The Health Status of Pacific Children and Young People in New Zealand 2015

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3 IN NEW ZEALAND The Health Status of Pacific Children and Young People in New Zealand 2015 Jean Simpson, Mavis Duncanson, Glenda Oben, Judith Adams, Andrew Wicken, Melanie Pierson, and Sarah Gallagher New Zealand Child and Youth Epidemiology Service Department of Women s and Children s Health University of Otago May 2017 iii

4 This report was produced as the result of a contract between the Ministry of Health and the Paediatric Society of New Zealand, and was written by the New Zealand Child and Youth Epidemiology Service (NZCYES). The NZCYES is located in the Department of Women s and Children s Health at the University of Otago s Dunedin School of Medicine. While every endeavour has been made to use accurate data in this report, there are currently variations in the way data are collected from DHBs and other agencies that may result in errors, omissions or inaccuracies in the information in this report. The NZCYES does not accept liability for any inaccuracies arising from the use of this data in the production of these reports, or for any losses arising as a consequence thereof. Acknowledgements Special thanks to the TAHA Well Pacific Mother and Infant Service and their Advisory Group who provided advice during the production of this report. Suggested citations Simpson J., Duncanson M., Oben G., Adams J, Wicken A, Pierson, M, and Gallagher, S. The Health Status of Pacific Children and Young People in New Zealand Dunedin: New Zealand Child and Youth Epidemiology Service, University of Otago; Suggested citations for the viewpoints Taule alo Russell N, Impressions from a Pacific student doctor. In: Simpson J., Duncanson M., Oben G., Adams J, Wicken A, Pierson, M, and Gallagher, S. The Health Status of Pacific Children and Young People in New Zealand Dunedin: New Zealand Child and Youth Epidemiology Service, University of Otago; Fa'alili-Fidow J, Viewpoint. In: Simpson J., Duncanson M., Oben G., Adams J, Wicken A, Pierson, M, and Gallagher, S. The Health Status of Pacific Children and Young People in New Zealand Dunedin: New Zealand Child and Youth Epidemiology Service, University of Otago; Cover Artwork: Pacific Isle Taniwha by Harry Lutevu This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License iv

5 TABLE OF CONTENTS Table of Contents... v List of Figures... viii List of Tables... x Introduction... 1 Background... 3 Report sections and indicators... 3 Conclusion... 3 The health of Pacific children and young people: improvements and areas for action... 5 Issues in infancy... 7 Births and perinatal deaths... 9 Introduction... 9 National trends and distribution... 9 Fetal deaths Introduction National trends and distribution Preterm births Introduction National trends and distribution Infant mortality and sudden unexpected death in infancy Introduction National trends and distribution Sudden unexpected death in infancy (SUDI) Issues for all ages Causes of death and hospitalisation Introduction Deaths Hospitalisations Ambulatory sensitive hospitalisations Introduction National trends and distribution Conditions of the respiratory system Upper respiratory tract infections Introduction National trends and distribution Tonsillectomy Introduction National trends and distribution Middle ear conditions: Otitis media and grommets Introduction National trends and distribution Bronchiolitis Introduction National trends and distribution Pneumonia Introduction National trends and distribution Asthma Introduction National trends and distribution v

6 Bronchiectasis Introduction National trends and distribution Impressions of a Pacific student doctor Common communicable diseases Pertussis Introduction National trends and distribution Meningococcal disease Introduction National trends and distribution Tuberculosis Introduction National trends and distribution Rheumatic fever and rheumatic heart disease Introduction National trends and distribution Serious skin infections Introduction National trends and distribution Gastroenteritis Introduction National trends and distribution Unintentional injuries Introduction National trends and distribution Falls Inanimate mechanical force Road traffic injury Non-traffic transport injury Thermal injury Poisoning Reproductive health Births Introduction National trends and distribution Terminations of pregnancy Introduction National trends and distribution Mental health Access to mental health services Introduction National trends and distribution Mental health hospitalisations Introduction National trends and distribution Suicide and self-harm Introduction National trends and distribution Appendices and references Appendix 1: Statistical significance testing Statistical significance testing in this report Appendix 2: Datasets used in this report vi

7 The National Mortality Collection The National Minimum Dataset The Birth Registration Dataset PRIMHD Dataset limitations Appendix 3: Ethnicity data Appendix 4: NZ Index of Deprivation Appendix 5: Clinical codes used References vii

