council of obstetric & paediatric mortality & morbidity · 2010. 5. 10. · the members of...

Council of Obstetric & Paediatric Mortality & Morbidity

Annual Report 2007

Depar tment o f Hea l th and Human Serv ices

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

Copyright State of Tasmania, Department of Health & Human Services, 2009.

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 2009

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Table of Contents Index of Tables 5

Index of Figures 7

Executive Summary 9

Babies 9

Mothers 9

Perinatal and Paediatric Deaths at a Glance 10

Perinatal Deaths 10

Maternal Deaths 10

Paediatric Deaths 11

Smoking and Pregnancy 11

Alcohol Consumption and Pregnancy 11

Data Collection and Reporting 12

Acknowledgments 14

Perinatal Registry Act 1994 15

Definitions Prescribed under the Perinatal Registry Act 16

Supplementary Definitions 17

Members of the Council of Obstetric & Paediatric Mortality & Morbidity 18

Members of Sub-Committees & Support Services 19

Committee Reports 20

Perinatal Mortality & Morbidity Sub-Committee 20

Basic Information on Stillbirths for 2007 20

Basic Information on Neonatal Deaths for 2007 24

Paediatric Mortality & Morbidity Sub-Committee 27

Paediatric Deaths for 2007 27

Maternal Mortality & Morbidity Sub-Committee 31

Maternal Deaths for 2007 31

Data Management Sub-Committee 32

Perinatal Statistics 33

Births and Birth Rates 33

Sex of Infants 36

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Birthweight 37

Low Birthweight 37

Apgar Scores 39

Resuscitation 40

Presentation at Delivery 41

Perinatal Mortality 41

Neonatal Mortality 43

Foetal 45

Neonatal 45

Perinatal 45

Autopsy Rates 46

Age of Mothers 46

Parity 49

Indigenous Status 49

Breastfeeding 50

Mode of Delivery 51

Caesarean Section 55

Induction of Labour 59

Augmentation of labour 61

Multiple Pregnancy 61

Maternal Hypertension 63

Postpartum Haemorrhage 64

Antepartum Haemorrhage 65

Smoking and Pregnancy 66

Smoking in Pregnancy: Comments from the Council 70

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

Notes 84

Notes 85

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Index of Tables Table 1: Perinatal Deaths for 2007 20

Table 2: Paediatric Deaths for 2007 27

Table 3: Breakdown of Sudden Infant Deaths and Deaths related to Injury for year 2007 27

Table 4: Livebirths* and Birth Rates for Tasmania 1992-2007 33

Table 5: Livebirths by Region 1997-2007 34

Table 6: Births by Hospital 1999-2007 34

Table 7: Proportion of Public and Private Patients 1992-2007 35

Table 8: Sex of all Infants Born in Tasmania 1997-2007 36

Table 9: Incidence of Low and Very Low Birthweight 1992-2007 37

Table 10: Outcome by Gestation 1996-2007* 38

Table 11: Apgar Score for all Births at Five Minutes 1997-2007 39

Table 12: Intubation Rate 1992-2007 40

Table 13: Resuscitation Rate 1997-2007 40

Table 14: Presentation at Delivery for all Births 1997-2007 41

Table 15: Perinatal Outcome 1997-2007 41

Table 16: Perinatal Mortality Rates 1992-2007 42

Table 17: Neonatal Mortality per 1 000 Births 1992-2007 43

Table 18: Neonatal Mortality, per 1000 Births, in Infants over 28 weeks Gestation 1992-2007 44

Table 19: Neonatal Mortality, per 1 000 Births, in Infants over 1 000 Grams Birthweight 1992-2007 44

Table 20: Foetal, Neonatal and Perinatal Death Rate per 1 000 Births by State and Territory 1998-2006 45

Table 21: Rate of Autopsies on Perinatal Deaths 1992-2007 46

Table 22: Age of Mothers 1992-2007 46

Table 23: Rates of Birth per 1 000 Female Population by Maternal Age 2000-2007 48

Table 24: Percentage of Births by Parity 1992-2007 49

Table 25: Mother's Indigenous Status 1999-2007 50

Table 26: All Births by Breastfeeding at Discharge 2000-2007 50

Table 27: Breastfeeding at Discharge by Public / Private Hospital 2000-2007 50

Table 28: Breastfeeding at Discharge by Parity 2000-2007 51

Table 29: Mode of Delivery 1998-2007 51

Table 30: Mode of Delivery by Gestation 2000-2007 54

Table 31: Emergency / Elective Caesarean Section Proportion 1997-2007 55

Table 32: Emergency / Elective Caesarean Section Proportion by Public / Private Hospitals 2000-2007 55

Index of Tables

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Table 33: Primary / Repeat Caesarean Section Proportion 1998-2007 55

Table 34: Primary / Repeat Caesarean Section Proportion by Public / Private Hospitals 2000-2007 56

Table 35: All births by Caesarean Section following Augmentation of Labour 2000-2007 58

Table 36: Induction Rate 1996-2007 59

Table 37: Percentage of Caesarean Sections following Induction of Labour 1996-2007 60

Table 38: Induction Rate by Public / Private Hospitals 2000-2007 60

Table 39: Augmentation of Labour 1997-2007 61

Table 40: All Births by Multiple Pregnancies 1997-2007 61

Table 41: Perinatal Mortality in Multiple Pregnancies 1997-2007 62

Table 42: Number of cases of Maternal Hypertension for all Births 1996-2007 63

Table 43: Percentage of cases of Maternal Hypertension for all births 1996-2007 63

Table 44: Incidence of Postpartum Haemorrhage 1992-2007 64

Table 45: Incidence of Antepartum Haemorrhage 1992-2007 65

Table 46: Type of Antepartum Haemorrhage 1997-2007 66

Table 47: Smoking Comparison 2007 and 1982* 66

Table 48: Proportion of Women Smoking Tobacco during Pregnancy by State and Territory, 2006 67

Table 49: Alcohol Consumption in 2007 72

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Index of Figures Figure 1: Birth Rate for Tasmania per 1 000 Head of Population 1992-2007 33

Figure 2: Proportion of Admitted Patient Elected Accommodation Status 1992-2007 35

Figure 3: Number of Infants Born by Sex 1997-2007 36

Figure 4: Percentage of all Births by Birthweight Groups 2000-2007 37

Figure 5: Number of Births with Apgar Score less than 6 at Five Minutes 1997-2007 39

Figure 6: Stillbirths & Neonatal Deaths 1997-2007 42

Figure 7: Perinatal Mortality Rate per 1 000 Births in Tasmania 1992-2007 and Australia 1998-2006 43

Figure 8: Proportion of Births by Maternal Age Groups 1992-2007 47

Figure 9: Proportion of Births by Maternal Age in Tasmania 2007 and Australia 2006 47

Figure 10: Mode of Delivery in Tasmania 1998-2007 52

Figure 11: Mode of Delivery in Public Hospitals in Tasmania 2007 and Australia 2006 52

Figure 12: Mode of Delivery for Private and Public Patients in Tasmania 2007 53

Figure 13: Caesarean Section Rates 1992-2007 56

Figure 14: Incidence of Postpartum Haemorrhage 1992-2007 64

Figure 15: Incidence of Antepartum Haemorrhage 1992-2007 65

Figure 16: Self-reported Tobacco Smoking Status during Pregnancy in Tasmania 2007 67

Figure 17: Self-Reported Tobacco Smoking Status during Pregnancy by Age, Tasmania 2007 68

Figure 18: Self-Reported Smoking Status by Public / Private Patients, Tasmania 2007 68

Figure 19: Self-Reported Tobacco Smoking Status during Pregnancy by Hospital, Tasmania 2007 69

Figure 20: Self-Reported Smoking Status during Pregnancy by Birthweight, Tasmania 2007 69

Figure 21: Self-reported Alcohol Consumption Status during Pregnancy in Tasmania 2007 72

Figure 22: Self-Reported Alcohol Consumption Status during Pregnancy by Age, Tasmania 2007 73

Figure 23: Self-Reported Alcohol Consumption Status by Public / Private Patients, Tasmania 2007 73

Figure 24: Self-Reported Alcohol Consumption Status during Pregnancy by Hospital, Tasmania 2007 74

Figure 25: Self-Reported Alcohol Consumption Status during Pregnancy by Birthweight, Tasmania 2007 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 2007.

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 2007, 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 2007 include:

Babies • The number of livebirths recorded on the Perinatal Data System in 2007 was 6314, an increase of

170 (2.7 per cent) since 2006 (6 144).

• Males accounted for 51 per cent of births and females 49 per cent.

• There were 94 multiple births including 93 sets of twins.

• The proportion of low birth weight babies (less than 2 500 grams) in Tasmania was 7 per cent, compared to the national proportion of 6.4 per cent in 2006.

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

Mothers

• 72 per cent of mothers were public patients and 27 per cent were private patients.

• 45 per cent of mothers were aged over 30 years. 6.8 per cent of mothers were under the age of 20 years, a higher proportion than the national average of 4.3 per cent in 2006.

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

• 3.7 per cent of mothers were identified as Aboriginal & Torres Strait Islanders.

• 68 per cent of mothers had an unassisted vaginal delivery and 10.6 per cent had an instrumental delivery.

• 29 per cent of mothers gave birth by caesarean section (compared to 21 per cent in 1998).

• Of the caesarean section deliveries, 53 per cent were elective and 47 per cent were emergencies.

• 80 per cent of mothers were breastfeeding at discharge.

• 28 per cent of mothers reported smoking during pregnancy with the rate for teenage mothers being 55 per cent.

• 15 per cent of mothers reported that they had consumed alcohol during pregnancy with the rate being greatest for mothers aged between 35-39 years (19 per cent) and for mothers who were reported as private patients (18 per cent) compared to public patients (13 per cent).

Executive Summary

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Perinatal and Paediatric Deaths at a Glance

Classification Total No. for 2007

(n=6 314) Rate per 1 000

Perinatal Mortality 62 9.8

Stillbirths 44 7.0

Neonatal Mortality 18 2.9

Total Infant Mortality (from 20 weeks to 1 year)

28 4.4

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

10 1.6

Paediatric Mortality 25* 0.21*

* ABS figure for total no. of children <18 yrs for 2007 in Tasmania is estimated at 117 547. 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 62 deaths in 2007. The perinatal autopsy rate was 27 per cent. As noted in 2006, Council believed that a post mortem examination would have been of benefit in many more of the perinatal deaths that occurred in 2007. The process of giving consent for an autopsy is recognised to be challenging for parents who have lost a baby in pregnancy. Thus, such a request is best handled by a senior member of the obstetric staff. 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 remains a significant and preventable cause of foetal loss. Antenatal care is now provided by many healthcare workers. As such, protocols should be developed by all units and by all practitioners in order to identify the ‘at risk’ foetus with inadequate growth.

A further perinatal death in 2007 in the setting of intended home birth raises concern of an increased risk of adverse outcome associated with home birth in Tasmania, with perinatal mortality being well above the rate reported internationally. The Council urges home birth practitioners to assess their clients carefully regarding suitability for home birth, to make them aware of the potential risks of home birth for their baby, and to consider possible alternatives.

