When The Shadow Comes - Coping with Pregnancy and Infant Loss

By Coertze, Nicci

When you lose a baby, you feel shocked, numb and in disbelief as to what has happened and totally overwhelmed by how much you have to deal with.  No one will ever fully understand what you go through as an individual, but as a baby loss specialist who has assisted many, many bereaved parents and as a bereaved mother herself, the author has a very good understanding as to how you will be feeling, and more importantly, how to cope, than most people. Losing a baby is against the natural order of things. It's overwhelming, frightening, exhausting and infinitely sad. Nothing anyone says can change that, but there are things you can do to feel a bit more prepared.  The information in this book will help you think about the unthinkable to enable you to have more control of a very traumatic situation and it will empower and inform you about difficult subjects surrounding pregnancy and infant loss that you never thought you would have to think about.

 

If you are a family member or friend of someone who has suffered pregnancy or infant loss, this book is for you too! It is filled with guidelines and advice and the best ways to deal with this incredible heartache. For care providers there are recommendations on best practice in hospitals and support to patients and what types of actions to avoid during this devastating experience. Baby loss professionals and care providers will gain new insights on how to best support bereaved parents and how to empower them during a very dark and difficult time in their lives.

 

This book is a must-have for anyone going through, or involved with pregnancy or infant loss!

• Language: English
• Publisher: NCI
• Release date: Oct 14, 2020
• ISBN: 9780620882415

Coertze, Nicci

My name is Nicci, I am 48 years old, mother to three beautiful boys, Nathin (25), Kevin (23) and my laatlammetjie Jaedin (10). My partner in life and love, Christo and I reside in a leafy suburb at the foot of the Magalies mountains. Memphis and Gracie are Boston Terrier fur-babies. I am your proverbial Jack of all trades! Since I started my career at the tender age of 18 I have been there and done that - from meeting Nelson Mandela when I worked as a secretary in parliament to cooking with Adam Liaw from masterchef Australia! After many years in the corporate world I decided to follow my heart - first as events manager and then as a photographer. Eventually my lifepath diverted to the doula world and to the bereavement side of being a doula. Besides being a Birth and Adoption Doula, Bereavement Specialist and loss mother, I am an avid reader, a writer, a professional birth photographer, business partner, content writer, and the CEO of NCOT. I launched South Africa's first ever Online Miscarriage & Infant Loss Bereavement Training Program as well as an initiative to honour our baby angels called We Remember Our Babies. I have also developed an online baby loss course specifically designed for bereaved parents. For more information, please visit: www.niccicoertze.com www.ncot4u.com www.werememberourbabies.online Or email [e-mail]

Book preview

GRATITUDE

Writing a book is never easy, let alone writing a book about such a sombre subject as pregnancy and infant loss.  But writing this book has been such a huge privilege. It has been growing in my heart for 5 years and when I felt my love and my experience on the subject matter had reached an equilibrium, this book was born. It is with immense gratitude and profound thanks that I acknowledge the following people who were part of my journey:

First of all, to my God and heavenly Father: You are a good, good father and I am loved by You. That gives me all the strength, and hope and peace that I need. Thank you!

My sons Nathin, Kevin and Jaedin: Thank you for loving me just the way I am. Each one of you is my ‘sonshine' and I love you more than all the stars in the sky. You are my reasons.

My angel babies:You are my inspiration.

Christo: Even though the subject makes you intensely uncomfortable, and even when you don't want to hear the heart wrenching details of every death, you are always there for me. Running a bath after a 36-hour labour and stillbirth, making sure I have something to eat (and supplying me with copious amounts of coffee!), passing me tissues when I can't keep the sadness inside and making lame jokes to try and distract me from my sometimes very difficult job. I know for a fact that you don’t always ‘get’ what I do and at times it is very difficult for you to understand my calling, yet you have never stood in my way – even when you possibly should have. For that I am so thankful.

My parents Ben and Marlene Potgieter for their love, prayers, and support. It is a privilege to have you in my life and one that I will not take for granted ever again. I love you!

All my friends and family (especially my grandparents) who are not on this earth anymore. I remember you.