8 LIST OF FIGURES Figure 1. Fetal, perinatal and neonatal death rates for Pacific infants, New Zealand Figure 2. Fetal deaths, Pacific infants, by type, New Zealand Figure 3. Preterm live births, by select Pacific ethnic groups, New Zealand Figure 4. Infant, neonatal, and post neonatal mortality, Pacific infants, New Zealand Figure 5. Sudden unexpected death in infancy (SUDI), by ethnicity, New Zealand Figure 6. Sudden unexpected death in infancy (SUDI), by Pacific ethnicity, New Zealand Figure 7. Ambulatory sensitive hospitalisations in Pacific 0 14 year olds, by ED status and age New Zealand Figure 8. Ambulatory sensitive hospitalisations in Pacific 0 4 year olds, by ED status and select Pacific group, New Zealand Figure 9. Hospitalisations for acute upper respiratory tract infections in Pacific 0 14 year olds, by select Pacific group, New Zealand Figure 10. Hospitalisations for acute upper respiratory tract infections (URTIs) in Pacific 0 14 year olds, by age, New Zealand Figure 11. Hospitalisations for acute upper respiratory tract infections in Pacific 0 14 year olds, by month, New Zealand Figure 12. Hospitalisations for tonsillectomy +/ adenoidectomy in 0 14 year olds, by ethnicity, New Zealand Figure 13. Hospitalisations for tonsillectomy +/ adenoidectomy in Pacific 0 14 year olds, by age, New Zealand Figure 14. Hospitalisations for otitis media in Pacific 0 14 year olds, by select Pacific group, New Zealand Figure 15. Hospitalisations for grommet insertion in Pacific 0 14 year olds, by select Pacific group, New Zealand Figure 16. Hospitalisations for otitis media and grommets in Pacific 0 14 year olds, by age, New Zealand Figure 17. Hospitalisations for otitis media and grommets in Pacific 0 14 year olds, by month, New Zealand Figure 18. Infants hospitalised for bronchiolitis, by ethnicity, New Zealand Figure 19. Hospitalisations for bronchiolitis in Pacific infants, by month, New Zealand Figure 20. Hospitalisations due to pneumonia in Pacific 0 24 year olds, by select Pacific group, New Zealand Figure 21. Hospitalisations for pneumonia in Pacific 0 24 year olds, by age, New Zealand Figure 22. Hospitalisations for pneumonia in Pacific 0 24 year olds, by age group and month of admission, New Zealand Figure 23. Hospitalisations for asthma in 0 24 year olds, by select Pacific group, New Zealand Figure 24. Hospitalisations for asthma in Pacific 0 24 year olds, by age, New Zealand Figure 25. Hospitalisations for bronchiectasis in 0 24 year olds, by ethnicity, New Zealand Figure 26. Hospitalisations for bronchiectasis in Pacific 0 24 year olds, by age, New Zealand Figure 27. Hospitalisations for bronchiectasis in Pacific 0 24 year olds, by admission month, New Zealand viii

9 Figure 28. Hospitalisations for pertussis in infants, by select Pacific groups, New Zealand Figure 29. Hospitalisations for pertussis in Pacific 0 24 year olds, by age, New Zealand Figure 30. Hospitalisations for pertussis in Pacific infants, by month, New Zealand Figure 31. Hospitalisations for meningococcal disease in Pacific 0 24 year olds, by ethnicity, New Zealand Figure 32. Hospitalisations for meningococcal disease in Pacific 0 24 year olds, by age, New Zealand Figure 33. Hospitalisations for tuberculosis in 0 24 year olds, by ethnicity, New Zealand Figure 34. Hospitalisations for acute rheumatic fever and rheumatic heart disease in 0 24 year olds, by ethnicity, New Zealand Figure 35. Hospitalisations for acute rheumatic fever and rheumatic heart disease in any Pacific 0 24 year olds, by age, New Zealand Figure 36. Hospitalisations involving skin infections in Pacific 0 24 year olds, by select Pacific group, New Zealand Figure 37. Hospitalisations involving skin infections in Pacific 0 24 year olds, by age, New Zealand Figure 38. Hospitalisations for gastroenteritis in 0 24 year olds, by select Pacific groups, New Zealand Figure 39. Hospitalisations for gastroenteritis in Pacific 0 24 year olds, by age New Zealand Figure 40. Hospitalisations from unintentional injuries in any Pacific 0 24 year olds, by age group, year of discharge, and injury type, New Zealand Figure 41. Hospitalisations from selected unintentional injuries in any Pacific 0 24 year olds, by age and injury type, New Zealand Figure 42. Hospitalisations involving unintentional fall-related injury in Pacific 0 24 year olds, by select Pacific groups, New Zealand Figure 43. Hospitalisations from unintentional fall-related injuries in any Pacific 0 24 year olds, by age and fall type, New Zealand Figure 44. Hospitalisations for injuries from inanimate mechanical forces in any Pacific 0 24 year olds, by age and force type, New Zealand Figure 45. Teenage birth rate, by ethnicity, New Zealand, Figure 46. Teenage birth rate, by select Pacific group, New Zealand Figure 47. Pacific teenage birth rate, by age, New Zealand Figure 48. Terminations of pregnancy by total and select age group, Pacific women New Zealand Figure 49. Pacific individuals aged 0 24 years seen by mental health services, New Zealand Figure 50. Pacific individuals aged 0 24 years seen by mental health services, by age group, New Zealand Figure 51. Pacific individuals aged 0 24 years seen by mental health services, by age at first contact of year, New Zealand, Figure 52. Deaths from suicide in 0 24 year olds, by ethnicity, New Zealand Figure 53. Hospitalisations for intentional self-harm in 0 24 year olds, by ethnicity, New Zealand Figure 54. Hospitalisations for intentional self-harm in Pacific 0 24 year olds, by age, New Zealand ix

