Socioeconomic inequalities in the rate of stillbirths by cause: a population-based study

Maternal ethnicity and socioeconomic deprivation: influence on adverse pregnancy outcomes

OBJECTIVE

To evaluate the relative importance of ethnicity and socioeconomic deprivation in determining the likelihood and prevalence of placentally derived composite of adverse pregnancy outcomes (CAPO) and composite of severe adverse pregnancy outcomes (CAPO-S).

METHODS

This was a single-center retrospective cohort study of data obtained in a tertiary maternity unit. Data regarding ethnicity and socioeconomic deprivation (as measured with indices of multiple deprivation) were collected for 13 165 singleton pregnancies screened routinely in the first trimester for pre-eclampsia using the Fetal Medicine Foundation combined risk-assessment algorithm. CAPO was defined as the presence of one or more interrelated outcomes associated with placental dysfunction, namely, hypertensive disorders of pregnancy, preterm birth, birth weight ≤ 10th centile and stillbirth. CAPO-S was defined as the presence of one or more of the following: hypertensive disorders of pregnancy at < 37 + 0 weeks, preterm birth at < 34 + 0 weeks, birth weight ≤ 5th centile and stillbirth at < 37 + 0 weeks.

RESULTS

The prevalence of CAPO was 16.3% in white women, 29.3% in black women and 29.3% in South Asian women. However, half (51.7%) of all CAPO cases occurred in white women. There was a strong interaction between ethnicity and socioeconomic deprivation, with a correlation coefficient of -0.223. Both ethnicity and socioeconomic deprivation influenced the prevalence of CAPO and CAPO-S, with the contribution of ethnicity being the strongest.

CONCLUSIONS

Black and Asian ethnicity, as well as socioeconomic deprivation, influence the prevalence of placenta-mediated adverse pregnancy outcomes. Despite this, most adverse pregnancy outcomes occur in white women, who represent the majority of the population and are also affected by socioeconomic deprivation. For these reasons, inclusion of socioeconomic deprivation should be considered in early pregnancy risk assessment for placenta-mediated CAPO. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A qualitative study of the dynamics of access to remote antenatal care through the lens of candidacy

OBJECTIVE

We aimed to explore the experiences and perspectives of pregnant women, antenatal healthcare professionals, and system leaders to understand the impact of the implementation of remote provision of antenatal care during the COVID-19 pandemic and beyond.

METHODS

We conducted a qualitative study involving semi-structured interviews with 93 participants, including 45 individuals who had been pregnant during the study period, 34 health care professionals, and 14 managers and system-level stakeholders. Analysis was based on the constant comparative method and used the theoretical framework of candidacy.

RESULTS

We found that remote antenatal care had far-reaching effects on access when understood through the lens of candidacy. It altered women's own identification of themselves and their babies as eligible for antenatal care. Navigating services became more challenging, often requiring considerable digital literacy and sociocultural capital. Services became less permeable, meaning that they were more difficult to use and demanding of the personal and social resources of users. Remote consultations were seen as more transactional in character and were limited by lack of face-to-face contact and safe spaces, making it more difficult for women to make their needs - both clinical and social - known, and for professionals to assess them. Operational and institutional challenges, including problems in sharing of antenatal records, were consequential. There were suggestions that a shift to remote provision of antenatal care might increase risks of inequities in access to care in relation to every feature of candidacy we characterised.

CONCLUSION

It is important to recognise the implications for access to antenatal care of a shift to remote delivery. It is not a simple swap: it restructures many aspects of candidacy for care in ways that pose risks of amplifying existing intersectional inequalities that lead to poorer outcomes. Addressing these challenges through policy and practice action is needed to tackle these risks.

Socioeconomic inequality and stillbirth rate disparities among native and foreign mothers: evidence from Greece

We study, for the first time, stillbirth differentials among native and migrant populations in Greece using national vital registration microdata for the period of 2010–2014. We employ conventional demographic measures and propose a standardization procedure to delineate the effect of selected distributions of livebirths on the observed stillbirth rates. The stillbirth rate among immigrant mothers is 40% higher than among natives, an excess which persists throughout gestational intervals and age groups. Our findings also show a clear gradient of stillbirth rates by maternal education, favoring more educated women, and this finding applies to both native and immigrant mothers. Our standardization methodology shows that the distribution of births by maternal educational level and age play a role; this finding implies that elevated immigrant stillbirth rates may be attributed to a certain extent to the specific characteristics of this group, since immigrant women have, on average, a younger age structure and lower educational attainment.

