Ethnicity and birth outcome: New Zealand trends 1980-2001. Part 1. Introduction, methods, results and overview

BACKGROUND: New Zealand Government policy during the past decade has placed a high priority on closing socioeconomic and ethnic gaps in health outcome. AIM: To analyse New Zealand's trends in preterm and small for gestational age (SGA) births and late fetal deaths during 1980-2001 and to undertake ethnic specific analyses, resulting in risk factor profiles, for each ethnic group. METHODS: De-identified birth registration data from 1 189 120 singleton live births and 5775 stillbirths were analysed for the period 1980-2001. Outcomes of interest included preterm birth, SGA and late fetal death while explanatory variables included maternal ethnicity, age and New Zealand Deprivation Index decile. Trend analysis was undertaken for 1980-1994 while multivariate logistic regression was used to explore risk factors for 1996-2001. RESULTS: During 1980-1994, preterm birth rates were highest amongst Maori women. Preterm rates increased by 30% for European/other women, in contrast to non-significant declines of 7% for Maori women and 4% for Pacific women during this period. During the same period, rates of SGA were highest amongst Maori women. Rates of SGA declined by 30% for Pacific women, 25% for Maori women and 19% for European/other women during this period. Rates of late fetal death were highest amongst Pacific women during 1980-1994, but declined by 49% during this period, the rate of decline being similar for all ethnic groups. CONCLUSIONS: The marked differences in both trend data and risk factor profiles for women in New Zealand's largest ethnic groups would suggest that unless ethnicity is specifically taken into account in future policy and planning initiatives, the disparities seen in this analysis might well persist into future generations.     

Unexplained fetal death: Are women with a history of fetal loss at higher risk?

Aims: To identify factors, including the loss of a previous pregnancy before 20 weeks gestation, which are associated with increased risk of singleton antepartum unexplained fetal death (UFD) in Western Australia (WA) using information recorded in routine data collections.
Methods: All fetal deaths in WA from 1990 to 1999 that underwent thorough post-mortem investigations were classified using the Perinatal Society of Australia and New Zealand Perinatal Death Classification System. All UFDs were selected as cases and unmatched controls were randomly drawn from all live births in WA occurring during the study period. Demographic and clinical information on cases and controls was obtained from the WA Midwives' Notification System. Multivariable logistic regression was carried out to determine the independent effect of risk factors and calculate odds ratios.
Results: Almost one quarter (22%) of stillbirths were unexplained. Primigravid and primiparous women with a history of pregnancy loss before 20 weeks were at higher risk of UFD than multiparous women who had not experienced any loss. Women with a history of fetal death (after 20 weeks) had the highest risk of UFD.
Conclusion: The current practice of closely monitoring pregnant women with a history of fetal loss or death should continue as this study suggests they may have a higher risk of poor obstetric outcome. Larger studies are needed to confirm the association between previous pregnancy loss and UFD.     

Systematic multidisciplinary approach to reporting perinatal mortality: Lessons from a five-year regional review

Background:  Because of differences in reporting criteria throughout the world, comparing perinatal mortality rates and identifying areas of concern can be complicated and imprecise.
Aims:  To detail the systematic approach to reporting perinatal deaths and to identify any significant differences in outcomes in the Australian Capital Territory (ACT).
Methods:  Review of perinatal deaths from 2001 to 2005 in the ACT using the Australian and New Zealand Antecedent Classification of Perinatal Mortality (ANZACPM) and the Australian and New Zealand Neonatal Death Classification (ANZNDC) systems.
Results:  ACT residents' perinatal mortality rate was 10.6 per 1000 total births, fetal death rate 7.5 per 1000 total births and neonatal death rate 3.2 per 1000 live births. The three leading antecedent causes of perinatal death were congenital anomalies, spontaneous preterm birth and unexplained antepartum death. The three leading causes of neonatal death were extreme prematurity, cardiorespiratory disorders and congenital anomalies. Multiple births attributed to 20% (65 of 321) of perinatal deaths. Perinatal autopsy was performed in 50% of cases, but in only 64% of unexplained antepartum deaths.
Conclusions:  Causes of perinatal death for the ACT and surrounding New South Wales region are similar to other states using this classification system. The following are considered important lessons to promote accurate perinatal mortality reporting: (i) a universal reporting system for Australia utilising a multidisciplinary team; (ii) a high perinatal autopsy rate, especially in the critical area of antepartum death with no identifiable cause; and (iii) standardised definitions for avoidability. Attention to these areas may prompt further research and changes in practice to further reduce perinatal mortality.     

