Understanding Perinatal Death: A Systematic Analysis of New York City Fetal and Neonatal Death Vital Record Data and Implications for Improvement, 2007–2011

Levels, Trends, and Risk Factors for Stillbirths in the United States: 2000-2017

OBJECTIVE

This study documents 2000 to 2017 trends in stillbirth rates and changes in associations between known maternal and fetal risk factors and stillbirths for 2000 to 2002 versus 2015 to 2017 in the United States.

STUDY DESIGN

We conducted a retrospective, population-based analysis of stillbirths and live-births using national vital statistics data. We calculated annual stillbirth rates overall and by gestational age; and examined stillbirth rates by maternal age, race-ethnicity, and state for 2000 to 2002 versus 2015 to 2017. We used Chi-squared tests to examine associations between maternal and fetal risk factors separately for early (20-27 weeks) and late (28+ weeks) stillbirths compared with live-births for 2000 to 2002 versus 2015 to 2017.

RESULTS

Stillbirth rates declined by 7.5% (p < 0.001) during 2000 to 2006 but remained flat at approximately 6 stillbirths per 1,000 births thereafter. Throughout 2000 to 2017, there were significant improvements in stillbirth rates at 39+ weeks nationally (p < 0.001), but rates varied greatly between and within states. Sociodemographic (advanced maternal age, Black race, low education, unmarried status, and rural residence), obstetric, and other medical factors (>3 births, use of infertility treatment, maternal obesity, diabetes, chronic hypertension, eclampsia, no prenatal care, and tobacco use) were significantly more prevalent in women with late than early stillbirths or live births. Notably, late and total stillbirth rates were approximately 30% higher for women >35 years than for women <35 years and twice as high for non-Hispanic Black than non-Hispanic White women; American Indian/Alaska Native women represented the only racial-ethnic group with significantly higher late stillbirth rates in 2015 to 2017 than in 2000 to 2002. Pregnancy and fetal factors (multiple pregnancy, male fetus, and breech presentation) were more prevalent in women with early than late stillbirths or live births.

CONCLUSION

U.S. stillbirth rates have plateaued since 2006. There are persistent differential risk profiles for early versus late stillbirths which can inform stillbirth prevention strategies (e.g., close observation of women with risk factors for stillbirth) and new research into the causes of stillbirths by gestational age.

KEY POINTS

· U.S. stillbirth rates have plateaued since 2006.. · Stillbirth rates vary between and within U.S. states and by maternal and fetal factors.. · Early versus late stillbirths have different risk profiles which can guide stillbirth prevention strategies..

Perinatal mortality audits and reporting of perinatal deaths: systematic review of outcomes and barriers

BACKGROUND

Perinatal deaths are a devastating experience for all families and healthcare professionals involved. Audit of perinatal mortality (PNM) is essential to better understand the factors associated with perinatal death, to identify key deficiencies in healthcare provision and should be utilised to improve the quality of perinatal care. However, barriers exist to successful audit implementation and few countries have implemented national perinatal audit programs.

CONTENT

We searched the PubMed, EMBASE and EBSCO host, including Medline, Academic Search Complete and CINAHL Plus databases for articles that were published from 1st January 2000. Articles evaluating perinatal mortality audits or audit implementation, identifying risk or care factors of perinatal mortality through audits, in middle and/or high-income countries were considered for inclusion in this review. Twenty articles met inclusion criteria. Incomplete datasets, nonstandard audit methods and classifications, and inadequate staff training were highlighted as barriers to PNM reporting and audit implementation. Failure in timely detection and management of antenatal maternal and fetal conditions and late presentation or failure to escalate care were the most common substandard care factors identified through audit. Overall, recommendations for perinatal audit focused on standardised audit tools and training of staff. Overall, the implementation of audit recommendations remains unclear.

SUMMARY

This review highlights barriers to audit practices and emphasises the need for adequately trained staff to participate in regular audit that is standardised and thorough. To achieve the goal of reducing PNM, it is crucial that the audit cycle is completed with continuous re-evaluation of recommended changes.

Worth the paper it's written on? A cross-sectional study of Medical Certificate of Stillbirth accuracy in the UK

BACKGROUND

The Medical Certificate of Stillbirth (MCS) records data about a baby's death after 24 weeks of gestation but before birth. Major errors that could alter interpretation of the MCS were widespread in two UK-based regional studies.

METHODS

A multicentre evaluation was conducted, examining MCS issued 1 January 2018 to 31 December 2018 in 76 UK obstetric units. A systematic case-note review of stillbirths was conducted by Obstetric and Gynaecology trainees, generating individual 'ideal MCSs' and comparing these to the actual MCS issued. Anonymized central data analysis described rates and types of error, agreement and factors associated with major errors.