Protocol for the Healing After Loss (HeAL) Study: a randomised controlled trial of interpersonal psychotherapy (IPT) for major depression following perinatal loss

INTRODUCTION

This protocol describes a study testing the efficacy of interpersonal psychotherapy (IPT) for major depressive disorder following perinatal loss (early and late fetal death and early neonatal death). Perinatal loss is associated with elevated risk of major depressive disorder and post-traumatic stress disorder (PTSD). Perinatal loss conveys specific treatment needs. The trial will be the first fully powered randomised trial of treatment for any psychiatric disorder following perinatal loss.

METHODS AND ANALYSIS

A sample of 274 women in Flint and Detroit areas in Michigan who experience a major depressive episode following a perinatal loss will be randomised to group IPT for perinatal loss or to group coping with depression. We anticipate that 50% of the sample will have co-occurring PTSD. Assessments occur at baseline, mid-treatment (8 weeks), post-treatment (16 weeks) and follow-up (28 weeks). Clinical outcomes include time to recovery from major depressive episode (primary), depressive symptoms, PTSD symptoms and time to recovery from PTSD. Additional outcomes include social support, social role functioning (including parental functioning for those with living children), well-being, grief (including complicated grief and fault beliefs) and fear of subsequent pregnancies. Social support and grief are hypothesised mediators of IPT effects on time to recovery from major depressive episode.

ETHICS AND DISSEMINATION

The trial was approved by Michigan State University's Biomedical Institutional Review Board. It has a data and safety monitoring board and has been submitted to the community-based organisation partners community ethics review board. Written operating procedures outline methods for protecting confidentiality, monitoring and recording adverse events, and safeguarding participants. We will share study results with research and clinical communities, community organisations through which we recruited, and will offer results to study participants. Deidentified datasets will be available through the National Institute of Mental Health Data Archive and to qualified investigators on request.

TRIAL REGISTRATION NUMBER

NCT04629599.

Economic crisis and stillbirth ratios: Evidence from Southern Europe

In this paper we assess the impact of the recent European recession on stillbirth indices over the course of the 2000s and 2010s; the analysis focuses on four Southern European countries (Greece, Italy, Spain, Portugal), which were seriously affected by the sovereign debt crisis from around 2008 to 2017. We use national vital statistics and established economic indicators for the period 2000-2017; stillbirth ratios (stillbirths per 1000 livebirths) are the chosen response variable. For the purpose of the study, we employ correlation analysis and fit regression models. The overall impact of economic indicators on the stillbirth indices is sizeable and statistically robust. We find that a healthy economy is associated with low and declining levels of stillbirth measures. In contrast, economic recession appears to have an adverse effect (Greece, Italy and Spain), or an unclear impact (Portugal), on the stillbirth outcome. This study provides evidence of the adverse effect of the European sovereign debt crisis and ensuing period of austerity on a scarcely explored aspect of health.

Fully Automated 3-D Ultrasound Segmentation of the Placenta, Amniotic Fluid, and Fetus for Early Pregnancy Assessment

Volumetric placental measurement using 3-D ultrasound has proven clinical utility in predicting adverse pregnancy outcomes. However, this metric cannot currently be employed as part of a screening test due to a lack of robust and real-time segmentation tools. We present a multiclass (MC) convolutional neural network (CNN) developed to segment the placenta, amniotic fluid, and fetus. The ground-truth data set consisted of 2093 labeled placental volumes augmented by 300 volumes with placenta, amniotic fluid, and fetus annotated. A two-pathway, hybrid (HB) model using transfer learning, a modified loss function, and exponential average weighting was developed and demonstrated the best performance for placental segmentation (PS), achieving a Dice similarity coefficient (DSC) of 0.84- and 0.38-mm average Hausdorff distances (HDAV). The use of a dual-pathway architecture improved the PS by 0.03 DSC and reduced HDAV by 0.27 mm compared with a naïve MC model. The incorporation of exponential weighting produced a further small improvement in DSC by 0.01 and a reduction of HDAV by 0.44 mm. Per volume inference using the FCNN took 7-8 s. This method should enable clinically relevant morphometric measurements (such as volume and total surface area) to be automatically generated for the placenta, amniotic fluid, and fetus. The ready availability of such metrics makes a population-based screening test for adverse pregnancy outcomes possible.

Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study

BACKGROUND

Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations.

METHODS

This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women's social and medical risk factors and the service attended.

