributable to increased fertility-related drugs and reproduction technology; delay in childbearing and the increasing number of older mothers. Triplet and higher order multiple births have remained relatively stable in recent years with a rate of 0.3 to 0.4 per 1 000 mothers since 1999, but decreasing to a rate of 0.2 per 1 000 mothers in 2008 nationally.

Table 41: Perinatal Mortality in Multiple Pregnancies 2000-2009

Year Twin Deaths* Triplet Deaths*

No. % No. % 2000 10 5.5 1 33.3

2001 4 2.2 0 0.0

2002 9 5.5 0 0.0

2003 9 4.9 0 0.0

2004 6 2.9 2 22.2

2005 6 3.4 0 0.0

2006 2 1.2 0 0.0

2007 9 4.7 0 0.0

2008 6 2.9 0 0.0

2009 7 4.2 1 11.1

* Includes stillbirths and neonatal deaths; (note: 2005 and 2006 figures have been corrected from previous report); note: the Perinatal Mortality for Twin 1 is

14.3/1000 and for Twin 2 is 18.6/1000.

Twin pregnancies encompass monochorionic and dichorionic twins. It is recognised that monochorionic twins pose special risks in the form of (a) diamniotic – twin to twin transfusion syndrome, and (b) monoamniotic – cord entanglement. These pregnancies are often interrupted prematurely so the risks attached are not the same as for singleton pregnancies. The extra risk to second twins has been noted in the literature21, hence consultant associated management is necessary. There is a widespread trend towards delivering term twins by caesarean section, however this data supports the Tasmanian practice of offering vaginal deliveries having ruled out contraindications to vaginal delivery.

20 Laws, P.J., Li, Z. & Sullivan, E.A., (2010), Australia’s mothers and babies 2008, Perinatal statistics series, No. 24, Cat. no. PER 50, Canberra: AIHW.

21 Smith, G., Pell, J. & Dobbie, R. (2002), ‘Birth order, gestational age, and risk of delivery related perinatal death in twins: retrospective cohort study’, British Medical Journal, vol. 325, 2 November, pp. 1004-1006.


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Table 42: Perinatal Mortality in Multiple Pregnancies by Birth Order 2005-2009

Year

Twin 1 Twin 2 Triplet Stillbirth

Stillbirth Neonatal

death Stillbirth Neonatal

death Triplet 1 Triplet 2 Triplet 3 2005 2 0 3 1 0 0 0

2006 1 0 1 0 0 0 0

2007 1 3 3 2 0 0 0

2008 1 1 2 2 0 0 0

2009 3 1 2 1 0 0 1

* Data is not available prior to 2005.

Maternal Hypertension Table 43: Number of cases of Maternal Hypertension for all Births 2000-2009

Type of Hypertension

Pre-Existing Hypertension in

pregnancy* Eclampsia Nil Total No. % No. % No. % No. % No.

1998 69 1.1 317 5.1 2 ^ 5 783 93.7 6 171

1999 66 1.1 342 5.6 0 0.0 5 737 93.4 6 145

2000 122 2.0 315 5.3 0 0.0 5 538 92.7 5 975

2001 101 1.8 283 4.9 0 0.0 5 342 93.3 5 726

2002 103 1.8 252 4.4 0 0.0 5 359 93.8 5 714

2003 81 1.5 249 4.5 0 0.0 5 215 94.0 5 545

2004 83 1.5 245 4.4 0 0.0 5 212 94.1 5 540

2005 91 1.5 350 5.9 0 0.0 5 475 92.5 5 916

2006 91 1.5 320 5.2 0 0.0 5 733 93.3 6 144

2007 101 1.6 357 5.7 0 0.0 5 856 92.7 6 314

2008 86 1.3 318 4.9 0 0.0 6 055 93.7 6 459

2009 108 1.7 345 5.4 0 0.0 5 916 92.9 6 369

* Due to data accuracy concerns in relation to the recording of pregnancy induced hypertension and Pre-eclampsia, these figures have been combined as

Hypertension in Pregnancy.

The number of cases of maternal hypertension reported in Tasmania in 2009 was lower than reported in the previous few years since 2005 but still higher than figures reported between 2000 and 2004. An increasing rate of obesity in the general population and maternal obesity rates in association with increasing maternal ages in the obstetric population have been known to impact on the state of maternal hypertension and have significant potential implications for the well-being of mother and foetus.


