Maternal Mortality Review Committee Research Articles

Comparing Internal and External Severe Maternal Morbidity (SMM) Review in Illinois [06L

INTRODUCTION: A majority of states have implemented maternal mortality review committees, but Illinois is the only state to also implement facility-level, multidisciplinary review of SMM at all obstetric hospitals as recommended by the Centers for Disease Control and Prevention and American College of Obstetricians and Gynecologists. METHODS: Facility-level multidisciplinary SMM review was implemented in all perinatal networks in 2017 using a modified 2-factor scoring system recommended by CDC/ACOG (ICU admission and >4 units of packed red blood cells). A standing external, multidisciplinary SMM review committee was also established to review a subset of reviewed cases to improve the hospital review process and to compare external committee decisions to the internal review. RESULTS: The external committee found 34% of SMMs were potentially preventable compared to 16% across internal review. In external review, the most common factors contributing to SMM was medical decision making, however internal review found pre-existing conditions and pregnancy complications as leading preventable factors. The external committee found more provider (63% vs 16%) and system (41% vs 16%) opportunities to alter SMM than the internal committees (patient factors). CONCLUSION: This study is the first to present findings on statewide implementation of SMM review both within hospital and by external committee and compare parallel facility-level and state-level review. External review shows more preventability and more provider and system opportunities to prevent SMM compared to internal review. External review by a multidisciplinary committee provided more opportunities to identify strategies to alter outcomes, however both offer opportunities for quality improvement and population-based findings.

Addressing Maternal Deaths in North Carolina: Striving to Reach Zero.

Maternal mortality in North Carolina remains a challenge to families, health systems, and communities. The Maternal Mortality Review Committee is part of the process required to prevent these events. In this commentary, we present an abbreviated description of the 2014-2015 Maternal Mortality Review Committee report, set for publication in December, 2019.

Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions.

The rising trend in pregnancy-related deaths during the past 2 decades in the United States stands out among other high-income countries where pregnancy-related deaths are declining. Cardiomyopathy and other cardiovascular conditions, hemorrhage, and other chronic medical conditions are all important causes of death. Unintentional death from violence, overdose, and self-harm are emerging causes that require medical and public health attention. Significant racial/ethnic inequities exist in pregnancy care with non-Hispanic black women incurring 3 to 4 times higher rates of pregnancy-related death than non-Hispanic white women. Varied terminology and lack of standardized methods for identifying maternal deaths in the United States have resulted in nuanced data collection and interpretation challenges. State maternal mortality review committees are important mechanisms for capturing and interpreting data on cause, timing, and preventability of maternal deaths. Importantly, a thorough standardized review of each maternal death leads to recommendations to prevent future pregnancy-associated deaths. Key interventions to improve maternal health outcomes include 1) integrating multidisciplinary care for women with high-risk comorbidities during preconception care, pregnancy, postpartum, and beyond; 2) addressing structural racism and the social determinants of health; 3) implementing hospital-wide safety bundles with team training and simulation; 4) providing patient education on early warning signs for medical complications of pregnancy; and 5) regionalizing maternal levels of care so that women with risk factors are supported when delivering at facilities with specialized care teams.

Maternal mortality: beyond overmedicalized solutions

Maternal deaths, particularly racial disparities in maternal deaths, represent a deeper problem than their medicalized solutions reflect-one deeply rooted in the devaluation of women's well-being, institutional inequality, and racism. Most policy solutions for addressing maternal mortality involve actionable goals within the purview of healthcare providers, medical institutions, and insurance providers. Although we should continue studying the causes of maternal mortality through maternal mortality review committees, reducing racism in medicine with implicit bias training, and standardizing pregnancy care, there is a pressing need to challenge the processes and institutions that lead to health inequities. A woman's income level, insurance status, housing stability, country of origin, gender identity, or skin color should not dictate how likely she is to die from a pregnancy-related cause.

Changing the conversation: applying a health equity framework to maternal mortality reviews

The risk of maternal death in the United States is higher than peer nations and is rising and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death and, when appropriate, to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the community vital signs, the social and community context in which women live, work, and seek health care, maternal mortality review committees may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.

Rural Focus and Representation in State Maternal Mortality Review Committees: Review of Policy and Legislation.

