This Perinatal Mortality National Clinical Audit (PMNCA) Report provides information on perinatal deaths arising from births occurring in the Republic of Ireland (ROI) for the reporting year 2021.
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This document provides an overview of the findings and recommendations, for further information, please access the full report in the button below.
Definitions
A stillbirth is when a baby is born at or after 24 weeks of pregnancy, or weighing 500g or more, with no signs of life
Neonatal death is when a baby dies within the first 28 days of being born.
Overall perinatal mortality rate (PMR) is the number of stillbirths and early neonatal deaths per 1,000 total births (live births and stillbirths from 24 weeks gestation or weighing >500g).
Corrected PMR is the Perinatal mortality rate excluding perinatal deaths associated with or due to a major congenital anomaly.
Our rates show the number of babies that passed away at different stages of their gestational age or days of life for every 1000 babies being born in Ireland
Maternal Characteristics
The findings presented below relate to characteristics of mothers of stillbirths and early neonatal deaths born with a birthweight ≥500g or having achieved a gestational age ≥24 weeks
Maternal age: The age profile of mothers who experienced a stillbirth was similar to that of mothers who experienced early neonatal death. Mothers experiencing early neonatal deaths were slightly more likely to be aged 40 or more.
Ethnicity: While the numbers involved were small, Irish Traveller, Asian and Black ethnicities were overrepresented in the mothers who experienced perinatal deaths in 2021 (12.1%) compared to their reported presence 5.0% of the female 15-49-year-old population.
Gestation at booking: Of the 318 cases with data, approximately three percent were not booked (2.8%), twenty percent (20.1%) booked into hospital before 12 weeks gestation, and more than seventy percent (70.8%) attended for antenatal care between 12- and 19-weeks’ gestation (Table 1.9). In 2021, the median gestational age at booking was 13 weeks.
Body Max Index (BMI): omen in the overweight category who experienced perinatal loss were overrepresented relative to the population of women who gave birth in 2021. This was reflected in the perinatal mortality rate of 6.46 per 1,000 for overweight women. Thus, overweight women had a 46% higher risk of perinatal mortality compared to women who gave birth in 2021 with a lean BMI (p-value= 0.003).
Smoking and substance use: Smoking status of the mothers at their time of booking was recorded for 335 (93.8%) of the 357 women. Of these, 38 (11.3%) were smokers at the time of booking. Seventeen were smoking between one and nine cigarettes per day (n=17 of 32, 53.1%, missing information for six women), and fifteen were smoking at least up to 10 cigarettes per day (n=15 of 32, 46.9%).
Previous pregnancy problems and pre-existing medical problems: the most common previous pregnancy problems in women who experienced perinatal loss were Caesarean labour delivery (20%) and experiencing a pre-term birth or mid-trimester loss (8%). The most common type of pre-existing medical problems were psychiatric disorders (10%), followed by endocrine disorders (6%)
Infant characteristics
The findings presented below are based on stillbirths and early neonatal deaths born with a birthweight≥500g or having achieved a gestational age ≥24 weeks.
Multiple births: An increased risk of perinatal mortality associated with multiple pregnancies compared to singleton pregnancy was again found in 2021. The perinatal mortality rate for babies in multiple pregnancies was 4.46 times higher than singleton births at 23.37 per 1,000 live births (p<0.001)
Birthweight: In approximately seventy-five per cent of perinatal deaths (n=269, 75.4%) the birthweight was less than 2,500 grams (Table 1.22). For stillbirths, 75.2% had a birthweight below 2,500g (n=179 of 238) and 75.6% of neonatal deaths (n=90 of 119) also registered weight below this value. This is in contrast to the overall population of births in 2021, of whom less than 6% had a birthweight below 2,500g (n=3,619 of 60,841, 5.9%). Thus, highlighting the association between perinatal deaths and low birth weight.
Fetal growth restriction: A diagnosis of FGR was reported for 72 (20.7%) of the 348 deaths, 54 (23.5%) stillbirths and 18 (15.3%) early neona-tal deaths. An antenatal diagnosis of FGR (as op-posed to diagnosis based on observation at deliv-ery or post-mortem) was reported for 51 perinatal deaths of the 72 with a diagnosis of FGR (n=51 of 72, 70.8%), 35 stillbirths (n=35 of 54, 64.8%) and 16 early neonatal deaths (n=16 of 18, 88.9%).
Stillbirths
Stillbirths accounted for 66.7% of perinatal deaths in 2021.
Specific placental conditions were the most common cause of death in stillbirths in 2021 (n=78 of 238, 32.8%). This is in contrast to previous years when major congenital anomaly was the most common cause of death. The last time specific placental conditions were the most prevalent cause of death in stillbirths was in 2017
The most commonly occurring placental condition was fetal vascular malperfusion (n=18 of 78, 23.1%), followed by maternal vascular malperfusion and cord pathology with distal disease accounting 16 deaths each (n=16 of 78, 20.5%).