My soul-friend and book doula, Stephanie Nel, who has heard more stories than I’m sure she cares to remember! Who doesn’t mind the heart wrenching details and the shattering emotions after I have assisted bereaved parents, who debriefs me after every traumatic death. Who is my sounding board, my fiercest (and most fair) critic, my greatest supporter, and my amazing business consultant. My friend who picks up the pieces, who hugs me until it hurts and who is always there for me:No matter where life may take us, I will always think of you and smile (and this is a huge shoutout to Noah and Ed too!).

My dear friend and psychologist Dr. Catherine van Heerden: Thank you for encouraging (and nagging!) me to write this book. You are a fierce woman and soft warrior - thank you for our journey, it is a privilege to be a witness to your life.

My traumatologist and 'mother hen', Elize Thirion: Thank you for believing in me when precious few other people did.And thank you for helping me become a better person.

Dr. Mariatha Yazbek for the eloquent foreword.You are the epitome of ethical conduct in the medical industry, and I have the utmost respect for you as an academic, specialist midwife and person.

My amazing NCOT students who journeyed with me and who taught me more than I could ever teach them - thank you!

My girls Roxanne Badenhorst and Georgia Croeser: Thank you for your love and support and most importantly, for loving my sons. I love you! Thank you for editing this book Georgie, I know it wasn’t easy for you!

My ex-husband Stéfan and his wife Mia for nurturing, educating, and loving our son and ‘laatlammetjie’, Jaedin. Thank you for raising our angel so that I can help parents say goodbye to theirs.

My friends and family (by blood and by love):Anel Alexander, Dawn Blank, Santi Britz, Quinne Brown, Luco Crispin, Kelly & Jonathan Croeser, Ronén, Kalila and Emma de la Rey, Lidi de Waal, Amor and Tertius Dreyer, Thea Du Plooy, Eric Elronde, Framande Guesthouse (Yolande and Frans), Lindy Gould, Natasha Henning, Mariandra Heunis en die muise, Linda Josi,

Dr. Jacques Koning, Sanet Kruger, Jan Kruger, Elsie Moulder,

Annatjie Kurfurst, Joe Lategan, Fran & Brian Lee, Adriaan Lubbe,

Dr. Johan Markram, Georgi Mertz, Mienke, Ryno & Verna Mulder,

Sonia Muller,Ina Rabe,Brigitte Radley, Gerrie Riekert, Nanki Robbertse,

Liannie Robertson, Anrich Stander, Belinda Tredoux, Anton van Niekerk, Rianto & Yolande Van Reenen, Johann, Annatjie & Alwyn van Staden, Sandra Vaughn and Juanita Wilson

You have either loved me, supported me, inspired me, or changed me for the better (or all of the above!).  I am so very thankful for all of you!

And last, but most certainly not least: To all the parents who have suffered pregnancy and infant loss and who have allowed me to sit with them, mourn with them and remember with them. YOU are the reason I have written this book. YOU inspire me every single day. And on the days when I feel like giving up, YOU are the reason I don’t! THANK YOU for sharing your special, special angels with me. And for those of you who shared your stories in this book:I salute you! I am a better person because of you and your precious children.

With so much love and gratitude in my heart,

FOREWORD

When The Shadow Comes

The birth of a baby is an important lifetime event which marks the beginning of a transition to parenthood. Occasionally, this lifetime event becomes a calamity when the pregnancy does not end in the birth of a healthy full-term baby.

Pregnancy loss is a common occurrence, affecting 15% to 25% of all pregnancies globally. Any pregnancy loss, at any stage, remains a devastating experience, as many expecting parents already make a significant emotional investment in their prospective child, some from the first moment they find out about the pregnancy. Perinatal loss may be attributed to infertility, miscarriage, abortion, death during pregnancy and birth, and death of a baby following illness or anomalies such as congenital malformations not compatible with life.

The purpose of this book is to provide general information on pregnancy loss for bereaved parents, care providers, and family and friends. This includes an explanation of the medical terminology around pregnancy loss, death associated with pregnancy and birth complications, and much needed practical tips in the immediate and long-term management of the loss. Professionals involved in the care of bereaved parents often do not know the protocols, practicalities, and arrangements after a perinatal loss such as making mementos, assisting with funeral arrangements, counselling and referral of these parents.

