Why babies die in unplanned out‐of‐institution births: an enquiry into perinatal deaths in Norway 1999–2013

Abstract

IntroductionThe aims were to describe causes of death associated with unplanned out‐of‐institution births, and to study whether they could be prevented.Material and methodsRetrospective population‐based observational study based on data from the Medical Birth Registry of Norway and medical records. Between 1 January 1999 and 31 December 2013, 69 perinatal deaths among 6027 unplanned out‐of‐institution births, whether unplanned at home, during transportation, or unspecified, were selected for enquiry. Hospital records were investigated and cases classified according to Causes of Death and Associated Conditions.Results63 cases were reviewed. There were 25 (40%) antepartum deaths, 10 (16%) intrapartum deaths, and 24 neonatal (38%) deaths. Four cases were in the unknown death category (6%). Both gestational age and birthweight followed a bimodal distribution with modes at 24 and 38 weeks and 750 and 3400 g, respectively. The most common main cause of death was infection (n = 14, 22%), neonatal (n = 14, 22%, nine due to extreme prematurity) and placental (n = 12, 19%, seven placental abruptions). There were 86 associated conditions, most commonly perinatal (n = 32), placental (n = 15) and maternal (n = 14). Further classification revealed that the largest subgroup was associated perinatal conditions/sub‐optimal care, involving 25 cases (40%), most commonly due to sub‐optimal maternal use of available care (n = 14, 22%).ConclusionsInfections, neonatal, and placental causes accounted for almost two‐thirds of perinatal mortality associated with unplanned out‐of‐institution births in Norway. Sub‐optimal maternal use of available care was found in more than one‐fifth of cases.

Very preterm birth before arrival at hospital

“…Given the precipitous nature of unplanned birth before arrival at a hospital, women who deliver preterm at home or in transit are disadvantaged by lack of antenatal corticosteroid exposure, tocolytics to suppress preterm labour, fetal monitoring and choices about mode of delivery. If birth is further complicated by an obstetric emergency, such as placental abruption, cord prolapse, or breech presentation, prognosis is extremely poor . Obtaining accurate obstetric complication and birth data for BBAs is extremely difficult as these births often occur without a healthcare professional present.…”

“…Risk factors associated with birth before arrival at hospital reported in local and international literature include young maternal age, higher parity, older multiparous women, illicit drug use, lower education and little or no antenatal care . Lack of, or sub‐optimal antenatal care attendance, and concealment of pregnancy are also cited as key risk factors associated with perinatal mortality in BBAs . However, all these studies reported outcomes of all BBAs, most of which were term or near‐term gestation, as opposed to the group we studied who were <32 weeks’ gestation.…”

“…An enquiry into deaths of BBAs in Norway in 1999–2013 concluded poor outcomes in BBAs were seldom due to sub‐optimal performance of healthcare providers immediately around the time of birth . Although providing additional training for paramedics on management of birth has been advocated as a strategy to improve outcomes the effectiveness of training for an event rarely encountered, with limited opportunities to consolidate skills, is questionable.…”

“…Unintentional birth before arrival (BBA) at a hospital is a relatively rare event, reported at rates of 0.4% of all births in Australia and 0.2% in Victoria . However, compared with birth in a hospital and planned home birth, unintentional BBA is associated with increased risks of perinatal mortality and neonatal morbidity, even at term gestation . Births occurring very preterm (<32 weeks’ gestation) and extremely preterm (<28 weeks’ gestation) are at even greater risk of adverse outcomes …”

Unplanned Out-of-Hospital Birth—Short and Long-Term Consequences for the Offspring

“…Importantly, a significant proportion of unplanned out-of-hospital deliveries occur preterm, which is also probably a major contributor to the higher mortality of these infants. It is believed that if these deliveries were to occur in-hospital, some perinatal mortality cases may have been prevented [8].…”