Maternal Deaths In 2007, no maternal deaths were reported for Tasmania. Despite this finding, the Maternal Mortality & Morbidity Subcommittee 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 will provide a significant step in initiating a comprehensive study of serious maternal morbidity events considered to contribute significantly to maternal morbidity in Australia and will be undertaken nationally (including New Zealand) and progressed in 2008 under the support from the National Health & Medical Research Council (NH&MRC). The System will undertake 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.

Executive Summary

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Paediatric Deaths The Paediatric Mortality and Morbidity Sub-Committee noted that the number of paediatric deaths in Tasmania in 2007 was 25 (estimated at 0.21 per 1 000 persons aged 0-17 years). The major cause of death was injuries (n=7, 28 per cent) and conditions determined at birth (n=7, 28 per cent) followed by other acquired conditions (n=6, 24 per cent) and unexplained infant deaths (n=3, 12 per cent; two cases had been found to have associated risk factors with one of these cases also known to child protection services) (Note: 2 of the cases included within the reported findings are still under investigation by the Coroner).

The issue of safe sleeping practices continues to be highlighted as an important factor to consider as all unexplained infant deaths had such risk factors present. All family health care providers should be fully informed about the concept of safe sleeping.

Over a quarter of all paediatric deaths reported in 2007 were due to road trauma. While this proportion is lower than reported in 2006, road trauma remains the most important single cause of preventable death in Tasmania’s children.

A tragic death reported as a result of an accidental injury highlighted the need to maintain continual vigilance when young children are present, particularly when working with vehicles, machinery or heavy loads.

Although no case reported in this year was linked to effects of child abuse, Council continues to consider child protection issues and the importance of identifying children (and if relevant, their siblings) known to Disability, Child Youth and Family Services in order to undertake Child Death Reviews as required. Currently, a formal Child Death Review Framework is being established for Tasmania to undertake review of selected cases as requested.

Smoking and Pregnancy The proportion of mothers smoking during pregnancy in 2007 in Tasmania was 28 per cent which is higher than the reported rates from most other States in 2006. Maternal smoking continues to be more prevalent among younger women, particularly those aged less than 20 years (55 per cent). Of most concern, the proportion of expectant teenage mothers that smoke remains at the elevated levels reported in 2006 and previous years.

The data have also confirmed the significant association between birth weight and smoking status during pregnancy, with a higher proportion of low birth weight babies born to mothers who smoked (9.8 per cent) compared to non-smoking mothers (4.1 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 This has been the first year to review data regarding alcohol consumption during pregnancy since its recent inclusion on the Perinatal Data Collection Form. From the data available in 2007, the overall proportion of mothers consuming alcohol during pregnancy Tasmania was 15 per cent. Maternal alcohol consumption appeared to be more prevalent among older women, particularly those aged between 35-39 years (19 per cent). It also appeared that alcohol consumption was more prevalent among private patients (18 per cent) compared to public patients (13 per cent).

The data showed that 7.7 per cent of babies born to mothers who consumed alcohol during pregnancy were of low birth weight, compared to 6.9 per cent for mothers who did not consume alcohol during pregnancy. This difference was not statistically significant. NH&MRC has recently recommended that women should not consume alcohol during pregnancy as there has been no safe level of alcohol

Executive Summary

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consumption identified. Alcohol has been associated with intrauterine growth restriction, stillbirth and the foetus is susceptible to Foetal Alcohol Spectrum Disorders (FASD)1. 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.

Data Collection and Reporting The Council continues to review the Perinatal Data Collection Form and data collection recommendations made by external agencies are now included on a running list for consideration and discussion by Council, with a view to their implementation at the time online access becomes available.

The development and establishment of a statewide Electronic Perinatal Database is being progressed, and will eventually allow the process of data entry and extraction more streamlined providing clinicians with more timely access to the data.

Terms of Reference for a Data Management Subcommittee have been refined and accepted to enable the subcommittee to provide an information reporting role where data items (as per additions to perinatal data collection form provided by COPMM) can be reviewed and formatting issues related to Annual Reports can be addressed. Membership on this subcommittee will include obstetric, paediatric and midwifery (1 each) Council member or nominees, nominees from Clinical Data Services Unit, DHHS and statistical/epidemiological nominee(s), Population Health DHHS.

Associate Professor Peter Dargaville

Chairperson

Council of Obstetric and Paediatric Mortality and Morbidity

1 NHMRC Australian Guidelines to Reduce Health Risks from Drinking Alcohol, Australian Government, 2009.

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

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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;

• Clinical Data Unit, Corporate Planning and Performance;

• 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.

Perinatal Registry Act 1994

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Perinatal Registry Act 1994 The Perinatal Registry Act was given Royal Assent on the 10th May, 1994. Under the Act the Council of Obstetric and Paediatric Mortality and Morbidity was established, and given the following functions (c.f., 6. Functions of Council):

(a) To investigate the circumstances surrounding, and the conditions that have or may have caused –

(i) Maternal, late maternal and perinatal deaths in Tasmania; and

(ii) Deaths of children in Tasmania in the age group from 29 days to 17 years (inclusive); and

(iii) Congenital abnormalities in children born in Tasmania; and

(iv) Injuries, illness or defects suffered by pregnant women or viable foetuses in Tasmania at any time before or during childbirth;

(b) To maintain a perinatal data collection for the purpose of –

(i) collecting, studying, researching and interpreting information relating to deaths referred to in paragraph (a); and

(ii) Collecting, studying, researching and interpreting information relating to births in Tasmania; and

(iii) Identifying and monitoring trends in respect of perinatal health (including congenital abnormalities); and

(iv) Providing information to the Secretary on the requirements for, and the planning of, obstetric and neonatal care; and

(v) providing information to persons employed in health care and to researchers; and

(vi) Maintaining a register of congenital abnormalities;

(c) To provide information for the education and instruction in medical theory and practice in obstetrics and paediatrics for legally-qualified medical practitioners and nurses;

(d) To investigate and report on any other matters relating to obstetric and paediatric mortality and morbidity referred to the Council by the Minister or the Secretary;

(e) To perform any other function imposed by this Act or any other Act or the regulations.


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Definitions Prescribed under the Perinatal Registry Act 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.

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


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.2

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.3

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

2 Willinger, M., James, L.S. & Catz, C. 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 3 National Health Data Dictionary V10.0


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Supplementary Definitions4 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.

4 Definitions derived from ‘Williams Obstetrics – 20th edition’ by Cunningham MacDonald Gant Leveno Gilstrap

Hankins Clark; Copyright 1997 & www.uptodate.com, August 2008

Members of the Council of Obstetric & Paediatric Mortality & Morbidity

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Organisation Membership 2007 Current Membership

as of Feb 2009 Nominees of the University of Tasmania (2)

Professor Allan Carmichael Professor Allan Carmichael Associate Professor Bipin Gupta

Person nominated by the Secretary employed in delivery of Neonatal Services

Dr Simon Parsons (Chair) Associate Prof Peter Dargaville (Chair)

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

Mr Nick Goddard Mr Tony Sansom

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 Elizabeth Hallam Dr David Strong

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.

Mr Peter Askey-Doran Mr Peter Askey-Doran

Additional Member Nominated by Council to Represent Community interests

Ms Ros Escott Mr David Fanning, (Commissioner for Children)

Ms Ros Escott Mr Paul Mason (Commissioner for Children)


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Members of Sub-Committees & Support Services Name of Subcommittee Membership in 2007

Current Membership as of Feb 2009

Maternal Mortality & Morbidity Subcommittee

Dr Shelby Jarrell (Chair) Dr Melwyn D’Mello Ms Ruth Forrest

Associate Professor Bipin Gupta (Chair) Dr James Brodribb Mr Peter Askey-Doran Dr Amanda Dennis

Paediatric Mortality & Morbidity Subcommittee

Dr Elizabeth Hallam (Chair) Dr Thomas (Geoff) Shannon Dr Chris Lawrence Dr Simon Parsons Mr David Fanning

Dr Chris Lawrence (Chair) Dr Michelle Williams Dr Thomas (Geoff) Shannon Dr Anita Cornelius Mr Paul Mason Senior Child Protection Consultant (tbc)

Perinatal Mortality & Morbidity Subcommittee

Dr Simon Parsons (Chair) Dr James Brodribb Dr Peter Dargaville

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

Data Management Subcommittee

Remains inactive- Council to discuss issues directly

Revised TOR’s completed for this committee with membership to include Chair of COPMM, obstetric, paediatric & midwifery Council members (1 each) or nominees; nominees Clinical Data Services Unit, DHHS; and statistical/epidemiological nominee(s), Population Health, DHHS.

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)

Ms Peggy Tsang (CDS) Ms Helen Galea (CDS) Ms Diane Hickie (CDS)

Compilation of this 2007 Annual Report by: Executive: Dr Jo Jordan (Care Reform, Safety & Quality Unit) Support Staff: Ms Peggy Tsang (Clinical Data Services) Ms Helen Galea (Clinical Data Services) Ms Diane Hickie (Clinical Data Services)

Committee Reports

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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 62 perinatal deaths in Tasmania who died in 2007. Eighteen of these deaths were neonatal deaths (live born infants who did not live beyond 28 days of age) and 44 were stillbirths. The overall perinatal mortality rate was 9.8 per 1 000 births. The neonatal mortality rate was 2.9 per 1 000 births, with a stillbirth rate of 6.9 per 1 000 births.

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

Table 1: Perinatal Deaths for 2007

Cause of Death Number of deaths

2000 2001 2002 2003 2004 2005 2006∗ 2007∗ Congenital Abnormality 9 16 12 15 8 6 5+8 15+6

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

Hypertension 1 2 2 0 0 0 0+2 0

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

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

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

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

Foetal Growth Restriction 1 1 1 3 9 9 0+4 6

Spontaneous Pre-Term 15 8 19 19 10 10 4+6 3+6

Unexplained Antepartum Deaths 16 16 16 15 1 5 6 3

No Obstetric Antecedent 1 0 2 2 0 0 0 4

Birth Trauma 0 0 1 0 0 0 0 0

Overlying - - - - - - - 1

TOTALS 61 57 73 73 51 48 55 62

* The + symbol indicates neonatal deaths plus stillbirths

Basic Information on Stillbirths for 2007

There were 44 stillbirths for 2007, 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=44)

Gestation (weeks)

Number in 2007

%2007 % 2006 % 2005

20-24 28 64 38 49

25-29 3 6.8 12 7.7

30-34 3 6.8 24 18

35-39 7 16 21 18

40+ 3 6.8 5 7.7

Committee Reports

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Classification according to Perinatal Society of Australian and New Zealand

Stillbirths 2007

Category No. %2007 % 2006 %2005

1 Congenital anomalies 15 34 19 13

2 Perinatal infection 2 4.5 0 0

3 Hypertension 0 0 4.7 0

4 Antepartum haemorrhage 1 2.3 12 10

5 Maternal conditions 2 4.5 2.4 2.3

6 Specific perinatal conditions 6 14 14 22

7 Hypoxic peripartum death 2 4.5 9.4 2.3

8 Foetal growth restriction 6 14 9.4 23

9 Spontaneous preterm labour 3 6.8 14 13

10 Unexplained antepartum deaths 3 6.8 14 13

11 No obstetric antecedent 4 9.0 0 0

12 Birth trauma 0 0 0 0

Classification by gestation period

20 to 24 weeks gestation (28)

Category Causes of stillbirth

1 Trisomies (T13x2, T18x2, T21x3) – 7 cases; neural tube defects – 3 cases; multiple organ anomalies – 3 cases.

4 Preterm labour after an abruption – 1 case.

5 Delivery due to severe fulminating pre-eclampsia – 1 case.

6 Foetal hydrops – 1 case; twin-twin transfusion syndrome – 2 twins; labour induction for PPROM where to prospect of survival was deemed poor – 1 case.