The postnatal journey for the grieving parents and their extended family members does not stop immediately after the burial but takes a lifetime for most to make the transition from grief to acceptance. Health care providers in hospitals and at home often fall short in providing bereaved parents the much-needed support. Bonding is part of the grieving process and babies are taken away long before parents, other siblings and family members could say goodbye. Health care providers often do not understand the types of pregnancy loss parents experience, the various stages of grieving and their own attitudes in the care they provide to grieving parents. Some parents never receive any explanation regarding their loss, making the journey even harder. Parents often end up blaming themselves for the death of their baby. Nobody can be prepared for this journey.

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Nicci Coertze, a doula, birth and loss photographer, bereavement specialist and bereaved mother herself, managed to capture the essence of pregnancy loss in this book. During her career journey, Nicci assisted many bereaved parents with miscarriage, stillbirths, and early neonatal deaths. She has become part of the mementos of the pregnancy loss journey of many bereaved parents. The true stories of baby loss as reflected by bereaved parents provide a glimpse for health care professionals, other bereaved parents and even the general public in the never-ending journey of parental loss.

This book is definitely a recommended read.

DR. MARIATHA YAZBEK

Midwife specialist and senior lecturer

PREFACE

Death humbles you. It leaves many people wounded and scarred (and scared!), but you are also awakened to the miracle and the fragility that is life. It opens your eyes to the absolute gift it is to breathe (and have those you love, breathe) every single day.  My name is Nicci, and I am a doula, birth and loss photographer and perinatal bereavement specialist from Pretoria (South Africa). I assist parents with miscarriages, stillbirths, and infant loss as a baby loss professional. I have held many, many angels in my hands and I know all of their names.

I deal with indescribable pain and heartache. My job is not an easy one, in fact, it’s probably one of the most emotionally challenging professions out there. But it is made bearable by knowing that I could help a mother or father carry the load, even if it’s only for a little while.  Usually, my clients and I have a lot of time talk and cry and yes, even laugh. Sometimes it’s much easier to talk about your pain to a stranger – somebody that you don’t feel guilty over because you are ‘burdening’ them with your pain. Someone that won’t judge, just listen – who may shed a tear or two with you, but who will not fall apart.

Perinatal bereavement is obviously nothing new. But people have never talked about it the way they are starting to talk about it today.  The time is absolutely NOW. Parents need our support. They need our expertise. Medical personnel need the know-how we bring. Everyone deserves the comfort and the calm presence that a bereavement specialist brings.

As a baby loss professional and doula, I am learning more and more about life, death, loss, and everything in between every day. It is my dream that our profession will be formally recognized and acknowledged in South Africa and that baby loss professionals’ services, like midwives, will be covered by medical aids.  I am so very grateful to say that my ‘job’ is not a job at all, but a calling and I treasure it as such.

How to use this book:

The book has been conveniently divided into 5 parts:

Part 1:  Information

Part 2:  Content for bereaved parents

Part 3:  Content for care providers and BLP’s

Part 4:  Content for family and friends

Part 5:  General content

The chapters are short, yet impactful and it has been specifically written in a way that will assist you to immediately benefit from the information. You have easy access to content that is applicable to your unique situation. Whether you are a bereaved parent, care provider, family member or friend you will find content that immediately speaks to your needs.

You can of course always read all the other information at a later stage to empower yourself with insight and knowledge about the intricacies of pregnancy and infant loss.

Please note that when I refer to a 'baby loss professional' in this book, it also means 'bereavement doula' or 'perinatal bereavement worker'.

Whether you are a parent who has lost a baby, a family member, friend, care provider or other medical professional - it is my wish that this book will make a difference to your life, and the lives of others. And that when the shadow comes, you will at least be a little prepared to deal with it.

With deep gratitude,

PART 1:  INFORMATION

CHAPTER 1 - INFO: DEFINITIONS OF RELEVANT TERMS:

Perinatal:  The period before and the period just after birth.

Premature infant:  Infant born before 37 weeks of gestation.