10 LIST OF TABLES Table 1. Summary of the indicators in the report Health Status of Pacific Children and Young People in New Zealand Table 2. Births and deaths of Pacific infants, New Zealand Table 3. Distribution of fetal deaths, by type and Pacific ethnicity, New Zealand Table 4. Fetal deaths, by Pacific ethnicity, New Zealand Table 5. Pacific fetal deaths, by main cause of fetal death, New Zealand Table 6. Pacific fetal deaths, by type and main maternal cause of fetal death, New Zealand Table 7. Any Pacific neonatal and post neonatal mortality, by main underlying cause of death, New Zealand Table 8. Deaths in Pacific 1 14 year olds, by main underlying cause, New Zealand Table 9. Deaths in Pacific year olds, by main underlying cause, New Zealand Table 10. Hospitalisations in any Pacific 0 14 year olds, by primary diagnosis, New Zealand Table 11. Hospitalisations in any Pacific year olds, by primary diagnosis, New Zealand Table 12. Ambulatory sensitive hospitalisations in any Pacific 0 4 year olds, by ED status and primary diagnosis, New Zealand Table 13. Ambulatory sensitive hospitalisations in 0 4 year olds by ED status and ethnicity, New Zealand Table 14. Ambulatory sensitive hospitalisations in 0 4 year olds, by ED status and any Pacific group, New Zealand Table 15. Hospitalisations for acute upper respiratory tract infections in Pacific 0 14 year olds, by primary diagnosis, New Zealand Table 16. Hospitalisations for acute upper respiratory tract infections in 0 14 year olds, by Pacific ethnicity, New Zealand Table 17. Hospitalisations for tonsillectomy +/ adenoidectomy in Pacific 0 14 year olds, by primary diagnosis, New Zealand Table 18. Hospitalisations for tonsillectomy +/ adenoidectomy in Pacific 0 14 year olds, by Pacific ethnicity, New Zealand Table 19. Hospitalisations for conditions of the middle ear and mastoid in Pacific 0 14 year olds, by primary diagnosis, New Zealand Table 20. Hospitalisations for grommet insertion in Pacific 0 14 year olds, by primary diagnosis, New Zealand Table 21. Hospitalisations for otitis media in 0 14 year olds, by Pacific ethnicity, New Zealand Table 22. Hospitalisations for grommet insertion in 0 14 year olds, by Pacific ethnicity, New Zealand Table 23. Infants hospitalised for bronchiolitis, by demographic factor, New Zealand Table 24. Hospitalisations for pneumonia in 0 24 year olds, by age group and ethnicity, New Zealand Table 25. Hospitalisations for pneumonia in 0 24 year olds, by Pacific group, New Zealand Table 26. Hospitalisations for asthma in Pacific 0 24 year olds, by primary diagnosis, New Zealand Table 27. Hospitalisations for asthma in 0 24 year olds, by age group and ethnicity, New Zealand x

11 Table 28. Hospitalisations for asthma in 0 24 year olds, by Pacific ethnicity, New Zealand Table 29. Hospitalisations for bronchiectasis in 0 24 year olds, by Pacific ethnicity, New Zealand Table 30. Hospitalisations for pertussis in Pacific infants, by primary diagnosis, New Zealand Table 31. Hospitalisations for pertussis in infants, by ethnicity, New Zealand Table 32. Hospitalisations for meningococcal disease in Pacific 0 24 year olds, by ethnicity, New Zealand Table 33. Hospitalisations for meningococcal disease in 0 24 year olds, by ethnicity and Pacific group, New Zealand Table 34. Hospitalisations for tuberculosis in 0 24 year olds, by Pacific ethnicity, New Zealand Table 35. Hospitalisations for acute rheumatic fever and rheumatic heart disease in 0 24 year olds, by age group and ethnicity, New Zealand Table 36. Hospitalisations for acute rheumatic fever and rheumatic heart disease in 0 24 year olds, by Pacific ethnicity, New Zealand Table 37. Hospitalisations for skin infections in Pacific 0 24 year olds, by primary diagnosis, New Zealand Table 38. Hospitalisations involving skin infections in 0 24 year olds, by age group and ethnicity, New Zealand Table 39. Hospitalisations involving skin infections in 0 24 year olds, by Pacific ethnicity, New Zealand Table 40. Hospitalisations for gastroenteritis in 0 24 year olds, by age group and ethnicity, New Zealand Table 41. Hospitalisations for gastroenteritis in 0 24 year olds, by Pacific ethnicity, New Zealand Table 42. Deaths due to unintentional injuries in any Pacific 0 24 year olds, by age group and cause of injury, New Zealand, Table 43. Hospitalisations from unintentional injuries in any Pacific 0 24 year olds, by age group and cause of injury, New Zealand Table 44. Hospitalisations from unintentional injuries in sole Pacific 0 24 year olds, by age group and cause of injury, New Zealand Table 45. Hospitalisations from unintentional fall-related injuries in any Pacific 0 24 year olds, by age group and cause of injury, New Zealand Table 46. Hospitalisations for unintentional fall-related injuries in 0 24 year olds, by Pacific ethnicity, New Zealand Table 47. Hospitalisations for injuries from exposure to an inanimate mechanical force in any Pacific 0 24 year olds, by age group and cause of injury, New Zealand Table 48. Hospitalisations for injuries from exposure to an inanimate mechanical force in 0 24 year olds, by Pacific ethnicity, New Zealand Table 49. Teenage birth rate, by ethnicity, New Zealand Table 50. Individuals aged 0 24 years seen by mental health services, by Pacific ethnicity, New Zealand Table 51. Individuals of Pacific ethnicity aged 0 24 years with diagnosis seen by mental health services, by age group and diagnosis presence, New Zealand Table 52. Hospitalisations for mental health conditions in 0 24 year olds, by ethnicity and primary diagnosis, New Zealand Table 53. Deaths from suicide in 0 24 year olds, by age group and ethnicity, New Zealand Table 54. Hospitalisations for intentional self-harm in 0 24 year olds, by ethnicity, New Zealand Table 55. Variables used in NZDep2013 index of deprivation xi

