1.21 Perinatal mortality

Key messages

• During the 5-year period 2015–2019, there were 1,031 babies of Indigenous women who died during the perinatal period: 715 (69%) were stillborn, and 316 (31%) died within 28 days of birth.
• In 2015–2019, for babies born to Indigenous women, the perinatal mortality rate was 15 per 1,000 births, compared with 9.0 per 1,000 for babies born to non-Indigenous women.
• Between 2006 and 2019, the perinatal mortality rate among babies of Indigenous women decreased by one-quarter (25%) resulting in narrowing of the gap (by 42%) compared with the non-Indigenous perinatal mortality rate.
• Over the decade from 2010 to 2019, the perinatal mortality rate among babies of Indigenous women did not change significantly, nor did the gap between rates for Indigenous and non-Indigenous women.
• The perinatal mortality rate for babies born to Indigenous women ranged from 24 perinatal deaths per 1,000 births in the Northern Territory to 9.5 per 1,000 in Tasmania in 2015–2019.
• The most common causes of perinatal death among babies born to Indigenous women were congenital anomalies (21% of perinatal deaths) and spontaneous pre-term birth (20%).
• A study among Indigenous women in Townsville showed that sustained access to community-based, integrated, shared antenatal services significantly reduced the perinatal mortality rate compared with a control group (from 60 to 14 deaths per 1,000 births).

Why is it important?

Perinatal mortality is defined as deaths commencing from at least 20 weeks gestation (fetal deaths or ‘stillbirths’) and deaths of liveborn babies within 28 days of birth (neonatal deaths) (Figure 1.21.1). 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 (Eades 2004; Performance Indicator Reporting Committee 2002).

In July 2020, the National Agreement on Closing the Gap (the National Agreement) identified the importance of making sure Aboriginal and Torres Strait Islander people enjoy long and healthy lives, and ensuring Aboriginal and Torres Strait Islander children are born healthy and strong. To support these outcomes the National Agreement specifically outlines the following targets to direct policy attention and monitor progress:

• Target 1—Close the Gap in life expectancy within a generation, by 2031, (with infant and child mortality as supporting indicators)
• Target 2—By 2031, increase the proportion of Aboriginal and Torres Strait Islander babies with a healthy birthweight to 91 per cent.

For the latest data on the Closing the Gap targets, see the Closing the Gap Information Repository.

The new National Aboriginal and Torres Strait Islander Health Plan 2021-2031 (the Health Plan), provides a strong overarching policy framework for Aboriginal and Torres Strait Islander health and wellbeing and is the first national health document to address the health targets and priority reforms of the National Agreement.

Both the National Agreement and the Health Plan are discussed further in the Implications section of this measure.

Figure 1.21.1: Definitions of perinatal death

Source: Stillbirths and neonatal deaths in Australia (AIHW 2021).

Findings

What does the data tell us?

Data in this measure is from the AIHW National Perinatal Mortality Data Collection (NPMDC), with demographic information regarding perinatal death records in the NPMDC sourced from the National Perinatal Data Collection (NPDC). These data are sourced from midwives and other birth attendants, who collect information from mothers, perinatal administrative and clinical record systems. This is different to previous reporting on this measure, which used ABS perinatal deaths data, based on death registrations.

The AIHW data collection has been selected because of more complete data on the numbers of stillbirths and a more complete capture of causes of perinatal deaths using the Perinatal Society of Australia and New Zealand (PSANZ) Perinatal Mortality Classification System. For example, in 2018, based on the NPMDC there were 2,115 stillbirths recorded, compared with 1,682 in the ABS data (AIHW 2020). In addition, the proportion of deaths where the cause was unspecified or not stated is lower in the NPMDC than in the ABS data (for example, 17% NPMDC data over the 2-year period 2017–2018, compared with 42% in the ABS data) (analysis of ABS 2019; AIHW 2021).

Therefore, the data presented in the update for this measure are not comparable to those published previously (see Data sources and quality for additional information on the differences between these two data collections).