Ethnicity and birth outcome: New Zealand trends 1980-2001: Part 3. Pregnancy outcomes for Pacific women

BACKGROUND: Pacific women in New Zealand reside in areas of higher socioeconomic deprivation compared to women from other ethnic groups. Pacific women and their health are further disadvantaged because of genetic predisposition and sociocultural factors that cause ill-health. The correlations between pregnancy outcomes, risk factors and other health indices in Pacific women need evaluation. AIMS: To examine trends in preterm birth, small for gestational age (SGA) and late fetal death for Pacific women during 1980-2001 and to explore risk factors which make this group vulnerable to adverse birth outcome. METHODS: De-identified birth registration data from 1 189 120 singleton live births and 5775 stillbirths were analysed for 1980-2001. Outcomes of interest included preterm birth, SGA and late fetal death while explanatory variables included maternal ethnicity, age and NZ Deprivation Index decile. Trend analysis was undertaken for 1980-1994 and multivariate logistic regression was used to explore risk factors for 1996-2001. RESULTS: Pacific women had the lowest rates of preterm birth and SGA when compared to Maori and European women. In addition, preterm birth rates underwent a non-significant 4% decline and SGA rates a 30% decline during 1980-1994. Although there has been a 49% decline in late fetal deaths during 1980-1994, the rate remained higher for Pacific women than for Maori and European/other women. CONCLUSIONS: Despite residing in areas of high socioeconomic deprivation, which is associated with poor pregnancy outcomes for Maori and European/other women, Pacific women had better pregnancy outcomes, with lower preterm and SGA rates. The significant decline in rates of late fetal death during the past two decades is a cause for celebration; however, the rate remains higher for Pacific women than for other ethnic groups. Biological, cultural and social factors might explain the better pregnancy outcomes for Pacific women and these factors should be considered when developing future prevention programmes.     

Ethnicity and birth outcome: New Zealand trends 1980-2001: Part 2. Pregnancy outcomes for Maori women

BACKGROUND: While traditionally Maori perinatal mortality has been similar to that of other ethnic groups, rates of preterm birth, small for gestational age (SGA) and teenage pregnancy have remained high. AIMS: To review current trends in preterm birth, SGA and teenage pregnancy for Maori during 1980-2001 and to highlight the major factors that have influenced Maori reproductive outcomes during this period. METHODS: De-identified birth registration data from 1 189 120 singleton live births and 5775 stillbirths were analysed for 1980-2001. Outcomes of interest included preterm birth, SGA and late fetal death while explanatory variables included maternal ethnicity, age and NZ Deprivation Index decile. Trend analysis was undertaken for 1980-1994 and multivariate logistic regression was used to explore risk factors for 1996-2001. RESULTS: During 1980-1994, Maori women had the highest preterm birth rates of any ethnic group in New Zealand, but in relative terms, inequalities declined as a consequence of a non-significant 7% fall in rates being offset by a statistically significant 30% increase for the European/other ethnic group. Rates of SGA were also higher amongst Maori women but declined by 25% during the 1980-1994 period. In addition, Maori women experienced significant socioeconomic gradients in SGA, with risk for Maori women in the most deprived NZDep areas being double that of Maori living affluent areas. Paradoxically, while Maori women had high rates of teenage pregnancy, this did not confer additional risk for preterm birth or SGA during the 1996-2001 period. CONCLUSIONS: While high rates of teenage pregnancy amongst Maori women appear not to confer additional risk for preterm birth or SGA, the social consequences of early childbearing may well be significant. The persistence of elevated rates of preterm birth and large socioeconomic gradients in SGA amongst Maori suggest that broader social and policy interventions are necessary if Maori are to achieve optimal birth outcomes in the coming decades.     