RESULTS

Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02-0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14-0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32-4.27) and low birth weight (RR 2.31, CI 1.24-4.32), and a decrease in induction of labour (RR 0.65, CI 0.45-0.95) compared to community-based antenatal care, this was despite women's medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49-6.50), demonstrating the protective nature of community-based antenatal care.

CONCLUSIONS

This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.

Stillbirth maternity care measurement and associated factors in population-based surveys: EN-INDEPTH study

BACKGROUND

Household surveys remain important sources of maternal and child health data, but until now, standard surveys such as Demographic and Health Surveys (DHS) have not collected information on maternity care for women who have experienced a stillbirth. Thus, nationally representative data are lacking to inform programmes to address the millions of stillbirths which occur annually.

METHODS

The EN-INDEPTH population-based survey of women of reproductive age was undertaken in five Health and Demographic Surveillance System sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda (2017-2018). All women answered a full birth history with additional questions on pregnancy losses (FBH+) or full pregnancy history (FPH). A sub-sample, including all women reporting a recent stillbirth or neonatal death, was asked additional maternity care questions. These were evaluated using descriptive measures. Associations between stillbirth and maternal socio-demographic characteristics, babies' characteristics and maternity care use were assessed using a weighted logistic regression model for women in the FBH+ group.

RESULTS

A total of 15,591 women reporting a birth since 1 January 2012 answered maternity care questions. Completeness was very high (> 99%), with similar proportions of responses for both live and stillbirths. Amongst the 14,991 births in the FBH+ group, poorer wealth status, higher parity, large perceived baby size-at-birth, preterm or post-term birth, birth in a government hospital compared to other locations and vaginal birth were associated with increased risk of stillbirth after adjusting for potential confounding factors. Regarding association with reported postnatal care, women with a stillbirth were more likely to report hospital stays of > 1 day. However, women with a stillbirth were less likely to report having received a postnatal check compared to those with a live birth.

CONCLUSIONS

Women who had experienced stillbirth were able to respond to questions about pregnancy and birth, and we found no reason to omit questions to these women in household surveys. Our analysis identified several potentially modifiable factors associated with stillbirth, adding to the evidence-base for policy and action in low- and middle-income contexts. Including these questions in DHS-8 would lead to increased availability of population-level data to inform action to end preventable stillbirths.

Associations of area-level deprivation with adverse obstetric and perinatal outcomes in Bavaria, Germany: Results from a cross-sectional study

Background

We investigated associations of area-level deprivation with obstetric and perinatal outcomes in a large population-based routine dataset.

Methods

We used the data of n = 827,105 deliveries who were born in hospitals between 2009 to 2016 in Bavaria, Germany. The Bavarian Index of Multiple Deprivation (BIMD) on district level was assigned to each mother by the zip code of her residential address. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) for preterm deliveries, Caesarian sections (CS), stillbirths, small for gestational age (SGA) births and low 5-minute Apgar scores by BIMD quintiles with and without adjustment for potential confounders.

Results

We observed a significantly increased risk for preterm deliveries in mothers from the most deprived compared to the least deprived districts (e.g. OR [95% CI] for highest compared to lowest deprivation quintile: 1.06 [1.03, 1.09]) in adjusted analyses. Increased deprivation was also associated with higher SGA and secondary CS rates, but with lower proportions of stillbirths, primary CS and low Apgar scores. When one large clinic with an unusually high stillbirth rate was excluded, the association of BIMD with stillbirths was attenuated and almost disappeared.

Conclusions

We found that area-level deprivation in Bavaria was positively associated with preterm and SGA births, confirming previous studies. In contrast, the finding of an inverse association between deprivation and both stillbirth rates and low Apgar score came somewhat surprising. However, we conclude that the stillbirths finding is spurious and reflects regional bias due to a clinic which seems to specialize in termination of pregnancies.

Understanding high rates of stillbirth and neonatal death in a disadvantaged, high-migrant district in France: A perinatal audit

INTRODUCTION

The objective of this study is to investigate factors associated with risks of perinatal death in a disadvantaged, high-migrant French district with mortality rates above the national average.

MATERIAL AND METHODS

The study design is a perinatal audit in 2014 in all 11 maternity units in the Seine-Saint-Denis district (25 037 births). The data come from medical chart abstraction, maternal interviews and peer assessor confidential review of deaths. A representative sample of live births in the same district, from the 2010 French Perinatal Survey, was used for comparisons (n = 429). The main outcome measures were stillbirth and neonatal death (0-27 days) at ≥22 weeks of gestation.