Postpartum Haemorrhage

Table 44: Incidence of Postpartum Haemorrhage 2000-2009

Year No. Incidence of Total Births

% 2000 245 4.5

2001 244 4.3

2002 246 4.3

2003 227 4.1

2004 238 4.3

2005 202 3.4

2006 178 2.9

2007 224 3.5

2008 212 3.3

2009 248 3.9

Figure 15: Incidence of Postpartum Haemorrhage 1992-2009

Antepartum Haemorrhage

Table 45: Type of Antepartum Haemorrhage 2000-2009

Year Placenta Praevia

No. Abruptio Placenta

No. Incidence of Total Births

% 2000 22 37 1.0 2001 26 36 1.1 2002 21 28 0.9 2003 16 27 0.8 2004 18 25 0.8 2005 22 21 0.7 2006 27 17 0.7 2007 25 17 0.7 2008 33 19 0.8 2009 23 28 0.8

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Smoking and Pregnancy Following a revision and update of the Perinatal Data Collection Form in 2005, data exploring the smoking status of Tasmanian women during pregnancy continue to be available for review in 2009, supplementing previous work conducted in the 1980’s by the late Professor Joe Correy (Obstetric and Neonatal Report, Tasmania 1981) and Dr Neville Newman.

Table 46: Smoking Comparison 2009 and 1982

Age 1982*

% Age 2005

% 2006

% 2007

% 2008

% 2009

% Overall 35.3 27.6 27.1 27.9 26.9 23.9

<20 55.2 <20 54.0 55.2 55.2 47.6 34.9

21-25 46.0 20-24 43.8 40.9 44.2 41.6 39.5

26-30 30.2 25-29 26.4 26.6 26.7 22.8 25.0

>30 21.2 >30 16.7 16.6 18.5 16.6 14.7

Public Not

reported 35.7 35.5 36.2 34.3 32.2

Private Not

reported 8.3 6.9 6.8 7.0 5.7

*Obstetric and neonatal Report – Tasmania 1982

The 2009 data on smoking prevalence during pregnancy are derived from self-reported information obtained by clinicians from the mother and reported to the Perinatal Data Collection.

Smoking during pregnancy is regarded as one of the key preventable causes of low birth weight and pre-term birth. Low birth weight (LBW) babies (less than 2 500 grams) are more likely to die in the first year of life and are more susceptible to chronic illness later in life, such as heart and kidney disease and diabetes.

In 2009, 23.9 per cent of Tasmanian women indicated that they had smoked tobacco during their pregnancy, with 14.6 per cent reporting to have smoked less than 10 cigarettes per day and 9.3 per cent reporting to have smoked more than 10 cigarettes daily.

Figure 16: Self-reported Tobacco Smoking Status during Pregnancy in Tasmania 2009

DHHS, Perinatal Database No. of mothers who reported= 6 226

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Data available for other jurisdictions show that in 2008, Tasmania continued to show that it had the highest proportion of women who smoked during pregnancy (see Table 47). Overall nationally, 16.2 per cent of women in these states and territories smoked during pregnancy with this proportion changing little over the previous five years22.

Table 47: Proportion of Women Smoking Tobacco during Pregnancy by State and Territory, 2008

Jurisdiction % Smoked during pregnancy NT 23.5

TAS 26.9

SA 20.1

QLD 19.3

WA 15.4

ACT 14.0

NSW 12.8

Source: Australia's Mothers and Babies 2008, National Perinatal Statistics Unit; data not available for VIC

Table 46 and Figure 17 show that maternal smoking continues to be more prevalent among younger women in Tasmania, particularly those aged less than 25 years. The proportion of women smoking during pregnancy continues to decline significantly for women aged 30 years and over. In general, the overall trend is consistent with that reported in 2008 although it is encouraging to note that there is a statistically significant reduction in mothers smoking during pregnancy who are aged less than 20 years. This group in fact has been reported to undertake smoking practices less during pregnancy than the women aged between 20 to 24 years, a difference which is statistically significant.

Figure 17: Self-Reported Tobacco Smoking Status during Pregnancy by Age, Tasmania 2009

DHHS, Perinatal Database

22 Laws, P.J., Li, Z. & Sullivan, E.A.,(2010), Australia’s mothers and babies 2008, Perinatal statistics series, No. 24, Cat. no. PER 50, Canberra: AIHW.