In the 5-year period 2015–2019, nationally:

• there were 1,031 perinatal deaths of babies born to Aboriginal and Torres Strait Islander women, and 13,213 perinatal deaths of babies born to non-Indigenous mothers. Deaths of babies born to Indigenous women accounted for 7.2% of all perinatal deaths (Table D1.21.1).
• nearly 7 in 10 perinatal deaths of babies born to Indigenous women were stillbirths (also known as fetal deaths) (69%, or 715 deaths) (Table D1.21.4). A further 20% of perinatal deaths occurred in the first 24 hours after birth (206 deaths), and the remaining 11% (110 deaths) occurred within 28 days of birth (Table D1.21.6, Figure 1.21.2).

Figure 1.21.2: Stillbirths and neonatal deaths as a proportion of perinatal deaths, by Indigenous status of the mother, Australia, 2015–2019

Note: These data are not comparable with ABS registrations of deaths data used in previous reporting of this measure (see National Perinatal Mortality Data Collection for details).  

Sources: Tables D1.21.4 and D1.21.6. AIHW analysis of the National Perinatal Mortality Data Collection and the National Perinatal Data Collection.

In 2015–2019, for babies born to Indigenous women:

• the perinatal mortality rate was 15 per 1,000 births
• the neonatal mortality rate was 4.6 per 1,000 live births
• the rate of stillbirths was 10 per 1,000 births.

For babies born to Indigenous women, the rate of perinatal deaths in the 5-year period 2015–2019 was lower than in the preceding 5-year period 2010–2014, with about 2 fewer deaths per 1,000 births (15 compared with 17 deaths per 1,000 births). This was driven by a reduction in neonatal mortality rates, which declined from 5.8 to 4.6 deaths per 1,000 live births, with no significant change in the rate of stillbirths (Table D1.21.4).

Figure 1.21.3: Stillbirths, neonatal and perinatal mortality rates for babies born to Indigenous women, Australia, 2010–2014 and 2015–2019

Note: These data are not comparable with ABS registrations of deaths data used in previous reporting of this measure (see National Perinatal Mortality Data Collection for details).   

Source: Table D1.21.4. AIHW analysis of the National Perinatal Mortality Data Collection and the National Perinatal Data Collection.

Perinatal mortality by states and territories

In the period 2015–2019, the perinatal mortality rate for babies born to Indigenous mothers varied between jurisdictions.

• The rate was highest in the Northern Territory (24 perinatal deaths per 1,000 births), followed by South Australia (18 per 1,000) and Western Australia (17 per 1,000).
• The rate was lowest in Tasmania (9.5 per 1,000) and ranged between 12 and 15 per 1,000 in New South Wales, Victoria and Queensland.
• The perinatal mortality rate in the Northern Territory was 2.5 times as high as that in Tasmania (Table D1.21.4, Figure 1.21.4).

Since the 5-year period 2010–2014, the largest decline in perinatal mortality for babies born to Indigenous mothers was in Victoria, where the rate declined from 23 to 14 deaths per 1,000 births in 2015–2019. In contrast to data at the national level, the decline in Victoria was predominantly driven by the decreasing rates of stillbirths (which declined from 17.0 to 10.5 deaths per 1,000), with no significant change in the rate of death for Indigenous neonates (Table D1.21.4).

Figure 1.21.4: Perinatal mortality rates among babies born to Indigenous women, by state and territory of birth, 2015–2019

Note: These data are not comparable with ABS registrations of deaths data used in previous reporting of this measure (see National Perinatal Mortality Data Collection for details).  

Source: Table D1.21.4. AIHW analysis of the National Perinatal Mortality Data Collection and the National Perinatal Data Collection.

Perinatal mortality by remoteness

In the period 2015–2019, rates for perinatal mortality for babies born to Indigenous mothers increased with increasing remoteness. The rate was about twice as high in Very remote areas (24 perinatal deaths per 1,000 births) as in Major cities (12 per 1,000) and Inner regional areas (13 per 1,000) (Table D1.21.7 Figure 1.21.5).

Figure 1.21.5: Perinatal mortality rates among babies born to Indigenous women, by remoteness, 2015–2019

Note: These data are not comparable with ABS registrations of deaths data used in previous reporting of this measure (see National Perinatal Mortality Data Collection for details).  

Source: Table D1.21.7. AIHW analysis of the National Perinatal Mortality Data Collection and the National Perinatal Data Collection.

Leading cause of perinatal mortality

Causes of perinatal deaths (including stillbirths and neonatal deaths) are presented as the single most important factor that led to the chain of events which resulted in death as defined by the Perinatal Society of Australia and New Zealand Perinatal Death Classification (PSANZ-PDC).