Between 1990 and 2013, maternal mortality nearly doubled in the United States and rural residents experienced decreasing access to obstetric care. To improve maternal health, many states have established maternal mortality and morbidity review committees (MMRCs). We assessed the extent of rural representation in state policy efforts related to MMRCs. We reviewed publicly available information on MMRCs (websites, statutes, bills, media) in all 50 states and the District of Columbia, separately identifying highly rural states (with >30% of the population being rural residents). We assessed whether each state 1) had established an MMRC, 2) had passed legislation requiring an MMRC, 3) had considered, but not passed, legislation requiring an MMRC, 4) mentioned rural populations in MMRC legislation, 5) required representation on the MMRC from any particular groups, and 6) required rural representation on the MMRC. As of December 2018, MMRCs were established in 45 states and the District of Columbia, an increase from 23 in 2010. Legislation was in place in 27 states, up from 6 in 2010. Only three states specifically mentioned rurality in legislation (including one highly rural state), and only two states required rural representation among their MMRC members (neither of which were highly rural states). Recent growth in MMRCs has had a limited focus on rural residents, despite their worse health outcomes and more limited access to health care, including obstetric services. Lack of rural representation may hamper geographically tailored efforts to reverse rising rates of maternal morbidity and mortality nationally.

Maternal drug-related death and suicide are leading causes of postpartum death in California

Reducing maternal mortality is a priority in the United States and worldwide. Drug-related deaths and suicide may account for a substantial and growing portion of maternal deaths, yet information on the incidence of and sociodemographic variation in these deaths is scarce. We sought to examine incidence of drug-related and suicide deaths in the 12 months after delivery, including heterogeneity by sociodemographic factors. We also explored maternal decedents' health care utilization prior to death. This retrospective, population-based cohort study followed up 1,059,713 women who delivered a live-born infant in California hospitals during 2010-2012 to ascertain maternal death. Analyses were conducted using statewide, all-payer, longitudinally-linked hospital and death data. A total of 300 women died during follow-up, a rate of 28.33 deaths per 100,000 person-years. The leading cause of death was obstetric-related problems (6.52 per 100,000 person-years). Drug-related deaths were the second leading cause of death (3.68 per 100,000 person-years), and suicide was the seventh leading cause (1.42 per 100,000 person-years); together these deaths comprised 18% of all maternal deaths. Non-Hispanic white women, Medicaid-insured women, and women residing in micropolitan areas were especially likely to die from drugs/suicide. Two thirds of women who died, including 74% of those who died by drugs/suicide, made ≥1 emergency department or hospital visit between their delivery and death. Deaths caused by drugs and suicide are a major contributor to mortality in the postpartum period and warrant increased clinical attention, including recognition by physicians and Maternal Mortality Review Committees as a medical cause of death. Importantly, emergency department and inpatient hospital visits may serve as a point of identification of, and eventually prevention for, women at risk for these deaths.

Role of the Perinatal Nurse on a Statewide Maternal Mortality Review Committee

To identify the role of the perinatal nurse as a member of the Statewide Maternal Mortality Review Committee (MMRC). The charge of this committee is to analyze statewide maternal mortality data to identify trends and emerging issues and to generate public health–focused recommendations for preventing maternal deaths. With the increase of complex maternal mortality cases in 2015, additional disciplines were added to the review committee, to include anesthesiology, cardiology, family medicine, and perinatal nursing. Perinatal nurses provide the bedside perspective on factors that contributed potentially to a death. The Centers for Disease Control and Prevention Maternal Mortality Review Information Application was also implemented to guide case abstraction, case narrative development, data analysis, and documentation of committee decisions. Evidence-based committee recommendations resulting from identified trends were then distributed to Illinois administrative perinatal centers for implementation at hospitals across the state. Committee outcomes include the identification of factors contributing to maternal mortality, recommendations for improved practice, and analysis of repeating trends. Perinatal nurses on the MMRC advocate for statewide public health policy and legislation to improve obstetric practice. Perinatal nurses affect change at the hospital, network, and state levels by implementing committee recommendations. Collaboration of perinatal nurses within the Illinois Perinatal Code 640 enhances the ability to implement change at every tier. The organizational structure of the perinatal program is composed of the Illinois Department of Public Health Office of Women’s Health & Family Services (IDPH OWHFS), the Administrative Perinatal Centers (APC), and their affiliated network hospitals. In 2009, MMRC identified obstetric hemorrhage as a leading preventable cause of death. As of August 2018, cardiac pathology and opioid abuse were identified as significant contributors to maternal mortality. At the bedside, perinatal nurses are critical in early identification of factors that contribute to maternal mortality. The APC perinatal nurses disseminate state-level policies and initiatives and provide education and assistance to hospitals to improve perinatal care. At IDPH OWHFS, the perinatal nurses provide hospital oversight of perinatal services within Illinois.

Vital Signs: Pregnancy-Related Deaths, United States, 2011-2015, and Strategies for Prevention, 13 States, 2013-2017.