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13 INTRODUCTION

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15 Background This report is one of a series of three reports on the health of Pacific children and young people in New Zealand produced for the Ministry of Health, and it fits into the current reporting cycle as follows: Year 1: The Determinants of Health for Pacific Children and Young People (prepared during 2014) Year 2: The Health Status of Pacific Children and Young People (prepared during 2015) Year 3: Pacific Children and Young People with Chronic Conditions and Disabilities (prepared during 2016) Despite some recent improvements, Pacific peoples in New Zealand continue to experience greater disadvantage across a range of socioeconomic indicators. Improving incomes, education, employment and housing is critical to improving health outcomes. 1 The report aims to provide an overview of the health status of Pacific children and young people in New Zealand, and to assist those working to improve child and youth health to use collated recent data when they are developing programmes and interventions to address child and youth health needs. Report sections and indicators This report is based on an Indicator Framework 2 developed in 2007 in which the indicators for each of the three reports in the series were identified. The indicators in this year s report were developed from Craig et al s indicators for the individual and whānau health and wellbeing stream. They are presented in the following sections: Issues in infancy Issues for all ages 0 24 year olds Conditions of the respiratory system Common communicable diseases Unintentional injury Reproductive health Mental health Within each section data are provided for Pacific children and young people aged 0 24 years with comparative national data for selected indicators. Data quality, statistical significance, and demographic data Appendix 1: Statistical significance testing outlines how the significance of the associations presented has been signalled in the text with the words significant, or not significant in italics. If the words significant or not significant do not appear in the text, then the associations described do not imply statistical significance or nonsignificance. Appendix 2: Datasets used in this reportdatasets used in this report contains information on the data sources used to develop each indicator. It is advisable to read the contents of these appendices when interpreting any information in this report. To ensure anonymity, where numbers are less than five, the report suppresses these numbers and their associated rates. This report uses prioritised Pacific, any Pacific and sole Pacific classifications of Pacific ethnicity. These classifications are explained further in Appendix 3: Ethnicity data. Overview of the health status of children and young people in New Zealand Table 1 on the following page provides an overview of the indicators in this year s report. Conclusion This report provides an overview of the health status of Pacific children and young people in New Zealand to assist with addressing child and youth health needs in a systematic way. The Ministry of Health, district health boards, Pacific health providers and others working in the health sector may use the epidemiological data in this report as a complement to knowledge of existing services and key stakeholders views. All users should be mindful of existing Government policy, and that for any approaches developed to be effective, they need to be congruent with the evidence contained in the current literature. If there is no sound evidence base, planners should build an evaluation arm into their programmes to ensure the best use of available resources. Introduction 3

16 Table 1. Summary of the indicators in the report Health Status of Pacific Children and Young People in New Zealand 2015 Pacific non-māori non-pacific Indicator n Rate (95% CI) n Rate (95% CI) 1 Fetal deaths ( ) 1, ( ) 2 Preterm births 2, ( ) 13, ( ) 3 Infant mortality ( ) ( ) 4 Sudden unexpected death in infancy ( ) ( ) 5 Ambulatory sensitive hospitalisations in 0 4 year olds* 18, ( ) 52, ( ) 6 Acute upper respiratory infections in 0 14 year olds 4, ( ) 17, ( ) 7 Tonsillectomy ± adenoidectomy in 0 14s year olds ( ) 11, ( ) 8 Otitis media in 0 14 year olds ( ) 1, ( ) 9 Grommets in 0 14 year olds 2, ( ) 13, ( ) 10 Bronchiolitis in infants 6, ( ) 7, ( ) 11 Pneumonia in 0 24 year olds 4, ( ) 8, ( ) 12 Asthma in 0 24 year olds 6, ( ) 17, ( ) 13 Bronchiectasis in 0 24s ( ) ( ) 14 Pertussis in under 1 year olds ( ) ( ) 15 Meningococcal disease in 0 24 year olds ( ) ( ) 16 Tuberculosis in 0 24 year olds ( ) ( ) 17 Acute rheumatic fever in 0 24 year olds ( ) ( ) 18 Rheumatic heart disease in 0 24 year olds ( ) ( ) 19 Any skin infections in 0 24 year olds 12, ( ) 25, ( ) 20 Gastroenteritis in 0 24 year olds 4, ( ) 24, ( ) 21 Unintentional injury hospitalisations of 0 24 year olds 10, ( ) 56, ( ) 22 Teenage births 2, ( ) 6, ( ) 23 Clients aged 0 24 year olds seen by mental health services 3,658 2, (2, ,635.58) 36,817 3, (3, ,596.61) 24 Mental health hospitalisations of 0 24 year olds 12, ( ) 25, ( ) 25 Suicide among 0 24 year olds ( ) ( ) 26 Intentional self-harm in 0 24 year olds ( ) 3, ( ) Note: The denominators for the rates can be found in the relevant chapter. *Emergency department cases included Introduction 4