Significance of Antinuclear Antibody Testing in Unexplained Second and Third Trimester Fetal Deaths

The purpose of this study was to determine if a group of patients with unexplained second or third trimester fetal demise have an increased prevalence of antinuclear antibodies (ANA) when compared to controls. During a 5-year period from January 1989 through December 1993, the records of all fetal deaths ≥ 500 g or ≥ 20 weeks of gestation that occurred at our institution were reviewed. In these women the ANA titers were checked at the discretion of the physician. The proportion of positive ANA tests in the group of women with explained fetal deaths was compared to that in women with unexplained fetal deaths. These results were then compared to a control group of healthy gravidas presenting to labor and delivery in the third trimester. During this time period, 848 fetal deaths were recorded. Our study population consisted of 286 patients who had an unexplained second or third trimester fetal demise with a record of having an ANA drawn. Of the 376 explained fetal deaths, 190 had an ANA assayed. The control group included 299 healthy third trimester gravidas. In the group of patients with unexplained fetal death, 11.5% (33/286) had a positive ANA, whereas 16% (31/190) of ANA tests were positive in cases of explained fetal death (P = 0.17). In the control group, 14% (43/299) had a positive ANA. There were three distinct immunofluorescence patterns: nucleolar, speckled, and homogeneous. The first two were seen more often in the control group, whereas the latter was seen more frequently in those patients with fetal death (P = 0.10). The incidence of a significant circulating ANA titer was similar in patients and controls. Moreover, there was no significant association between circulating antinuclear antibody titers and fetal outcome. More patients with a fetal death had a homogeneous nuclear fluorescence pattern when compared to controls; however, this finding was not statistically significant. Therefore, we do not recommend routine testing for ANA in women with unexplained second or third trimester fetal death.     

Fetal growth restriction and other factors associated with neonatal death in New Zealand

BACKGROUND: There are few studies of risk factors for neonatal death in Australia or New Zealand. AIMS: To assess in a cohort of neonatal deaths (i) the demographic and clinical risk factors; (ii) the relationship between low weight for gestation using population and customised centiles; and (iii) the cause of death by the Perinatal Society of Australia and New Zealand Perinatal and Neonatal death classifications. METHODS: A retrospective study of 410 babies who died, in the neonatal period, at National Women's Hospital, between 1993 and 2000. Demographic and clinical data were compared with that from a referent population of live births with neonatal deaths removed (n=68 905). RESULTS: The overall neonatal death rate was 5.9 per 1000 live births and after exclusion of congenital abnormalities was 3.9 per 1000 live births. Infants of Maori women had increased risk compared to European (adjusted odds ration (AOR) 1.52; 95% CI 1.06, 2.18), as did those born to primipara (AOR 1.52; 95% CI 1.10, 2.11), mothers with >or=1 previous low-birthweight baby (AOR 2.97; 95% CI 1.99, 4.44), >or=1 miscarriage (AOR 1.35; 95% CI 1.00, 1.81), and an index multiple pregnancy (AOR 10.51; 95% CI 8.04, 13.76). Infants of Chinese mothers had decreased risk (AOR 0.42; 95% CI 0.18, 0.96). Fifty (34%) babies were small for gestational age by customised and 26 (17%) by population centiles. The most common classification of neonatal death was congenital abnormality (34.6%), followed by extreme prematurity (34.1%). CONCLUSIONS: This study emphasises the importance of suboptimal fetal growth as an important risk factor for neonatal death especially when customised centiles are used.     