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There has been a slight decrease in self-reported smoking during pregnancy by private patients (5.7 per cent in 2009 vs. 6.6 per cent in 2008) and decrease in self-reported smoking during pregnancy by public patients (32.2 per cent in 2009 vs. 34.3 per cent in 2008); only the decline in smoking during pregnancy for public patients was statistically significant (p=0.034) However, smoking during pregnancy continues to be more prevalent for public patients (32.2 per cent) compared to private patients (5.7 per cent) (Figure 18). As reported in previous years, this trend continues to reflect the higher prevalence of smoking among lower socio-economic groups. It is encouraging though to find that the percentage reported in 2009 for public patients who smoked during pregnancy is lower than the percentage reported in the previous year.

Figure 18: Self-Reported Smoking Status by Public / Private Patients, Tasmania 2009


For patients delivering in public hospitals, as shown in Figure 18, smoking during pregnancy continued to be reported in 2009 most frequently by patients at the Royal Hobart Hospital (33.9 per cent) up from 30.8 per cent the previous year, and the least frequently (24.2 per cent) reported by patients at the Launceston General Hospital also slightly higher than figures reported in 2008 (23.7 per cent). It is interesting to note that while there was an overall trend for a reduced number of women smoking during pregnancy in 2009, there was however, for all public hospitals, a slight increase in the percentage of mothers who were reported to have smoked during pregnancy in 2009 compared to figures reported in the previous year. The increase from 2008 to 2009 was only statistically significant for the RHH (p=0.037). It is important to remember that a key factor in the variations reported between public hospitals relates to the differences in the patient mix at the three hospitals.

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Figure 19: Self-Reported Tobacco Smoking Status during Pregnancy by Hospital, Tasmania 2009


Low birthweight (LBW) is defined as a weight of less than 2 500 grams and includes babies that are small for gestational age as well as premature.

Based on the number of births (excluding multiple births, as multiparous births often result in low birth weight babies regardless of the mother’s smoking status) whose mothers answered the smoking questions, a total of 169 babies had a birthweight of less than 2 500 grams. Of these, 17 per cent (28) had a birthweight of less than 1 500 grams (very LBW). In 2009, a total of 12.2 per cent of all women who had smoked in pregnancy had a LBW baby compared to 5.2 per cent of women who reported not to have smoked (see Figure 20), a difference which is statistically significant (p<0.0001). This figure representing the proportion of low birth weight babies in mothers who smoked remains relatively steady with figures reported in 2008 (12.4 per cent) and is a finding which continues to highlight the potential deleterious effects of smoking on birth weight. The relative risk of having a LBW in 2009 was 2.34 (95%CI: 1.95, 2.80) in women who smoked in pregnancy compared with those who reported not to smoke.

Figure 20: Self-Reported Smoking Status during Pregnancy and Birthweight, Tasmania 2009

Note: NB multiparous births have been omitted; DHHS, Perinatal Database Page 69 of 83


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It continues to be important to note that a number of sources of error may influence the strength of this association. For example, since some women may be uncomfortable in disclosing their smoking status during the course of their pregnancy the reported data may not therefore provide an accurate measure of trends. Furthermore, maternal smokers may have other risk factors associated with LBW babies including younger maternal age, poorer prenatal care, inadequate maternal weight gain or other substance abuse. Such factors were not adjusted for in the analyses. If one or more of these factors is positively associated with LBW, they may be responsible for some of the excess risk that is attributed to maternal smoking. That is, the relative risk estimate of RR = 2.34 may be an overestimate due to confounding (Epidemiology Unit, Population Health, 2011).

Smoking in Pregnancy: Comments from the Council

As cited previously, evidence suggests that smoking cessation strategies do result in a reduction in the frequency of smoking, where low cost/intensity strategies, utilising maternity care providers at antenatal visits have been found to be as effective as high intensity strategies.

In view of this evidence, QUIT Tasmania has commenced the use of a resource developed by Quit South Australia in 2008 to train midwives on how to provide intervention on smoking cessation during pregnancy. QUIT Tasmania have also trained staff that can provide counselling support specifically for pregnant women on the Quitline. Positive outcomes have been welcomed where the review of the data available from 2009 has demonstrated that such smoking cessation programmes as undertaken by Quit Tasmania have provided beneficial effects across all age groups in this year especially with regard to younger mothers aged less than 20 years. There still seems to be some work to do to ensure a more positive effect for public hospitals.

