The postponement of neonatal deaths into the postneonatal period: evidence from Massachusetts

Primary birthing attendants and birth outcomes in remote Inuit communities--a natural "experiment" in Nunavik, Canada

BACKGROUND

There is a lack of data on the safety of midwife-led maternity care in remote or indigenous communities. In a de facto natural "experiment", birth outcomes were assessed by primary birthing attendant in two sets of remote Inuit communities.

METHODS

A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989-2000: primary birth attendants were Inuit midwives in the Hudson Bay (1529 Inuit births) vs western physicians in Ungava Bay communities (1197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, post-neonatal death, preterm, small-for-gestational-age and low birthweight birth. Multilevel logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects.

RESULTS

The aORs (95% confidence interval) for perinatal death comparing the Hudson Bay vs Ungava Bay communities were 1.29 (0.63 to 2.64) for all Inuit births and 1.13 (0.48 to 2.47) for Inuit births at > or =28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined.

CONCLUSION

Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care compared with the Ungava Bay communities with physician-led maternity care. These findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote indigenous communities.

[Neonatal and perinatal mortality in hospitals of the Basque Country-Navarre Neonatal Study Group (GEN-VN) during the period 2000-2006]

BACKGROUND

In 2000, the Basque-Navarre Neonatal Study Group (GEN-VN) was created with a clear objective of studying the perinatal and neonatal health outcomes in newborns.

OBJECTIVE

The aim of this investigation is to present the trends of neonatal and perinatal mortality and their causes in the hospitals of the Basque-Navarre Neonatal Study Group from 2000 to 2006.

PATIENTS AND METHOD

A descriptive study was carried out on the 157,623 births in the participating hospitals of the Basque-Navarre Neonatal Study Group, from 2000 to 2006. During this period, of the total births, 156.904 were born alive, there were 719 foetal deaths and 363 newborns died within the first 28 days of life. Perinatal and neonatal mortality was analysed, raw and stratified by gestational age and birth weight.

RESULTS

The Basque -Navarre Neonatal Study Group collects from 80.5% to 96.8% of all the births reported by the authorities. There is a decreasing trend in foetal and perinatal mortality rates from 2000 to 2006. However, neonatal mortality rates shows a stable trend when compared with the descense in the last years of the 20th century. The most frequent causes of death are respiratory, infections and the congenital anomalies.

CONCLUSIONS

Collecting regional data improves the quality of neonatal and perinatal mortality studies. Very low birth weight and very low gestational age newborns require special quality of care due their high mortality (54.8% of neonatal mortality in 2006), therefore further studies are required on the impact of these newborns on neonatal mortality in our hospitals.

Decreasing trend in postneonatal mortality

OBJECTIVE

The objective was to evaluate the postneonatal mortality rate at our institution from 1999 to 2006 as a follow-up to a previous report from our hospital covering 1993 to 1998 and to investigate the causes of death in infants dying in the postneonatal period.

STUDY DESIGN

We identified all infant deaths before discharge from the nursery aged > or =28 days. Clinical data for all cases and autopsy records where available were reviewed and the cause of death was determined for each infant.

RESULT

Total nursery deaths for the 7 years were 211, of which 14 (6.6%) occurred after the neonatal period. This represents a decreasing trend from the 12% reported in 1993 to 1998. Causes of death were the complications of prematurity and congenital defects. The five infants whose cause of death was the complications of prematurity had chronic lung disease, four had abdominal surgery for perforation and resection and two had intraventricular hemorrhage (IVH) Gr IV. All infants had multiple organ failure by the time of death and the final event was infection and/or renal failure. The nine congenital defects included two trisomy 21 with complications, one CHARGE association with heart defects, one hypertrophic cardiomyopathy and two others with multiple congenital heart defects. Of the three remaining infants, the anomalies included one with hydranencephaly, one with caudal regression and one with multiple vascular liver tumors.

CONCLUSION

Along with the general decrease in infant mortality, postneonatal mortality is decreasing as a percentage of nursery deaths. The causes of death include complications of prematurity and congenital defects.

The effect of plurality and gestation on the prevention or postponement of infant mortality: 1989-1991 versus 1999-2001

Advances in perinatal technology that improved survival may have also resulted in prolonged death from the neonatal to the postneonatal period for some infants. The objectives of this study were to determine if the medical advances that occurred in the 1990s benefited infants of multiple births more than their singleton counterparts, and if these changes prevented or postponed mortality for the smallest and most immature infants. The study population included live births of 22 to 43 weeks' gestation from the 1989-1991 and 1999-2001 US Birth Cohort Linked Birth/Infant Death Data Sets. Odds ratios were calculated to evaluate the change in risk by plurality, gestation, and to compare the change to that for singletons. Neonatal and infant mortality rates declined for all pluralities; postneonatal mortality increased for births at less than 26 weeks, but declined at later gestations. In general, the risk of death for twins and triplets compared to singletons decreased, and the improvement in survival was greater for multiples during the early neonatal period and overall. Infant mortality rates improved by 28% for singletons, 32% for twins and triplets during the 1990s, although for the most premature infants, some deaths were postponed from the early to the late neonatal period.

