Perinatal Death: Epidemiology and Etiology

(1)

Perinatal death: epidemiology and etiology

Maria Teresa Neto MD,PhD Maria Teresa Neto MD,PhD Neonatal Intensive Care Unit Neonatal Intensive Care Unit

Hospital de Dona Estefânia Hospital de Dona Estefânia

Centro Hospitalar de Lisboa Central, EPE, Centro Hospitalar de Lisboa Central, EPE, Faculdade de Ciências M

Faculdade de Ciências Médicas, Universidade Nova de Lisboaédicas, Universidade Nova de Lisboa

Portugal Portugal

(2)

(3)

Epidemiology

Over 130 million babies are born every yearOver 130 million babies are born every year

About 3 million die in the first 7 days of lifeAbout 3 million die in the first 7 days of life

There are about 3.2 million stillbirths (2.08 to 3.79)There are about 3.2 million stillbirths (2.08 to 3.79)

Mean perinatal mortality rate worldwide 21.5/1000 livebirths + stillborn

(4)

Epidemiology

There is a wide gap in stillbirth rates between highThere is a wide gap in stillbirth rates between high-

-income countries

income countries -- 2/1000 births in Finland 2/1000 births in Finland -- and and low

low--income regions income regions –– 40/100040/1000

98% of stillbirths occur in low and middle98% of stillbirths occur in low and middle--income income

countries

(5)

The downward escalade

Since the 1990s neonatal mortality reduction has Since the 1990s neonatal mortality reduction has

been smaller than postneonatal and infant mortality

The proportion of underThe proportion of under--five mortality rates due to five mortality rates due to

deaths in the first month of life has been increasing

The great component of neonatal mortality is by The great component of neonatal mortality is by

deaths occurring in the first week of life

The great component of perinatal mortality is foetal The great component of perinatal mortality is foetal

death

(6)

Deaths in the first month Deaths in the first week

Foetal deaths

Perinatal mortality rate

The downward escalade

(7)

Neonatal

Relative decreasing rates of mortality

Postneonatal

(8)

New strategies

It is urgent to implement measure to reduce It is urgent to implement measure to reduce

foetal and intrapartum deaths

foetal and intrapartum deaths –– about 2 about 2 million

million

It is urgent to reduce deaths in the first week It is urgent to reduce deaths in the first week

of life

of life -- ¾¾ of neonatal deaths of neonatal deaths

(9)

Sensitive indicators of the status of health systemsSensitive indicators of the status of health systems

They show the availability of rapid response to They show the availability of rapid response to

foetal and mother life

foetal and mother life--threatening conditions often threatening conditions often unpredictable, access in time to a tertiary level of

unpredictable, access in time to a tertiary level of

care and coordinated actions between

obstetricians, paediatricians and midwives

Maternal and foetal outcomes at birth

(10)

Perinatal mortality rates

The mirror of organization of perinatal care and The mirror of organization of perinatal care and

the developmental grade of a society

(11)

Epidemiology

Difficulties

Countries with vital statistics /reported rates Countries with vital statistics /reported rates

(2009)

(2009) –– 33 33 (Cousens, 2011)(Cousens, 2011)

Countries where the number of deaths have to Countries where the number of deaths have to

be evaluated by estimates

be evaluated by estimates -- 160160

No reliable data No reliable data –– 33 33

Other sources of knowledge: surveillance systems and household

surveys

(12)

(13)

Bias

Different definitions

Gestational age to define abortion, stillborn Gestational age to define abortion, stillborn

WHO WHO –– 22 weeks, 500g, 25cm 22 weeks, 500g, 25cm

WHO WHO -- 28 weeks, 1000g, 35cm for international comparison28 weeks, 1000g, 35cm for international comparison

USA (NCHS) USA (NCHS) -- 20 weeks, 350g; 20 weeks, 350g;

UK UK -- 24 weeks24 weeks

Portugal Portugal -- 24 weeks 24 weeks -- Directorate General of Health Directorate General of Health