In general, the positive findings found across age groups demonstrate that such interventions to reduce smoking in pregnancy continue to be important especially in view of evidence suggesting that where intrauterine growth restriction continues to be a significant contributor to perinatal mortality, any strategy that reduces the incidence of growth restriction may correspondingly reduce the stillbirth rate.

Recommendation:

As reported in previous years, interventions to reduce smoking in pregnancy are important particularly in view of reducing the incidence of growth restriction and potentially stillbirth rate. Standard antenatal care should therefore continue to incorporate smoking reduction advice for all women who smoke as provided by QUIT Tasmania.


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Alcohol Consumption and Pregnancy The effects of alcohol consumption during pregnancy have been extensively reported in medical literature. Alcohol is evidenced to have deleterious effects on foetal development and birth outcomes. Alcohol is a teratogen and exposure of the foetus to alcohol may result in a spectrum of adverse effects - Foetal Alcohol Spectrum Disorders (FASD)23. Foetal Alcohol Syndrome (FAS) has been described in children exposed to high levels of alcohol in utero as a result of either chronic or intermittent maternal alcohol use10. Alcohol has been found to cross the placental barrier causing such problems as reduced foetal growth or weight, characteristic facial abnormalities, damaged neurons and brain structures as well as other physical, mental or behavioural problems24. In particular, the primary effect of FAS is permanent central nervous system damage, especially to the brain. Furthermore, developing brain cells and structures are underdeveloped or malformed by prenatal alcohol exposure and as such are often associated with an array of primary cognitive and functional disabilities (e.g., attention and memory deficits) and secondary disabilities (e.g., mental health problems and drug addiction)25. In fact, foetal alcohol exposure has been found to be a primary cause of neurological problems and mental retardation26. Of great concern is that while the risk of birth defects is greatest with high, frequent maternal alcohol intake during the first trimester, alcohol exposure throughout pregnancy, and before a pregnancy is confirmed, can have negative consequences on the development of the foetal brain since the foetal brain continues to develop throughout the whole pregnancy10,27.

High level and/or frequent intake of alcohol in pregnancy has also been associated with increased risk of miscarriage, stillbirth and premature birth28. In addition, there is new evidence to suggest that prenatal alcohol exposure may increase the risk of alcohol dependence in adolescence29.

It is also necessary to highlight that timing is important and not all “heavy” drinkers will have an affected child10.

23 National Health and Medical Research Council (NHMRC) (2009), Australian Guidelines to Reduce Health Risks from Drinking Alcohol, Canberra.

24 Ulleland, C.N. (1972). The offspring of alcoholic mothers. Annals New York Academy of Sciences, 197, 167-169. PMID 4504588.

Streissguth, A. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Brookes Publishing. ISBN 1-55766-283-5.

25 Streissguth, A.P., Barr H.M., Kogan, J. & Bookstein, F.L. (1996). Understanding the occurrence of secondary disabilities in clients with fetal alcohol

syndrome (FAS) and fetal alcohol effects (FAE): Final report to the Centers for Disease Control and Prevention on Grant No. RO4/CCR008515 (Tech. Report No. 96-06). Seattle: University of Washington, Fetal Alcohol and Drug Unit.

26 Abel, E.L., & Sokol, R.J. (1987). Incidence of fetal alcohol syndrome and economic impact of FAS-related anomalies: Drug alcohol syndrome and economic impact of FAS-related anomalies. Drug and Alcohol Dependency, 19(1), 51-70. PMID 3545731.

27 Guerri, C. (2002). Mechanisms involved in central nervous system dysfunctions induced by prenatal ethanol exposure. Neurotoxicity Research, 4(4), 327-335. PMID 12829422.

28 O’Leary C.M., (2004). Fetal alcohol syndrome: diagnosis, epidemiology and developmental outcomes. Journal of Paediatric Child Health, 40: 2-7.

29 Alanti R., Mamun, A.A., Williams, G. et.al., (2006). In utero alcohol exposure and prediction of alcohol disorders in early adulthood: A birth cohort study. Arch. Gen. Psychiatry, 63: 1009-1016.


In view of the potential problems associated with alcohol consumption during pregnancy, data exploring the alcohol consumption status of Tasmanian women during pregnancy was available for review last year and continues to be collected for review. Available data on alcohol consumption during pregnancy is derived from self-reported information obtained by clinicians from the mother and reported to the Perinatal Data Collection.