La mortalité infantile en Europe et au Canada : un problème résolu?

Les enjeux de la mortalité Joeto-infantile des pays à très faible mortalité devront davantage s'énoncer en termes de santé. Santé physique d'abord, la technologisation croissante du processus de la reproduction se traduisant par une augmentation de La survie d'enfants de très faible poids de naissance et, dans certains pays, par une inflation des accouchements très multiples. Santé sociale ensuite, car la persistance des inégalités sociales et leur augmentation probable dans certains pays impliquent que les niveaux observés globalement n'ont pas encore atteint un seuil incompressible. Les statistiques d'état civil offrent, dans bon nombre de pays d'Europe, la possibilité d'élaborer des indicateurs (incidence de naissances de petit et de très petit poids, risques spécifiques selon le poids de naissance, risques différentiels selon les caractéristiques sociales des parents...) permettant de suivre et, dans une certaine mesure, de comparer l'évolution de ces phénomènes.

Postneonatal mortality in Alabama: why no progress in the 90s?

PURPOSE

To examine the factors associated with postneonatal mortality.

METHODS

Logistic regression was used to examine the effects of various variables on postneonatal mortality in Alabama.

RESULTS

The most important predictor of postneonatal mortality was birth weight. Social and economic variables were also important in explaining postneonatal mortality.

CONCLUSIONS

Reductions in postneonatal mortality may require closer case management of low birth weight neonatal survivors. Survival of these infants creates a cohort at risk of postneonatal mortality. Many of these low birth weight infants are born into an environment where their mothers' parenting potential is compromised by youth and poverty. This may be responsible for the failure to reduce postneonatal mortality and explain its increasing proportion of infant deaths; deaths may be being postponed from the neonatal to the postneonatal period.

Mortality and time to death in very low birth weight infants: California, 1987 and 1993

BACKGROUND

Recent advances in perinatal technology have dramatically increased the survival of very low birth weight (VLBW) infants (<1500 g). The possibility that these advances may also prolong the time to death and increase pain and suffering has been of concern, but there have been no population-based evaluations of this issue.

METHODS

Infant, neonatal, and postneonatal mortality rates and time to death for infants 500 to 749 g, 750 to 999 g, 1000 to 1499 g, and all VLBW infants born during 1987 were compared with those outcomes for infants born in 1993 using statewide California linked birth/death cohort files. To assess the effects of improved survival and changes in time until death, we calculated the total days of life preceding an infant death per 1000 live born infants (TDD).

RESULTS

VLBW infants comprised.96% of California's live births in 1987 and.92% of those in 1993. Between 1987 and 1993, VLBW infant mortality rate decreased 28.4% (from 290.7 to 208.3 per 1000 live born VLBW infants), VLBW neonatal mortality rate decreased 30. 3% (from 244.5 to 170.4), and VLBW postneonatal mortality rate decreased 25.3% (from 61.2 to 45.7 per 1000 VLBW alive at 28 days; P <.05 for each rate). Infant mortality rates decreased by 18.8% (718. 1 to 583.0 per 1000) for infants 500 to 749 g, 43.3% (375.1 to 202. 6) for infants 750 to 999 g, and 40.1% (127.9 to 76.7) for infants 1000 to 1449 g (P <.05 for each group). Neonatal mortality and postneonatal mortality rates also decreased in all 3 VLBW subgroups. These reductions in mortality rates were not accompanied by a significant difference in the distribution of times to death or a significant increase in the average time to death for all VLBW infants (22.0 vs 23.6 days) or for those with birth weights of 500 to 749 g (12.7 vs 71.5 days). Reduced mortality in larger infants was accompanied by an increase in the average time to death, from 24. 3 to 32.5 days in infants 750 to 999 g and from 32.3 to 47.0 days in infants 1000 to 1449 g. TDD decreased from 6410 to 4908 days for all VLBW infants. TDD was also reduced 26.4% (2401 days), 24.3% (2115 days), and 22.5% (1043 days) for the 3 VLBW birth weight groups.

CONCLUSIONS

Both mortality rate and timing of death are important when assessing the impact of advances in perinatal technology. Although the average time to death was significantly increased in VLBW infants weighing >750 g, between 1987 and 1993, advances in perinatal technology dramatically decreased VLBW mortality. In the State of California in 1993, this resulted in 452 fewer VLBW deaths and 8233 fewer days preceding a VLBW death than expected.

