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Tier 1 - Health status and outcomes

1.21 Perinatal mortality

Key facts

Why is it important?

Perinatal mortality is defined as deaths commencing from at least 20 weeks of gestation (fetal deaths or ‘stillbirths’) and deaths of live-born babies within the first 28 days after birth (neonatal deaths). Most of these deaths are due to factors that occur during pregnancy and childbirth. Perinatal mortality reflects the health status and health care of the general population, access to and quality of preconception, reproductive, antenatal and obstetric services for women, and health care in the neonatal period. Broader social factors such as maternal education, nutrition, smoking, alcohol use during pregnancy and socioeconomic disadvantage are also important (Performance Indicator Reporting Committee 2002; Eades 2004).

Findings

What does the data tell us?

Data is sourced from the ABS Perinatal Deaths Collection, where information is provided by the eight individual jurisdictional Registrars of Births, Deaths and Marriages to the ABS for coding and compilation. For the period 2014–2018, the perinatal mortality rate for Aboriginal and Torres Strait Islander babies was 10 per 1,000 births compared with 7.6 per 1,000 births for non‑Indigenous babies (Figure 1.21.1). Of the 826 Indigenous babies who died during the perinatal period, fetal deaths (also known as stillbirths) accounted for 59% of perinatal deaths for Indigenous babies, compared with 71% of perinatal deaths for non-Indigenous babies (Table D1.21.4, Figure 1.21.2). Data in this measure are for the five jurisdictions with Indigenous identification data of adequate quality (New South Wales, Queensland, Western Australia, South Australia and the Northern Territory).

Figure 1.21.1: Fetal, neonatal and perinatal mortality rates, by Indigenous status, NSW, Qld, WA, SA and NT combined, 2014–2018

The column chart shows that, overall, the perinatal mortality for Indigenous babies was 10.1 per 1,000 live births, compared to 7.6 per 1,000 live births for non-Indigenous babies; the fetal mortality rate was 6 per 1,000 for Indigenous and 5.4 per 1,000 for non-Indigenous babies; and the neonatal mortality rate was 4.1 per 1,000 for Indigenous babies and 2.2 for non-Indigenous babies.

Source: Table D1.21.4. AIHW and ABS analysis of the ABS Perinatal Deaths Collection.

Figure 1.21.2: Child and infant mortality for Indigenous Australians, NSW, Qld, WA, SA and NT combined, 2014–2018

This chart shows that, of 826 Indigenous babies who died during the perinatal period, 490 were foetal deaths (stillbirths) with at least 20 weeks gestation, and 349 deaths were neonatal deaths (from birth to 27 days); of the 603 deaths of children aged 0 to 4, 14 were infant deaths (birth to less than 1 year), and 89 deaths of children aged 1 to 4.

Source: Table D1.21.4, D1.22.1 AIHW and ABS analysis of the ABS Perinatal Deaths Collection.

Between 1998 and 2018, there was a significant decrease (of 55%) in the perinatal mortality rate for Indigenous Australians, from 18 to 9 per 1,000 births, representing an average yearly decline of 0.5 per 1,000 births. The perinatal mortality rate also decreased for non-Indigenous Australians but by a smaller amount (by 26%), from 9.5 to 7.2 per 1,000 births, resulting in a significant reduction in the gap for perinatal mortality between Indigenous and non-Indigenous Australians over this period.

The greatest improvement in the perinatal death rate for Indigenous Australians was seen between 1998 and 2008, with a significant (41%) decline (from 18 to 9.7 per 1,000) in the rate and a significant (70%) narrowing of the gap (from 8.6 to 1.8 percentage points) over the period. Between 2008 and 2018, the perinatal mortality rate for Indigenous Australians continued to decline (by 6%; not significant) and the gap widened (by 12%; not significant). For non-Indigenous Australians over the same period, a significant decline (of 11%) was observed (Table D1.21.2, Figure 1.21.3).