8 Unexplained stillbirth, cord hypercoiling with IUGR – 1 case.

9 Preterm labour following second trimester bleeds – 1 case, preterm labour with amnionitis – 1 case; recurrent bleeds from low lying placenta and preterm labour – 1 case.

10 Unexplained stillbirth, died at 17 weeks but delivered at 20 weeks – 1 case.

Committee Reports

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1 Triploidy – 1 case.

2 Premature rupture of membranes with amnionitis – 1 case.

8 Severe IUGR ? maternal autoimmune thrombocytopenia (platelet count 80) – 1 case



1 Triploidy, pregnancy left to natural outcome – 1 case

8 Unexplained severe IUGR – 1 case

10 Unexplained, low protein S and elevated AFP at 14 weeks – 1 case

35-39 weeks gestation (7)


6 Second twin with true knot in the cord, plus the cord tight around the neck – 1 case; Rhesus iso-immunisation in first affected pregnancy in spite of anti-D prophylaxis – 1 case.

7 Second twin, died before delivery by emergency CS – 1 case; unexplained intrauterine asphyxia – 1 case

10 Unexplained cause, being investigated – 1 case.

11 Unexplained causes – 2 cases

40+ weeks gestation (3)


2 CMV infection – 1 case

1 Intrauterine asphyxia, multiple anomalies of CNS and face – 1 case

11 Unexplained cause, found to have trisomy 21 – 1 case

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Discussion & Recommendations on Stillbirths

There are some important features demonstrated from these figures:

1. 64 per cent of all stillbirths occurred in the 20-24 week group and 46 per cent of these (13/28) were due to major chromosomal abnormalities. It is clear that 18-20 week anomaly scanning is resulting in the identification of lethal anomalies which contribute, in a large measure, to the overall perinatal loss. Many of the trisomies (18 and 21) are amenable to first trimester combined screening. It remains unknown whether the mothers of these babies were offered first trimester Down syndrome screening or not.

2. Council recommends that first trimester screening for aneuploidy should be freely available to all

women in Tasmania with appropriate counselling. The uptake of aneuploidy screening (first or second trimester) should be included with the result on the perinatal data collection form.

3. 30 per cent of all stillbirths, overall, were associated with major congenital anomalies. Neural tube

defects continue to occur and reduction is achievable with the use of periconceptual folate supplementation. Since approximately 50% of pregnancies are unplanned, there is a significant chance many women will not be taking in enough folic acid peri-conceptually. Some women will be taking medications that are known to increase the risk of neural tube defects (in particular anticonvulsants), and some pre-existing medical conditions increase the risk e.g. diabetes mellitus. As such, all practitioners caring for women of reproductive age should be prepared to give advice about periconceptual folate. Furthermore, it has been recognised that in obese women (BMI >30) that the usual recommended dose of folate (400 µg) daily is insufficient in reducing the rate of neural tube defects. Hence, in obese women (and in view of increasing BMIs), it would seem prudent to recommend a dose of 5mg of folate daily although this has not yet been confirmed in clinical trials.

4. 40 per cent (4/10) of babies dying in utero after 35 weeks did so as a result of asphyxia. These

were all peripartum and as such would fall under the CTG monitoring guidelines. Antepartum monitoring for at risk pregnancies within and without hospital settings would also fall under these guidelines. This outcome is disappointing. The introduction of a systematic process for foetal monitoring, The Foetal Surveillance Education Program, by RANZCOG should result in minimisation of the prospect of foetal demise due to asphyxia. It would be appropriate for all maternity units to regularly review their use of CTGs and foetal monitoring guidelines.

5. Stillbirth was more commonly unexplained as gestation advanced. However “unexplained” does

not imply the cause is unknowable, as in many cases investigations were incomplete. The Council urges all who care for pregnant women to investigate any stillbirth in accordance with previously published guidelines by this Council.

6. Reviews of notes indicate that investigations for stillbirth remain incomplete in a large proportion

of cases. Post-mortem examination (general or restricted), MRI and X-ray examination of stillborn babies are under-utilised processes that are recommended in the investigation of a stillbirth.

7. Infection (amnionitis) and mid-trimester bleeding are continuing causes for very preterm labour and

foetal loss. Discussion about these issues has occurred in previous reports of the Council.

8. Finally, all practitioners should be aware that if involved with the management of a pregnancy that results in a stillbirth they will be requested by the Council to provide details of all investigations. This will be sent out about 6 months after the event so that there is time to finalise all results, and also for the appropriate maternity unit audit process to be undertaken. It is hoped that timely collection of this information will enable an even better assessment of the causes of perinatal loss in Tasmania.

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Basic Information on Neonatal Deaths for 2007

There were a total of 18 neonatal deaths.

Classification of Neonatal Deaths according to Perinatal Society of Australian and New Zealand

Category No. (2007) %2007 %2006

1 Congenital anomalies 6 33 39

2 Perinatal infection 1 5.6 15

3 Hypertension 0 0 0

4 Antepartum haemorrhage 2 11 7.7

5 Maternal conditions 0 0 0

6 Specific perinatal conditions 0 0 7.7

7 Hypoxic peripartum death 2 11 0

8 Foetal growth restriction 0 0 0

9 Spontaneous preterm labour 6 33 31

10 Unexplained antepartum deaths 0 0 0

11 No obstetric antecedent 0 0 0

12 Birth trauma 0 0 0

Note: 1 infant died as a result of Overlying

Congenital Abnormalities

There were 6 neonatal deaths in Tasmania associated with a congenital abnormality.

• Hypoplastic left heart syndrome (22 weeks gestation).

• CNS abnormalities including congenital paralysis due to pontocerebellar hypoplasia with spinal muscular atrophy and malformation of eye, ear, face and neck (38 weeks gestation).

• Severe urinary tract malformation with prenatal renal failure (two cases, 26 and 34 weeks gestation).

• Severe urinary tract malformation with prenatal renal failure in a second twin (34 weeks gestation).

• Chromosomal and neurological abnormalities leading to obtundation, hypotonia, impaired feeding and temperature instability (38 weeks gestation).

Perinatal Infection

One infant (39 weeks gestation) died of perinatal infection with an unspecified organism.

Antepartum Haemorrhage

Two infants died after antepartum haemorrhage, in one case caused by placental abruption (24 weeks gestation), and in another of indeterminate origin (23 weeks).

Hypoxic Peripartum Death

There were two deaths related to peripartum hypoxia, with the following antecedents:

• Intrapartum complications in a planned home birth, delivered in hospital (41 weeks gestation)

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• No apparent complications (40 weeks gestation).

Spontaneous Pre-Term

There were 6 neonatal deaths associated with extreme prematurity:

• Preterm twins (two sets, at 20 and 23 weeks gestation).

• Singleton infant (23 weeks gestation).

• Singleton infant (25 weeks gestation).

Issues:

The review of neonatal mortality identified the following issues:

• Tasmania’s current neonatal mortality rate of 2.9 per 1 000 continues to be low compared to most national figures. The low rate is due to a further fall in deaths due to extreme prematurity and congenital abnormalities. The former probably reflects better obstetric care and neonatal intensive care. The latter may represent better antenatal screening and the early termination of pregnancies with major foetal anomalies, but the Council does not currently collect data on terminations under 20 weeks gestation.

• Survival for babies at 23 weeks in Tasmania remains low (20 per cent), with 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.

Recommendations on Neonatal Deaths:

1. Home births should not be undertaken in anything other than low risk circumstances (and even then, the available Tasmanian data point to a high perinatal mortality associated with intention to deliver at home).

Women requesting home birth in Tasmania should be assessed for risk factors and referred for appropriate review when complications are identified. They should be made aware of the increased risk of adverse events, in particular perinatal mortality.

The outcomes of home birth in the Tasmanian setting should be continually reviewed as the available Tasmanian data suggests a high perinatal mortality. Analysis of the data across 2005-20075 for neonatal deaths by place of birth found that, compared to hospital birth, the relative risk (RR) of a neonatal death as a result of homebirth was 7.28 with an accompanying 95 per cent confidence interval of (3.56, 14.92) which is statistically significant. In summary, it appears from analysis of the available data that the risk of neonatal death for a baby born at home is 7.28 times that for a baby who was not born at home. Note that this is an unadjusted risk estimate, that does not take into account confounding factors in both the home birth and hospital birth populations that may influence risk of neonatal death (e.g., gestation, maternal age, underlying conditions, etc). The perinatal mortality associated with home birth in Tasmania also appears to be substantially higher than that recently reported amongst 320,000 Dutch women intending to deliver at home6 (risk of perinatal death 25.9 times higher, 95% confidence limits 6.46, 107).

5 [Raw Data for 2005/2006/2007: Homebirth total=120, neonatal death=2; hospital birth total=18641, neonatal death=44]

6 de Jonge A, et al. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG 2009;116:1177–1184. [Raw Data: Intended home total=321,307, intrapartum or early neonatal death=207].

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Recommendations on Neonatal Deaths (continued):

2. Recommendations related to in-hospital care: Obstetric consultants should be notified at an early stage of high risk labour, including patients transferred from a home birth situation. Scalp electrode to be placed where there is inadequate CTG recordings in the setting of high risk labour.

3. For infants less than 30 weeks, early in utero transfer of women threatening to deliver prematurely is to be much preferred over delivery in a regional centre. The opportunity to expedite transfer as soon as possible should not be missed.

4. The risk of overlying as outlined in paediatric deaths is highlighted here for infants less than 29 days old. All new parents should be educated during the antenatal and postnatal periods in safe sleeping practices and providing a safe sleeping environment for their infant. (It is stressed that a safe sleeping environment which excludes infant’s sleeping with parents is important in reducing the risk of infant deaths.)

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Paediatric Mortality & Morbidity Sub-Committee

Paediatric Deaths for 2007

The Council’s Terms of Reference in relation to paediatric mortality and as specified under the Perinatal Registry Act, 1994 and the Perinatal Registry Amendment Bill 2005 (The Bill) 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 2007 was 25, with an estimated paediatric mortality rate of 0.21 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. Paediatric deaths for the years 2001 to 2007 have been classified below.

Table 2: Paediatric Deaths for 2007

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

Acquired conditions 8 8 5 3 7 5 6

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

Injuries 4 12 4 10 8 20* 7

Cases still under investigation by the Coroner

1 1 2 0 0 0 2

Unknown/Indeterminate 2 1 1 0 1 1 0

TOTAL 26 27 21 18 25 35 25

* Two unexplained infant deaths were associated with risk factors with one of these cases being also known to child protection services. The remaining case

represented a true SIDS case.

Table 3: Breakdown of Sudden Infant Deaths and Deaths related to Injury for year 2007

Year Unexplained Infant Deaths no risk factors

Unexplained Infant Deaths

with risk factors Injury

Injury with suspected child

abuse 2007 1 2 7 0

1. CONDITIONS DETERMINED AT BIRTH

In 2007, there were 7 reported paediatric death cases in this category, the causes of which were:

• structural abnormalities of brain and brain stem, with bilateral bulbar palsy and tracheostomy (age < 1yr).