Neonatal period:  First 28 days of life.

Perinatal period: 28th week of gestation through first seven days after delivery.

Embryo: Your developing baby is called an embryo from the moment of conception to the eighth week of pregnancy. After the eighth week and until the moment of birth, your developing baby is called a foetus.  The difference between an embryo and a foetus has to do with the different phases of baby’s development. The embryo is defined as the developing pregnancy from the time of fertilization until the end of the eighth week of gestation, when it becomes known as a foetus.

Foetus:  A baby that has not been born (inside the womb) is always a foetus. A baby that has been born is called a newborn.  In SA, a foetus born before 26 weeks without giving a single breath, is regarded as medical waste.  In SA weight is NOT applicable.

Miscarriage or spontaneous abortion: Naturally occurring, spontaneous expulsion of a human foetus, especially between the twelfth and twenty-seventh weeks of gestation.

Late miscarriage:  Doctors describe a late miscarriage as one that happens after 12 weeks and before 24 weeks of pregnancy. Late miscarriages are much rarer than early miscarriages. Just one or two per cent of all pregnancies end in a miscarriage in the second trimester of pregnancy. However, in reality, for many parents who have suffered a late miscarriage, the word miscarriage doesn’t properly capture the gravity and impact of their loss, as they may feel that they have suffered the loss of a baby, or a stillborn baby.

Stillbirth:  A stillborn baby is one who is lost at or after 24 weeks of pregnancy. It results in a baby born without signs of life.  About 1 in 160 pregnancies ends in stillbirth in SA. Most stillbirths happen before labour begins, but a small number occur during labour and delivery.

Foetal death:  Death of foetus prior to complete expulsion or extraction from the mother of a product of human conception (irrespective of duration of pregnancy) that is not an induced termination of pregnancy. Sometimes the term stillbirth is used for such foetal deaths.

Loss:  Can be described as that sense that all is not well. It is produced by an event which is perceived to be negative by the individuals involved and results in long-term changes to one’s social situations, relationships, or cognitions.

Grief:  Refers to the reaction to loss - the emotional response to loss: the complex amalgam of painful effects including sadness, anger, helplessness, guilt, despair. It incorporates diverse psychological (cognitive, social-behavioural) and physical (physiological-somatic) manifestations. Grief can be the result of any change that requires a person to give up or let go of what they have enjoyed or loved or found meaningful.

Mourning: Describes the psychological processes that occur in bereavement; the processes whereby the bereaved person gradually undoes the psychological bonds that bound him or her to the deceased. This is the slow process of recognising what has been lost and how our lives will now be different without that person.

Suffering:  Refers to the width of the gap between the reality of ‘what is’ and ‘what is desired’.

Bereavement: Is the objective situation of having lost someone significant; the reaction to the loss of a close relationship. The origin of the term bereavement means the state of being deprived. Bereavement deprives us of the living presence of someone we love or care about.

CHAPTER 2 - INFO: WHAT IS A BABY LOSS PROFESSIONAL?

According to the Institute of Medicine report on When Children Die: Improving Palliative and End-of-Life Care for Children and Their Families, more children die in the first year of life than in all other childhood years combined. Importantly, two-thirds of these infant deaths are neonatal deaths. These staggering losses and their impact on the families require that more attention be given to the special needs of these families.

People often ask me, So what does a baby loss professional DO Nicci?. The simple answer is nothing, yet at the same time, everything. Because in medical terms baby loss professionals do not ‘do’ much – although I have been the only one present in more births than I care to think about and in loss situations have pretty much done everything (sometimes out of scope because I literally had no other choice) – from delivering the baby, delivering the placenta, cleaning baby alone (as neither hospital staff nor the parents were up to doing it), handing the baby over to the parents, taking photos and helping with the paperwork! But as a rule of thumb, I am not supposed to ‘do’. I am supposed to ‘be’ there. And that I try to do to the very best of my ability.