RESULTS

There were 1120 MCSs suitable for assessment, with 126 additional submitted data sets unsuitable for accuracy analysis (total 1246 cases). Gestational age demonstrated 'substantial' agreement [K = 0.73 (95% CI 0.70-0.76)]. Primary cause of death (COD) showed 'fair' agreement [K = 0.26 (95% CI 0.24-0.29)]. Major errors [696/1120; 62.1% (95% CI 59.3-64.9%)] included certificates issued for fetal demise at <24 weeks' gestation [23/696; 3.3% (95% CI 2.2-4.9%)] or neonatal death [2/696; 0.3% (95% CI 0.1-1.1%)] or incorrect primary COD [667/696; 95.8% (95% CI 94.1-97.1%)]. Of 540/1246 [43.3% (95% CI 40.6-46.1%)] 'unexplained' stillbirths, only 119/540 [22.0% (95% CI 18.8-25.7%)] remained unexplained; the majority were redesignated as either fetal growth restriction [FGR: 195/540; 36.1% (95% CI 32.2-40.3%)] or placental insufficiency [184/540; 34.1% (95% CI 30.2-38.2)]. Overall, FGR [306/1246; 24.6% (95% CI 22.3-27.0%)] was the leading primary COD after review, yet only 53/306 [17.3% (95% CI 13.5-22.1%)] FGR cases were originally attributed correctly.

CONCLUSION

This study demonstrates widespread major errors in MCS completion across the UK. MCS should only be completed following structured case-note review, with particular attention on the fetal growth trajectory.

Perinatal Mortality Analysis in Espírito Santo, Brazil, 2008 to 2017

This is an ecological and time-series study using secondary data on perinatal mortality and its components from 2008 to 2017 in Espírito Santo, Brazil. The data were collected from the Mortality Information System (SIM) and Live Births Information System (SINASC) of the Unified Health System Informatics Department (DATASUS) in June 2019. The perinatal mortality rate (×1000 total births) was calculated. Time series were constructed from the perinatal mortality rate for the regions and Espírito Santo. To analyze the trend, the Prais-Winsten model was used. From 2008 to 2017 there were 8132 perinatal deaths (4939 fetal and 3193 early neonatal) out of a total of 542,802 births, a perinatal mortality rate of 15.0/1000 total births. The fetal/early neonatal ratio was 1.5:1, with a strong positive correlation early neonatal mortality rate, perinatal mortality rate, r (9) = 0.8893, with a significance level of p = 0.000574. The presence of differences in trends by health region was observed. Risk factors that stood out were as follows: mother's age ranging between 10 and 19 or 40 and 49 years old, with no education, a gestational age between 22 and 36 weeks, triple and double pregnancy, and a birth weight below 2499 g. Among the causes of death, 49.70% of deaths were concentrated in category of the tenth edition of the International Classification of Diseases, fetuses and newborns affected by maternal factors and complications of pregnancy, labor, and delivery (P00-P04), and 11.03% were in the category of intrauterine hypoxia and birth asphyxia (P20-P21), both related to proper care during pregnancy and childbirth. We observed a slow reduction in the perinatal mortality rate in the state of Espírito Santo from 2008 to 2017.

Design and Methodology of the Study of Associated Risks of Stillbirth (SOARS) in Utah

OBJECTIVES

The Utah Study of Associated Risks of Stillbirth (SOARS) collects data about stillbirths that are not included in medical records or on fetal death certificates. We describe the design, methods, and survey response rate from the first year of SOARS.

METHODS

The Utah Department of Health identified all Utah women who experienced a stillbirth from June 1, 2018, through May 31, 2019, via fetal death certificates and invited them to participate in SOARS. The research team based the study protocol on the Pregnancy Risk Assessment Monitoring System surveillance of women with live births and modified it to be sensitive to women's recent experience of a stillbirth. We used fetal death certificates to examine survey response rates overall and by maternal characteristics, gestational age of the fetus, and month in which the loss occurred.

RESULTS

Of 288 women invited to participate in the study, 167 (58.0%) completed the survey; 149 (89.2%) responded by mail and 18 (10.8%) by telephone. A higher proportion of women who were non-Hispanic White (vs other races/ethnicities), were married (vs unmarried), and had ≥high school education (vs <high school education) responded to the survey. Differences between responders and nonresponders by maternal age, gestational age of the fetus, or month of delivery were not significant. Among responders, item nonresponse rates were low (range, 0.6%-5.4%). The question about income (4.8%) and the questions about tests offered and performed during the hospital stay had the highest item nonresponse rates.

CONCLUSIONS

The response rate suggests that a mail- and telephone-based survey can be successful in collecting self-reported information about risk factors for stillbirths not currently included in medical records or fetal death certificates.