• respiratory failure, chronic lung aspiration and tetrasomy 15Q (age 1 yr).

• gastric perforation with a history of acute airway obstruction with probable aspiration, in the context of peritoneal dialysis after nephtrectomy for congenital nephrotic syndrome (age 20 months).

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• recent respiratory infection and aspiration pneumonia in the context of severe scoliosis and multiple congenital malformations (teenager).

• respiratory failure due to Hunter’s Syndrome (teenager).

• congestive cardiac failure secondary to dilated cardiomyopathy in the setting of Duchenne’s muscular dystrophy (age 16 yrs). It is believed that a statewide muscle clinic should be established for all myopathy cases (with input from the disciplines of respiratory medicine/ICU/neurology and rehabilitation).

• cerebellar haemorrhage due to the rupture of a vascular malformation (preschool age).

2. ACQUIRED CONDITIONS

In 2007, there were 6 deaths in children ranging from 2 months to 9 years, the causes of which were:

• brain stem pontine glioma (two cases).

• metastatic Wilm’s tumour (age 9 years).

• medulloblastoma (age 2 years).

• epilepsy with cerebral palsy (age 9 years).

• congenital heart disease (age 2 mths).

3. UNEXPLAINED INFANT DEATH

In 2007, three paediatric ‘unexplained infant deaths’ were reported in infants aged between 2.5 months to 3.5 months with one of these cases representing a true case of SIDS while the other couple of cases were known to be associated with risk factors with one of these cases also known tho child protection services. As was found in recent years, the deaths reported in 2007 were primarily attributed to an unsafe sleeping environment, especially co-sleeping (bed sharing) with a parent or unsafe bedding.

Investigation of these cases found that a:

• 2.5 month old male known to child protection services was put to bed in an unsafe sleeping environment consisting of a couch and a large pillow covered with a small child’s blanket. This infant was found to be well-developed, hydrated and apparently well cared for with non-specific findings with no evidence of abuse or infectious disease to explain the death. Toxicology of testing of post-mortem blood revealed no drugs. No report of co-sleeping or foul play at the scene was found.

• 3 month old female infant died whilst co-sleeping with an adult. It was noted that there had been suspected drug association with the parents of this infant and that parental toxicology screening would be beneficial in such cases. Two primary risk factors therefore were found to contribute to the death of this 3-month old infant including alcohol consumption by a parent and its possible effect to suppress the startle response and co-sleeping with an adult.

• 3.5 month old female infant died as a result of Sudden Infant Death Syndrome where this infant’s homeless family was living in a tent next to bushland. Autopsy revealed pleural and thymic petechiae and haemorrhagic areas posteriorly and inferiorly in the lungs with congestion. Viral testing revealed a picornavirus on PCR in the oropharynx, trachea and heart muscle, probably rhinovirus. While this most likely accounted for the chest type symptoms, it

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did not appear to be associated with significant pneumonia or other pathology. Upper respiratory infections are not uncommon in SIDS.

4. INJURY

Considerably fewer children died as a result of injury in 2007 compared to figures reported in 2006 with a total of 7 paediatric death cases reported.

Five of the 7 deaths were a result of injuries sustained as a result of road trauma. These deaths included two being the result of a motor cycle accident; one being the result of multiple blunt traumatic injuries sustained as a passenger in a road traffic crash; one being a result of a motor vehicle striking a bicycle; and one being the result of motor vehicle striking a pedestrian.

One death involved a toddler being crushed by a log while playing on a pile of logs where severe injuries to the head were sustained including multiple skull fractures and bruising of the brain. This particular case highlighted the need to be ever vigilant when young children are present, particularly when working with vehicles, machinery or heavy loads.

One infant died as a consequence of positional asphyxia due to entrapment between the pram wall and the pram mattress. It was considered that this death may have been a consequence of a product design fault and as such issues of product safety and design should be considered in the review of such death cases.

5. CASES STILL UNDER INVESTIGATION

There were two deaths in this category during 2007. Two cases included deaths of adolescents as a result of suspected suicide and suspected homicide respectively and are still under investigation by the Coroner.

6. UNKNOWN/INDETERMINATE

No paediatric death case was classified in this category in 2007.

The number of paediatric deaths in Tasmania reported in 2007 was lower than the total reported in 2006. In particular, the number of cases related to death through suicide was considerably lower in this year. In addition, no deaths as a result of drowning incidences were reported in this year.

Even though the number of paediatric deaths resulting from road/traffic trauma was lower in this year compared to the previous year, measures to improve road and traffic safety will continue to help prevent such unnecessary paediatric deaths in Tasmania.

The number of deaths listed as ‘unexplained infant death’ (previously called SIDS) reported in 2007 was slightly lower compared to the number of cases reported in 2006. Primary risk factors identified in unexplained infant death cases reported in Tasmania continue to primarily include risk factors such as unsafe sleeping environments where infants had co-slept with parents in association with parental drug use.

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Recommendations:

1. Despite the lower numbers of cases reported as Unexplained Infant Deaths in 2007 compared to 2006, 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.

2. It is recommended that parental toxicology screening for those parents of infants with suspected drug association should be carefully considered in reported cases of Unexplained Infant Deaths.

3. The number of children dying as a result of road trauma in 2007, although lower than reported in 2006, still continues to be a concern especially since this is preventable. In response to this concern, Council has previously recommended effective strategies to reduce the risk of road trauma. The Council is heartened to find that the Tasmania Road Safety Council through its development of a Tasmanian Road Safety Strategy 2007-2011, has recently ensured that the implementation of a dual divided carriageway between our major cities has commenced and that construction of better bicycle and pedestrian trail systems, ensuring that they remain separate from our roads continues to be progressed. The issue of daytime running headlights could still be examined in the future by the appropriate authorities.

4. Children who have been previously known to child protection services and who have been reported to have died continues to remain a concern to Council. A Child Death Review Framework for Tasmania is currently being established 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.

5. The one death from accidental injury where a toddler had sustained fatal injuries from being crushed by a log whilst playing outside highlights the need for parents/adults to be ever vigilant in their supervision when young children are present, particularly when working with vehicles, machinery or heavy loads.

6. The death of an infant as a consequence of sustaining positional asphyxia due to entrapment between a pram wall and pram mattress highlights potential product design faults and the need to consider issues of product safety and design particularly with the review of such death cases.

7. The Council recommends that consideration be given to the establishment of a statewide muscle clinic for all myopathy cases, with input from the disciplines of respiratory medicine/ICU/neurology and rehabilitation).

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Maternal Mortality & Morbidity Sub-Committee

Maternal Deaths for 2007

It is noted that the Perinatal Registry Amendment Bill 2005 (The Bill) brings Tasmanian legislation in line with that of other States and Territories and with the relevant definitions for ‘maternal death’ and ‘late maternal death’ as defined by the World Health Organisation. It amends the definition for a maternal death to include deaths to 42 days post pregnancy and it includes the definition of late maternal death.

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


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


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

No maternal deaths were reported in Tasmania in 2007.

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 will provide a significant step in initiating a comprehensive study of serious maternal morbidity events considered to contribute significantly to maternal morbidity in Australia and will be undertaken nationally (including New Zealand) and progressed in 2008 under the support from the National Health & Medical Research Council (NH&MRC). Furthermore, it will be based at the Perinatal Reproductive Epidemiology Research Unit (PRERU) at the University of NSW. The System will undertake active surveillance and epidemiological research of selected obstetric conditions with the aim to improve 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. Once established, the system will be designed to facilitate research by those interested in maternal care.

Tasmanian hospitals in conjunction with Victorian hospitals (public and private) have agreed to participate in the AMOSS with a nominated hospital person required to complete a monthly surveillance card to identify cases of interest. All six main providers of birthing services in Tasmania (i.e., RHH, HPH, Calvary Health, LGH, Mersey Community and North West-Burnie) have confirmed their interest to participate in AMOSS. The AMOSS project has been successfully launched federally in Canberra on 25th June 2009 and data collection on initially six morbid events is expected to commence shortly thereafter. Additional maternal morbid events as determined by an Advisory Group will be included as part of future data collections.

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The AMOSS website will become operational by the end of July 2009 http://www.npsu.unsw.edu.au/NPSUweb.nsf/page/AMOSS.

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.

Recommendations:

Nil

Data Management Sub-Committee The Data Management Sub-Committee has not met since February 2003. Subsequently no official report has been submitted from this subcommittee for this 2007 Report. It has been agreed to reconvene this subcommittee in the near future however to progress data collection issues related to the Electronic Perinatal Database and discuss Report formatting issues etc.

Of note during 2007 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.

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

Council continues to maintain a running list of recommendations for revision of the Perinatal Data Collection Form to be considered and implemented at a time when the Electronic Perinatal Database is available.

Progress in database:

The development and establishment of a statewide Electronic Perinatal Database is currently being progressed to provide obstetric units with access to clinical information for management, planning, teaching and research purposes. The database will be 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.

Review the structure of the Annual Report

The 2007 report format continues to follow the improved format developed in 2006 with further refinements being incorporated as required to ensure a more effective format for clearer presentation of data. The role of the Data Management subcommittee will be to provide opportunities to discuss and revise formatting issues as required.

Perinatal Statistics

33


Births and Birth Rates Table 4: Livebirths* and Birth Rates for Tasmania 1992-2007

Year No. Births Birth rate per 1000 population 1992 7 025 14.9

1993 6 861 14.5

1994 6 845 14.5

1995 6 817 14.4

1996 6 331 13.4

1997 6 309 13.4

1998 6 171 13.1

1999 6 145 13.1

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 6 314 12.8

NB: Australian Bureau of Statistics estimates Tasmania’s population 491 675 in 2006 (ABS Cat no. 3101.0, September quarter 2007). Please note this

estimation of population is a preliminary figure only and is subject to change.

* Births as per Perinatal Data Forms provided by maternity units and maternity service providers. ABS recorded in 2007 a total of 6 622 births for Tasmania,

an increase on the respective 2006 figure of 6 475 births.

The number of births recorded in 2007 continues to show an upward trend.

Figure 1: Birth Rate for Tasmania per 1 000 Head of Population 1992-2007

10

11

12

13

14

15

16

1992 1994 1996 1998 2000 2002 2004 2006 2008

Year

Birt

h R

ate


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Table 5: Livebirths by Region 1997-2007

Year South North Northwest 1997 3 087 1 705 1 505

1998 3 028 1 699 1 509

1999 2 993 1 769 1 411

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 3 183 1 714 1 411

The increase in the number of births in Tasmania reported in 2007 is varied across Tasmania with the Southern region reporting the highest increase (4.0 per cent) since 2006 followed by the Northwest (3.1 per cent) and (0.06 per cent) increase in the Northern region.

Table 6: Births by Hospital 1999-2007

Hospital 1999 No.