Major congenital anomaly was the second most common cause of death in stillbirths in 2021 (n=68 of 238, 28.6%). There was a chromosomal disorder in almost 49% of the stillbirths in 2021 due to major congenital anomalies (n=33 of 68, 48.5%). Of all the stillbirths due to major congenital anomalies, more than 90.0% (n=61 of 66, 92.4% unknown for two cases) had an antenatal diagnosis made by a consultant fetal medicine specialist either in the unit of reference (n=45) or in another unit (n=16). Multiple anomalies (n=10), anomalies of the cardiovascular system (n=10), central nervous system (n=5), musculoskeletal (n=4), gastro-intestinal (n=3) systems, urinary tract (n=2) and metabolic disorders (n=1) led to 35 (51.5% of 68) stillbirths.
Covid-19 Pandemic and Perinatal Mortality 2021
In the Irish context, among perinatal deaths occurring in 2021, a total of one early neonatal deaths and nine stillbirths were due to SARS-CoV-2 placentitis; six of these cases occurred in the third wave and four in the fourth wave. Using the NPEC classification system, still-births due to SARS-CoV-2 placentitis were classified as ‘other placental condition’
Antepartum stillbirth
There were 14 cases of stillbirths where the baby was known to be alive at the onset of care in labour. Thus, intrapartum deaths accounted for 5.9% of stillbirths in the Republic of Ireland in 2021. Major congenital anomaly was the main cause of death for fifty per cent of the 14 intrapartum deaths (n=7, 50.0%). The next most common cause of death was infection (n=3).
Early neonatal deaths
Early neonatal deaths accounted for 33% of all perinatal deaths in 2021.
Major congenital anomaly was the most common cause of early neonatal death in 2021 (n=59 of 119, 49.6%), followed by respiratory disorder, accounting for more than one-fourth of early neonatal deaths (n=31, 26.1%)
More than fifty-three per cent of the early neonatal deaths occurred within 24 hours of delivery – 1 completed day (n=63, 53.4%, Table 4.6, unknown for one early neonatal death). Within this cohort, major congenital anomalies (n=38 of 63, 60.3%) and respiratory disorders (n=19 of 63, 30.2%), mainly severe pulmonary immaturity (n=12 of 19, 63.2%), were the main cause of death.
Late neonatal deaths
Late neonatal deaths accounted for 11% of the perinatal deaths in 2021
Major congenital anomaly was the most common cause of death in 2021 (n=13, 32.5%). The next most common causes were respiratory and neurological disorders, each disorder accounting for seven deaths (n=7, 17.5%, respectively). Other causes of death in 2021 included gastrointestinal disorders (n=4, 10.0%), and infections (n=3, 7.5%). Sudden infant death syndrome accounted for two deaths (n=2, 5.0%). Three further deaths were unexplained pending post-mortem or other investigation (n=3, 7.5%).
Recommendations
Based on the findings of this and previous reports, the NPEC Perinatal Mortality National Clinical Audit Governance Committee makes the following recommendations:
Robust clinical audit of perinatal outcomes in all maternity units in Ireland is vital for quality patient care. Funding should be provided to ensure protected time for clinical audit and implementation of its findings. This funding might be best channelled through midwifery and obstetric management posts where clinical audit is embedded within job descriptions. Owner; the Quality and Patient Directorate in the HSE.
National data on social factors impacting on perinatal loss, e.g. smoking and alcohol abuse, remain difficult to collate. Consideration should be given to methodologies to capture this information consistently. Owner; the NPEC and the NWIHP.
A communication policy should be developed regarding neonatal outcomes in babies whose care has been transferred post-delivery. This should ensure the flow of vital information between tertiary maternity units/ paediatric centres and the referring maternity unit that is essential to inform appropriate follow up care, including counselling of women experiencing perinatal loss. It is also necessary to inform clinical audit in the referring maternity unit. Owner: National Clinical Lead for Neonatology and NWIHP.
The establishment of a confidential review for stillbirth and neonatal deaths should be considered in order to enhance the learning to assist better care. This could take the format of a standardized review of specific cohorts, such as:
- Unexpected intrapartum-related deaths
- Multiple pregnancies
- Stillbirths (normally formed babies)
All healthcare professionals (obstetricians, GPs and midwives) should see every interaction with a woman as an opportunity to address weight, nutrition and lifestyle to optimize her health. This also supports the HSE Programme ‘Making Every Contact Count’ (MECC).3 Owner; All Healthcare staff.
Standardised approach to improved antenatal detection of fetal growth restriction (FGR) with timely delivery is a potential preventative strategy to reduce perinatal mortality. A multidisciplinary working group should be developed to address a national standardised approach to the detection of FGR. A national approach should include a standardised training program for all staff involved in antenatal care and also evalu-ate the use of a standard growth curve and man-agement options across the Irish maternity service. Owner; the NWIHP and the IOG.
The NPEC advocates the introduction and use of a ‘Care Bundle’ approach in an attempt to lower perinatal mortality; similar approaches in other countries have achieved a reduction. An example of a ‘Care Bundle’ is outlined below.
Help us disseminate our findings
Citation for this report: San Lazaro Campillo I, Manning E, Corcoran P, Keane J, McKernan J, Escanuela Sanchez T, Greene RA, on behalf of the Perinatal Mortality National Clinical Audit Governance Committee. Perinatal Mortality National Clinical Audit in Ireland Annual Report 2021. Cork: National Perinatal Epidemiology Centre, 2023.