Over the period 1998 to 2018, the fetal death rate for Indigenous Australians declined by 50%, and the neonatal death rate declined by 61%. This improvement was attributed to the period 1998 to 2008, when the rates declined significantly (by 38% and 45%, respectively), while from 2008 to 2018, the rate of decline slowed (to 6% and 8%, respectively). These declines were not significant (Table D1.21.3).

Note that due to the small number of deaths, time series data for perinatal mortality are volatile and should be interpreted with caution. Large percentage fluctuations from year to year could be due to small variations in death numbers.

Figure 1.21.3: Perinatal mortality rates, by Indigenous status, NSW, Qld, WA, SA and NT, 1998–2018

This line graph shows that the rate of perinatal mortality for Indigenous babies decreased from 18 per 1,000 live births in 1998 to 9.0 per 1,000 live births in 2018, and that for non-Indigenous babies decreased from 9.5 to 7.2 per 1,000. The gap between the mortality rates for Indigenous and non-Indigenous babies narrowed from 8.6 to 1.8 per 1,000 live births.

Source: Table D1.21.2. AIHW and ABS analysis of the ABS Perinatal Deaths Collection.

Perinatal mortality by jurisdiction

In the period 2014–2018, the perinatal mortality rate for Indigenous Australians varied between the five jurisdictions. It was lowest in New South Wales (6.1 per 1,000 births, or 176 deaths) and highest in the Northern Territory (20.2 per 1,000 births, or 140 deaths). The largest gap between Indigenous and non-Indigenous Australians was in the Northern Territory, where the rate for Indigenous Australians was almost twice the rate for non‑Indigenous Australians (20 and 11 per 1,000 births, respectively). Perinatal mortality rates were slightly lower for Indigenous than non-Indigenous Australians in New South Wales, 6.1 compared with 7.2 per 1,000 births, respectively (Table D1.21.4, Figure 1.21.4).

Figure 1.21.4: Perinatal mortality rates, by Indigenous status and jurisdiction, NSW, Qld, WA, SA and NT, 2014–2018

The column chart shows that the rate of perinatal mortality for Indigenous babies was highest in the Northern Territory (20.2 per 1,000 live births), followed by Queensland (11.6 per 1,000), and lowest in New South Wales (6.1 per 1,000); The Northern Territory also had the largest gap between Indigenous and non-Indigenous mortality rates (21.3 compared with 9.0 per 1,000 live births), while in New South Wales the Indigenous mortality rate was lower than the non-Indigenous rate (6.1 compared with 7.2 per 1,000).

 Source: Table D1.21.4. AIHW and ABS analysis of the ABS Perinatal Deaths Collection.

Leading cause of perinatal mortality

From 2014 to 2018, the leading cause of perinatal mortality for Indigenous babies was a group of conditions originating in the perinatal period, including birth trauma and disorders specific to the fetus/newborn (accounting for 48% of deaths), followed by disorders related to the length of gestation and fetal growth (27% of deaths), and congenital malformations, deformations and chromosomal abnormalities (14% of deaths). The two main conditions in the mother leading to perinatal deaths were complications of the placenta, cord and membranes, and complications of pregnancy (both 13% of deaths) (Table D1.21.5).

Deaths due to premature birth/inadequate fetal growth were more likely for Indigenous babies than for non-Indigenous babies—27% compared with 18%, respectively. A lower proportion of deaths for Indigenous babies compared with non-Indigenous babies was due to congenital malformations (14% compared with 21%, respectively) and a group of conditions originating in the perinatal period (48% compared with 54%, respectively) (Table D1.21.5, Table 1.21-1).