Trends in the cause of late fetal death, 1982-2000

BACKGROUND: Progress in reducing late fetal deaths has slowed in recent years, despite changes in intrapartum and antepartum care. OBJECTIVES: To describe recent trends in cause-specific fetal death rates. DESIGN: Retrospective cohort study. SETTING: North of England. POPULATION/SAMPLE: 3,386 late fetal deaths (> or = 28 weeks of gestation and at least 500 g), occuring between 1982 and 2000. METHODS: Data on deaths were obtained from the Northern Perinatal Mortality Survey. Data on live births were obtained from national birth registration statistics. Rate ratios (RR) and 95% confidence intervals (CI) for fetal deaths in 1991-2000 compared with 1982-1990 were calculated. MAIN OUTCOME MEASURES: Cause-specific late fetal death rates per 10,000 total births. RESULTS: Mortality in singletons declined from 51.5 per 10,000 births in 1982-1990 to 42.0 in 1991-2000 (RR 0.82, 95% CI 0.76-0.87). There was a greater decline in multiples, from 197.9 to 128.0 per 10,000 (RR 0.65, 95% CI 0.51-0.83). In singletons, the largest reductions occurred in intrapartum-related deaths, and deaths due to congenital anomalies, antepartum haemorrhage and pre-eclampsia. There was little change in the rate of unexplained antepartum death occurring at term (RR 0.97, 95% CI 0.84-1.11) or preterm (RR 0.94, 95% CI 0.82-1.07), these accounting for about half of all late fetal deaths. Unexplained antepartum deaths declined in multiple births and in singletons of birthweight < 1500 g. CONCLUSIONS: While late fetal mortality due to many specific causes has declined, unexplained antepartum death rates have remained largely unchanged. Improved identification of deaths due to growth restriction and infection, which may otherwise be classified as unexplained, is important. Further investigation of the underlying aetiologies of genuinely unexplained deaths is needed.     

Sudden unexpected neonatal death in the first week of life: Autopsy findings from a specialist centre

Objective. Sudden unexpected early neonatal death (SUEND) in the first week of life shares features with sudden unexpected death in infancy (SUDI) but is not included as SUDI, which is limited to post-perinatal deaths. The aim of this study was to review SUEND autopsies performed in a single specialist centre over a 10-year period, (1996–2005).

Methods. Retrospective analysis of >1500 consecutively performed paediatric autopsies performed by paediatric pathologists at one centre conducted according to a standard protocol including ancillary investigations. SUENDs were identified and autopsy findings reviewed.

Results. Of 1516 post-mortem examinations, 180 were first-week neonatal deaths, 55 (31%) presenting as SUEND. Thirty-two (58%) were explained following autopsy, whilst the remainder were unexplained; most deaths during sleep were associated with adult co-sleeping. Around 40% of explained deaths were associated with undiagnosed congenital abnormalities, mainly congenital heart disease. In addition, there were nine infection-related deaths and three deaths from unsuspected metabolic disease (fatty acid oxidation defects).

Conclusion. There are distinct differences between SUEND and SUDI, with significantly more explained deaths in the former and a much greater proportion due to congenital abnormalities and metabolic disease.     

Maternal mortality in Greece (1980-1996)

OBJECTIVE: To use data from the National Statistical Service of Greece to examine trends in maternal mortality and risk factors for maternal deaths. STUDY DESIGN: Maternal mortality in Greece has been studied from years 1980 to 1996 in total, by cause of death, by residency (urban/rural) and by maternal age. The maternal mortality ratio (MMR) has been defined as the number of deaths per 100,000 live births. RESULTS: From years 1980 to 1996, there have been 136 maternal deaths (MMR: 7). The number of deaths has significantly decreased during this period and six major causes of death have been identified, resulting in 80% of maternal deaths. A simulation of maternal mortality between urban and rural areas has been achieved during the last decade. Also, maternal mortality rises dramatically with age. CONCLUSIONS: Although overall rates of maternal mortality in Greece have been significantly decreased over the last years, an improved recording of maternal deaths is necessary for identifying preventable factors and developing effective interventions.     

A 50-year audit of maternal mortality in the Peninsula Maternal and Neonatal Service, Cape Town (1953-2002)