BackgroundApproximately 700 women die from pregnancy-related complications in the United States every year.MethodsData from CDC’s national Pregnancy Mortality Surveillance System (PMSS) for 2011–2015 were analyzed. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births; PRMRs) were calculated overall and by sociodemographic characteristics. The distribution of pregnancy-related deaths by timing relative to the end of pregnancy and leading causes of death were calculated. Detailed data on pregnancy-related deaths during 2013–2017 from 13 state maternal mortality review committees (MMRCs) were analyzed for preventability, factors that contributed to pregnancy-related deaths, and MMRC-identified prevention strategies to address contributing factors.ResultsFor 2011–2015, the national PRMR was 17.2 per 100,000 live births. Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1–6 days postpartum, 21.4% 7–42 days postpartum, and 11.7% 43–365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing. Approximately sixty percent of pregnancy-related deaths from state MMRCs were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. MMRC data indicated that multiple factors contributed to pregnancy-related deaths. Contributing factors and prevention strategies can be categorized at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care.ConclusionsPregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death. Approximately three in five pregnancy-related deaths were preventable.Implications for Public Health PracticeStrategies to address contributing factors to pregnancy-related deaths can be enacted at the community, health facility, patient, provider, and system levels.

Severe Maternal Morbidity, A Tale of 2 States Using Data for Action-Ohio and Massachusetts.

Purpose Describe how Ohio and Massachusetts explored severe maternal morbidity (SMM) data, and used these data for increasing awareness and driving practice changes to reduce maternal morbidity and mortality. Description For 2008-2013, Ohio used de-identified hospital discharge records and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify delivery hospitalizations. Massachusetts used existing linked data system infrastructure to identify delivery hospitalizations from birth certificates linked to hospital discharge records. To identify delivery hospitalizations complicated by one or more of 25 SMMs, both states applied an algorithm of ICD-9-CM diagnosis and procedure codes. Ohio calculated a 2013 SMM rate of 144 per 10,000 delivery hospitalizations; Massachusetts calculated a rate of 162. Ohio observed no increase in the SMM rate from 2008 to 2013; Massachusetts observed a 33% increase. Both identified disparities in SMM rates by maternal race, age, and insurance type. Assessment Ohio and Massachusetts engaged stakeholders, including perinatal quality collaboratives and maternal mortality review committees, to share results and raise awareness about the SMM rates and identified high-risk populations. Both states are applying findings to inform strategies for improving perinatal outcomes, such as simulation training for obstetrical emergencies, licensure rules for maternity units, and a focus on health equity. Conclusion Despite data access differences, examination of SMM data informed public health practice in both states. Ohio and Massachusetts maximized available state data for SMM investigation, which other states might similarly use to understand trends, identify high risk populations, and suggest clinical or population level interventions to improve maternal morbidity and mortality.

Checking the pregnancy checkbox: Evaluation of a four-state quality assurance pilot.

The 2003 revision of the standard United States death certificate included a set of "pregnancy checkboxes" to ascertain whether a woman was pregnant at the time of her death or within the preceding year. Studies validating the pregnancy checkbox have indicated a potentially high number of errors, resulting in inflated maternal mortality rates. In response to concerns about pregnancy checkbox data quality, four state health departments implemented a quality assurance pilot project examining the accuracy of the pregnancy checkbox for 2016 deaths. State staff conducted searches for birth or fetal death reports that matched a death certificate, within a year of death. If a pregnancy checkbox was marked, but no match was found between certificates, confirmation of the pregnancy was attempted through active follow-up with the death certifier. From December 2017 to January 2018, the quality assurance pilot was evaluated through three focus groups with key stakeholders. The evaluation aimed to describe opportunities and challenges to implementation, sustainability, and lessons learned. Opportunities for implementing the pilot included written documentation of the quality assurance process, improved certifier response, improved data quality, and increased data timeliness for Maternal Mortality Review Committees. Challenges included initial delays in certifier response, staff turnover, high caseloads in relation to resources, and lack of pilot prioritization in the health department. All four pilot states plan to sustain the pregnancy checkbox quality assurance process in some capacity. Implementing quality assurance processes for the pregnancy checkbox may ultimately improve state and national maternal death data quality.

Putting the “M” back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

Challenges and Opportunities in Identifying, Reviewing, and Preventing Maternal Deaths.

Despite many efforts at the state, city, and national levels over the past 70 years, a nationwide consensus on how best to identify, review, and prevent maternal deaths remains challenging. We present a brief history of maternal death surveillance in the United States and compare the three systems of national surveillance that exist today: the National Vital Statistics System, the Pregnancy Mortality Surveillance System, and maternal mortality review committees. We discuss strategies to address the perennial challenges of shared terminology and accurate, comparable data among maternal mortality review committees. Finally, we propose that with the opportunity presented by a systematized shared data system that can accurately account for all maternal deaths, state and local-level maternal mortality review committees could become the gold standard for understanding the true burden of maternal mortality at the national level.