RESULTS

The audit included 218 women and 227 deaths (156 stillbirths, 71 neonatal deaths); 75 women were interviewed. In addition to primiparity and multiple pregnancy, overweight and obesity increased mortality risks (50% of cases, adjusted odds ratios [aOR] 1.7, 95% confidence interval [CI] 1.1-2.8, and aOR 1.9 [95% CI 1.1-3.2], respectively) as did the presence of preexisting medical/obstetric conditions (28.6% of cases, aOR 3.2, 95% CI 2.0-5.3). Problems accessing or complying with care were noted in 25% of medical records and recounted in 50% of interviews. Assessors identified suboptimal factors in 73.2% of deaths and judged 33.9% to be possibly or probably preventable. Care not adapted to risk factors and poor healthcare coordination were frequent suboptimal factors. Possibly preventable deaths were higher (P < .05) for women with gestational diabetes or hypertension (44.6%) than women without (29.0%).

CONCLUSIONS

Preventive actions to improve healthcare referral and coordination, especially for overweight and obese women and women with medical and obstetrical risk factors, could reduce perinatal mortality in disadvantaged areas.

Assessing the deprivation gap in stillbirths and neonatal deaths by cause of death: a national population-based study

OBJECTIVE

To investigate socioeconomic inequalities in cause-specific stillbirth and neonatal mortality to identify key areas of focus for future intervention strategies to achieve government ambitions to reduce mortality rates.

DESIGN

Retrospective cohort study.

SETTING

England, Wales, Scotland and the UK Crown Dependencies.

PARTICIPANTS

All singleton births between 1 January 2014 and 31 December 2015 at ≥24 weeks' gestation.

MAIN OUTCOME MEASURE

Cause-specific stillbirth or neonatal death (0-27 days after birth) per 10 000 births by deprivation quintile.

RESULTS

Data on 5694 stillbirths (38.1 per 10 000 total births) and 2368 neonatal deaths (15.9 per 10 000 live births) were obtained from Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK). Women from the most deprived areas were 1.68 (95% CI 1.56 to 1.81) times more likely to experience a stillbirth and 1.67 (95% CI 1.48 to 1.87) times more likely to experience a neonatal death than those from the least deprived areas, equating to an excess of 690 stillbirths and 231 neonatal deaths per year associated with deprivation. Small for gestational age (SGA) unexplained antepartum stillbirth was the greatest contributor to excess stillbirths accounting for 33% of the deprivation gap in stillbirths. Congenital anomalies accounted for the majority (59%) of the deprivation gap in neonatal deaths, followed by preterm birth not SGA (24-27 weeks, 27%).

CONCLUSIONS

Cause-specific mortality rates at a national level allow identification of key areas of focus for future intervention strategies to reduce mortality. Despite a reduction in the deprivation gap for stillbirths and neonatal deaths, public health interventions should primarily focus on socioeconomic determinants of SGA stillbirth and congenital anomalies.

Inequalities and stillbirth in the UK: a meta-narrative review

OBJECTIVE

To review what is known about the relationship between stillbirth and inequalities from different disciplinary perspectives to inform stillbirth prevention strategies.

DESIGN

Systematic review using the meta-narrative method.

SETTING

Studies undertaken in the UK.

DATA SOURCES

Scoping phase: experts in field, exploratory electronic searches and handsearching. Systematic searches phase: Nine databases with no geographical or date restrictions. Non-English language studies were excluded.

STUDY SELECTION

Any investigation of stillbirth and inequalities with a UK component.

DATA EXTRACTION AND SYNTHESIS

Three authors extracted data and assessed study quality. Data were summarised, tabulated and presented graphically before synthesis of the unfolding storyline by research tradition; and then of the commonalities, differences and interplays between narratives into resultant summary meta-themes.

RESULTS

Fifty-four sources from nine distinctive research traditions were included. The evidence of associations between social inequalities and stillbirth spanned 70 years. Across research traditions, there was recurrent evidence of the social gradient remaining constant or increasing, fuelling repeated calls for action (meta-theme 1: something must be done). There was less evidence of an effective response to these calls. Data pertaining to socioeconomic, area and ethnic disparities were routinely collected, but not consistently recorded, monitored or reported in relation to stillbirth (meta-theme 2: problems of precision). Many studies stressed the interplay of socioeconomic status, deprivation or ethnicity with aggregated factors including heritable, structural, environmental and lifestyle factors (meta-theme 3: moving from associations towards intersectionality and intervention(s)). No intervention studies were identified.