OBJECTIVE: To audit trends in maternal mortality in the Peninsula Maternal and Neonatal Service (PMNS) over a 50-year period, with respect to rates and patterns of causation. DESIGN: Retrospective and prospective audit. SETTING: The PMNS, an integrated perinatal service composed of primary, secondary and tertiary facilities in Cape Town. Population All women giving birth in the area of the Cape Peninsula served by the PMNS over the 50-year period. METHODS: Data on maternal deaths were collected for 1953-2002 inclusive, from annual obstetric and gynaecological reports. Three triennia (1954-1956, 1981-1983 and 1999-2001) were selected for a detailed comparison of trends in rates and causes of death. MAIN OUTCOME MEASURES: Maternal mortality rates (MMRs). Causes of maternal deaths. RESULTS: Total deliveries increased from 7315 in 1953 to 27,575 in 2002. The MMR declined from 301 deaths per 100,000 deliveries in 1953 to 31.2 in the triennium, 1987-1989. From 1999, the MMR increased, reaching 112 in 2002. Comparing 1954-1956 (MMR of 253.9) with 1981-1983 (MMR of 43.8), there was a marked decline in the MMR related to hypertension (80.4 to 11.3), haemorrhage (50.8 to 4.2), abortion (55 to 4.2), suspected pulmonary embolism (25.4 to 2.8), pregnancy-related sepsis (8.5 to 4.2) and cardiac disease (21.2 to 2.8). Comparing 1981-1983 (MMR of 43.8) with 1999-2001 (MMR of 59.4), there was a decline in the MMR associated with abortion (4.2 to 0). The MMR for haemorrhage, suspected pulmonary embolism and cardiac disease remained the same. There was a slight increase in the MMR attributed to hypertension (11.3 to 14.5) and pregnancy-related sepsis (4.2 to 7.3). There was a marked increase in the MMR associated with non-pregnancy-related infections/AIDS (4.2 to 18.2). CONCLUSIONS: The MMR for all causes of maternal death declined significantly from 1953 to 1981 as a result of several interventions. From 1999, there has been a non-significant increase in MMR, predominantly due to the burden of HIV/AIDS-related mortality.     

Ethnicity and birth outcome: New Zealand trends 1980-2001: Part 4. Pregnancy outcomes for European/other women

BACKGROUND: In the early 1980s European/other women made up 80% of New Zealand's population and experienced rates of preterm birth that were lower than for other ethnic groups. Rates of small for gestational age (SGA) and late fetal death were intermediate between those of Maori and Pacific women. AIMS: To examine trends in preterm birth, SGA and late fetal death for European/other women during 1980-2001 and to explore risk factors which make this group vulnerable to adverse birth outcome. METHODS: De-identified birth registration data from 1 189 120 singleton live births and 5775 stillbirths were analysed for 1980-2001. Outcomes of interest included preterm birth, SGA and late fetal death while explanatory variables included maternal ethnicity, age and NZ Deprivation Index decile. Trend analysis was undertaken for 1980-1994 and multivariate logistic regression was used to explore risk factors for 1996-2001. RESULTS: During 1980-1994, rates of preterm birth rose by 30% for European/other women, in contrast to a non-significant decline of 7% for Maori women and 4% for Pacific women. Rates of SGA declined 19% for European/other women, compared to 25% for Maori and 30% for Pacific women. Preterm birth and SGA were positively associated with teenage pregnancy and increasing NZDep deprivation. During 1980-1994, rates of late fetal death declined by 49%, with declines being similar for all ethnic groups. CONCLUSIONS: The progressive rise in preterm birth during the past two decades is a cause of concern for European/other women, particularly as it appears confined to this ethnic group. While rates of SGA have declined, albeit at a slower rate than for other ethnic groups, the elevated risk amongst teenagers and those living in the more deprived NZDep areas suggests that greater gains are achievable if interventions are targeted towards these particular groups.     

The changing pattern of fetal death, 1961-1988.

The aim of this study was to assess any changes in cause-specific fetal death rates in the nonreferred population of a tertiary care unit. The fetal death rate (per 1000 births) among 88,651 births diminished from 11.5 in the 1960s to 5.1 in the 1980s. Fetal death due to intrapartum asphyxia and Rh isoimmunization has almost disappeared. Toxemia and diabetes continue to make similar and small contributions to fetal death rates. There has been a significant decline in unexplained antepartum fetal deaths and in those caused by fetal growth retardation, but no significant change in the death rate due to intrauterine infection or abruptio placentae. During the 1960s, the risk of fetal death was increased in women with hypertension, diabetes, or a history of stillbirth; during the 1980s, only women with a history of insulin-dependent diabetes were at risk. Improved application of current knowledge may help decrease the fetal death rate caused by fetal growth retardation. Reduction in deaths due to abruptio placentae, intrauterine infections, or lethal malformations, as well as unexplained antepartum deaths, appears to depend on better understanding of the etiology of these disorders.     

