LAUSR

Exposure of the fetus to significant intrapartum hypoxia ischaemia rate. For planning clinical practice improvement (CPI) there is a need may result in a range of adverse outcomes including stillbirth, neonatal encephalopathy (NE) and postnatal death. Indeed, intrapartum-related events are estimated to account for nearly a quarter of neonatal deaths and are second only to prematurity as a cause of neonatal mortality [1]. Furthermore, survivors may develop a variety of important sequelae including cerebral palsy (CP),which is relatively common, and non-motor morbidities such as cognitive dysfunction [2–5]. In high income countries (HIC), national quality improvement programmes such as Each Baby Counts in UK [6] and NE Task Force in New Zealand [7] are underway and aim to both prevent NE and improve outcomes. In this edition of the journal, Tann et al. [8] describe the follow up of infantswith NE, in Uganda, a low income country (LIC) with a neonatal mortality of 27/ 1000 live births. It is important to appreciate that the greatest burden from intrapartum related events falls on lower income countries due to their higher prevalence of NE. Indeed, 96% of an estimated 1.15 million babies worldwide who developed NE, associated with intrapartum events, in 2010 were born in low and middle-income countries [ 9]. This number approximates to 8.5 cases per 1000 live births worldwide. However, the distribution is heterogeneous and this averaged rate includes a huge variation. The national rate of NE for New Zealand was reported as 1.0/1000 term births for 2016 [10], a rate approximately 10 times higher has been reported fromNepal [11] and at the upper endof the scale a prevalence of hypoxic ischaemic encephalopathy equal to 10.7% (albeit including preterm infants) was reported from a single centre in Tanzania [12]. Although adverse outcome is a recognised consequence of NE, the nature of the sequelae is both variable and influenced by the health care provided. A composite of outcomes may measure the overall burden, so is often used in interventional trials, but it should be noted that death and long-term impairment are competing outcomes. If there is little or no neonatal intensive care provided the impairment rate is low due to poor survival. However, with increasing provision of neonatal life support (as opposed to neurologically focussed interventions such as cooling) death may be less common but with higher impairment