Table 1.21-1: Proportion of deaths for perinatal babies by underlying cause of death and Indigenous status, NSW, Qld, WA, SA and NT combined, 2014–2018

Column a: Indigenous
Column b: Non-Indigenous

Main condition in the fetus/infant

Fetal deaths (a)

Fetal deaths (b)

Neonatal deaths (a)

 Neonatal deaths (b)

Perinatal deaths (a)

Perinatal deaths (b)

Other conditions originating in the perinatal period

66.1%

63.2%

21.1%

31.2%

47.8%

53.9%

Disorders related to length of gestation and fetal growth

16.1%

13.2%

43.5%

28.0%

27.2%

17.5%

Congenital malformations, deformations and chromosomal abnormalities

13.9%

19.8%

14.3%

24.2%

14.0%

21.1%

Respiratory and cardiovascular disorders

2.4%

2.5%

10.4%

9.4%

5.7%

4.5%

Infections specific to the perinatal period

0.8%

0.6%

5.4%

4.0%

2.7%

1.6%

Other conditions

0.6%

0.6%

5.4%

3.3%

2.5%

1.4%

Main condition in the mother

Fetal deaths (a)

Fetal deaths (b)

Neonatal deaths (a)

 Neonatal deaths (b)

Perinatal deaths (a)

Perinatal deaths (b)

Complications of placenta, cord and membranes

13.7%

13.5%

11.3%

10.7%

12.7%

12.7%

Maternal complications of pregnancy

10.2%

7.3%

16.7%

10.4%

12.8%

8.2%

Maternal conditions that may be unrelated to present pregnancy

7.8%

4.4%

3.3%

2.8%

5.9%

3.9%

Complications of labour, and delivery and noxious influences transmitted via placenta or breast milk

3.7%

1.3%

7.4%

4.5%

5.2%

2.2%

Total deaths (number)

490

5,393

336

2,222

826

7,615

Source: Table D1.21.5. AIHW and ABS analysis of the ABS Perinatal Deaths Collection.

What do research and evaluations tell us?

Low birthweight is associated with a higher risk of neonatal mortality. In the United States, low birthweight babies account for 60% of all infant deaths. In the Australian context, Indigenous infants born with low birthweights are at greater risk of death in the first year of life (Eades 2004).

A study of 503 babies born to Indigenous Australian mothers in Darwin (1987–1990) found that 28% of low birthweight could be attributable to maternal malnutrition while smoking more than half a packet a day contributed 18%. For babies born small for gestational age, 18% could be attributed to maternal age under 20 years. Risk factors for pre-term birth were predominantly obstetric: pregnancy-induced hypertension (26%) and other obstetric conditions (16%) (Sayers & Powers 1997).

A more recent study of Indigenous mothers in the Northern Territory found that teenagers were more likely to have normal births than 20–34 year olds. While babies of teenagers weighed 135 grams less than those of adults, once adjusting for remoteness, antenatal visits and other factors, differences were eliminated. The authors concluded that young maternal age is not a risk factor for adverse perinatal outcomes among Indigenous women, but rather, having babies in disadvantaged circumstances meant they were challenged socially and clinically (Steenkamp et al. 2017).

Gibberd and others (2019) found that a large proportion of poor birth outcomes in Western Australia among Indigenous infants, including perinatal deaths, were attributable to smoking, alcohol and substance misuse, and assault:

  • Maternal smoking was associated with 49% higher odds of perinatal death.
  • Alcohol was associated with 83% higher odds of perinatal deaths.
  • Drug use was found to be associated with pre-term births but not perinatal deaths (Gibberd et al. 2019).

Panaretto and others (2007) show that sustained access to community-based, integrated, shared antenatal services improved perinatal outcomes among Indigenous Australian women. The study of patients in Townsville demonstrated significant improvements in care planning, completion of cycle-of-care, and antenatal education activities with a significant reduction in perinatal mortality (Panaretto et al. 2007). The Australian Institute of Health and Welfare (AIHW 2014) presented a number of examples of antenatal care programs that have an effect on low birthweight, pre-term birth and child mortality. The Australian Government has funded initiatives which have resulted in improvements in antenatal care for Indigenous mothers, including New Directions: Mothers and Babies Services and the Healthy for Life program, and other state-based initiatives include the New South Wales Aboriginal Maternal and Infant Health Service and the Australian Capital Territory Aboriginal Midwifery Access Program.

Implications

Progress in decreasing the Indigenous perinatal mortality rate has stalled since 2008, and this is cause for concern. This points to the need for continued and enhanced efforts to improve maternal and child health. However, it also points to some limitations with the data, and as such, the trends should be interpreted with caution.