CONCLUSION

Research investigating inequalities and stillbirth in the UK is underdeveloped. This is despite repeated evidence of an association between stillbirth risk and poverty, and stillbirth risk, poverty and ethnicity. A specific research forum is required to lead the development of research and policy in this area, which can harness the multiple relevant research perspectives and address the intersections between different policy areas.

PROSPERO REGISTRATION NUMBER

CRD42017079228.

How do women with social risk factors experience United Kingdom maternity care? A realist synthesis

BACKGROUND

Echoing international trends, the most recent United Kingdom reports of infant and maternal mortality found that pregnancies to women with social risk factors are over 50% more likely to end in stillbirth or neonatal death and carry an increased risk of premature birth and maternal death. The aim of this realist synthesis was to uncover the mechanisms that affect women's experiences of maternity care.

METHODS

Using realist methodology, 22 papers exploring how women with a wide range of social risk factors experience maternity care in the United Kingdom were included. The data extraction process identified contexts (C), mechanisms (M), and outcomes (0).

RESULTS

Three themes, Resources, Relationships, and Candidacy, overarched eight CMO configurations. Access to services, appropriate education, interpreters, practical support, and continuity of care were particularly relevant for women who are unfamiliar with the United Kingdom system and those living chaotic lives. For women with experience of trauma, or those who lack a sense of control, a trusting relationship with a health care professional was key to regaining trust. Many women who have social care involvement during their pregnancy perceive health care services as a system of surveillance rather than support, impacting on their engagement. This, as well as experiences of paternalistic care and discrimination, could be mitigated through the ability to develop trusting relationships.

CONCLUSIONS

The findings provide underlying theory and practical guidance on how to develop safe services that aim to reduce inequalities in women's experiences and birth outcomes.

Volume and vascularity: Using ultrasound to unlock the secrets of the first trimester placenta

Fetal growth restriction (FGR) is a major cause of perinatal morbidity and mortality. Identifying which pregnancies are at risk of FGR facilitates enhanced surveillance and early delivery before fetal demise can ensue. However, existing risk stratification strategies yield an unacceptably low detection rate. A robust and reliable first trimester screening test for FGR would not only enable high-risk women to be appropriately monitored but would facilitate future trials for possible interventions to enhance fetal growth. Both the volume and vascularity of the first trimester placenta has been demonstrated to be linked to adverse pregnancy outcomes including FGR and pre-eclampsia. The investigation of novel ultrasound markers for FGR are discussed along with the development of methods for fully automatic placental volume estimation which has the potential for use as part of a multi-variable population-based screening test.

A multisite audit to assess how women with complex social factors access and engage with maternity services

OBJECTIVE

to audit women with socially complex lives' documented access to and engagement with antenatal care provided by three inner city, UK maternity services in relation to birth and neonatal outcomes, and referral processes.

BACKGROUND

women living socially complex lives, including young mothers, recently arrived immigrants, non-English speaking, and those experiencing domestic violence, poor mental health, drug and alcohol abuse, and poverty experience high rates of morbidity, mortality and poor birth outcomes. This is associated with late access to and poor engagement with antenatal care.

METHOD

data was collected from three separate NHS trusts data management systems for a total of 182 women living socially complex lives, between January and December 2015. Data was presented by individual trust and compared to standards derived from NICE guidelines, local trust policy and national statistic using Excel and SPSS Version 22. Tests of correlation were carried out to minimise risks of confounding factors in characteristic differences.

FINDINGS

non-English speaking women were much less likely to have accessed care within the recommended timeframes, with over 70% of the sample not booked for maternity care by 12 weeks gestation. On average 89% primiparous women across all samples had less than the recommended number of antenatal appointments. No sample met the audit criteria in terms of number of antenatal appointments attended. Data held on the perinatal data management systems for a number of outcomes and processes was largely incomplete and appeared unreliable.

CONCLUSION

this data forms a baseline against which to assess the impact of future service developments aimed at improving access and engagement with services for women living with complex social factors. The audit identified issues with the completeness and reliability of data on the perinatal data management system.

Understanding determinants of unequal distribution of stillbirth in Tehran, Iran: a concentration index decomposition approach

OBJECTIVE

The present inquiry set to determine the economic inequality in history of stillbirth and understanding determinants of unequal distribution of stillbirth in Tehran, Iran.