2000 No.

2001 No.

2002 No.

2003 No.

2004 No.

2005 No.

2006 No.

2007 No.

Royal Hobart Hospital (QAH)

2 084 2 007 1 823 1 831 1 633 1 688 1 836 1 912 2 030

Launceston General Hospital (QVH)

1 641 1 587 1 512 1 493 1 482 1 505 1 583 1 638 1613

District Hospitals 159 119 101 78 61 60 37 47 44

NWRH Mersey Campus NA* NA NA NA NA NA 492 551 540

Private Hospitals† 2 195 2 216 2 250 2 230 2 284 2 193 1901 1 947 2034

Others (includes homebirths) 66 46 40 82 85 94 67 49 53

TOTAL 6 145 5 975 5 726 5 714 5 545 5 540 5 916 6 144 6314

* Not available-included in private hospitals † includes for some years public patients at the North West Private Hospital


35

Table 7: Proportion of Public and Private Patients 1992-2007

Year Public % Private % 1992 55.5 44.5

1993 57.9 42.1

1994 60.0 40.0

1995 63.0 37.0

1996 64.8 34.2

1997 70.8 29.2

1998 71.5 28.5

1999 72.3 27.1

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

Figure 2: Proportion of Admitted Patient Elected Accommodation Status 1992-2007

0

20

40

60

80

1992 1994 1996 1998 2000 2002 2004 2006 2008

Year

Perc

enta

ge

Public % Private %

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 (27.5 per cent) and public patients (71.6 per cent) in 2007 remained at a similar level to that reported in 2006 and comparable to national figures reported in 2006 (i.e., proportion of public patients was 70.1 per cent and 29.9 per cent for private patients).


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Sex of Infants Table 8: Sex of all Infants Born in Tasmania 1997-2007

Year Male Female Indeterminate Total

No. % No. % No. % No. 1997 3 307 52 3 001 48 1 ^ 6 309

1998 3 237 52 2 932 48 2 ^ 6 171

1999 3 232 53 2 912 47 1 ^ 6 145

2000 3 211 54 2 762 46 2 ^ 5 975

2001 3 073 54 2 650 46 3 ^ 5 726

2002 2 930 51 2 782 49 2 ^ 5 714

2003 2 909 52 2 635 48 1 ^ 5 545

2004 2 904 52 2 632 48 0 ^ 5 540

2005 3 036 51 2 880 49 0 ^ 5 916

2006 3 180 52 2 964 48 0 ^ 6 144

2007 3 230 51 3 084 49 0 ^ 6 314

^ Less than 0.1 per cent.

Figure 3: Number of Infants Born by Sex 1997-2007

2,400

2,600

2,800

3,000

3,200

3,400

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Num

ber

of B

irths

Male Female

Male births continue to slightly exceed female births, accounting for 51 per cent of all Tasmanian births in 2007. This is comparable to national trends reported in 2006 with male births reported as higher (51.5 per cent) than female births. The 2006 national sex ratio, defined as the number of male liveborn babies per 100 female liveborn babies, was 106.4.


37

Birthweight Figure 4: Percentage of all Births by Birthweight Groups 2000-2007

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

500-9

99

1000

-1499

1500

-1999

2000

-2499

2500

-2999

3000

-3499

3500

-3999

4000

-4999

4500

+

Weight

Perc

enta

ge o

f Birt

hs

2000 2001 2002 2003 2004 2005 2006 2007

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 1992-2007

Year Number – Very Low Birthweight (<1 500 grams)

% Proportion of all births

Number - Low Birthweight

(<2 500 grams)

% Proportion of all births

1992 114 1.6 325 4.6

1993 86 1.3 300 4.4

1994 83 1.2 306 4.5

1995 111 1.6 321 4.7

1996 66 1.1 345 5.5

1997 90 1.4 303 4.8

1998 89 1.4 335 5.4

1999 98 1.6 320 5.2

2000 104 1.7 309 5.2

2001 74 1.3 325 5.7

2002 102 1.8 328 5.7

2003 104 1.9 356 6.4

2004 91 1.6 334 6.0

2005 76 1.3 313 5.3

2006 67 1.1 356 5.8

2007 71 1.1 421 6.7

The percentage of very low birthweight infants reported in Tasmania for 2007 remained at a similar lower level to that reported in 2006 which was generally lower than figures reported for Tasmania previously.


38

The percentage of low birthweight infants reported in Tasmania in 2007 however continued to increase compared to previous figures reported. In 2006, the national percentage of very low birthweight infants was 1.1 per cent of all livebirths and the percentage of low birthweight infants accounted for 6.4 per cent of liveborn babies.

Table 10: Outcome by Gestation 1996-2007*

Year % Survival

23 wks

24 wks

25 wks

26 wks

27 wks

24-27 wks

28 Wks

29 wks

30 wks

1996 0 0 N/A 100 86 75 100 89 100

1997 25 100 75 50 100 78 100 92 100

1998 0 0 50 100 67 78 80 92 89

1999 100 100 33 60 86 65 100 100 100

96-99 29 67 50 72 87 73 94 93 98

2000 N/A 50 50 73 91 77 91 92 100

2001 N/A 0 50 40 100 57 100 100 100

2002 0 33 25 78 83 64 100 86 91

2003 N/A 33 50 71 100 67 88 100 100

00-03 0 30 43 69 93 67 94 94 98

2004 0 50 67 100 100 79 80 100 100

2005 N/A 100 50 100 100 89 100 100 92

2006 N/A 0 89 100 33 67 100 100 100

2007 50 100 50 75 100 89 93 100 100

04-07 33 55 72 93 93 81 91 100 97

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

outcome from year to year within individual gestational age groups is largely a function of small numbers.

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% 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.


39

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 wellbeing. 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 1997-2007

Apgar Score

1997 %

1998 %

1999 %

2000 %

2001 %

2002 %

2003 %

2004 %

2005 %

2006 %

2007 %

1 0.1 ^ 0.2 0.1 ^ 0.1 ^ ^ ^ ^ ^

2 0.1 0.1 0.1 0.0 0.0 0.1 0.1 ^ ^ ^ ^

3 0.1 0.1 0.2 0.2 0.1 0.1 ^ ^ ^ ^ ^

4 0.1 0.2 0.3 0.2 0.2 0.2 0.2 0.1 0.2 0.1 0.1

5 0.4 0.4 0.3 0.3 0.2 0.5 0.3 0.3 0.3 0.3 0.3

6 0.7 0.9 0.9 0.5 0.7 0.8 0.8 0.8 0.5 0.6 0.5

7 1.8 1.8 2.0 1.8 1.8 2.0 1.6 1.3 1.2 1.5 1.5

8 4.5 4.2 4.2 5.0 4.2 4.4 4.3 3.9 4.3 3.7 4.0

9 53.2 56.8 58.9 60.0 60.0 58.7 58.7 59.3 63.6 62.2 63.3

10 37.7 33.8 31.3 30.7 31.0 31.9 32.4 32.8 28.9 30.5 29.2

^ Less than 0.1 per cent

Figure 5: Number of Births with Apgar Score less than 6 at Five Minutes 1997-2007

0

20

40

60

80

100

120

140

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

No.

of B

irths

Figure 5 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.


40

Resuscitation The following table shows all intubations in the delivery room, including those done in conjunction with other methods of resuscitation. There has been no significant change in the percentage of all births requiring intubation since 2005.

Table 12: Intubation Rate 1992-2007

Year Number of Intubations

Number of Births

Percentage of all Births requiring Intubation

1992 40 6 392 0.6

1993 50 6 795 0.7

1994 36 6 787 0.5

1995 44 6 748 0.6

1996 50 6 331 0.8

1997 58 6 309 0.9

1998 38 6 171 0.6

1999 42 6 145 0.7

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 6 314 0.5

Table 13: Resuscitation Rate 1997-2007

Year Number of

Resuscitations Number of

Births Percentage of all Births requiring Resuscitation

1997 884 6 309 14.0

1998 799 6 171 12.9

1999 794 6 145 12.9

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 6 314 7.0


41

Presentation at Delivery Table 14: Presentation at Delivery for all Births 1997-2007

Year Vertex n (%)

Face & Brow n (%)

Breech n (%)

Other n (%)

Not Stated n (%)

1997 5 881 (93) 17 (^) 286 (5) 34 (1) 91 (1)

1998 5 635 (90) 26 (^) 221 (4) 65 (1) 314 (5)

1999 5 516 (89) 25 (^) 250 (4) 87 (1) 317 (5)

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)

^ 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 2005-2007.

Perinatal Mortality The Tasmanian Perinatal Mortality rate per 1 000 births in 2007 was found to be lower (9.3 deaths per 1 000 births) than the national figure of 10.3 deaths per 1 000 births reported in 2006. Causes of Perinatal Mortality are outlined in Table 1.

Table 15: Perinatal Outcome 1997-2007

Outcome Stillbirth Liveborn and

survived* Neonatal

death Unknown Total

1997 52 6 249 8 0 6 309

1998 37 6 115 14 5 6 171

1999 44 6 082 17 2 6 145

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

* Survived to first hospital discharge.


42

Figure 6: Stillbirths & Neonatal Deaths 1997-2007

0

2

4

6

8

10

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Dea

th P

er 1

000

Birt

hs

Stillbirth Neonatal death

Table 16: Perinatal Mortality Rates 1992-2007

Year Number of

Perinatal deaths* Number of

Births

Rate of Perinatal Mortality per 1 000

births 1992 93 7 025 13.2

1993 66 6 861 9.6

1994 58 6 845 8.5

1995 69 6 817 10.1

1996 53 6 331 8.4

1997 60 6 309 9.5

1998 56 6 171 9.1

1999 63 6 145 10.2

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

* Includes neonatal deaths occurring following first hospital discharge.

It is evident that although the perinatal mortality rate in 2007 increased from the rate reported in 2006, this rate however remains generally lower than the rates reported in Tasmania since 1999, and continues to be lower than the national number of perinatal deaths. In 2006, the national stillbirth rate was 7.4 per 1 000 births; the neonatal death rate was 3.0 per 1 000 live births; and the perinatal death rate was 10.3 per 1 000 births.


43

Figure 7: Perinatal Mortality Rate per 1 000 Births in Tasmania 1992-2007 and Australia 1998-2006

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Rat

e

Tasmania Australia

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.

Table 17: Neonatal Mortality per 1 000 Births 1992-2007

Year Number of

Neonatal Deaths Neonatal

Mortality Rate 1992 42 6.0

1993 19 3.0

1994 10 1.5

1995 20 3.0

1996 12 2.0

1997 12* 2.0

1998 14 2.3

1999 17 2.8

2000 16 2.7

2001 14 2.4

2002 24 4.2

2003 24 4.5

2004 13 2.3

2005 9 1.5

2006 13 2.1

2007 19 3.0

* Previously quoted figure of 8 neonatal deaths in 1997 was found to be anomalous and thus updated in this report

The neonatal mortality rate per 1 000 births reported in Tasmania in 2007 is slightly higher (although not significantly; p=0.3199) than the rate recorded in 2006 (see Table 17 above) and equivalent to the national neonatal mortality rate reported in 2006. Despite this increase, the majority of improvements continue to be associated with infants < 1 000 grams or < 28 weeks gestation (see Table 10).


44

Table 18: Neonatal Mortality, per 1000 Births, in Infants over 28 weeks Gestation 1992-2007

Year Number Neonatal


1993 9 1.3

1994 5 0.7

1995 14 2.0

1996 3 0.5

1997 7* 1.2

1998 5 0.8

1999 7 1.2

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


Table 19: Neonatal Mortality, per 1 000 Births, in Infants over 1 000 Grams Birthweight 1992-2007

Year Number Neonatal


1993 13 1.9

1994 7 0.8

1995 6 0.8

1996 3 0.5

1997 8* 1.3

1998 3 0.5

1999 2 ^

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

^ Less than 0.1 per cent.