Improvements in the health of Indigenous Australian infants are possible with reductions in key risk factors during pregnancy such as smoking, alcohol, drug misuse and assault (Gibberd et al. 2019). Enhanced primary care services and continued improvement in, and access, to culturally appropriate antenatal care have the capacity to support improvements in the health of the mother and baby. Protective factors such as not smoking during pregnancy and cultural-based resilience of mothers (related to social, emotional wellbeing and connection to the community) could reduce the risk of adverse outcomes. This supports the need for efforts to support preconception care, including smoking cessation and increasing maternal cultural-based resilience (Westrupp et al. 2019). This highlights the centrality of culture and the importance of strengthening communities, reinforcing positive behaviours and improving the social determinants of health (DoH 2015).

Improving data collections is critical to informing actions to improve outcomes for mothers and babies, including reducing perinatal and infant mortality. However, these data improvements have the potential to affect the measurement of both numerator and denominator in the statistics.

The perinatal mortality numerator uses the number of perinatal deaths, which includes all registered fetal deaths (at least 20 weeks gestation or at least 400 grams birth weight) and all registered neonatal deaths (all live born babies who die within 28 completed days of birth, regardless of gestation or birth weight). The perinatal mortality denominator uses all births, including live births and stillbirths of at least 20 completed weeks of gestation or with a birthweight of at least 400 grams.

A number of deaths occur each year for which the Indigenous status is not stated on the death registration form—0.7% of all deaths registered in 2018 (ABS 2019). Thus, there may be some degree of under-identification of Indigenous Australians in mortality data.

Efforts to improve the registration of births and deaths, and to improve Indigenous status identification, improve the quality of the data but also introduce volatility to the Indigenous rate due to the relatively small numbers in both numerator and denominator. This affects comparability over time.

The policy context is at Policies and strategies.

References

  • ABS (Australian Bureau of Statistics) 2019. Causes of Death, Australia, 2018. Canberra: Australian Bureau of Statistics.
  • AIHW (Australian Institute of Health and Welfare) 2014. Timing impact assessment of COAG Closing the Gap targets: Child mortality. Canberra: AIHW.
  • DoH (Australian Government Department of Health) 2015. Implementation plan for the National Aboriginal and Torres Strait Islander health plan 2013–2023. Canberra: Commonwealth of Australia.
  • Eades S 2004. Maternal and Child Health Care Services: Actions in the Primary Health Care Setting to Improve the Health of Aboriginal and Torres Strait Islander Women of Childbearing age, Infants and Young Children. Darwin: OATSIH.
  • Gibberd A, Simpson JM, Jones J, Williams R, Stanley F & Eades SJ 2019. A large proportion of poor birth outcomesamong Aboriginal Western Australians are attributable to smoking, alcohol and substance misuse, and assault. BMC Pregnancy & Childbirth 19.
  • Panaretto KS, Mitchell MR, Anderson L, Larkins SL, Manessis V, Buettner PG et al. 2007. Sustainable antenatal care services in an urban Indigenous community: the Townsville experience. Medical Journal of Australia 187:18-22.
  • Performance Indicator Reporting Committee 2002. Plan for Federal/Provincial/Territorial Reporting on 14 Indicator Areas. Canada: PIRC.
  • Sayers S & Powers J 1997. Risk factors for Aboriginal low birth weight, intrauterine growth retardation and preterm birth in the Darwin Health Region. Australia and New Zealand Journal of Public health 21:524-30.
  • Steenkamp M, Boyle J, Kildea S, Moore V, Davies M & Rumbold A 2017. Perinatal outcomes among young Indigenous Australian mothers: A cross-sectional study and comparison with adult Indigenous mothers. Birth 44:262-71.
  • Westrupp E, D’Esposito F, Freemantle J, Mensah FK & JM N 2019. Health outcomes for Australian Aboriginal and Torres Strait Islander children born preterm, low birthweight or small for gestational age: a nationwide cohort study. PloS one.

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