In the period 2015–2019, for babies born to Indigenous women, the top 2 leading causes of death accounted for 4 in 10 perinatal deaths (409 deaths or 40%). These were:

• congenital anomalies (211 or 21%), including structural, functional, or chromosomal malformations; and
• spontaneous preterm (that is, onset of preterm labour or rupture of membranes) (198 or 20%) (Table 1.21-1).

Unexplained antepartum death was the next most common cause (129 or 13%) and is characterised as a fetal death prior to labour where no cause is identified. This was followed by maternal conditions such as medical (for example, diabetes) or surgical (for example, appendicitis) disorders (116 deaths, 11%); perinatal infections (86 deaths, 8.5%); and antepartum haemorrhage (81 deaths. 8.0%). Among babies born to Indigenous women in the 2015–2019 period, a lower proportion of deaths were due to congenital anomalies than for non-Indigenous women (21% compared with 32%) (Table D1.21.5, Table 1.21-1).

Leading cause of stillbirth mortality

In the period 2015–2019, the top 3 leading causes of stillbirths among babies born to Indigenous women accounted for just over half (51%) of all stillbirths. These include congenital anomalies (133 deaths or 19% of all stillbirths), unexplained antepartum deaths (129 or 18%) and maternal conditions (102 or 14%). The next most common causes of stillbirth deaths were spontaneous preterm (91 or 13%) and antepartum haemorrhage (64 or 9.0%) (Table D1.21.5, Table 1.21-1).

Table 1.21-1: Perinatal and stillbirth deaths among babies born to Indigenous women, by underlying cause of death (PSANZ-PDC), Australia, 2015–2019

PSANZ-PDC	Perinatal deaths (number)	Perinatal Deaths (%)	Stillbirths (number)	Stillbirths (%)
Congenital anomaly	211	20.8	133	18.8
Spontaneous preterm	198	19.5	91	12.8
Unexplained antepartum death	129	12.7	129	18.2
Maternal conditions	116	11.4	102	14.4
Perinatal Infection	86	8.5	53	7.5
Antepartum haemorrhage	81	8.0	64	9.0
Specific perinatal conditions	60	5.9	38	5.4
Other causes of death	134	13.2	99	14.0
Total with stated cause of death	1,015	100.0	709	100.0
Not stated cause of death	16	. .	6	. .
Total deaths	1,031	. .	715	. .

. . not applicable

Note: Percentages calculated after excluding ‘not stated’ cause of death.

Source: Table D1.21.5. AIHW analysis of the National Perinatal Mortality Data Collection and the National Perinatal Data Collection.

Leading cause of neonatal mortality

For babies born to Indigenous women in the 2015–2019 period, the top 3 leading causes of death accounted for 69% of all neonatal deaths (deaths within 28 days of birth). These include spontaneous preterm (107 deaths or 35% of all neonatal deaths), congenital anomaly (78 or 26%) and perinatal infection (33 or 11%) (Table D1.21.5). There were some differences in the leading causes of neonatal deaths based on timing of death. Among babies born to Indigenous women:

• In the first 24 hours after birth the leading causes of neonatal death were spontaneous preterm (85 or 41% of all neonatal death in the first 24 hours), followed by congenital anomalies (46 or 22%) and perinatal infection (25 or 12%).
• Within 28 days of birth the leading causes of neonatal death were congenital anomalies (32 or 29%), spontaneous preterm (22 or 20%), and no obstetric antecedent (13 or 12%) (Table D1.21.6). The category no obstetric antecedent includes sudden infant death syndrome (SIDS), postnatally acquired infection, accidental asphyxiation and other accidents, poisoning or violence.

Table 1.21-2: Neonatal deaths among babies born to Indigenous women, by underlying cause of death (PSANZ-PDC), Australia, 2015–2019

PSANZ-PDC	Neonatal deaths (number)	Neonatal deaths (%)
Spontaneous preterm	107	35.0
Congenital anomaly	78	25.5
Perinatal Infection	33	10.8
Specific perinatal conditions	22	7.2
Antepartum haemorrhage	17	5.6
Maternal conditions	14	4.6
Other causes of death	35	11.4
Total with stated cause of death	306	100.0
Not stated cause of death	10	. .
Total deaths	316	. .

