Confidential enquiry of stillbirths in current obstetric practice

Epidemiology of stillbirths based on different gestational thresholds at a tertiary hospital

INTRODUCTION

The stillbirth rate (SBR) is an important public health indicator. We studied the distribution of maternal and fetal characteristics and time trends of the SBR at KK Women's and Children's Hospital (KKH), Singapore, from 2004 to 2016 based on various definitions of stillbirth.

METHODS

Data was obtained from the Data Warehouse and Stillbirth Reporting System of KKH from 2004 to 2016. SBRs were calculated based on three definitions (fetal deaths at ≥ 20 weeks, 24 weeks or 28 weeks of gestation per 1,000 total births) and were described with maternal and fetal characteristics, and by year.

RESULTS

From 2004 to 2016, the SBR declined by 44.7%, 25.5% and 18.9% based on Definitions I, II and III, respectively. The SBR at KKH in 2016 was 5.2 (Definition I), 4.1 (Definition II) and 3.0 (Definition III) per 1,000 total births. The SBR was significantly higher in women aged ≥ 35 years, nulliparas and female fetuses. The number of live births at 24-27+6 weeks of gestation was more than four times higher than that of stillbirths (822 vs. 176). There were 104 (12.7%) neonatal deaths during this gestation period, giving a high survival rate of 87.3%.

CONCLUSION

The SBR in KKH is relatively lower than that in other developed countries. There is a need to consider revising our hospital and national definitions of the stillbirth lower boundary from 28 weeks to 24 weeks of gestation. This would allow us to make better comparisons with other developed countries, in line with improvements in healthcare.

Perinatal mortality audits and reviews: Past, present and the way forward

Perinatal deaths are devastating for families and staff involved. Failure to examine perinatal deaths for substandard care prevents learning and may lead to recurrence of events, as well as prolonged morbidity in bereaved families and hospital staff. Perinatal mortality reviews can identify factors contributing to suboptimal care. An integrative literature review was carried out to study the different types of perinatal mortality reviews currently being done internationally, establishing a comparison and examining promising new developments. We start by outlining issues with the classification of perinatal deaths and the different types of perinatal mortality reviews carried out in high-income countries. We reflect on the challenges that are encountered in the current processes and we then comment on how these may be overcome. Current literature shows that differences in classifications of perinatal deaths continue to impede important international comparisons. National perinatal mortality audits can provide reliable high-quality data to facilitate national and international benchmarking. Confidential enquiries give expert assessment on anonymised information to initiate system-wide improvements, but to provide local information on perinatal deaths unit-based multi-disciplinary team reviews are required. Additionally, there is a need to shift from a blame-culture to a focus on achieving best practice by learning from mistakes. Review tools and processes have been implemented in some countries to standardize perinatal mortality reviews, but there is still more work to be done. Involving the bereaved parents in the perinatal mortality review process is important and ways to achieve this are progressing. A structured approach to the perinatal mortality review process should be developed to facilitate sharing of experiences and challenges at national (or international) level. To achieve a reduction in the number of stillbirths and neonatal deaths, it is crucial to ensure that the perinatal mortality audit and review cycle is completed with implementation and re-evaluation of recommended changes in maternity services.

Integrated Perinatal Care and beyond

The concept of Integrated Perinatal Care was initiated with the formation of the KKH Perinatal Team in 1993 to further improve the maternal and perinatal care. All staff in the team are committed to providing labouring women and women with high-risk pregnancies with the highest possible standards of care to allow the best outcomes and birthing experience for mothers, babies and families. Teamwork as well as national and worldwide collaborations are the hallmarks of this team.

Impacts of participating in confidential enquiry panels: a qualitative study

OBJECTIVE

To describe the impacts of participating in confidential enquiry panels for the Confidential Enquiry into Stillbirths and Deaths in Infancy.

DESIGN

Qualitative interview study.

SETTING

The former northern health region of England.

SAMPLE

Eighteen health professionals who had participated in at least one confidential enquiry panel.

METHODS

Semistructured one-to-one interviews using purposive sampling; transcripts were analysed by identifying recurring themes. Data were organised and coded using NUD*IST.

MAIN OUTCOME MEASURES

Views on the impacts of participation on clinical practice and views on the strengths and limitations of confidential enquiries.

RESULTS

Participants valued attendance at panels as a learning experience that provoked reflection on their own clinical practice. Participants felt that taking part had a positive impact on their clinical thinking and practice by increasing their awareness of standards of care. These impacts occurred through both the detailed examination of cases and the interaction with colleagues from different disciplines and hospitals. Learning impacts were cascaded to colleagues through informal discussion and teaching. Concrete examples of changes in practice at the organisational level, stimulated by panel attendance, were reported.

CONCLUSIONS

The confidential enquiry approach was supported not only as an effective way of assessing care but also as a valuable learning experience that motivated change in clinical practice. Local benefits of nationally coordinated confidential enquiries should be valued and supported in their future development. Wide multidisciplinary participation in enquiry panels coordinated through regional clinical networks should be promoted.