(excludes interruptions from statistics)

Portugal Portugal -- 22 weeks 22 weeks -- National Institute for Statistics National Institute for Statistics

(official data; excludes interruptions from statistics)

(14)

Bias

Different definitions

Ratio Ratio –– stillborn per 1000 live birthsstillborn per 1000 live births

Rate Rate -- stillborn per 1000 live births and stillborn per 1000 live births and

stillborn

(15)

The burden of the problem

The two components of the perinatal mortality The two components of the perinatal mortality

Foetal mortality Foetal mortality -- 2/3 of perinatal mortality 2/3 of perinatal mortality

rates

rates -- bad knowledge on data and causes. bad knowledge on data and causes.

Few programmes to decrease its rate. Few programmes to decrease its rate.

Unrecognised as a problem. Unrecognised as a problem.

Lack of research and searching for solutionsLack of research and searching for solutions

Early neonatal mortality Early neonatal mortality -- ¾¾ of all of all

neonatal deaths

neonatal deaths -- better knowledge. Middle better knowledge. Middle and high

and high--income countries know their data and income countries know their data and have well assessed programmes to decrease its

have well assessed programmes to decrease its

rates

(16)

The burden of the problem

High

High--income countriesincome countries

Perinatal mortality: foetal/late foetalPerinatal mortality: foetal/late foetal and and early neonatal.early neonatal.

Neonatal mortality: from birth to 28 days Neonatal mortality: from birth to 28 days –– early neonatal early neonatal

and late neonatal mortality

Infant mortality: Infant mortality: neonatalneonatal ((earlyearly and late) and postneonataland late) and postneonatal

Reduction of infant mortality rates are obtained

reducing early neonatal mortality

(17)

The burden of the problem

Low/middle

Low/middle--income countriesincome countries

Perinatal mortality: late foetalPerinatal mortality: late foetal and early neonatal. and early neonatal.

Neonatal mortality: from birth to 28 days –Neonatal mortality: from birth to 28 days – early neonatalearly neonatal and and

late neonatal mortality late neonatal mortality

Infant mortality: neonatal (early and late) and Infant mortality: neonatal (early and late) and postneonatalpostneonatal

Reduction of infant mortality rates are obtained

reducing postneonatal mortality

(18)

Stillbirth

A major public health problem not

recognised

The large contribution of stillbirth to perinatal The large contribution of stillbirth to perinatal

death rates

(19)

Millennium Development Goals

WHO

1 - Eradicate extreme poverty and hunger 2 - Achieve universal primary education

3 - Promote gender equality and empower women 4 - Reduce under-five mortality of 2/3

5 - Reduce maternal mortality 1990-2015 by 75%

6 - Combat HIV/AIDS, malaria and others 7 - Environment sustainability

(20)

Goals in perinatal health

““Adressing the health of mothers and newborns is Adressing the health of mothers and newborns is

fundamental to the achievement of not only

MDGs 4 and 5 but also several other MGDs, most

notably MGD1 (eradicate extreme poverty and

hunger); MGD2 (achieve universal primary

education); MGD3 (promote gender equality and

empower women) and MGD6 (combat HIV/AIDS,

malaria and other diseases)

malaria and other diseases)”” Darmstad,

(21)

The orphan reality

UN Millennium Development Goals 2015 UN Millennium Development Goals 2015 –– no no

mention on stillbirth

DisabilityDisability--adjusted lifeadjusted life--years lost for stillbirth years lost for stillbirth –– not not

present in the Global Burden of Disease metrics

The International Classification of Diseases does not The International Classification of Diseases does not

identify the dead foetus as an individual death

As stillbirth is not recognised as a death As stillbirth is not recognised as a death

interventions to reduce them are not widely

assessed

(22)

Is a stillborn different from a neonatal

death?

Both were alive before being dead and just Both were alive before being dead and just

some minutes may separate the two conditions

Why being upset and searching for causes and Why being upset and searching for causes and

trying to reduce neonatal death and do not do

the same for stillbirth?