Source: Table D1.21.5. AIHW analysis of the National Perinatal Mortality Data Collection and the National Perinatal Data Collection.

Table 1.21-2 presents data using the Perinatal Society of Australia and New Zealand Perinatal Death Classification (PSANZ-PDC). There is also an additional classification, the PSANZ Neonatal Death Classification (PSANZ-NDC), which is applied only to neonatal deaths. The purpose of this classification system is to identify the single most significant condition present in the neonatal period (the time between birth and 28 days) that caused the baby’s death. Using the PSANZ-NDC, nearly half (140 or 47%) of neonatal deaths of babies born to Indigenous mothers were due to extreme prematurity compared with just over a third (1,153 or 36%) for babies born to non-Indigenous mothers (Table D1.21.5).

Key comparisons with non-Indigenous Australians

In 2015–2019, the perinatal mortality rate among babies born to Indigenous women was 1.7 times as high as for non-Indigenous women (15 compared with 9.0 per 1,000). Rates of stillbirth and neonatal deaths of babies born to Indigenous women were 1.5 and 2.0 times as high as for babies born to non-Indigenous women, respectively.

The perinatal mortality rate was higher for babies born to Indigenous women than for babies born to non-Indigenous women in most jurisdictions, except Tasmania where the rates were similar (9.5 and 9.2, respectively) (Table D1.21.4).

Changes over time

Between 2006 and 2019 for babies born to Indigenous women, there was a significant decrease (of 25%) in the perinatal mortality rate, from 19 to 15 per 1,000 births (Table D1.21.2). Over the same period, for neonates born to Indigenous women the mortality rate significantly decreased (by 38%) from 7.2 to 4.4 deaths per 1,000 live births. There was no significant change in the stillbirth rate for babies born to Indigenous women (Table D1.21.3).

There were also declines in the perinatal and neonatal death rates for babies born to non-Indigenous women over the same period, albeit to a lesser extent (9.3% and 20%, respectively), with no significant change in the stillbirth rate.

In terms of absolute reductions in rates, the perinatal mortality rate decreased by more each year for babies born to Indigenous women than for babies born to non-Indigenous women (0.4 compared with 0.1 deaths per 1,000, respectively). This was also the case for neonates born to Indigenous and non-Indigenous women (0.2 compared with <0.1 deaths per 1,000, respectively). As a result, the absolute gap (rate difference) between Indigenous and non-Indigenous perinatal and neonatal mortality rates narrowed by 42% and 50%, respectively.

Over the most recent decade, 2010 to 2019, there were no significant changes in the rates of perinatal, neonatal, or stillbirth mortality among babies born to Indigenous women. There were also no significant reductions in the absolute gap (rate difference) between Indigenous and non-Indigenous perinatal, neonatal or stillbirth mortality rates over this period.

The relative difference (rate ratio) in perinatal mortality rates between Indigenous and non-Indigenous Australians has fluctuated over the last decade. Between 2010 and 2019, the relative difference (rate ratio) for both total perinatal mortality and stillbirth rates between the two populations was highest in 2011 (2.0 and 1.9, respectively) and was lowest in 2015 (1.3 and 1.2, respectively). For neonatal mortality rates, the relative difference between the Indigenous and non-Indigenous populations ranged between 1.8 (in 2015) and 2.6 (in 2013) (Table D1.21.2, Table D1.21.3, Figure 1.21.6).

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.

To describe trends in perinatal mortality data, linear regression has been used to calculate the per cent change over time. This means that information from all years of the specified time period are used, rather than only the first and last points in the series (see Statistical terms and methods).

Figure 1.21.6: Perinatal, neonatal and stillbirth mortality rates and changes in the gap for babies born to Indigenous women, Australia, 2006 to 2019

Note: These data are not comparable with ABS registrations of deaths data used in previous reporting of this measure (see National Perinatal Mortality Data Collection for details).  

Sources: Table D1.21.2 and D1.21.3. AIHW analysis of the National Perinatal Mortality Data Collection and the National Perinatal Data 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 than 20–34 year olds to have vaginal births with a gestation period of 37–41 weeks and a vertex presentation. 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 et al. (2019) found that among Indigenous infants born in Western Australia between 1998 and 2010:

• Maternal smoking was associated with 49% higher odds of perinatal death.
• Alcohol misuse was associated with 83% higher odds of perinatal deaths.