Baby loss professionals provide support in situations of fatal perinatal outcomes and comfort parents when a baby passes away.  It is not a glamorous job. We clean up vomit, blood, amniotic fluid, and spilled apple juice. We make a client’s bed over and over again, fluff pillows and offer ice cubes, lip balm and hugs. We kick vending machines on behalf of fathers desperately looking for a can of soda at 2am in the morning and we beg gynaecologists to give permission for more medication for a mom that is writhing in pain. We also beg unit managers to allow a heartbroken father a ‘sleepover’ to be with his wife who is in labour (with their dead baby) when it is against hospital policy, and sleep is the very last thing we know they are going to do.  We see raw pain and we hear the most agonizing, haunting cries you will ever hear in your life. And sometimes we hold a little body and that baby’s heart beats for the last time in our hands.  It is not an easy calling, but we do it with great pride and love for our clients who are going through the unimaginable.

If I must make a list of everything I do as a baby loss professional, it becomes quite an impressive one. But you see, I don’t like to do that. Make lists. Or write job descriptions or limit myself to a certain number of things I can/will/want to do. Because the reason I am a baby loss professional, the very reason I absorb so much of my clients’ pain and heartache, is very simple:  I want to comfort as many as I can. I want to console broken parents and try to make the journey of the births of their children bearable by being there, acting as a buffer between them and the cold medical world and cruel strangers who are sometimes so wrapped up in their own professions that they do not think twice before inflicting pain (most of the time unknowingly so) on helpless, grieving parents. I wish I could say this does not happen often. I cannot... 

Not one birth or miscarriage is the same. On that note, I really do not like the word ‘miscarriage’. Because nothing is ‘missed’ – whether you are 20 or 40 weeks pregnant, you go through the same labour pains - and everything is carried: Guilt, shame, grief, anger, fear...

The Oxford dictionary offers two explanations for the word miscarriage:  The spontaneous or unplanned expulsion of a foetus from the womb before it can survive independently; and the unsuccessful outcome of something planned.  I prefer the second definition.  Because whether it is because of a baby dying in utero, a medical termination, or a stillbirth, this encompasses pretty much what it is:  An unsuccessful outcome for something that was very much planned, wanted and looked forward to. I don’t like the first definition because I don’t care for the word ‘foetus’ and let me explain why.

I am an ex-director of a non-profit company called ‘the Voice of the Unborn Baby’ (founded by Sonja Smith). VOTUB fights for parents’ rights to choose whether they want to say goodbye to their child by having a funeral or cremation for them. But because of what I coined an archaic law in the South African law books, foetuses who are born before 26 weeks of gestation must be treated as medical waste and are incinerated with needles, syringes, amputated limbs, and other medical waste products. And the only way to get around this horrific law is for parents to make an affidavit to state that they need the ‘medical tissue’ or ‘placenta’ for religious and/or cultural purposes. They also must fill out a mountain of forms required by the hospitals to enable them to have the child removed from the hospital’s premises.  I have had to complete too many of these affidavits.  I cannot explain to you in words how much it grieves me to put my clients through this horrific conundrum of paperwork to enable them to give dignity and respect to their dead child. Yes, child.  Because not once have I ever heard a parent speak about their ‘foetus’. No, they speak with much love and affection about their child, their baby, their angel – never ever, their foetus.

Being a baby loss professional in South Africa is not easy. Very few people know about this profession, and time and time after time I must explain to a nurse or a doctor or a hospital manager what it is that I do. I am hoping that this book will give people some peace of mind as to the level of professionalism and skill baby loss professionals have. But at the end of the day no one piece of paper can equip you to deal with raw, unadulterated pain and the grief of a mother losing her child - of a dad losing his dream of being a father. No qualification can prepare you to hold a little body in your hands and feel life slipping away without you being able to do anything about it.

No university can help you deal with your tears the night after the fact, when you cry for a little life lost and for the pain of parents who will never ever forget. Nothing can prepare you fully for this job.

But as a baby loss professional you are there – in the midst of pain and turmoil and tears and anger.  You are there to hold a mom’s hand whilst she is in the throes of birthing her dead baby.  You console an inconsolable father who does not have the know-how or strength to carry his own grief, let alone the mother of his child’s. You comfort sobbing grandparents. Sometimes you even clamp the cord because no one else is there. You gently clean and wrap a precious little baby and take photos for families to keep as a reminder that their baby was born. Born still, but still born. And because of baby loss professionals, parents do not have to face the daunting task of the birth of their stillborn or miscarried child alone.  Baby loss professionals empower and remind loss parents that they do have a voice. That someone cares!