(23)

Perinatal mortality data

Dependent on the perinatal organization, Dependent on the perinatal organization,

definitions, policies, economics, social and ethnic

conditions, religious believes, women

conditions, religious believes, women´´s rights, etcs rights, etc

Perinatal mortality data are neither consistent nor Perinatal mortality data are neither consistent nor

correct: in low

correct: in low--income countries because they are income countries because they are not registered; in high

not registered; in high--income countries because income countries because definitions are not uniform vg different Estates of

definitions are not uniform vg different Estates of

the US

(24)

Dependence on the angle of vision

In highIn high--income countries the scale is small; personal income countries the scale is small; personal

problems have a great impact; psychological and

decisional issues are prominent

In lowIn low--income countries, problems are discussed by income countries, problems are discussed by

region, country or continent and are related to public

health care, organizational and sanitary conditions.

Personal problems are left hidden under the veil of

the

the ““usualusual”” high mortality rates as if there were no high mortality rates as if there were no psychological effects on the mother /family

(25)

Problems

HighHigh--income countries income countries –– the scope of the problem is the scope of the problem is

known: numbers and causes are published.

Deviations are diagnosed and correction is possible

LowLow--income countries income countries –– neither the true burden of neither the true burden of

the problem is known nor its causes, making

difficult to implement cost effective interventions

(26)

Evolution?

““Stillbirth rates in lowStillbirth rates in low--income countries are now income countries are now

where they were in high

where they were in high--income countries 50 to income countries 50 to 100 years ago

100 years ago””

Froen JF et al Lancet 2011

It is estimated that stillbirth rate has declined by It is estimated that stillbirth rate has declined by

14.5% from 1995 to 2009

14.5% from 1995 to 2009 (from 22.1 stillbirth/1000 (from 22.1 stillbirth/1000 births to 18.9 stillbirths/1000 births

(27)

The burden of the problem

Reduction of neonatal mortality is closely linked Reduction of neonatal mortality is closely linked

to health care delivered to the mother at any

time

time –– before and during pregnancy and during before and during pregnancy and during delivery

delivery

Mother, foetal and neonatal mortality rates will Mother, foetal and neonatal mortality rates will

profit from the same policies

(28)

Stillbirth is not just a lowStillbirth is not just a low--income country problem income country problem

In 2008 in the UK stillbirths account for twoIn 2008 in the UK stillbirths account for two--thirds thirds

of perinatal death.

In 2009 in Portugal foetal death accounted for In 2009 in Portugal foetal death accounted for

63.8% of perinatal deaths

Despite being much more frequent than other Despite being much more frequent than other

paediatric conditions, programmes and funding for

research are scarce

(29)

0 5 10 15 20 25 30 35 40 45 1 9 6 9 1 9 7 0 1 9 7 1 1 9 7 2 1 9 7 3 1 9 7 4 1 9 7 5 1 9 7 6 1 9 7 7 1 9 7 8 1 9 7 9 1 9 8 0 1 9 8 1 1 9 8 2 1 9 8 3 1 9 8 4 1 9 8 5 1 9 8 6 1 9 8 7 1 9 8 8 1 9 8 9 1 9 9 0 1 9 9 1 1 9 9 2 1 9 9 3 1 9 9 4 1 9 9 5 1 9 9 6 1 9 9 7 1 9 9 8

Austria Belgica Dinamarca Alemanha Finlandia França Grecia Irlanda Italia Luxemburgo Holanda Portugal Espanha Suecia Reino Unido

Perinatal mortality rate

Portugal and other European countries

(30)

Perinatal mortality rate in Portugal

(2004 (2004--2009)2009) 4,4 _4,3 4,6 4,4 4 4,6 0 10 2004 5 6 7 8 9

Per thousand live births+stillbirths >28weeks GA

(31)

Perinatal mortality rate in EU

(2005 (2005--2007)2007) 0 1 2 3 4 5 6 7 8 9 Port ugal 07 Ger man y06 Aus tria 06 Bel gium Den mar k05 Spa in05 Finl and Fran ce01 Hol and Irla nd Italy UK Sw eden 05