Epidemiological investigation of perinatal deaths in Recife-Pernambuco: a quality assessment

OBJECTIVE

to evaluate the completeness of perinatal death investigation sheets, stratified by age components.

METHOD

descriptive study carried out in Recife, PE, in 2014. Among 308 perinatal deaths, 46 were excluded from this study due to association with congenital malformations, and 7 due to missing investigation sheets. Analysis included 255 deaths (160 fetal deaths, and 95 preterm neonatal deaths). The degree of completeness of 98 variables was calculated. They were aggregated into six blocks: identification, prenatal care, birth care, family characteristics, occurrence of death and conclusions and recommendations.

RESULTS

the median rate of completeness for perinatal death investigation sheets was 85.7% (82.8% for records of fetal deaths and 89.5% for records of preterm neonatal deaths). The best-filled information block was "identification" (96.1%), as well as its components: fetal (94.7%) and preterm neonatal (97.9%). The worst was "prenatal care" (69.8%), along with its components: fetal (73.8%) and preterm neonatal (67.4%).

CONCLUSION

investigation sheets had good completeness; there were differences between variables and components of perinatal death.

Deaths of women hospitalized for childbirth and abortion, and of their concept, in maternity wards of Brazilian public hospitals

The aim of this cross-sectional hospital-based study of 7,845 pregnancies was to analyze deaths of women hospitalized for childbirth and abortion, and fetal and neonatal deaths, in public hospitals in the cities of São Paulo, Rio de Janeiro and Niteroi (RJ), Brazil, in 2011. Outcomes of the pregnancies were: one maternal death, 498 abortions, 65 fetal deaths, 44 neonatal deaths and 7,291 infant survivors. Data were collected through interviews, medical records and the women's pregnancy records, and from the Mortality Information System (SIM). The study population was described and kappa coefficients of causes of death (from the SIM, and certified by research) and mortality health indicators were estimated. The maternal mortality ratio was 13.6 per 100,000 live births (LB), the fetal death rate was 8.8‰ births and the neonatal mortality rate was 6.0‰ LB. The drug most used to induce abortion was Misoprostol. The main causes of fetal and neonatal deaths were respiratory disorders and maternal factors. Congenital syphilis, diabetes and fetal death of unspecified cause were under-reported in the SIM. Kappa coefficients by chapter were 0.70 (neonatal deaths) and 0.54 (stillbirths). Good quality care in reproductive planning, prenatal care, during labor and at birth will result in prevention of deaths.

Perinatal deaths preventable by intervention of the Unified Health System of Brazil

OBJECTIVE

To describe the epidemiological characteristics of perinatal deaths through the actions of the Unified Health System.

METHODS

This is a descriptive study of temporal analysis with a population of perinatal deaths of mothers residing in Recife, Brazil, from 2010 to 2014. A list was used to classify the preventable diseases and the variables were analysed using Epi lnfo™ version 7.

RESULTS

The perinatal deaths totalled 1,756 (1,019 foetal and 737 neonatal premature) with a reduction of neonatal deaths (-15.8%) and an increase of foetal deaths (12.1%) in the study period. The main causes of death were foetus and newborn affected by the mother´s condition and asphyxia/hypoxia at birth.

CONCLUSIONS

Most deaths were avoidable, especially in the group of appropriate care to mothers during pregnancy. Faults in the care provided to women at birth explain the percentage of deaths caused by asphyxia/hypoxia. The reduction of preventable perinatal mortality is associated with the increased access and quality of care, which ensures health promotion, disease prevention, treatment and specific and timely care.

Evaluation of the Completeness, Data Quality, and Timeliness of Fetal Mortality Surveillance in Wyoming, 2006-2013

Purpose The number of fetal deaths in the United States each year exceeds that of infant deaths. High quality fetal death certificate data are necessary for states to effectively address preventable fetal deaths. We evaluated completeness of detection of fetal deaths among Wyoming residents that occur out-of-state, quality of cause-of-death data, and timeliness of Wyoming fetal death certificate registration during 2006-2013. Description The numbers of out-of-state fetal deaths among Wyoming residents recorded by Wyoming surveillance and reported by the National Vital Statistics System were compared. Quality of cause-of-death data was assessed by calculating percentage of fetal death certificates completed in Wyoming with ill-defined, unknown, or missing cause-of-death entries. Timeliness was determined using the time between the fetal death and filing of the fetal death certificate with the Wyoming Department of Health Vital Statistics Service. Assessment Wyoming surveillance detected none of the 76 out-of-state fetal deaths among Wyoming residents reported by the National Vital Statistics System. Among 263 fetal death certificates completed in Wyoming and collected by Wyoming surveillance, 108 (41%) contained ill-defined, unknown, or missing cause-of-death entries. Median duration between the fetal death and filing with the Wyoming Vital Statistics Service was 33 days. Conclusion Wyoming fetal mortality surveillance is limited by failure to register out-of-state fetal deaths among residents, poor quality of cause-of-death data, and lack of timeliness. Strategies to improve surveillance include automating interjurisdictional sharing of fetal death data, certifier education, and electronic fetal death registration.