Impact of increased neonatal survival on postneonatal mortality in the United States

Neonatal intensive care has increased neonatal survival, but has also led to postponement of some of the neonatal deaths to the postneonatal period, particularly in very low birthweight (< 1.5 kg) infants. Our report assesses the impact of the increased neonatal survival and the accompanying delayed deaths on the crude postneonatal mortality rate of the US, using the national livebirth cohort data of 1960, 1980, and 1986. With increased neonatal survival, very low birthweight infants comprised 0.68% of all neonatal survivors in 1986, compared with only 0.31% in 1960. However, postneonatal mortality was increased in infants with birthweights < 1.0 kg from 69 per 1000 neonatal survivors in 1960 to 116 per 1000 in 1986. All other birthweight groups (> 1.0 kg) showed significant reductions in their postneonatal mortality, although the 1.0-1.5 kg group showed the least improvement. Thus, in 1986, 12.1% of all postneonatal deaths were from the very low birthweight neonatal survivors, as compared with 2.7% in 1960. If there had been no improvement in neonatal survival of very low birthweight infants since 1960, the crude postneonatal mortality rate of the US would have been 5.5% and 7.9% less than the actual rates of 3.65 and 3.45 per 1000 neonatal survivors in 1980 and 1986, respectively. However, the impact of these delayed deaths in very low birthweight infants was far less than the increase in their neonatal survival: an additional 416 per 1000 very low birthweight infants survived to 1 year of age in 1986 as compared with 1960. Delayed deaths in the 1.5-2.5 kg birthweight group had a very small effect on postneonatal mortality and there was no such effect of delayed deaths in the > 2.5 kg birthweight group.

Age at neonatal death in Ontario, 1979-1987: implications for the interpretation of mortality markers

Recent evidence concerning time trends in infant mortality rates suggests faster falls in early compared with late deaths. This may be due to rapid advances in neonatal care. This study was undertaken to examine the timing of neonatal death in Ontario between 1979 and 1987. Trends with time, gestational age and type of birth hospital were examined. Evidence suggests that, controlling for level of birth hospital and gestational age, there was a time trend of an increasing proportion of late neonatal deaths. This suggests that early neonatal mortality was decreasing more rapidly than late neonatal mortality. Controlling for year of birth and gestational age, it was observed that the proportion of late neonatal deaths was higher for those born in a tertiary rather than community hospital. In combination, these findings suggest that, due to advances in neonatal care, a disproportionately high number of early neonatal deaths are increasingly being prevented. The findings have implications for the interpretation of routinely available mortality markers. The authors conclude that early neonatal death rate may be becoming a less useful marker and that a measure of perinatal mortality which includes late neonatal deaths would be a useful addition to the currently collected mortality markers.

Importance of the first day death rate in infant mortality

The conventional partition of infant mortality into neonatal and postneonatal deaths, with the 28th day postpartum as the dividing line, has lost much of its epidemiological rationale in countries with low infant death rates. Infant deaths are concentrated increasingly at the start of the neonatal period: one out of three infant deaths in the United States occurs during the first 24 hours. Circumstances of early neonatal deaths differ considerably from those of later neonatal deaths. Failure to monitor separately early and late neonatal mortality can compromise the recognition of distinct epidemiological patterns. Racial disparities in the US tend to be larger for first day deaths than for any other infant deaths. Total US infant mortality declined rapidly in the 1950s and 1960s but first day deaths rose at a steady pace. Surveillance of infant mortality, whether on the national or the community level, should encompass first day, first month and first year death rates.

Preventing and postponing death: trends in Tennessee infant mortality

Infants born in Tennessee between 1984 and 1988 experienced reduced mortality compared with those born in the 5 years previous. For all birthweight singleton infants, the reduction from 10.2 to 8.4 deaths per 1000 live births represents an 18% decline in mortality. The most impressive gain made was for very low birthweight (less than 1500 g) infants in the neonatal period, where mortality was reduced 24%. However, for these infants there was nearly a sixfold increase in the postneonatal mortality associated with prematurity-related causes.

Causes of infant mortality in a multiethnic population

Causes of infant mortality and their change over time in five ethnic groups were investigated using linked infant death and live birth certificates from the State of Hawaii, 1968-1983. Over the study period, there were 3,324 deaths of which 31 percent were to Whites, 26 percent to Hawaiians, 17 percent to Asians, 15 percent to Filipinos and 10 percent to other ethnic groups. Significant changes in the proportion of deaths by cause occurred over the period. Perinatal causes remained the most frequent, but their relative contribution to annual infant deaths declined from 61 percent to 47 percent. The proportion of deaths from congenital anomalies increased from 19 percent to 30 percent, while the proportion of deaths from infectious diseases declined from 14 percent to 4 percent. There was a significant difference in the proportion of deaths by cause between ethnic groups in the early years of the study period. However, during the last four years 1980-1983, no significant difference between ethnic groups was observed.