Because there is such a huge need for baby loss professionals in South Africa, I have written an Online Bereavement Training Program to enable as many people as possible in South Africa with a heart for bereavement, to assist parents going through loss.  Students are equipped with the right information, tools, and coping skills to guide families in South Africa going through the unimaginable. There are also many other grief-related courses on offer. More information can be found here:  www.ncot4u.com

There are millions of people worldwide who do much more than we do daily, who work with much more horrific, unspeakable things and who never ever get any glory for it.  We do not want glory. We want parents to feel supported and informed when they are at their weakest. Yes, we most probably think more with our hearts than the average person. We, we do things many people will feel they will never be able to do, but that doesn’t make us angels. It makes us baby loss professionals.  

CHAPTER 3 - INFO:  PERINATAL AND NEONATAL MORTALITY

A baby is never more vulnerable than before it is born, and in its first month of life. In fact, approximately 40% of child deaths, globally, occur before the first month of life is completed.

Another sad truth is that this figure does not represent the thousands upon thousands of babies whose deaths are not even reported, because the birth takes place in rural regions, where access to the nearest hospital or local government office is a day or more’s walk away. Likewise, many deaths are not reported because many people still view a miscarriage or a stillbirth as something to be forgotten, swept under the carpet or to ‘get over’. So, this figure is merely an estimate.

Globally, approximately 2.6 million babies are stillborn per year (according to the Lancet’s publication in April 2017). This translates to about 1 in every 200 pregnancies in countries with the lowest rate (high income countries, mostly in the West) and 1 in every 15 pregnancies in countries with the highest rate (low-income countries, mostly in Africa and Asia).

Half of all stillbirths occur during labour. Two-thirds of all stillbirths occur in rural areas where specialist obstetric help is either non-existent or not easily available. In high-risk pregnancies (irrespective of the country) the figure is approximately 1 for every 50 pregnancies. Statistics on the number of unexplained stillbirths range from about half to about 70% that cannot be explained, depending on the country involved.

South African Statistics

Approximately 23 000 babies die every year (the equivalent of a daily crash of 4 full minibus taxis, killing all passengers) - which is 61 stillbirth babies and 58 neonatal (newborn) deaths every DAY in South Africa.

In towns and cities, the rate of deaths is higher – 1 for every 25 live births, compared to 1 for every 40 live births in rural areas. At first sight, this statistic makes no sense. However, given the vast stretches of our nation that are either inaccessible by road, isolated during the winter months, or simply miles from any hospital, there are probably thousands more whose births and deaths are never reported. If you take this into account, then this statistic makes a little more sense. In addition, many people who give birth to a baby under 1000g will probably never register their child, which also skews the results somewhat.

Perinatal Mortality

What does perinatal mean?

Perinatal means ‘around the time of birth’. Perinatal usually applies to the last months of pregnancy and the first week after delivery.

What is a perinatal death?

Perinatal deaths are all infants that are born dead plus infants that are born alive but die within the first 7 days after delivery, i.e., stillbirths and early neonatal deaths.

What is the perinatal mortality rate in South Africa?

As representative perinatal mortality data are not available for all regions of South Africa, the exact perinatal mortality rate is not known. However, information from many sites suggests that the overall perinatal mortality rate in South Africa, for infants of 500 g or more, is approximately 36/1000. This varies widely between different areas from 35/1000 in metropolitan areas, such as Cape Town, to over 50/1000 in some poor, rural areas. The perinatal mortality rate for most of South Africa is, therefore, typical of a low- and middle-income country while the rate in metropolitan regions is still about three times higher than that of high-income countries.

What are the primary causes of perinatal death?

In South Africa, the common identifiable primary causes of perinatal death are:

Spontaneous preterm labour.

Intrapartum hypoxia.

Hypertensive disorders.

Antepartum haemorrhage.

Infections.

Foetal abnormalities.

Intrauterine growth restriction.