Building U.S. Capacity to Review and Prevent Maternal Deaths.

In the United States, the risk of death during and up to a year after pregnancy from pregnancy-related causes increased from ∼10 deaths per 100,000 live births in the early 1990s to 17 deaths per 100,000 live births in 2013. While vital statistics-based surveillance systems are useful for monitoring trends and disparities, state and local maternal mortality review committees (MMRCs) are best positioned to both comprehensively assess deaths to women during pregnancy and the year after the end of pregnancy, and identify opportunities for prevention. Although the number of committees that exist has increased over the last several years, both newly formed and long-established committees struggle to achieve and sustain progress toward reviewing and preventing deaths. We describe the key elements of a MMRC; review a logic model that represents the general inputs, activities, and outcomes of a fully functional MMRC; and describe Building U.S. Capacity to Review and Prevent Maternal Deaths, a recent multisector initiative working to remove barriers to fully functional MMRCs. Increased standardization of review committee processes allows for better data to understand the multiple factors that contribute to maternal deaths and facilitates the collaboration that is necessary to eliminate preventable maternal deaths in the United States.

Partnering of Public, Academic, and Private Entities to Reestablish Maternal Mortality Review in Georgia.

The pregnancy-related mortality ratio in the United States has increased over the past 25 years. Georgia's pregnancy-related mortality ratio is among the highest in the United States. Confronted with this harsh reality, Georgia reestablished maternal mortality review as one strategy to address its high maternal mortality. To achieve a comprehensive process for review of maternal deaths involved securing the knowledge, resources, and support of physician experts, public health agencies and professional organizations as well as representatives in the state legislature. The six key steps in successfully reinstating maternal mortality review were 1) establishing a maternal mortality advisory committee, 2) developing a defined methodology for comprehensive case identification, 3) convening an introductory maternal mortality review committee meeting, 4) securing legislative protection for the committee, 5) conducting a mock mortality review, and 6) completing a formal first-year case review and producing a summary report of initial findings. This first case review revealed the leading causes of pregnancy-related deaths in Georgia as hemorrhage, hypertension, cardiac disease, embolism, and seizures. Our objective in this commentary is to share our experiences and advocate for engaging public, private, and academic partners in working on complex and multifactorial public health issues such as high maternal mortality.

Addressing maternal deaths due to violence: the Illinois experience

Homicide, suicide, and substance abuse accounted for nearly one fourth of all pregnancy-associated deaths in Illinois from 2002 through 2013. Maternal mortality review in Illinois has been primarily focused on obstetric and medical causes and little is known about the circumstances surrounding deaths due to homicide, suicide, and substance abuse, if they are pregnancy related, and if the deaths are potentially preventable. To address this issue, we implemented a process to form a second statewide maternal mortality review committee for deaths due to violence in late 2014. We convened a stakeholder group to accomplish 3 tasks: (1) identify appropriate committee members; (2) identify potential types and sources of information that would be required for a meaningful review of violent maternal deaths; and (3) revise the Maternal Mortality Review Form. Because homicide, suicide, and substance abuse are closely linked to the social determinants of health, the review committee needed to have a broad membership with expertise in areas not required for obstetric maternal mortality review, including social service and community organizations. Identifying additional sources of information is critical; the state Violent Death Reporting System, case management data, and police and autopsy reports provide contextual information that cannot be found in medical records. The stakeholder group revised the Maternal Mortality Review Form to collect information relevant to violent maternal deaths, including screening history and psychosocial history. The form guides the maternal mortality review committee for deaths due to violence to identify potentially preventable factors relating to the woman, her family, systems of care, the community, the legal system, and the institutional environment. The committee has identified potential opportunities to decrease preventable death requiring cooperation with social service agencies and the criminal justice system in addition to the physical and mental health care systems. Illinois has demonstrated that by engaging appropriate members and expanding the information used, it is possible to conduct meaningful reviews of these deaths and make recommendations to prevent future deaths.

The Case for a National Maternal Mortality Review Committee

The United States has the highest maternal mortality ratio of any high-resource country; the 2014 ratio of 22 per 100,000 live births is in fact four to five times higher than that of the best-performing nations, and recent data suggest that this ratio may be increasing. The causes of this disparity are unknown and may be related to social, economic, cultural, or medical issues or a combination of factors. Repeated counts of categories of maternal death are of little assistance in determining the actual cause of death or in identifying preventive measures. Furthermore, when based on administrative data, such tallies may themselves be inaccurate. We propose the creation of a national maternal mortality review committee, modeled after those in other high-resource nations, to assist in addressing the problem of maternal mortality in the United States.