In 2009, a total of 6 280 pregnant women in Tasmania reported on their use of alcohol during pregnancy. As with the data available for smoking during pregnancy, it is important to note that some women may be similarly uncomfortable in disclosing their alcohol consumption status during the course of their pregnancy and as such the data provided may not be entirely accurate.

Table 48 and Figure 21 below show that overall 11.2 per cent of Tasmanian women indicated that they had consumed alcohol during their pregnancy with 10.2 per cent reporting to have consumed less than one standard alcoholic drink per day and 1.0 per cent reporting to have consumed more than one alcoholic drink per day.

Table 48: Alcohol Consumption in 2009

Age 2007

% 2008

% 2009

% Overall 14.6 12.6 11.2

<20 15.9 14.4 8.7

20-24 12.1 12.9 10.5

25-29 14.0 14.5 9.7

30-34 14.2 12.6 11.0

35-39 19.0 15.3 16.1

>39 16.6 17.2 11.7

Public 13.3 11.7 9.7

Private 18.2 15.5 15.0

Figure 21: Self-reported Alcohol Consumption Status during Pregnancy in Tasmania 2009

DHHS, Perinatal Database No. of mothers who reported= 6 280

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It appears that maternal alcohol consumption continues to be more prevalent among the older mothers in Tasmania especially after the age of 35 years. The proportion of women consuming alcohol during pregnancy is lowest for women aged less than 35 years, particularly in the 25-29 year and less than 20 year age groups (Table 48 & Figure 22).

Figure 22: Self-Reported Alcohol Consumption Status during Pregnancy by Age, Tasmania 2009


Figure 23: Self-Reported Alcohol Consumption Status by Public / Private Patients, Tasmania 2009


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Alcohol consumption during pregnancy by private patients (15.0 per cent) appears to be more prevalent compared to public patients (9.7 per cent) as shown above in Table 48 & Figure 23, the difference also being statistically significant (p<0.001). This may reflect a higher prevalence of alcohol consumption among the higher socio-economic groups. It is also evident however that alcohol consumption reported in 2009 is lower than reported in the previous year by both private and public patients; however, only the decrease in alcohol consumption by public patients is statistically significant. Of those who reported consuming alcohol during pregnancy, the consumption of more than one alcoholic drink was reported by 9.7 per cent of public patients and 15.0 per cent of private patients.

With regard to the proportion of Tasmanian mothers from public hospitals reporting to have consumed alcohol during pregnancy, Figure 23 shows that in 2009, alcohol consumption during pregnancy continues to be reported most frequently by patients at the Launceston General Hospital (11.3 per cent) and least frequently (5.1 per cent) reported by patients at the Mersey, the latter proportion being statistically significantly lower than for the other two hospitals (p<0.002). Similar to the Smoking and Pregnancy data, a key factor in these variations may relate to difference in the patient mix at the three hospitals.

Figure 24: Self-Reported Alcohol Consumption Status during Pregnancy by Hospital, Tasmania 2009


As indicated previously, low birthweight (LBW) is defined as a weight of less than 2 500 grams and includes babies that are small for gestational age as well as premature.

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Based on the number of births (excluding multiple births, as multiparous births often result in low birth weight babies regardless of the mother’s smoking status) whose mothers answered the alcohol consumption questions, a total of 59 babies, had a birthweight of less than 2 500 grams. Of these, 19 per cent (11) had a birthweight of less than 1 500 grams (very LBW). In 2009, a total of 9.3 per cent of all women who had consumed alcohol during pregnancy had a LBW baby compared to 6.5 per cent of women who reported not to consumed alcohol (Figure 25), a statistically significant difference (p=0.006). The relative risk of having a LBW baby in 2009 was 1.42 (95% CI: 1.11, 1.83) in women who consumed alcohol in pregnancy compared to those who reported not having consumed alcohol. It is important to note that a number of sources of error may influence findings of this analysis. Since some women may be uncomfortable in disclosing alcohol consumption during the course of their pregnancy, the reported data may not provide an accurate measure of alcohol consumption during pregnancy. Furthermore, other risk factors associated with LBW babies may be involved, including smoking, younger maternal age, poorer prenatal care, inadequate maternal weight gain, or other substance abuse. Such factors were not adjusted for in the analyses.