45

Table 20: Foetal, Neonatal and Perinatal Death Rate per 1 000 Births by State and Territory 1998-2006

Year Aus TAS NT ACT NSW VIC QLD SA WA Foetal 1998 5.3 6.5 6.8 7.7 5.4 7.9 5.5 5.1 5.1 1999 5.1 5.8 8.6 7.2 4.4 5.8 5.2 4.5 5.5 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

Neonatal 1998 3.0 3.3 6.3 4.5 2.7 2.9 4.0 2.1 2.4 1999 3.4 5.0 7.6 4.5 3.7 3.4 3.1 2.1 2.9 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

Perinatal 1998 8.3 9.8 13.1 12.2 8.1 7.7 9.6 7.2 7.5 1999 8.5 10.7 16.1 11.7 8.1 9.2 8.2 6.6 8.3 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

Source: Australia’s mothers and babies 2000- 2006 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 5.1, p.68, 2006)


46

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 overall rate of autopsy has increased in recent times despite evidence of a drop in percentages reported in 2007.

Table 21: Rate of Autopsies on Perinatal Deaths 1992-2007

Year Autopsy Rate % 1992 43.0

1993 47.0

1994 48.0

1995 47.5

1996 66.0

1997 35.0

1998 Unknown

1999 37.0

2000 46.0

2001 23.0

2002 7.4

2003 7.8

2004 2.0

2005 33.0

2006 38.5

2007 26.8

Age of Mothers Table 22: Age of Mothers 1992-2007

Year Under 20 years of age %

20 – 24 years of age %




Over 40 years of age %

1992 7 23 35 26 8 1

1993 7 23 35 26 8 1

1994 7 23 33 26 9 1

1995 7 22 33 27 9 1

1996 8 22 33 27 9 1

1997 8 21 34 26 10 1

1998 8 20 33 26 11 2

1999 8 20 32 27 11 2

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


47

In Tasmania, the age of mothers in the various groups reported in 2007 is consistent with those reported in 2006 with a slight decrease in the 30-34 age group. In general however, the 25-29 year olds and the 30-34 year old group continue to remain higher than the other age groups included in assessment in 2007, a trend consistent with national reports from 2006 and consistent with an upward trend in maternal age in recent years. In 2006, the average age of women at the time of birth has increased where nationally the mean age was 29.8 years compared with 28.7 years in 1997 and the median age in 2006 was 30.0 years. The proportion of older mothers in Tasmania aged 35 years plus has continued to show an overall increase in recent times which corresponds to national figures reporting an increase from 15.0 per cent in 1997 to 21.4 per cent in 2006. Furthermore, national figures has shown evidence for an increase in the proportion of first-time mothers in the older age groups between 1997 and 2006 (of women aged 35-39 years, 27.6 per cent were first-time mothers compared with 22.6 per cent in 1997; of women aged 40 years and over, one-quarter had their first baby in 2006 compared with 20.8 per cent in 1997; of all first-time mothers 14 per cent were aged 35 years or older in 2006 compared with 8.4 per cent in 1997).

The trend in delayed childbearing has been attributed to a number of factors including social, educational and economic and increased access to assisted reproduction technology7.

Figure 8: Proportion of Births by Maternal Age Groups 1992-2007

0

10

20

30

40

1992 1994 1996 1998 2000 2002 2004 2006 2008

Year

Prop

ortio

n of

Birt

hs

< 20 20 – 24 25 – 29 30 – 34 35 – 39 40 +

Figure 9: Proportion of Births by Maternal Age in Tasmania 2007 and Australia 2006

0

5

10

15

20

25

30

35

< 20 20 – 24 25 – 29 30 – 34 35 – 39 40 +

Age Group

Prop

ortio

n of

Birt

hs

Tasmania 2007 Australian 2006

7 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,


48

Table 23: Rates of Birth per 1 000 Female Population by Maternal Age 2000-2007

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

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

29.3 28.7 27.9 26.3 24.5 26.1 26.6 25.2

20 – 24

2000 2001 2002 2003 2004 2005 2006 2007

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

86.0 78.2 84.1 73.0 73.9 77.9 80.4 84.0

25 – 29

2000 2001 2002 2003 2004 2005 2006 2007

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

114.2 115.9 116.2 109.6 114.7 118.6 120.3 118.7

30 – 34

2000 2001 2002 2003 2004 2005 2006 2007

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

99.6 98.4 96.9 104.4 97.6 110.7 112.9 119.0

35 – 39

2000 2001 2002 2003 2004 2005 2006 2007

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

37.6 38.9 40.1 41.0 44.0 49.5 51.5 52.4

40 – 44

2000 2001 2002 2003 2004 2005 2006 2007

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

6.9 7.0 9.1 6.5 7.2 7.6 8.7 10.9

45 –49

2000 2001 2002 2003 2004 2005 2006 2007

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

0.3 0.1 0.3 0.6 0.2 0.4 0.6 0.2

*Australian Bureau of Statistics Demography – Tasmania 3311.6 2000, 2001, ABS Population by Age & Sex 3201.0 June 2002 - 2007


49

Parity

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 24: Percentage of Births by Parity 1992-2007

Year Para 1

% Para 2

% Para 3

% Para 4

% Para 5 and

over % 1992 39 33 18 7 3

1993 39 33 16 7 4

1994 39 34 20 6 3

1995 40 33 17 6 4

1996 40 34 16 6 4

1997 41 34 15 6 3

1998 39 34 16 6 4

1999 40 34 16 6 4

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

Nationally in 2006, 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 (15.4 per cent) had given birth twice previously and 9.4 per cent had given birth three or more times.

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 elevated in 2007. In 2007, 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 2006, there were 10 183 Aboriginal or Torres Strait Islander women who gave birth, representing 3.7 per cent of all mothers in 2006.


50

Table 25: Mother's Indigenous Status 1999-2007

Status 1999 2000 2001 2002 2003 2004 2005 2006 2007 Aboriginal 13 11 15 12 122 118 183 175 201

Torres Strait Islander 4 1 3 3 4 7 15 14 15

Aboriginal & Torres Strait Islander

47 46 30 25 22 7 24 30 20

Other 1 450 1 444 1 081 756 2 980 5 368 5 694 5 928 6 078

Not Stated 4 631 4 473 4 597 4 918 2 417 36 0 0 0

Breastfeeding

Trends reported in Tasmania (see tables below) indicate that the percentage of both public and private hospital patients’ breastfeeding at discharge has generally increased since year 2000. Overall, the percentage of private hospital patients’ breastfeeding at discharge continues to be higher than reported in public hospital patients.

Table 26: All Births by Breastfeeding at Discharge 2000-2007

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 5 124 1 183 81.2

Table 27: Breastfeeding at Discharge by Public / Private Hospital 2000-2007

Year Public (% Yes) Private (% Yes) 2000 71 78

2001 68 84

2002 71 73

2003 73 82

2004 73 80

2005 77 91

2006 78 91

2007 78 89


51

Table 28: Breastfeeding at Discharge by Parity 2000-2007

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

Mode of Delivery Table 29: Mode of Delivery 1998-2007

Year Total Births

Unassisted Vaginal Instrumental* Deliveries Caesarean Sections

Number % Number % Number %

1998 6 261 4 348 69 489 8 1 335 21

1999 6 192 4 392 71 443 7 1 263 20

2000 5 970 4 038 68 564 9 1 322 22

2001 5 735 3 797 68 571 10 1 335 23

2002 5 718 3 849 67 583 10 1 249 22

2003 5 552 3 507 63 573 10 1 449 26

2004 5 531 3 412 62 582 10 1 508 27

2005 5 916 3 815 64 520 9 1 581 27

2006 6 144 4 024 65 446 7 1 677 27

2007 6 314 3 837 60 670 10 1 807 29

* Instrumental Deliveries includes forceps, forceps rotation & vacuum extraction. Vaginal Breech deliveries were less than 0.1 per cent in 2005 (not included

here).


52

Figure 10: Mode of Delivery in Tasmania 1998-2007

0

20

40

60

80

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

Perc

enta

ge

Unassisted Vaginal Instrumental* Deliveries Caesarean Sections

* 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.

Figure 11: Mode of Delivery in Public Hospitals in Tasmania 2007 and Australia 2006

71.4

28.6

72.4

27.6

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Vaginal Delivery Caesarean Sections

Perc

enta

ge

Tasmania 2007 Australia 2006

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.


53

Figure 12: Mode of Delivery for Private and Public Patients in Tasmania 2007

45

66

159

25

40

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

Public Patient Private Patient

Per

cent

age

Non-ins trumenta l Vag ina l Ins trumenta l Caes arean S ections

Note: 53 mothers who had not declared insurance status undertook all non-instrumental vaginal deliveries

As shown in Figure 12 above, private patients in Tasmania in 2007 were found to undergo more caesarean sections and instrumental vaginal deliveries than their public patient counterparts. Conversely, more non-instrumental deliveries were performed for public patients compared to private patients during this year. Overall in Tasmania in 2007 the total LSCS rate was 28.6 per cent; the total unassisted vaginal delivery rate was 60.1 per cent and the total instrumental delivery rate was 10.6 per cent.

Expanding upon this:

• The rate of vaginal deliveries in Tasmanian public hospitals in 2007 was higher than rates reported nationally (58.1 per cent) in 2006;

• The higher Caesarean section rates reported in 2007 in Tasmanian public hospitals were comparable to the national findings (30.8 per cent) reported in 2006. National figures derived from 2006 have shown caesarean section rates to be higher in private hospitals compared with public hospitals across all age groups;

• Of the vaginal deliveries nationally reported in public hospitals in 2006, 62.5 per cent were spontaneous, 2.9 per cent were forceps deliveries, 6.4 per cent were vacuum extraction and 0.5 per cent was vaginal breech; and

• Of the vaginal deliveries nationally reported in private hospitals in 2006, 43.9 per cent were spontaneous, 5.1 per cent were forceps deliveries. 9.6 per cent were vacuum extraction and 0.2 per cent was vaginal breech.


54

Table 30: Mode of Delivery by Gestation 2000-2007

Gestation in weeks Year Vaginal Delivery

Caesarean Section

Total

No. (%) No. (%) Number

20 – 24

2000 2001 2002 2003 2004 2005 2006 2007

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

3 (11) 0

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

28 23 23 30 27 24 22 39

25 – 29

2000 2001 2002 2003 2004 2005 2006 2007

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

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

47 27 47 44 36 29 27 34

30 - 34

2000 2001 2002 2003 2004 2005 2006 2007

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

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

154 151 149 154 157 120 166 147

35 - 39

2000 2001 2002 2003 2004 2005 2006 2007

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

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

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

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

40 and over

2000 2001 2002 2003 2004 2005 2006 2007

2 590 (86) 2 426 (86) 2 521 (87) 2 197 (84) 2 157 (83) 2 337 (83) 2 417 (84) 2 431 (83)

429 (14) 389 (14) 376 (13) 414 (16) 428 (17) 470 (17) 442 (16) 512 (17)

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


55

Caesarean Section Table 31: Emergency / Elective Caesarean Section Proportion 1997-2007

Year Emergency

Number Emergency

% Elective Number

Elective %

1997 659 52.5 597 47.5

1998 561 54.0 478 46.0

1999 637 53.3 559 46.7

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

Table 32: Emergency / Elective Caesarean Section Proportion by Public / Private Hospitals 2000-2007

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

Table 33: Primary / Repeat Caesarean Section Proportion 1998-2007

Year Primary Number

Primary %

Repeat Number

Repeat %

1998 772 57.7 565 42.3

1999 764 60.5 499 39.5

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 1018 56.3 790 43.6


56

Table 34: Primary / Repeat Caesarean Section Proportion by Public / Private Hospitals 2000-2007

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

Figure 13: Caesarean Section Rates 1992-2007

0

5

10

15

20

25

30

1992 1994 1996 1998 2000 2002 2004 2006 2008

Year

Perc

enta

ge

The incidence of caesarean section (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, which is still below Australian national rates.