17 THE HEALTH OF PACIFIC CHILDREN AND YOUNG PEOPLE: IMPROVEMENTS AND AREAS FOR ACTION Jacinta Fa'alili-Fidow An updated look at health outcomes for Pacific children and young people in New Zealand shows evidence of both improvements and stagnation over the last two decades. This report from the latest series of Pacific child and youth health reports continues to highlight the urgency of many ongoing concerns such as infant mortality, ASH rates among 0 4 year olds and suicide rates among year olds. There have been some encouraging shifts such as the overall drop in SUDI and unintentional injury death and hospitalisation rates. However, other outcomes have remained relatively stable with slight fluctuations year by year. There were no major revelations for pregnancy indicators and outcomes in the first year of life with most rates remaining the same. The fetal death rate from 2000 to 2012 showed no overall change and the rate of pre-term births also remained relatively stable. The ethnic-specific difference is still evident with pre-term births significantly higher for Cook Islands women than for other Pacific women, attributed in part to the higher prevalence of smoking among Cook Islands women during pregnancy. 3 The infant mortality rate for Pacific infants was significantly higher when compared with non-māori non-pacific infants, and although SUDI rates have dropped over the last decade for Pacific, other causes of neonatal and post-neonatal deaths have kept the rate of infant deaths relatively high. The movement to prioritise pregnancy health has been a positive development to improve both maternal health services and health promotion/health literacy programmes. Genetic causes of mortality and morbidity in the perinatal period are unavoidable (notwithstanding epigenetics) however, correlations have also been noted with environmental and behavioural factors, 4 maternal age and socioeconomic disadvantage. 5 Two-thirds of Pacific pregnancies are unplanned 3 presenting further challenges for pregnancy health. However, while Pacific women have the lowest rate of access to a Lead Maternity Carer (75% in 2014) 6 compared with other ethnic groups, this rate is an improvement on previous years (66.1% in 2012 and 65.9% in 2010). 7,8 Nonetheless only 30% of those who register with a Lead Maternity Carer present in the first trimester. Opportunities for improving pregnancy outcomes are often lost and, for some, the consequences of these lost opportunities continue to manifest during infancy and childhood. Ambulatory Sensitive Hospitalisation rates have increased for Pacific children 0 4 year olds for several indicators between 2000 and The data show ethnic-specific variance with Tongan children displaying higher ASH rates and Cook Islands children the lowest. This is an interesting turn of events given the higher rates of fetal and perinatal deaths among Cook Islands women. ASH rates reflect limited or no access to primary care services and so the rates suggest that Cook Islands families - who are entitled to New Zealand health services and have a greater proportion of English-speaking families are experiencing better access to primary healthcare services compared with Samoan and Tongan families. The higher ASH rates among Pacific children are also reflective of varied access to Well Child Services, with some Pacific children receiving delayed checks or no checks at all at the time this data was collected. 9 The low rates of tonsillectomy and grommets despite high rates of throat infections and otitis media, reiterates further the disproportionate response of health intervention to health problems in Pacific children. While the obvious response is to improve the accessibility of primary healthcare services to effectively respond to these preventable admissions, a real opportunity lies with improving health literacy of Pacific families and children themselves. The latter approach requires challenging, sometimes tedious, work and is premised on having the right amount of engagement at the right time and with the right people or medium. These community-based, grass-roots health promotion approaches are not as appealing or as measurable as say a systems approach that arguably provides clearer indicators for evaluation. However, sophisticated health systems, on their own, have limited results for those whose health behaviours are shaped by sociocultural influences. The improvements in SUDI rates can be attributed to an improvement of research and reporting, collaboration across the sector, identification of key risk factors including smoking during pregnancy and an increased focus on community engagement and activities such as those held on Safe Sleep Day. It is unsurprising that the rates for most health outcomes associated with poverty have remained stubbornly high. Skin and respiratory infections are such examples of poverty-related illnesses that have increased in the last decade, as have asthma and wheeze. Many factors contribute to these rates but arguably, the primary solution to The health of Pacific children and young people: improvements and areas for action 5