Observations Concerning “Unexplained” Fetal Demise in Pregnancy Complicated by Diabetes Mellitus

“Unexplained” feral death, although uncommon, continues to be a classic accident associated with diabetes mellitus during pregnancy. During a 9-year period at our hospital, the authors were in attendance when such unexplained fetal death was actually occurring in two pregnancies. These very rare clinical experiences may serve to provide new insights into these “unexplained” fetal deaths. We propose that placental edema and resultant impaired placenta-to-fetus oxygen transport is a contributing factor for these fetal deaths. Moreover, such placental edema can be linked to the glucose aberrations associated with maternal diabetes.     

Obstetric deaths in Bangladesh, 1996-1997.

OBJECTIVES: The purpose of this study was to measure and to describe obstetric deaths in Bangladesh. METHODS: We reviewed hospital records and interviewed health workers in clinic sites and field workers who cared for pregnant women. RESULTS: We obtained case reports of 28998 deaths of women aged 10-50, of which 8562 (29.5%) were maternal deaths. Most (7086, 82.8%) of these deaths were due to obstetric causes. The most common causes of direct obstetric death were eclampsia (34.3%), hemorrhage (27.9%), and obstructed and/or prolonged labor (11.3%). National direct obstetric death rate was estimated to be 16.9 per 100,000 women. CONCLUSIONS: Efforts to reduce fertility in Bangladesh have led to an estimated 49% reduction in the maternal mortality rate per 1000 women during the past 18 years. Variations in maternal mortality suggest the need to develop local strategies to improve obstetric care.     

Evaluation of fetal and neonatal mortality at the University Hospital of Troms?, Norway, from 1976 to 1989.

To investigate developments in perinatal care, all fetal and neonatal deaths among those born after at least 24 weeks of gestation at the University Hospital of Troms?, Norway from 1976 to 1989, were subjected to medical audit. A decrease in total mortality rate was found when based on maturity (greater than or equal to 24 weeks; 19.9-13.4%; p less than 0.01), and/or birth weight (greater than or equal to 500 g; 19.2-13.4%; p less than 0.05). This was mainly due to a decrease in fetal deaths (14.8-6.6%; p less than 0.0001). Deaths during labor (5.4-1.1%; p less than 0.001), and deaths before the onset of labour (9.4-5.5%; p less than 0.05) declined. The neonatal death rate remained virtually constant (5.2-6.8%). The incidence of conditions affecting the placenta and the umbilical cord, causing asphyxia and intra-uterine growth retardation, declined, from 9.2 to 5.0% (p less than 0.01), as did that caused by immaturity (2.8-1.3%; p less than 0.05). The rates of death caused by cerebral hemorrhage, respiratory distress syndrome, infections, and malformations did not change. There was no significant proportional change in the causes of death from the first to the last period. The rate of fetal death following suboptimal care declined (2.4-0.4%; p less than 0.01), while the corresponding neonatal death rate remained unchanged (0.9-1.1%). The proportions of both fetal and neonatal deaths occurring after suboptimal care were low (fetal: 16.2, 8.8, and 5.6%; neonatal: 17.1, 23.5, and 16.2%). These differences did not reach statistical significance.(ABSTRACT TRUNCATED AT 250 WORDS)     

Maternal mortality in Italy, 1980-1996

OBJECTIVE: To establish the extent of maternal mortality in Italy in between 1980 and 1996 in order to compare it with the international data. STUDY DESIGN: We conducted a retrospective study on maternal deaths in Italy from 1980 to 1996. Data have been collected by Italian Statistic Institute (ISTAT). We calculated both the maternal mortality rates and the percentages of causes of death in the whole period, according to WHO definitions. RESULTS: The data confirmed the trends of the previous decade: maternal mortality rates have decreased from 13.25 (1980) to 3.78 (1996) for 100000 live births. Haemorrhage and hypertension have been the main causes of maternal death, while pulmonary embolism has had a minor affect on maternal mortality rates compared to other countries, particularly in Europe. CONCLUSION: Italian data appear reassuring and encourage further investigations on detailed welfare problems.     