Figure 25: Self-Reported Alcohol Consumption Status during Pregnancy by Birthweight, Tasmania 2009


Recommendation:

In relation to recommendations around alcohol consumption during pregnancy from the NHMRC Australian Guidelines to Reduce Health Risks from Drinking Alcohol, Australian Government, 2009 (c.f. Guideline 4: Pregnancy and breastfeeding) Council agrees that:

A. For women who are pregnant or planning pregnancy, not drinking is the safest option.

B. For women who are breastfeeding, not drinking is the safest option.

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Attachment A: Guidelines for Investigation of “Unexplained” Stillbirths

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Introduction

For stillbirths where the cause is obvious, investigations should be targeted towards the cause. In all other cases where no cause is determined, the following guideline should be used.

A thorough and systematic approach will result in the likelihood of a cause being found and would help in counselling patients and might help prevent recurrences. While the list below is not meant to be comprehensive, it should serve as a guideline for investigation of stillbirths. All hospitals within the state are encouraged to implement the guideline.

Guideline

Detailed medical and social history of the mother

A possible cause for the stillbirth like intercurrent infection, cholestasis of pregnancy or drug use may be elicited by careful history taking and examination of the antenatal record.

Histopathology of placenta

Whether or not an autopsy is performed, all placentas should be sent for examination. The placenta should be placed in a dry sterile container (no formalin or saline), and sent for histopathological examination.

External examination of the baby

In cases where parental consent for autopsy cannot be obtained, external examination of the baby should be performed preferably by a perinatal pathologist or an experienced neonatologist. In addition, clinical photographs, X-rays and if possible MRI scans should be done.

Autopsy of the baby

After informed parental consent, an autopsy should be conducted by an experienced perinatal pathologist. One of the senior clinicians involved with the care of the patient should counsel the couple and explain the need for autopsy. Where consent for a full autopsy cannot be obtained from the parents, efforts should be made to at least obtain consent for limited autopsy including needle biopsies of appropriate organs.

Karyotype

Ideally obtained by amniocentesis prior to delivery, but if consent not obtained then placental biopsy and/or cord blood (if obtainable) or foetal skin should be sent for chromosomal analysis. Chromosomal analysis is still possible in macerated foetuses.


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Maternal Investigations

Where there is no obvious cause for death, the following investigations should also be performed:

a) Full Blood Count b) Maternal antibody screen c) Kleihauer Test (blood should be obtained prior to delivery) d) HbA1c (GTT if indicated) e) Liver function tests including serum bile acids f) Renal function tests including uric acid g) Thrombophilia screen including Anticardiolipin antibodies, Lupus anticoagulant and Activated

protein C resistance h) Maternal serology – CMV, Toxoplasmosis and Parvovirus (Rubella and syphilis if not already

done antenatally) i) Microbiology – foetal ear and throat swab, placental swab j) Drug history and urine drug screen if indicated

Attachment B: Perinatal Data Collection Form


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Feedback Form

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Feedback Form The Council of Obstetric & Paediatric Mortality & Morbidity is committed to ensuring that the Annual Report is a useful tool for Obstetricians, Paediatricians and Midwives in monitoring the care and outcomes for Mothers and Babies. To this end we would welcome your feedback. Please complete the following form and return it to:

Executive Safety and Quality Unit Care Reform Ground Floor, 34 Davey Street HOBART TAS 7000

Please circle one option

1. Did you find the information contained within this Report useful? Yes No If no, please specify what was lacking:

2. Is there additional information you would like to routinely see included in the

Report? Yes No

If yes, please specify:

3. Are there any other suggestions you would make to assist in improving the usefulness

of this Report? Yes No

If yes, please specify:

If you require further information please contact the Executive, Care Reform, Safety and Quality Unit on 6216 4366.

Notes

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Notes

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COUNCIL OF OBSTETRIC & PAEDIATRIC MORTALITY & MORBIDITY (TASMANIA) Care Reform- Safety and Quality Department of Health and Human Services

GPO Box 125, Hobart 7001 Ph: 6216 4366 Email: [email protected]

Visit: www.dhhs.tas.gov.au

Documents

Council of Obstetric & Paediatric Mortality & Morbidity · Alcohol Consumption and Pregnancy 5 ... Sex of Infants 34. Page ii Birthweight 35 ... Table 14: Presentation at Delivery