18 reversing these trends is addressing poverty, and in relation to this, the housing crisis. While political leaders and society debate the merits of investing in the economy of child health and wellbeing for wider and sustainable societal gain, the rates of preventable diseases and illnesses continue to rise, and along with them the negative impacts on families, communities and the populace, let alone the health system. The ever-increasing inequities in wealth are a global phenomenon, but it is now common knowledge that countries with the least inequities demonstrate better population outcomes. 10 Advocacy continues in a political minefield and while a cross-party working group 11 once provided a glimmer of hope, the ensuing silence from our country s leaders ignores the downstream consequences of inaction. Better reporting may be the reason behind the steady increase in Pacific access to mental health services from 2009 to 2014 but without the inclusion of all pathways such as paediatric referrals, we can continue to assume that not all children are counted. As with all data, these findings on access to services need to be matched with information about the quality and effectiveness of these services. Comparative analyses on recovery rates in developed and developing countries show a significantly lower rates of recovery for services with western models of mental health services when compared with holistic models. 12,13 Furthermore, migrant groups within developed countries fare worse as seen in comparisons between migrant Pacific and New Zealand born Pacific. 14 In light of this, quality improvements have been an important focus for many District Health Boards who have attempted to use Pacific models of mental health 15 for children and young people, and develop a Pacific mental health workforce. The rate of suicide among Pacific 15 24yr olds remains a priority for youth health. The increased government investment in Māori and Pacific suicide prevention is much needed and while the broader outcomes of this investment will not be seen for a few more years, awareness and discussion within the scope of what is considered safe, has been palpable; but it is not enough for many advocates who seek more. The sensitivity of the topic itself is one thing, but the complexity of what makes one susceptible to suicide differs for Pacific youth. Factors such as high educational achievement and employment are as much risk factors 16 as low achievement and unemployment. Among Pacific high school students, the risk factors are being female, household food insecurity, low levels of family connections and family monitoring. 17 Protective factors such as relationships, spirituality and culture and identity require a greater understanding in the context of Pacific youth growing up and living in New Zealand. Research into the complexities of suicide prevention and its reverse theme of resilience struggle to keep up with the evolving dynamics of Pacific youth and families over time. An optimist would view this reports findings as generally positive in that staving off rises in mortality or hospitalisation rates is worth more than significant improvements in rates across the board and they would argue that past and current investments are making some progress in child and youth health. It s a good thing though, that when it comes to health, most New Zealanders have the highest expectations and want to see decreases, if not elimination, of preventable deaths and morbidities. This report continues to demonstrate the value of good data and ongoing measurement of child and youth health outcomes to better focus our efforts and to ask further questions about our approaches. The glaringly obvious issues of poverty and housing continue to hover over any attempts to address child health and the ongoing challenges of promoting sustainable appropriate solutions that are affordable and easy to measure will hamper progress. But continuing to delay or ignore the courageous decisions required of our country s leaders to reduce the growing inequalities in New Zealand rather than simply tempering the situation would undoubtedly lead to a marked improvement in Pacific child health and in society overall. I would rather draw from the too-hard basket now and invest wisely now than contribute to the perpetuation of negative outcomes and a more costly health bill in future. The health of Pacific children and young people: improvements and areas for action 6

19 ISSUES IN INFANCY

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21 BIRTHS AND PERINATAL DEATHS Introduction The following section uses the Birth Registration Dataset, the National Mortality Collection and the National Minimum Dataset to review births and early deaths of Pacific infants in New Zealand. Data source and methods Data sources Livebirths: Deaths: Definitions Birth registration dataset National Mortality Collection Total births are livebirths plus fetal deaths Fetal death is when the infant is born deceased, weighing 400 grams or more, or is issued from its mother after the 20th week of pregnancy. 18 Fetal death rate = number of fetal deaths per 1,000 total (live + still) births Perinatal death is fetal deaths and early neonatal deaths Perinatal death rate = number of fetal and early neonatal deaths per 1,000 total (live + still) births Neonatal death is the death of a live-born infant before 28 completed days after birth, and comprises: Early neonatal death is death of a live-born infant before seven days (168 completed hours) after birth Late neonatal death is death of a live-born infant after seven days and before 28 completed days after birth Neonatal death rate = number of early and late neonatal deaths per 1,000 livebirths Early neonatal death rate = number of early neonatal deaths per 1,000 livebirths Late neonatal death rate = number of late neonatal deaths per 1,000 livebirths Notes on interpretation Note 1: An overview of the Birth Registration and National Minimum Datasets is provided in Appendix 2: Datasets used in this report National trends and distribution Between 2008 and 2012 there were 36,021 Pacific infants born in New Zealand, an average of 7,204 per year. Of these, 35,702 (99.1%) were live births and 319 were fetal deaths (also known as stillbirths). The Pacific fetal death rate in this time period was 8.86 deaths per 1,000 total births (Table 2). Between 2008 and 2012 there were 150 deaths of live-born Pacific infants in the first 27 days of life (neonatal deaths), an average of 30 deaths per year. Of these neonatal deaths, 121 were before seven days after birth (early neonatal deaths) and 29 deaths occurred after seven days but before 28 completed days after birth (late neonatal deaths). The early neonatal death rate was 3.39 deaths per 1,000 live births and the late neonatal death rate was 0.81 deaths per 1,000 live births (Table 2). Deaths that occurred around the time of birth (perinatal deaths) include fetal deaths and early neonatal deaths. Between 2008 and 2012 there were 440 Pacific perinatal deaths in New Zealand, an average of 88 deaths per year (Table 2). Table 2. Births and deaths of Pacific infants, New Zealand annual average Pacific Rate per 1,000 live births 95% CI Live births 35,702 7, Total births 36,021 7, Fetal deaths* Perinatal deaths* Neonatal deaths Early neonatal deaths Late neonatal deaths Source: Live births: Birth Registration Dataset; Deaths: National Mortality Collection; Ethnicity is level 1 prioritised; * Rate per 1,000 total births; Rate per 1,000 live births;.. =Not applicable Issues in infancy: Births and perinatal deaths 9

22 * Pacific death rate The perinatal death rate for Pacific infants was stable from to 2012 with year-to-year variation in rates. In the same time period both fetal and neonatal death rates were stable (Figure 1). Figure 1. Fetal, perinatal and neonatal death rates for Pacific infants, New Zealand Fetal death rate* Perinatal death rate* Neonatal death rate 0.0 Source: Live births: Birth Registration Dataset; Deaths: National Mortality Collection; * Rate per 1,000 total births; Rate per 1,000 live births; Ethnicity is level 1 prioritised; *2012 is a single year Issues in infancy: Births and perinatal deaths 10