The Egypt National Perinatal/Neonatal Mortality Study 2000.

OBJECTIVES: To estimate stillbirth, perinatal (PMR) and neonatal mortality rates (NMR) in Egypt and to assign main causes of death. STUDY DESIGN: Data were collected from a representative sample of women who gave birth from 17,521 households which were included in the Egypt Demographic and Health Survey (EDHS) 2000. Comparisons were made between three systems for classifying causes of death. RESULTS: The NMR was 25 per 1000 live births (17 early and eight late). Half the deaths occurred in the first two days of life. Neonatal causes of death were pre-maturity (39%), asphyxia (18%), infections (7%), congenital malformation (6%) and unclassified (29%). The PMR was 34 per 1000 births, mainly attributed to: asphyxia (44%) and prematurity (21%). The revised Wigglesworth classification agreed well with the physicians except the panel attributed more deaths to infections (20%). The WHO verbal autopsy algorithm left 48% of deaths unclassified. CONCLUSIONS: Infant mortality in Egypt is showing an epidemiological transition with a significant decrease in mortality, resulting in a disproportionate percentage of deaths in the first week of life. Infant mortality in Egypt declined 64% from 124 per 1000 between 1974 and 1978 to 44 per 1000 between 1995 and 1999, the decline being greatest among older infants; 55% of all infant deaths occurred during the neonatal period. The neonatal mortality rate in this study was estimated to be 25 per 1000 live births.     

Pregnancy-related deaths in four regions of Europe and the United States in 1999-2000: characterisation of unreported deaths

OBJECTIVE: We compared official maternal mortality statistics with those from a special study covering all pregnancy-associated deaths in two European countries (Finland and France) and in two US states (Massachusetts and North Carolina) in 1999-2000 to characterize pregnancy-related deaths that are not included in official statistics. STUDY DESIGN: We linked the official ICD-10-based maternal mortality data for 84 deaths with study data on 404 pregnancy-associated deaths. RESULTS: Of the pregnancy-associated deaths, 151 were pregnancy-related. We found 69 pregnancy-related deaths that had not been included as maternal deaths, and two deaths coded as maternal deaths that did not meet our definition for a pregnancy-related death. In total, 58 of these 69 deaths were from medical causes and 11 were from external causes or injuries (10 postpartum depression-related suicides and one accidental drug poisoning). The unreported deaths due to medical causes included 27 direct, 15 indirect, and two direct/indirect pregnancy-related deaths and 14 possibly pregnancy-related deaths. The most common causes of the unreported deaths due to medical causes were intracerebral hemorrhage (7 deaths), peripartum cardiomyopathy (4), pulmonary embolism (4) and pregnancy-induced hypertension (4). CONCLUSIONS: The collection of data on pregnancy-related and pregnancy-associated deaths is useful for countries with low maternal mortality figures. The use of various data-collection methods may substantially increase the quality of maternal mortality statistics.     

Unexplained Intracranial Haemorrhage in Utero: The Battered Fetus?

Summary: Twenty stillborn infants with unexplained intracranial haemorrhages were identified in a review of approximately 3,500 perinatal postmortems performed between 1966 and 1982. After apparently uneventful pregnancies, fetal death occurred before the onset of labour and was recognized at a mean of 10 days before delivery; 80% had subdural haemorrhages, others had intraventricular and/or intracerebral haemorrhages, and many had haemorrhages at more than one of these sites. These haemorrhages were of sufficient size to have caused death and no other causes were found at postmortem examinations.
All 20 mothers were immigrants to New Zealand from the Pacific Islands and almost all were older, married, multi-gravidas with uneventful medical histories and in stable socio-economic circumstances. In the period studied the incidence of stillbirths with unexplained intracranial haemorrhages was 1.15 per 1,000 Pacific Islander births and, at one hospital, these haemorrhages were found in 14.6% of Pacific Islander stillbirths. There were no unexplained intracranial haemorrhages in other racial groups.
Prenatal subdural haemorrhage without a history of maternal trauma is extremely rare. In the absence of supporting maternal histories and other fetal or maternal injuries the possibility that these are 'battered' fetuses remains circumstantial.