Per thousand live births+stillbirth

(32)

Perinatal mortality rate by level of

development

(2000)

0 10 20 30 40 50 60 70

World More develped regions

Less developed regions

Least developed countries

Per thousand live births+stillbirth

(33)

Perinatal mortality rate by regions

(2000)

0 10 20 30 40 50 60 70

Africa Asia Latin America

Europe Oceania

Per thousand live births+stillbirth >28 weeks

(34)

Neonatal mortality rate (/1000LB) in

Portugal

3,6 8,1 15,7 2,7 2,1 2,1 2,1 2,4 0 2 4 6 8 10 12 14 16 18 1979 1989 1999 2003 2005 2007 2008 2009 Source: INE Reform

(35)

0 1 2 3 4 5 6 7 8 9 10 Port ugal 07 Ger man y06 Aus tria 06 Bel gium Den mar k01 Spa in05 Finl and Fran ce05 Hol and Irla nd Italy UK Sw eden 05

Per thousand live births

WHO/Europe 2008

Neonatal mortality rate in EU

(2005

(36)

0 10 20 30 40 50

Africa Asia Latin America Industrialized countries

Per thousand live births

WHO/Health Monitor, January 2004

Neonatal mortality rates by region

(37)

Coverage of maternal health

services

97 65 99 53 0 20 40 60 80 100

Antenatal care Skilled birth attendance Developed countries Developing countries

(38)

USA

-

_-

Race and ethnic disparities

_{Race and ethnic disparities}

Hogue et al 2011 *

Assume there is a clear disparity for stillbirth rates Assume there is a clear disparity for stillbirth rates

for the non

for the non--Hispanic black deliveries that prevailed Hispanic black deliveries that prevailed throughout the 20

throughout the 20thth _{century and into the 21}_{century and into the 21}stst

century.

(39)

USA

-

_-

Race and ethnic disparities

_{Race and ethnic disparities}

Hogue et al 2011 *

In a review of the literature many factors were In a review of the literature many factors were

analysed: Socio

analysed: Socio--demographic conditions, demographic conditions, reproductive history, behavioural and pre

reproductive history, behavioural and pre--pregnancy pregnancy health factors, maternal medical disorders, factors

health factors, maternal medical disorders, factors

in current pregnancy

Conclusion: Conclusion: ““Although many factors including Although many factors including

genetics, environment, stress, social issues, access

and quality of medical care and behaviour

contribute to racial disparities in stillbirth the

reasons for the disparity remain unclear.

(40)

USA

-

_-

Race and ethnic disparities

_{Race and ethnic disparities}

Hogue et al 2011 *

In USA nonwhites did achieve the 1945In USA nonwhites did achieve the 1945--level level

stillbirth rate of whites 26 years later, in 1972

The nonThe non--Hispanic Black stillbirth rate in 2005 was Hispanic Black stillbirth rate in 2005 was

similar to the total white rate in 1990

similar to the total white rate in 1990 –– a gap of 15 a gap of 15 years

years

Also improvement of stillbirth rates was higher for Also improvement of stillbirth rates was higher for

non

non--Hispanic white than for nonHispanic white than for non--Hispanic black Hispanic black people

people

(41)

(42)

Etiology

The importance of knowing it

To evaluate the avoidable cases To evaluate the avoidable cases (Flenady , 2009)(Flenady , 2009)

To identify the underlying conditions of foetal To identify the underlying conditions of foetal

death and the chain of events leading to it

death and the chain of events leading to it (Flenady, 2009)

(Flenady, 2009)

To identify deficiencies in the provision of care To identify deficiencies in the provision of care

(Whitfield, 1986)

(43)

Causes of death

Difficulties

Foetal death

Classifications of perinatal death

(Flenady,

2009):

33 new systems and a further 12 modifications of them; 3 on stillbirth only. Non-registration of causes of stillbirth in low-income countries

Neonatal death

Classification of causes available in high-income countries but wide variation.