23 FETAL DEATHS Introduction The following section uses the Birth Registration Dataset, the National Mortality Collection and the National Minimum Dataset to look at fetal deaths for Pacific infants in New Zealand. Background A fetal death is death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life. 19 Fetal deaths include both spontaneous fetal deaths (often referred to as stillbirths) and deaths due to late termination of pregnancy. In New Zealand, the Births, Deaths, Marriages, and Relationships Registration Act 1995 requires all stillbirths to be registered and it defines a stillbirth as a dead fetus that weighed at least 400g when it issued from its mother or issued from its mother after the 20 th week of pregnancy. 20 Data sources and methods Indicator Fetal deaths Data sources Numerator: Denominator: Definition National Mortality Collection Birth Registration Dataset (live births only) and National Mortality Collection Fetal death is when the infant is born deceased, weighing 400 grams or more, or is issued from its mother after the 20th week of pregnancy. 18 Fetal deaths are further defined into: Intermediate: Fetal deaths occurring between 20 and 27 weeks gestation. Late: Fetal deaths occurring 28+ weeks gestation. Unspecified: Fetal deaths occurring from 20 weeks or more gestation where the main fetal cause of death was unspecified and no additional fetal or maternal causes of death were listed. Fetal death rate = number of fetal deaths per 1,000 total (live + still) births For gestational age specific rates, the denominator was those remaining in utero at the specified gestational age (e.g. the 22 week denominator excludes all births occurring at 20 and 21 weeks) In this section, the main (fetal) underlying cause of death was categorised into the following: congenital anomalies (chromosomal, CNS, CVS, other), malnutrition or slow fetal growth, extreme immaturity or low birth weight, intrauterine hypoxia: pre labour onset, intrauterine hypoxia: in labour or unspecified, congenital pneumonia, infections specific to perinatal period, fetal blood loss, unspecified cause, other causes. In addition, the first maternal cause of death (if present) was categorised into the following: incompetent cervix or premature rupture membranes, oligohydramnios, multiple pregnancy, placenta praevia or other placental separation or haemorrhage, other or unspecified placental anomalies, compression of umbilical cord, chorioamnionitis, maternal hypertensive disorders, placental transfusion syndrome, other causes. Notes on interpretation Note 1: Death registration data do not differentiate between spontaneous fetal deaths and late terminations of pregnancy. The admixture of spontaneous and induced fetal deaths is likely to be most prominent at earlier gestations (e.g. the high number of deaths attributed to congenital anomalies prior to 25 weeks gestation) and this must be taken into account when interpreting the data in this section. Note 2: 95% confidence intervals have been provided for the rate ratios in this section and where appropriate, the terms significant or not significant have been used to communicate the significance of the observed associations. Tests of statistical significance have not been applied to other data in this section, and thus (unless the terms significant or non-significant are specifically used) the associations described do not imply statistical significance or non-significance (see Appendix 1: Statistical significance testing). Note 3: An overview of the Birth Registration and National Minimum Datasets is provided in Appendix 2: Datasets used in this report. National trends and distribution The overall fetal death rate for Pacific infants was stable from 2000 to 2012 with year to year fluctuations using any, prioritised or sole Pacific ethnicity. Within this time period there was an overall slight decline in the rate of late fetal deaths and a slight increase in the rate of intermediate fetal deaths for Pacific infants (Figure 2). Issues in infancy: Fetal deaths 11

24 Fetal deaths per 1,000 births Figure 2. Fetal deaths, Pacific infants, by type, New Zealand Fetal deaths Prioritised Pacific Any Pacific Sole Pacific Fetal deaths Intermediate fetal deaths* Late fetal deaths Numerator: National Mortality Collection; Denominator: Birth Registration Dataset and National Mortality Collection; * rate per 1,000 births (live births and fetal deaths of 20 weeks gestation or more); rate per 1,000 births (live births and fetal deaths of 28 weeks gestation or more); rates for 2012 are based on a single year s data Table 3 shows there were 427 fetal deaths of Pacific infants in New Zealand from 2008 to 2012 using any Pacific ethnicity; 319 using level 1 prioritised Pacific ethnicity and 215 using sole Pacific ethnicity. For each of these three classifications of Pacific ethnicity around half of the fetal deaths occurred between 20 and 27 weeks gestation (intermediate fetal deaths) and half occurred from 28 weeks gestation (late fetal deaths). Table 3. Distribution of fetal deaths, by type and Pacific ethnicity, New Zealand Ethnicity total annual average Fetal deaths Rate per 1,000 births 95% CI Prioritised Pacific Any Pacific Sole Pacific Intermediate fetal deaths* Prioritised Pacific Any Pacific Sole Pacific Late fetal deaths Prioritised Pacific Any Pacific Sole Pacific Numerator: National Mortality Collection; Denominator: Birth Registration Dataset and National Mortality Collection; *rate per 1000 births (live births and fetal deaths of 20 weeks gestation or more); rate per 1000 births (live births and fetal deaths of 28 weeks gestation or more); Ethnicity is level 1 prioritised Compared with non-māori non-pacific infants, Pacific fetal death rates were significantly higher for any Cook Island Māori, and for sole Samoan and Sole Tongan infants. For all other Pacific ethnic groups the fetal death rates were not significantly different from non-māori non-pacific rates (Table 4). Issues in infancy: Fetal deaths 12