Fetal death certificate data quality: a tale of two U.S. counties

PURPOSE

Describe the relative frequency and joint effect of missing and misreported fetal death certificate (FDC) data and identify variations by key characteristics.

METHODS

Stillbirths were prospectively identified during 2006-2008 for a multisite population-based case-control study. For this study, eligible mothers of stillbirths were not incarcerated residents of DeKalb County, Georgia, or Salt Lake County, Utah, aged ≥13 years, with an identifiable FDC. We identified the frequency of missing and misreported (any departure from the study value) FDC data by county, race/ethnicity, gestational age, and whether the stillbirth was antepartum or intrapartum.

RESULTS

Data quality varied by item and was highest in Salt Lake County. Reporting was generally not associated with maternal or delivery characteristics. Reasons for poor data quality varied by item in DeKalb County: some items were frequently missing and misreported; however, others were of poor quality due to either missing or misreported data.

CONCLUSIONS

FDC data suffer from missing and inaccurate data, with variations by item and county. Salt Lake County data illustrate that high quality reporting is attainable. The overall quality of reporting must be improved to support consequential epidemiologic analyses for stillbirth, and improvement efforts should be tailored to the needs of each jurisdiction.

Trends in Stillbirth by Gestational Age in the United States, 2006-2012

OBJECTIVE

To evaluate stillbirth trends by gestational age.

METHODS

National Center for Health Statistics' fetal death and live birth data files were used to analyze the 2006 and 2012 cohorts of deliveries and compute gestational age-specific stillbirth rates at 20 weeks of gestation or greater using two methods: traditional (eg, stillbirths at 38 weeks of gestation/live births and stillbirths at 38 weeks of gestation) and prospective (stillbirths at 38 weeks of gestation/number of women still pregnant at 38 weeks of gestation). Changes in rates and in the percent distribution of stillbirths and live births were assessed.

RESULTS

In 2006 and 2012, the stillbirth rate was 6.05 stillbirths per 1,000 deliveries. There was little change in the percent distribution of stillbirths by gestational age from 2006 to 2012. However, the percent distribution of live births by gestational age changed considerably: births at 34-38 weeks of gestation decreased by 10-16%, and births at 39 weeks of gestation increased by 17%. Traditionally computed stillbirth rates were unchanged at most gestational ages, but rose at 24-27, 34-36, 37, and 38 weeks of gestation. However, rates were influenced by decreases in births at those gestational ages; the pattern of stillbirths by gestational age was unchanged. In contrast, there were no differences in prospective stillbirth rates at 21-42 weeks of gestation.

CONCLUSION

The lack of change in prospective stillbirth rates from 2006 to 2012 suggests that preventing nonmedically indicated deliveries before 39 weeks of gestation did not increase the U.S. stillbirth rate.

LEVEL OF EVIDENCE

II.

The Quality and Completeness of 2008 Perinatal and Under-five Mortality Data from Vital Registration, Jamaica

OBJECTIVE

To evaluate the completeness and timeliness of registration of stillbirths and under-five deaths and the validity of the certification and coding process.

SUBJECTS AND METHODS

Registered stillbirths and under-five deaths occurring in 2008 were compared to hospital, police, forensic pathologist and coroner's records. Missed cases and new information such as birthweight, gestation and date of birth were added to the database. A 10% random sample was evaluated to measure the quality of certification and coding.

RESULTS

Of 646 stillbirths [≥ 1000 g] and 933 under-five deaths, 69% and 79%, respectively were registered by December 31, 2009, for inclusion in the 2008 final demographic returns. Non-reporting of stillbirths was associated with infant gender, region and place of death (seven of 21 public hospitals accounted for 96% of unregistered stillbirths). Among under-five deaths, age at death, region, place and cause of death were important. Injury and community deaths increased with age. Registration delays including non-registration were associated with coroner's inquests. Most [80%] stillbirth certificates lacked usable cause of death data. Neonatal deaths due to prematurity and perinatal asphyxia were often misclassified by coders. The stillbirth [≥ 1000 g], infant and under-five mortality rates were 15, 20 and 22/1000 births/live births, respectively.

CONCLUSIONS

While registration of stillbirths and under-five deaths improved between 1998 and 2008, persistent under-reporting reduced official rates by 20-31%. A new perinatal death certificate documenting maternal and fetal causes of death and risk factors such as birthweight, gestation and age at death would improve stillbirth and neonatal death (0-28 days) data quality.