(44)

Causes of death

Difficulties

Stillbirth may be faced by the mother as a fatality Stillbirth may be faced by the mother as a fatality

In many countries the stillborn is not given a name, In many countries the stillborn is not given a name,

neither have a funeral nor is dressed or held by the

mother

In many regions it is a nonIn many regions it is a non--event. In others it a event. In others it a

non

non--counted eventcounted event

It may be hidden because of shame, superstition or It may be hidden because of shame, superstition or

supposed lack of care by the mother

(45)

Problems

““Although the causes of stillbirth are poorly Although the causes of stillbirth are poorly

understood they are associated with conditions

that are inherently dangerous to women

that are inherently dangerous to women´´s health: s health: obstetric emergencies such as eclampsia or

obstetric emergencies such as eclampsia or

underlying infections and diseases as malaria,

syphilis, chorioamnionitis

syphilis, chorioamnionitis””

(46)

Macro scale

–

Worldwide

Causes of perinatal death Causes of perinatal death

Causes of stillbirth and early neonatal death have

similar obstetric origin and are related to place of

delivery or miss of skilled birth attendance

(47)

Macro scale

–

Worldwide

Causes of perinatal death Causes of perinatal death

AsphyxiaAsphyxia may cause stillbirth or post natal death: may cause stillbirth or post natal death:

obstructed labour, eclampsia, abruptio placenta,

obstructed labour, eclampsia, abruptio placenta, foetal foetal malpresentation, umbilical cord complications

malpresentation, umbilical cord complications

Infection,Infection, responsible for 26% of deaths: bacterial responsible for 26% of deaths: bacterial -

-p

prolonged labour or prolonged rupture of membranes; rolonged labour or prolonged rupture of membranes; neonatal tetanus, syphilis, malaria, HIV

neonatal tetanus, syphilis, malaria, HIV

Prematurity: Prematurity: under nutrition,under nutrition, twins,twins,

Malformations: Malformations: undiagnosed, the smallest undiagnosed, the smallest

percentage <5%

(48)

Health

-

care workers in perinatal

medicine

Estimated numbers needed to ensure skilled Estimated numbers needed to ensure skilled

assistance to 80% of all births

assistance to 80% of all births –– 23 doctors, 23 doctors, nurses and midwives /10 000 people

nurses and midwives /10 000 people

Maternities in subMaternities in sub--Saharan Africa with skilled Saharan Africa with skilled

staff and equipment needed to perform

neonatal resuscitation

neonatal resuscitation –– 15%15%

In highIn high--income countries an excess of doctors income countries an excess of doctors

and nurses is the rule

(49)

(50)

Skilled birth attendance

Training in neonatal resuscitation in health care Training in neonatal resuscitation in health care

facilities would avert 30% of intrapartum

facilities would avert 30% of intrapartum--related related neonatal deaths

(51)

Caesarean section rates

Low

Low--income countriesincome countries 2%2%--5% 5%

Or/and when feasible

High

High--income countriesincome countries 28%28%--35% 35% And on demand

(52)

The first five causes of stillbirth

USA 2006 Portugal UK Southeast

Asia

(53)

Causes of neonatal death

Africa UK Southeast Asia Worldwide

Asphyxia Immaturity-related conditions Diarrhoeal diseases Preterm birth Prematurity and

low birth weight

Congenital malformations Tetanus Neonatal infections (1/3 to ½) Infection Pneumonia or sepsis Congenital malformations Preterm birth complications Birth asphyxia

(54)

The first five causes of infant death

USA 2006 UK Southeast Asia

Congenital malformations Congenital malformations

Diarrhoeal diseases Disorders related to short

gestation

Immaturity-related conditions

Malaria

SIDS SIDS Pneumonia

Maternal complications of pregnancy

Measles

(55)

Causes of death

-

Portugal 2004

-

2005

From 24 weeks to 28 days

(Wigglesworth modified) (Wigglesworth modified)