Higher Risk of Homicide Among Pregnant and Postpartum Females Aged 10-29 Years in Illinois, 2002-2011.

To examine whether being pregnant or postpartum was associated with excess risk for homicide among females in Illinois and to describe the association between pregnancy status and homicide by race, ethnicity, and age group. This is a retrospective, multicohort, ecologic study of females of reproductive age in Illinois between 2002 and 2011 using Illinois Department of Public Health maternal mortality data and vital records data. We compared pregnancy-associated homicides with live births using χ tests. Among maternal deaths in the state, we calculated mortality rates per 100,000 live births for homicide and other violent causes and the leading direct obstetric causes. We calculated aggregate, pregnancy-associated, and nonpregnancy associated homicide rates stratified by race or ethnicity and age group. There were 636 pregnancy-associated deaths in Illinois from 2002 to 2011. Of these, 82 (13%) were the result of homicide (5.0 [95% confidence interval (CI) 4.0-6.2]/100,000 live births). There were 931 homicides among females of reproductive age not associated with pregnancy (2.88 [95% CI 2.70-3.07]/100,000 population). More than half of the homicides were women aged 20-29 years (n=53 [64.6%]), non-Hispanic black women (n=43 [52.4%]), women residing in Cook County (n=47 [57.3%]), and unmarried women (n=57 [69.5%]). Pregnant and postpartum females aged 10-29 years were at twice the risk of homicide compared with their nonpregnant or postpartum counterparts (relative risk 2.20 [95% CI 1.70-2.85]). Non-Hispanic black and Hispanic females experienced higher rates of homicide than non-Hispanic white females irrespective of pregnancy or age. Although all violence against women must be addressed, we recommend that state maternal mortality review committees, in addition to reviewing deaths resulting from obstetric and clinical causes, should conduct in-depth reviews of pregnancy-associated homicides and other violent deaths.

Does maternal obesity impact pregnancy-related deaths? Michigan experience

Obesity is a multifactorial non-communicable condition that has become a public health epidemic worldwide. The Fifth Millennium Development Goal established the goal of a 75% reduction in the maternal mortality ratio (MMR) between 1990 and 2015. Maternal mortality has been difficult to track over time. Obesity affects pregnancy in more than 50% of women of reproductive age in the state of Michigan; the potential impact of maternal obesity and pregnancy-related deaths (PRDs) has not been studied in Michigan. We conducted a secondary analysis of maternal death cases originally reviewed by the Michigan Maternal Mortality Review Committee from 2004 to 2006 seeking to evaluate the impact of maternal obesity on PRD. Two hundred and five maternal deaths occurred during the period of the study, 61 were classified as PRD. The observed occurrence of PRDs in the obese population was 36 cases while in the non-obese was 25 cases. The study showed a 3.7× risk of PRD in the obese parturient.

Neonatal encephalopathy in New Zealand: Demographics and clinical outcome.

To establish the incidence of moderate to severe neonatal encephalopathy (NE) in term infants from New Zealand and to document demographic characteristics and neonatal outcomes. Cases were reported monthly via the New Zealand Paediatric Surveillance Unit (NZPSU). Data were collected from paediatricians for neonatal items and lead maternity carers for pregnancy and birth details. Term neonatal deaths in the Perinatal and Maternal Mortality Review Committee dataset that were because of hypoxia and/or neonatal deaths from hypoxic ischaemic encephalopathy were added to the cases identified via the NZPSU, if they had not previously been ascertained. For the period January 2010 to December 2012, there were 227 cases, equivalent to a rate of 1.30/1000 term births (95% CI 1.14-1.48). Rates of NE were high in babies of Pacific and Indian mothers but only reached statistical significance for the comparison between Pacific and NZ European. There was also a significant increase in NE rates with increasing deprivation. Resuscitation at birth was initiated for 209 (92.1%) infants with NE. Mechanical ventilation was required, following neonatal unit admission, in 171 (75.3%) infants. Anticonvulsants were used in 157 (69.2%) infants with phenobarbitone (65.6%), phenytoin (14.5%) and benzodiazapines (21.1%), the most common. Cooling was induced in 168 infants (74%) with 145 (86.3%) reported as commenced within a 6-h window. The rate of NE in New Zealand is consistent with reported international rates. Establishing antecedent factors for NE is an important part of improving care, which may inform strategic efforts to decrease rates of NE.