25 Table 4. Fetal deaths, by Pacific ethnicity, New Zealand Ethnicity total annual average Fetal deaths Any Pacific Rate per 1,000 births Rate ratio 95% CI Any Samoan Any Tongan Any Cook Island Māori Any Niue Any Fijian Any Tokelauan Any Other Pacific Any Pacific NOS <5 s s s s non-māori non-pacific 1, Sole Pacific Sole Samoan Sole Tongan Sole Cook Island Māori Sole Niue <5 s s s s Sole Fijian Sole Tokelauan <5 s s s s Sole Other Pacific Sole Pacific NOS <5 s s s s non-māori non-pacific 1, Numerator: National Mortality Collection; Denominator: Birth Registration Dataset and National Mortality Collection Distribution by cause The fetal cause of death was unspecified for 45% of any Pacific fetal deaths from ; where specified the most frequent cause was congenital anomalies followed by prematurity or low birth weight and malnutrition or slow fetal growth (Table 5). Main causes of fetal death and proportions were similar for sole Pacific infants. Table 5. Pacific fetal deaths, by main cause of fetal death, New Zealand Main cause of fetal death Any Pacific Fetal deaths annual average Rate per 1,000 bir ths 95% CI Per cent Congenital anomalies Prematurity or low birth weight Malnutrition or slow fetal growth Intrauterine hypoxia Hydrops fetalis (non-haemolytic disease) Fetal blood loss Neonatal aspiration of meconium, amniotic fluid, or mucus Infections specific to perinatal period <5 1 s s s Polycythaemia neonatorum <5 s s s s Congenital pneumonia <5 s s s s Other causes 24 s Unspecified cause of fetal death Total Numerator: National Mortality Collection; Denominator: Birth Registration Dataset and National Mortality Collection There was no listed maternal cause for 39.1% of Pacific fetal deaths from 2008 to Where listed, the most common maternal cause of Pacific fetal deaths was placenta praevia or placental separation and haemorrhage Issues in infancy: Fetal deaths 13

26 followed by other abnormalities of the placenta, incompetent cervix or premature rupture of membranes and maternal hypertensive disorders (Table 6). Main causes of fetal death and proportions were similar for sole Pacific infants. Table 6. Pacific fetal deaths, by type and main maternal cause of fetal death, New Zealand Main maternal cause of fetal death Placenta praevia/placental separation and haemorrhage Any Pacific Fetal deaths annual average Rate per 1,000 births 95% CI Per cent Other abnormalities of placenta Incompetent cervix/premature rupture of membranes Maternal hypertensive disorders Compression of umbilical cord Chorioamnionitis Placental transfusion syndromes Multiple pregnancy Oligohydramnios <5 s s s s Other causes No listed maternal cause Total Numerator: National Mortality Collection; Denominator: Birth Registration Dataset and National Mortality Collection Issues in infancy: Fetal deaths 14

27 PRETERM BIRTHS Introduction The following section reports on preterm birth rates using information from the Birth Registration Dataset. Background A preterm birth is a baby born alive before 37 completed weeks of pregnancy. 21 Infants born prematurely, especially those born very prematurely, are at risk of severe health problems in their early life and are also at risk of lifelong neurodevelopmental problems. 22 At the population level, interventions to reduce smoking and intimate partner violence, improve access to family planning to reduce the number of closely spaced pregnancies, and provide support to socially disadvantaged women could help reduce preterm birth rates. 23 Data sources and methods Indicator Proportion of live babies born prematurely Data sources Birth Registration Dataset Numerator: Live births between weeks gestation Denominator: Live births National Minimum Dataset Numerator: In-hospital live births between weeks gestation Denominator: In-hospital live births Definition Preterm birth per 100 live births Notes on interpretation Note 1: Year is year of registration, rather than year of birth. Note 2: In this analysis, stillborn infants have been excluded due to advice from the Ministry of Health that the Birth Registration Dataset provides less reliable information on stillborn infants than the National Mortality Collection. Stillbirth rates, however, are reviewed in the Fetal Deaths section. Note 3: Preterm births was classified according to the criteria of WHO into groups of 20 27, 28 31, and completed weeks ( Note 4: In the length of stay analyses (LOS), the set is limited to babies born in-hospital as identified by an event type code of 'BT'. Plurality was assigned using the 'Z38' code. Note 5: An overview of the Birth Registration and National Minimum Datasets are provided in Appendix 2: Datasets used in this report. National trends and distribution From 2000 to 2014 the preterm birth rate for Pacific infants was stable at around 6.8% of Pacific live births (sole Pacific) to 7.0% of Pacific live births (any Pacific). Preterm birth rates were generally higher than the overall Pacific rate for Cook Island Māori, and similar to the overall Pacific rate for Samoan and Tongan infants (Figure 3). Plurality and gestational age In New Zealand as a whole between 2010 and 2014 pre term birth rates differed by plurality, with preterm birth rates of 6.0% for live singleton births, 57.2% for live twin births and 97.2% for other live multiple births. Issues in infancy: Preterm births 15