2004 2005

Before labour 61,1% 54,8% Associated to immaturity and preterm

delivery

21,1% 18%

Congenital malformation 14,5% 9,2 During labour 7,4% 11,4%

(56)

Causes of death in Portugal

2009

Neonatal deaths

Congenital anomalies 12,2%

Gestation and foetal growth problems

10,6% Respiratory diseases 8%

Others 69%

Infant deaths

Congenital anomalies 14,3%

(57)

Levels of commitment

Public Public facilities facilities Health care Health care organization organization Control of infectious Control of infectious conditions* conditions* Water

Water Skilled birth Skilled birth attendance

attendance

Vaccines

Waste

Waste Prevention of Prevention of prematurity

prematurity

Screening

Food

Food PreventionPrevention

Treatment

Treatment *Malaria, syphilis, tetanus, HIV, diarrhoea

(58)

Malformations

Assessment of preventive measuresAssessment of preventive measures

Access and acceptance of antenatal diagnosis and Access and acceptance of antenatal diagnosis and

termination of pregnancy

Access to and acceptance of treatment for infants Access to and acceptance of treatment for infants

born with congenital malformations

(59)

Major gaps in knowledge

Number of foetal deaths in low/middle Number of foetal deaths in low/middle

income countries

Number of early and late neonatal deaths Number of early and late neonatal deaths

in countries without vital statistics

Causes of preterm birthCauses of preterm birth

Causes of stillbirthCauses of stillbirth

Causes of neonatal deaths in countries Causes of neonatal deaths in countries

without vital statistics

(60)

Possible interventions

General

Comprehensive emergency obstetric careComprehensive emergency obstetric care

Tetanus toxoid immunizationTetanus toxoid immunization

Antibiotics for preterm premature rupture Antibiotics for preterm premature rupture

of membranes

Antenatal steroids in preterm labourAntenatal steroids in preterm labour

Active management of the third stage of Active management of the third stage of

labour

Neonatal resuscitationNeonatal resuscitation

(61)

Possible interventions

Local

-

Conclusion

(63)

(64)

(65)

(66)

(67)

(68)

(69)

Children´s malnutrition

Underweight

0 10 20 30 40 50 60 Ango la 9 6 Afgh anis tan 04 Bahr ain 07 Bang lade sh 9 7 Beni m 0 6 Burk ina Faso 09 Buru ndi 0 0 Eritr ea 0 2 Indi a 06 Mal i 06 Paki stan 01 Som alia 06 Suda n 06 Tim or L este 03 Source WHO

(70)

The burden of the problem

7.6 million children under five died in 2010 7.6 million children under five died in 2010

(57/1000 live births)

70% of this mortality occurred in the first year 70% of this mortality occurred in the first year

of life

In 2008, 64% died because of infectious In 2008, 64% died because of infectious

diseases

diseases –– pneumonia and diarrhoea accounting pneumonia and diarrhoea accounting for one

(71)

Portuguese birth rate (1979

-

2009)

0 20000 40000 60000 80000 100000 120000 140000 160000 180000 1 9 7 9 1 9 8 0 1 9 8 1 1 9 8 2 1 9 8 3 1 9 8 5 1 9 8 6 1 9 8 7 1 9 8 9 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5 2 0 0 6 2 0 0 7 2 0 0 8 2 0 0 9

(72)

Twin Pregnancy

-

Portugal

1990

-

2009

0 0,5 1 1,5 2 1990 95 0 5 6 7 8 9 %

(73)

Twins

-

Portugal

2004

-

2009

1 2 3 4 5 2004 5 6 7 '8 9 %

(74)

Preterm and low birth weight rates

Portugal

4,1 12,3 5,7 6,8 _6,6 7,9 9,1 _8,9 _8,7 7,2 7,6 7,5 7,6 7,8 7,7 8,2 0 2 4 6 8 10 12 14 2001 2004 2005 2006 2007 2008 2009

Preterm Low birth weight

Best LBW EU 2007 Preterm births USA 2008

%