Though alcohol misuse was associated with higher odds of perinatal deaths than smoking, the prevalence of smoking as a risk factor was higher, and so accounted for a higher total proportion of perinatal deaths. The study found that 19% of perinatal deaths in Western Australia among Indigenous infants born between 1998 and 2010 were attributable to smoking, and 3% attributable to alcohol misuse (Gibberd et al. 2019).

Panaretto et al. (2007) showed 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. Comparing the study groups the rate of perinatal mortality in the pre-study group was 4.3 times as high as the rate in the study group (60 and 14 per 1,000 births, respectively; p<0.014) and the average number of antenatal visits was half that of the study group (3 compared with 6; p<0.001) (Panaretto et al. 2007).

Implications

The Indigenous perinatal mortality rate remains high. This points to the need for continued and enhanced efforts to improve maternal and child health. With regards to birthweight, the HPF feature article ‘Key factors contributing to low birthweight of Aboriginal and Torres Strait Islander babies’ further explores the factors contributing to birthweight among Indigenous Australian children and provides analysis of the level of improvement required in smoking rates to meet the birthweight target in the National Agreement.

Improvements in the health of Indigenous Australian infants are possible with reductions in key risk factors during pregnancy such as maternal smoking, alcohol, drug misuse and assault (Gibberd et al. 2019). Protective factors such as not smoking during pregnancy and cultural-based resilience among mothers (related to social, emotional wellbeing and connection to the community) could reduce the risk of adverse perinatal health outcomes (Westrupp 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.

This highlights the centrality of culture and the importance of strengthening communities, reinforcing positive behaviours and improving the social and cultural determinants of health (Department of Health 2015). This has been emphasised again in the new Health Plan which places culture at the foundation for Aboriginal and Torres Strait Islander health and wellbeing as a protective factor across the life course. The Health Plan, released in December 2021, is the overarching policy framework to drive progress against the Closing the Gap health targets and priority reforms. Implementation of the Health Plan aims to drive structural reform towards models of care that are prevention and early intervention focused, with greater integration of care systems and pathways across primary, secondary and tertiary care. It also emphasises the need for mainstream services to address racism and provide culturally safe and responsive care, and be accountable to Aboriginal and Torres Strait Islander people and communities.

The Health Plan suggests that efforts should be targeted at providing strengths based, culturally safe and holistic, affordable services to ensure a strong start to life. Birthing on Country services have the potential to support healthy pregnancies and should be explored as a way to offer an integrated, holistic and culturally safe model of care. For example, Birthing on Country services can support reduction and cessation of smoking in pregnancy through health-literacy approaches (Department of Health 2021).

As part of the National Agreement, the health sector was identified as one of 4 initial sectors for joint national strengthening effort and the development of a 3-year Sector Strengthening Plan. The Health Sector Strengthening Plan (Health-SSP) was developed in 2021, to acknowledge and respond to the scope of key challenges for the sector, providing 17 transformative sector strengthening actions. Developed through strong consultation across the Aboriginal and Torres Strait Islander community-controlled health sector and other Aboriginal and Torres Strait Islander health organisations, the Health-SSP will be used to prioritise, partner and negotiate beneficial sector-strengthening strategies.

The Australian Government funds initiatives which support improvements in antenatal care for Indigenous mothers, including the Australian Nurse Family Partnership Program (ANFPP), and the Healthy Mums Healthy Bubs budget measure as part of the Commonwealth’s Closing the Gap Implementation Plan.

Improving data collections is critical to informing actions to improve outcomes for mothers and babies, including reducing perinatal and infant mortality. A number of deaths occur each year for which the Indigenous status of the mother in the NPDC is not stated—1.1 % of all perinatal deaths in the 5-year period 2015-2019. Thus, there may be some degree of under-identification of Indigenous Australians in perinatal mortality data.

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) 2020. Stillbirths and neonatal deaths in Australia. Canberra: AIHW.
• AIHW 2021. Stillbirths and neonatal deaths in Australia 2017–2018. Canberra: AIHW.
• Department of Health (Austraian Government Department of Health) 2021. National Aboriginal and Torres Strait Islander health plan 2021–2031. Government of Australia.
• 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 outcomes among 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 birthweight, intrauterine growth retardation and preterm birth in the Darwin Health Region. Australian & 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 F & Nicholson J 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.