As reported last year, 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. As can be seen from figure 8 in the current report, there 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. Although the rate for the 40+ age group has trebled in 18 years, this represents a rise from 1 to 3 per cent. However the CS rate for the 40+ group is about double that for the 20-29 age group so as a demographic change alone it would be expected that the CS rate should rise without any change in background rates changing.

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


57

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 < 2. As has been well documented, the CS rate for primigravidae is much higher than for multipara. This concentration of primigravidae, who are also more 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. Although we have no obstetric weight data from Tasmania, 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.

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. It is noteworthy that in spite of the rising CS rates, there has only been a slight reduction in the normal vaginal delivery rates (see Figure 10). 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.

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 in the pre-term gestations, especially 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 clear the advent of the use of CTG to monitor foetuses in labour resulted in a significant rise in CS rates, it is questionable whether CTG is in part responsible for 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 Caesarean section 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


58

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, research 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.

Table 35: All births by Caesarean Section following Augmentation of Labour 2000-2007

Type of Augmentation

Year Primary Repeat % of all

Augmentations

ARM* only

2000 2001 2002 2003 2004 2005 2006 2007

25 35 34 37 44 73 96 97

5 2 5 7 9 6 14 17

5.4 6.5 5.8 6.6 8.6 10.2 11.2 12.5

Oxytocin only

2000 2001 2002 2003 2004 2005 2006 2007

34 35 38 57 60 82 96 91

3 0 1 1 5 3 2 6

19.1 17.6 18.5 22.6 26.5 23.2 21.6 21.3

Oxytocin & ARM*

2000 2001 2002 2003 2004 2005 2006 2007

18 22 19 25 24 66 66 103

1 3 2 1 4 5 2 4

16.2 17.1 16.0 19.7 21.0 20.7 24.5 24.6

Other

2000 2001 2002 2003 2004 2005 2006 2007

0 0 1 1 0 0 0 0

0 0 0 0 0 0 0 0

0 0

25.0 33.3

0 0 0 0

* ARM = Artificial Rupture of Membranes


59

Induction of Labour

Table 36: Induction Rate 1996-2007

Deliveries following Induction of Labour

Year Vaginal

deliveries Caesarean Section

deliveries Total

Induction Rate

Number (%) Number (%) Number % 1996 1 120 (85) 202 (15) 1 322 21

1997 1 113 (86) 181 (14) 1 294 21

1998 1 253 (84) 245 (16) 1 498 24

1999 1 282 (86) 210 (14) 1 492 24

2000 1 159 (85) 211 (15) 1 370 23

2001 1 157 (83) 235 (17) 1 392 24

2002 1 267 (87) 189 (13) 1 456 25

2003 1 192 (84) 235 (16) 1 427 32

2004 1 195 (81) 279 (19) 1 474 27

2005 1 433 (80) 349 (20) 1 782 30

2006 1 375 (80) 335 (20) 1 710 28

2007 1 315 (79) 350 (21) 1 665 26

The rate of induction of labour has shown an overall increase from 21 per cent in 1996 to 26 per cent in 2007 (see Table 36). The CS rate following labour induction has also increased from 15 per cent to 21 per cent since these years (see Table 37 below). 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 which may reverse these trends. Movement toward a statewide electronic obstetric database would facilitate the collection of such information for formal assessment.


60

Table 37: Percentage of Caesarean Sections following Induction of Labour 1996-2007

Year Total number of Caesarean

Sections

Number of Inductions of Labour with Caesarean

Section Delivery

Percentage of Caesarean Sections following

Induction of Labour %

1996 1 191 202 17

1997 1 263 181 14

1998 1 315 245 19

1999 1 252 210 17

2000 1 324 211 16

2001 1 334 235 18

2002 1 246 189 15

2003 1 451 235 16

2004 1 510 279 18

2005 1 582 349 22

2006 1 676 335 20

2007 1 808 350 19

Table 38: Induction Rate by Public / Private Hospitals 2000-2007

Year

Deliveries following Induction of Labour

Vaginal deliveries Number (%)

Caesarean Section Number (%)

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 915 (81) 518 (79) 215 (19) 134 (21) 27.1 37.6

2006 921 (80) 454 (81) 231 (20) 104 (19) 26.2 32.6

2007 863 (80) 452 (78) 222 (20) 128 (22) 23.9 33.4

Nationally in 2006, of women who gave birth, 58.1 per cent had a spontaneous vaginal birth; 0.4 per cent had a vaginal breech birth; and deliveries using forceps accounted for 3.5 per cent and vacuum extractions for 7.2 per cent. Labour was induced for 25.1 per cent and augmented for 19.4 per cent of mothers nationally in 2006. Induced labour is more likely in Tasmania’s private setting (33.4 per cent) than in other states and territories reported in 2006.

There was a continued increase in caesarean sections reported nationally with 30.8 per cent of mothers undergoing caesarean section deliveries in 2006. Again in 2006, national data has shown that caesarean section rates increase with maternal age and continues to be higher among older mothers and those who gave birth in private hospitals.


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Augmentation of labour

Table 39: Augmentation of Labour 1997-2007

Year Artificial

Rupture of Membranes

Oxytocin Other None Augmentation

Rate

1997 373 116 106 3 415 14.8

1998 406 180 98 3 155 17.8

1999 441 150 130 3 026 19.2

2000 498 165 64 2 958 20.4

2001 541 179 133 2 559 25.0

2002 667 210 136 2 377 29.9

2003 671 257 135 2 104 33.6

2004 618 245 138 2 217 31.1

2005 772 366 343 4 435 25.0

2006 985 454 277 4 431 27.9

2007 920 455 435 4 504 28.6

In Tasmania, 28.6 per cent of mothers were reported in 2007 to have undertaken augmentation of spontaneous labour. In contrast, 19.4 per cent of mothers nationally (2006) were reported to have their labour augmented. Furthermore, in 2006 nationally, the onset of labour was spontaneous for 56.6 per cent of all mothers giving birth and 25.1 per cent of mothers had their labour induced.

Multiple Pregnancy Table 40: All Births by Multiple Pregnancies 1997-2007

Year Number of infants born from a Twin pregnancy

Number of infants born from a Triplet*

pregnancy 1997 152 0

1998 185 3

1999 162 3

2000 180 3

2001 180 3

2002 164 3

2003 184 3

2004 197 9

2005 176 3

2006 172 6

2007 188 3

* 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.


62

The proportion of multiple births in Tasmania continues to be higher than the national average with 30.2 multiple pregnancies per 1 000 mothers recorded in Tasmania in 2007. There were 16.7 multiple pregnancies per 1 000 mothers in 2006 nationally. Multiple pregnancies in 2006 accounted for 1.7 per cent of all pregnancies: 4 515 twin pregnancies, 102 triplet pregnancies and five quadruplet pregnancies. It has been reported8 that while triplet and higher order multiple births have remained relatively stable in recent years the overall increasing national trend in multiple births in the last two decades is most likely attributable to increased fertility-related drugs and reproduction technology; delay in child-bearing and increasing number of older mothers.

Table 41: Perinatal Mortality in Multiple Pregnancies 1997-2007

Year Twin Deaths Triplet Deaths

No. % No. % 1997 5 3.3 0 0

1998 7 3.8 0 0

1999 6 3.7 0 0

2000 10 5.5 1 33

2001 4 2.2 0 0

2002 9 5.5 0 0

2003 9 4.9 0 0

2004 6 2.9 2 22

2005 5 2.8 0 0

2006 3 1.7 0 0

2007 9 4.7 0 0

8 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,


63

Maternal Hypertension Table 42: Number of cases of Maternal Hypertension for all Births 1996-2007

Type of Hypertension

Pre-Existing

Hyper- tension in

Pregnancy * Eclampsia Nil Total

1996 82 301 2 5 946 6 331

1997 36 293 6 5 974 6 309

1998 69 317 2 5 783 6 171

1999 66 342 0 5 737 6 145

2000 122 315 0 5 538 5 975

2001 101 283 0 5 342 5 726

2002 103 252 0 5 359 5 714

2003 81 249 0 5 215 5 545

2004 83 245 0 5 212 5 540

2005 91 350 0 5 475 5 916

2006 91 320 0 5 733 6 144

2007 101 357 0 5 856 6 314

* 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 2007 was higher than reported for any other year since 1996. This finding may well correlate with reports of an increasing rate of obesity in the general population and maternal obesity rates as well as consequences of increasing maternal age in the obstetric population. The effects of these can have significant potential implications for the well-being of mother and foetus.

Table 43: Percentage of cases of Maternal Hypertension for all births 1996-2007

Type of Hypertension

Pre-Existing

Hyper-tension in Pregnancy *

Eclampsia Nil

% % % % 1996 1.3 4.8 ^ 93.9

1997 0.6 4.6 0.1 94.7

1998 1.1 5.1 ^ 93.7

1999 1.1 5.6 0 93.4

2000 2.0 5.3 0 92.7

2001 1.8 4.9 0 93.3

2002 1.8 4.4 0 93.8

2003 1.5 4.5 0 94.0

2004 1.5 4.4 0 94.1

2005 1.5 5.9 0 92.5

2006 1.5 5.2 0 93.3

2007 1.6 5.6 0 92.7

^ Less than 0.1 per cent


64

Postpartum Haemorrhage

Table 44: Incidence of Postpartum Haemorrhage 1992-2007

Year Number Incidence % 1992 316 4.5

1993 295 4.3

1994 239 3.5

1995 320 4.7

1996 228 3.6

1997 160 2.5

1998 251 4.1

1999 252 4.1

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

Figure 14: Incidence of Postpartum Haemorrhage 1992-2007

2

2.5

3

3.5

4

4.5

5

1992 1994 1996 1998 2000 2002 2004 2006 2008

Year

Perc

enta

ge


65

Antepartum Haemorrhage

Table 45: Incidence of Antepartum Haemorrhage 1992-2007

Year Number Incidence % 1992 105 1.5

1993 123 1.8

1994 68 1.0

1995 68 1.0

1996 221 3.5

1997 113 1.8

1998 173 2.8

1999 123 2.0

2000 59 1.0

2001 63 1.1

2002 49 0.8

2003 43 0.8

2004 43 1.2

2005 109 1.8

2006 85 1.4

2007 110 1.7

Figure 15: Incidence of Antepartum Haemorrhage 1992-2007

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

1992 1994 1996 1998 2000 2002 2004 2006 2008

Year

Perc

enta

ge


66

Table 46: Type of Antepartum Haemorrhage 1997-2007

Type Placenta Praevia

Abruptio Placenta

Antepartum Haemorrhage (unclassified)

Total

1997 16 21 139 176 1998 11 6 154 171 1999 24 10 88 122 2000 22 37 3 62 2001 26 36 2 64 2002 21 28 0 49 2003 16 27 0 43 2004 18 25 0 43 2005 22 21 109 152 2006 27 17 85 129 2007 25 17 110 152

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 2007, 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 47: Smoking Comparison 2007 and 1982* Age 1982* (%) Age 2005 (%) 2006 (%) 2007 (%)

Overall 35.3 27.6 27.1 27.9

<20 55.2 <20 54 55.2 55.2

21-25 46.0 20-24 43.8 40.9 44.2

26-30 30.2 25-29 26.4 26.6 26.7

>30 21.2 >30 16.7 16.6 18.5

Public Not reported 35.7 35.5 36.2

Private Not reported 8.3 6.9 6.8

* Obstetric and neonatal Report – Tasmania 1982

The 2007 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.