Birth trauma.

Maternal diseases.

A few perinatal deaths are due to less common conditions or problems not related to the pregnancy (e.g., motor car accidents or assault).

(Most of the data on stillbirths and perinatal deaths in South Africa is taken from the Saving Babies report of South Africa which covers the years 2015-2017.)

What causes spontaneous preterm labour?

Preterm labour (labour before 37 weeks gestation), which has not been induced artificially, may be caused by:

Chorioamnionitis (often asymptomatic).

Preterm pre-labour rupture of the membranes (with or without obvious chorioamnionitis).

Cervical incompetence.

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What are the important causes of intrapartum hypoxia?

Labour related, especially prolonged labour, cephalopelvic disproportion and a hypertonic uterus.

Cord prolapse.

Except with cord prolapse, intrapartum hypoxia is almost always the result of uterine contractions, especially if the uterus does not relax normally between regular contractions. Intrapartum hypoxia presents with signs of foetal distress during labour. The early diagnosis and correct management of foetal distress and prolonged labour is very important.

Neonatal mortality

What is a liveborn infant?

A live born infant is legally defined as an infant that shows any sign of life at birth (i.e., breathes or moves). In practice, only infants weighing 500g or more, are included as live born infants. Therefore, every effort must be made to include all infants born alive and weighing 500g or more in the definition of a live born infant in South Africa.

Live born infants below 500g (or a 22-week gestation) at birth who only live for a few minutes are usually regarded as miscarriages and are not issued with a notification of death form. Infants below 500g at birth are usually regarded as live births rather than miscarriages only if they live for a number of hours after delivery. They should be issued with a notification of death form. Very uncommonly, even infants weighing less than 500g can survive.

What is a neonate?

A neonate (or newborn infant) is a live born infant aged between birth and 28 completed days after delivery. Therefore, a paediatrician who specialises in the care of infants in the first month of life is called a neonatologist.

What is neonatal mortality?

This is the number of live born infants who die in the first 28 days of life. They are known as neonatal deaths. All live born infants who die in the first 28 days of life must be issued with a notification of death certificate from a doctor. Nurses and midwives may not sign a notification of death form for a live born baby (only for stillbirths). Neonatal mortality can be divided into early and late neonatal mortality.

What is early neonatal mortality?

An early neonatal death is a death which occurs in the first week of life. Therefore, early neonatal mortality is the number of infants who are born alive but die in the first 7 completed days of life (i.e., the first week after birth). Early neonatal deaths and stillbirths are added to give the perinatal mortality.

What is late neonatal mortality?

The late neonatal mortality is the number of live born infants who die after 7 days but before 29 days of life (i.e., during the second, third and fourth week of life). Neonatal mortality, therefore, consists of both early and late neonatal deaths.

What is the early neonatal mortality rate?

The early neonatal mortality rate is the number of live born infants that die in the first week of life per 1000 live born deliveries. Only live born infants are considered when calculating the early neonatal mortality rate.

The early neonatal mortality rate is calculated as:

The number of early neonatal deaths ÷ The number of live born infants × 1000.

Note that early neonatal death rate is given per 1000 live born infants. This is different to the perinatal mortality rate and stillbirth rate which are expressed per 1000 total births (i.e., stillbirths plus live births).

The early neonatal mortality rate forms the greater part of the neonatal mortality rate (2/3) as most infants who die in the first month of life die in the first week. Most infants who die in the first week of life die on the first day.

The late neonatal mortality rate is the number of infants who die from 8 to 28 days after birth per 1000 live born infants. An infant that dies on day 7 is an early neonatal death while an infant who dies on day 8 is a late neonatal death. The early plus the late neonatal mortality rate gives the neonatal mortality rate. The late neonatal mortality rate is not often calculated as many of these infants are no longer cared for by the neonatal services when they die. As a result, the calculated late neonatal mortality rate is often incorrectly low.

What is the early neonatal mortality rate in high-income countries?

Less than 5 per 1000 live births for infants weighing 500g or more. This is very similar to the stillbirth rate in high-income countries.

What is the early neonatal mortality rate in low-income countries?

About 20/1000 live births for infants weighing