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CCOPMM reviews all perinatal, paediatric and maternal deaths in Victoria to consider the clinical features of each case and to assess how they could be prevented in future.

Perinatal death review

CCOPMM’s stillbirth and neonatal sub-committees consider cases once all available information has been collated. 

An assessment of whether a perinatal death is avoidable is undertaken by multidisciplinary review. This review identifies potential deficiencies in clinical care or system-wide faults. 

Preventable factors are also identified. These are often long-standing issues that require broad public health action, for instance smoking in pregnancy, maternal age, family violence, and other social and demographic factors.

Perinatal definitions and mortality rate

  • stillbirth: the birth of an infant of at least 20 weeks gestation or, if gestation is unknown, weighing at least 400 grams, who shows no signs of life after birth
  • neonatal death: death of a live born infant, regardless of gestational age at birth, within the first 28 completed days of life
  • stillbirth rate (per 1,000 total births) - number of stillbirths per 1,000 total live births and stillbirths
  • neonatal mortality rate (per 1,000 live births) - number of neonatal deaths per 1,000 total live births
  • perinatal mortality rate (per 1,000 total births) - number of total neonatal deaths plus stillbirths per 1,000 total live births and stillbirths

Note: The term ‘live birth’ means the birth of an infant, regardless of maturity or birth weight, who breathes or shows any other signs of life after being born (see WHO definition here). Such infants require registration as births, and if death occurs a Perinatal death certificate should be completed.

Post-neonatal infant, child and adolescent death review

CCOPMM creates a case file whenever a death certificate is received from the Victorian Registry of Births, Deaths and Marriages.

Information is then sought from several sources, including hospital case records, doctors, pathology departments, and coronial services.

The Child and adolescent sub-committee reviews complex or contentious cases. It classifies the death, discusses potential preventable factors, and makes recommendations on clinical or system improvements.

Infant, child and adolescent deaths are classified under one of the following categories:

  • determined at birth
  • sudden unexpected death in infancy (SUDI), including sudden infant death syndrome (SIDS)
  • unintentional injury
  • acquired disease
  • intentional injury
  • undetermined.

Post-neonatal infant and child death definitions

Infant death: a death occurring within one year of birth in a liveborn infant. This category includes neonatal deaths and post-neonatal deaths. For reporting purposes, infant deaths include only those born of at least 20 weeks gestation or, if gestation is unknown, weighing at least 400 grams.

Post-neonatal infant death: a death of an infant aged at least 28 days (where the first day of life is day zero) and less than one year of age.

Child death: a death of a child occurring on or after their first birthday and up to but not including their 18th birthday.

Infant mortality rate (per 1,000 total births): number of neonatal deaths and post-neonatal deaths per 1,000 total live births.

Maternal death and morbidity review

Reviews of maternal deaths and severe acute maternal morbidity (SAMM) are conducted by CCOPMM’s maternal mortality and morbidity sub-committee.

Maternal deaths are generally classified in one of three principal categories:

  1. direct maternal death - the death is considered to be due to a complication of the pregnancy itself, for example, haemorrhage from placenta praevia
  2. indirect maternal death - the death is considered to be due to a pre-existing condition aggravated by the physiological changes of pregnancy, for example, heart disease or diabetes
  3. incidental death - the death is considered unrelated to pregnancy, for example, a motor vehicle accident.

The sub-committee reviews and reports separately those deaths that fall into the category of ‘late maternal death’ - when death occurs within a year of the birth or termination of the pregnancy when the death is from direct or indirect causes. These occurrences are very rare.

Maternal death definition

CCOPMM uses the definition of maternal death recommended by the International Classification of Diseases (ICD-10): ‘the death of a woman while pregnant or within 42 days of the termination of the pregnancy irrespective of the cause of death’.

Maternal morbidity 

Severe acute maternal morbidity - SAMM

SAAM is considered an important safety and quality indicator for maternity care.

It is defined as a woman who nearly died but survived a complication that occurred during pregnancy, childbirth or within 42 days of birth or termination of pregnancy.

Why do we collect this information?

SAMM helps CCOPMM to improve its monitoring and reporting of severe morbidity.

Cases of serious maternal morbidity are more common than maternal deaths. By investigating these cases, CCOPMM can significantly improve how poor care or system factors are identified. This can in turn help inform priorities for the healthcare system in Victoria.

Comprehensive data on maternal morbidity is collected by the Victorian Perinatal Data Collection (VPDC), enhanced by both routine SAMM reporting and improved links between the VDPC and the Victorian Admitted Episodes Dataset.

Get in touch

Consultative Councils
Safer Care Victoria

Page last updated: 19 Jun 2019

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