67

In 2007, 28 per cent of Tasmanian women indicated that they had smoked tobacco during their pregnancy, with 15.8 per cent reporting to have smoked less than 10 cigarettes per day and 12.2 per cent reporting to have smoked more than 10 cigarettes daily.

Figure 16: Self-reported Tobacco Smoking Status during Pregnancy in Tasmania 2007

DHHS, Perinatal Database No. of mothers who reported= 6,218

Data available for other jurisdictions show that in 2006, Tasmania continued to show it to have the second highest proportion of women who smoked during pregnancy (see Table 48). Overall, 17.3 per cent of women in these states and territories smoked during pregnancy with no real change in this proportion over the previous four years9.

Table 48: Proportion of Women Smoking Tobacco during Pregnancy by State and Territory, 2006

Jurisdiction % NT 29.3

TAS 27.2

SA 22.0

QLD 20.3

WA 17.5

ACT 13.8

NSW 13.5

AIHW, National Perinatal Statistics Unit, Australia's Mothers and Babies 2006; data not available for VIC

Figure 17 shows 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 declines significantly for women aged 30 years and over. This trend is consistent with that reported in 2006.

9Laws, 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,

non-smoke

71.1%

smoke =< 10 daily 15.8%

smoke >10 daily

12.2%

unknown

0.9%


68

Figure 17: Self-Reported Tobacco Smoking Status during Pregnancy by Age, Tasmania 2007

55.2%

44.2%

26.7%

17.2% 16.2%22.9%

0%

10%

20%

30%

40%

50%

60%

< 20 20 - 24 25 - 29 30 - 34 35 - 39 > 39

DHHS, Perinatal Database

There have been slight increases in self-reported smoking during pregnancy by both private (6.8 per cent in 2007 vs. 6.2 per cent in 2006) and public patients (36.2 per cent in 2007 vs. 35.3 per cent in 2006); neither of these increases was statistically significant. However, smoking during pregnancy continues to be more prevalent for public patients (36.2 per cent) compared to private patients (6.8 per cent) (Figure18). As reported in previous years, this trend continues to reflect the higher prevalence of smoking among lower socio-economic groups. Despite the slight increase in smoking reported by public and private patients in 2007, the figures remained relatively stable in relation to last year’s reported findings. It therefore remains encouraging that the percentages reported in 2007 for both public and private patients who smoked during pregnancy is lower than the percentages reported in 2005.

Figure 18: Self-Reported Smoking Status by Public / Private Patients, Tasmania 2007

36.2%

6.8%

63.0%

91.9%

0%

20%

40%

60%

80%

100%

Public Private

S moked Not S moked


For public hospitals, as shown in Figure 19 (below) smoking during pregnancy continued to be reported in 2007 most frequently by patients at the Royal Hobart Hospital (33.3 per cent) down from 36.6 per cent the previous year, and the least frequently (24.3 per cent) reported by patients at the Launceston General Hospital also lower than figures reported in 2006 (27 per cent). In fact, it is heartening that all public hospitals showed an overall decrease in the percentage of mothers who were reported to have smoked during pregnancy in 2007 compared to figures reported in previous years since 2005. It is important to


69

remember that a key factor in the variations reported between public hospitals relates to the differences in the patient mix at the three hospitals.

Figure 19: Self-Reported Tobacco Smoking Status during Pregnancy by Hospital, Tasmania 2007

33.3%24.3% 25.6%

52.2% 64.7% 59.8%

14.5% 14.6%11.0%

0%

20%

40%

60%

80%

100%

RHH LGH Mers ey

S moked Not S moked Unknow n


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.

Excluding multiple births, a total of 345 babies had a birthweight of less than 2 500 grams. Of these, 22.3 per cent (77) had a birthweight of less than 1 500 grams (very LBW). In 2007, a total of 9.8 per cent of all women who had smoked in pregnancy had a LBW baby compared to 4.1 per cent of women who reported not to have smoked (see Figure 20). This figure representing the proportion of low birth weight babies in mothers who smoked is higher than that reported in 2006 (8.6 per cent) a finding which continues to highlight the potential deleterious effects of smoking on birth weight. The relative risk of having a LBW in 2007 was 2.40 (95 per cent 1.96-2.94) in women who smoked in pregnancy compared with those who reported not to smoke.

Figure 20: Self-Reported Smoking Status during Pregnancy by Birthweight, Tasmania 2007

Note: NB multiparous births have been omitted; DHHS, Perinatal Database

9.8% 4.1%

90.2%95.9%

0%

20%

40%

60%

80%

100%

Smoked Not Smoked

Low birthweight Normal birthweight


70

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 = 2.40 may be an overestimate due to confounding (Epidemiology Unit, Population Health, 2009).

Smoking in Pregnancy: Comments from the Council

As noted in previous reports since 2005, Council highlights that the prevalence of smoking has remained unchanged in the under 25 year age group since 1982, in spite of a general community response to smoking cessation strategies. Older age groups have, however, shown a reduction in smoking. It is clear that strategies aimed at reduction in smoking have worked, but only for those over 25 years.

There is evidence 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. Thus standard antenatal care should incorporate smoking cessation and/or reduction advice for all women who smoke. Since 2008 QUIT Tasmania has started using a resource developed by Quit South Australia to train midwives on how to provide intervention on smoking cessation during pregnancy. QUIT Tasmania also have trained staff that can provide counselling support specifically for pregnant women on the Quitline. It is hoped that beneficial effects of such programmes should be reflected in trends reported from 2008 onwards.

As noted in previous years since 2005, intrauterine growth restriction continues to be a significant contributor to perinatal mortality. As such, any strategy that may reduce the incidence of growth restriction may correspondingly reduce the stillbirth rate. Thus interventions to reduce smoking in pregnancy continue to be important.

Recommendation:

As reported in previous years since 2005, 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.


71

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)10. 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 problems11. 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)12. In fact, foetal alcohol exposure has been found to be a primary cause of neurological problems and mental retardation13. 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 pregnancy10,14.

High level and/or frequent intake of alcohol in pregnancy has also been associated with increased risk of miscarriage, stillbirth and premature birth15. In addition, there is new evidence to suggest that prenatal alcohol exposure may increase the risk of alcohol dependence in adolescence16.

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

10 NHMRC Australian Guidelines to Reduce Health Risks from Drinking Alcohol, Australian Government, 2009.

11 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.

12 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. 13 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.

14 Guerri, C. (2002). Mechanisms involved in central nervous system dysfunctions induced by prenatal ethanol exposure. Neurotoxicity Research, 4(4), 327-335. PMID 12829422. 15 O’Leary C.M., (2004). Fetal alcohol syndrome: diagnosis, epidemiology and developmental outcomes. Journal of Paediatric Child Health, 40: 2-7.

16 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.


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In view of the potential problems associated with alcohol consumption during pregnancy, data exploring the alcohol consumption status of Tasmanian women during pregnancy have recently become available for review. This year provides the first analysis of the available data on alcohol consumption prevalence during pregnancy derived from self-reported information obtained by clinicians from the mother and reported to the Perinatal Data Collection.

In 2007, a total of 6 218 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 49 and Figure 21 below show that overall 14.6 per cent of Tasmanian women indicated that they had consumed alcohol during their pregnancy with 13.3 per cent reporting to have consumed less than one standard alcoholic drink per day and 1.3 per cent reporting to have consumed more than one alcoholic drink per day.

Table 49: Alcohol Consumption in 2007 Age 2007 (%)

Overall 14.6

<20 15.9

20-24 12.1

25-29 14.0

30-34 14.2

35-39 19.0

>39 16.6

Public 13.3

Private 18.2

Figure 21: Self-reported Alcohol Consumption Status during Pregnancy in Tasmania 2007

non -drink,

83.8%drink >1,

1.3%

unknown,

1.6%

drink =< 1,

13.3%

DHHS, Perinatal Database No. of mothers who reported= 6,218


73

It appears that maternal alcohol consumption is 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 30 years, particularly in the 20-24 year age group (Figure 21).

Figure 22: Self-Reported Alcohol Consumption Status during Pregnancy by Age, Tasmania 2007

16.0% 16.6%

19.0%

14.2%14.0%

12.1%

0%

5%

10%

15%

20%

<20 20-24 25-29 30-34 35-39 >39


Figure 23: Self-Reported Alcohol Consumption Status by Public / Private Patients, Tasmania 2007

85.0% 80.5%

13.3% 18.2%

0%

20%

40%

60%

80%

100%

Public Private

Alcohol not consumed Alcohol consumed


Alcohol consumption during pregnancy by private patients (18.2 per cent) appears to be more prevalent compared to public patients (13.3 per cent) as shown above in Figure 23, the difference also being statistically significant (p<0.0001). This may reflect a higher prevalence of alcohol consumption among the higher socio-economic groups.

Reported alcohol consumption during pregnancy was higher among private patients. Of those who reported consuming alcohol, the consumption of more than one alcoholic drink was reported by 10.6 per cent of public patients and 5.5 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 2007, alcohol consumption during pregnancy was reported most frequently by patients at the Royal Hobart Hospital (15.1 per cent) and least frequently (5.4


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per cent) reported by patients at the Mersey, the latter proportion being statistically significantly lower than for the other two hospitals (p<0.0001). 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 2007

83.6% 83.9%93.1%

15.1% 14.8%5.4%1.5%1.3% 1.4%

0%

20%

40%

60%

80%

100%

RHH LGH Mersey

Alcohol not consumed Alcohol consumed Unknown


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.

Excluding those from multiple births, a total of 351 babies, had a birthweight of less than 2 500 grams. Of these, 23.4 per cent (82) had a birthweight of less than 1 500 grams (very LBW). In 2007, a total of 6.3 per cent of all women who had consumed alcohol during pregnancy had a LBW baby compared to 5.5 per cent of women who reported not to consumed alcohol (Figure 24), a difference which is not statistically significant (p=0.3613). The relative risk of having a LBW baby in 2007 was 1.14 (95 per cent CI 0.86, 1.50) 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 the strength of this association. 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. 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 alcohol consumption.


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Figure 25: Self-Reported Alcohol Consumption Status during Pregnancy by Birthweight, Tasmania 2007

5.5%6.3%

94.5%93.7%

0%

20%

40%

60%

80%

100%

Alcohol consumed Alcohol not consumed

Low birthweight Normal birthweight


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.

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.

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


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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 Care Reform- Safety and Quality Unit Health Services 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.

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

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

Visit: www.dhhs.tas.gov.au

council of obstetric & paediatric mortality & morbidity · 2010. 5. 10. · the members of...

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