METHODS

A population-based cross-sectional study was conducted on 5170 pregnancies in Tehran, Iran, since 2015. Principal component analysis (PCA) was applied to measure the asset-based economic status. Concentration index was used to measure socioeconomic inequality in stillbirth and then decomposed into its determinants.

RESULTS

The concentration index and its 95% CI for stillbirth was -0.121 (-0.235 to -0.002). Decomposition of the concentration index showed that mother's education (50%), mother's occupation (30%), economic status (26%) and father's age (12%) had the highest positive contributions to measured inequality in stillbirth history in Tehran. Mother's age (17%) had the highest negative contribution to inequality.

CONCLUSIONS

Stillbirth is unequally distributed among Iranian women and is mostly concentrated among low economic status people. Mother-related factors had the highest positive and negative contributions to inequality, highlighting specific interventions for mothers to redress inequality.

Seeking order amidst chaos: a systematic review of classification systems for causes of stillbirth and neonatal death, 2009-2014

BACKGROUND

Each year, about 5.3 million babies die in the perinatal period. Understanding of causes of death is critical for prevention, yet there is no globally acceptable classification system. Instead, many disparate systems have been developed and used. We aimed to identify all systems used or created between 2009 and 2014, with their key features, including extent of alignment with the International Classification of Diseases (ICD) and variation in features by region, to inform the World Health Organization's development of a new global approach to classifying perinatal deaths.

METHODS

A systematic literature review (CINAHL, EMBASE, Medline, Global Health, and PubMed) identified published and unpublished studies and national reports describing new classification systems or modifications of existing systems for causes of perinatal death, or that used or tested such systems, between 2009 and 2014. Studies reporting ICD use only were excluded. Data were independently double-extracted (except from non-English publications). Subgroup analyses explored variation by extent and region.

RESULTS

Eighty-one systems were identified as new, modifications of existing systems, or having been used between 2009 and 2014, with an average of ten systems created/modified each year. Systems had widely varying characteristics: (i) comprehensiveness (40 systems classified both stillbirths and neonatal deaths); (ii) extent of use (systems were created in 28 countries and used in 40; 17 were created for national use; 27 were widely used); (iii) accessibility (three systems available in e-format); (iv) underlying cause of death (64 systems required a single cause of death); (v) reliability (10 systems tested for reliability, with overall Kappa scores ranging from .35-.93); and (vi) ICD alignment (17 systems used ICD codes). Regional databases were not searched, so system numbers may be underestimated. Some non-differential misclassification of systems was possible.

CONCLUSIONS

The plethora of systems in use, and continuing system development, hamper international efforts to improve understanding of causes of death. Recognition of the features of currently used systems, combined with a better understanding of the drivers of continued system creation, may help the development of a truly effective global system.

Classification systems for causes of stillbirth and neonatal death, 2009-2014: an assessment of alignment with characteristics for an effective global system

Background

To reduce the burden of 5.3 million stillbirths and neonatal deaths annually, an understanding of causes of deaths is critical. A systematic review identified 81 systems for classification of causes of stillbirth (SB) and neonatal death (NND) between 2009 and 2014. The large number of systems hampers efforts to understand and prevent these deaths. This study aimed to assess the alignment of current classification systems with expert-identified characteristics for a globally effective classification system.

Methods

Eighty-one classification systems were assessed for alignment with 17 characteristics previously identified through expert consensus as necessary for an effective global system. Data were extracted independently by two authors. Systems were assessed against each characteristic and weighted and unweighted scores assigned to each. Subgroup analyses were undertaken by system use, setting, type of death included and type of characteristic.

Results

None of the 81 systems were aligned with more than 9 of the 17 characteristics; most (82 %) were aligned with four or fewer. On average, systems were aligned with 19 % of characteristics. The most aligned system (Frøen 2009-Codac) still had an unweighted score of only 9/17. Alignment with individual characteristics ranged from 0 to 49 %. Alignment was somewhat higher for widely used as compared to less used systems (22 % v 17 %), systems used only in high income countries as compared to only in low and middle income countries (20 % vs 16 %), and systems including both SB and NND (23 %) as compared to NND-only (15 %) and SB-only systems (13 %). Alignment was higher with characteristics assessing structure (23 %) than function (15 %).

Conclusions

There is an unmet need for a system exhibiting all the characteristics of a globally effective system as defined by experts in the use of systems, as none of the 81 contemporary classification systems assessed was highly aligned with these characteristics. A particular concern in terms of global effectiveness is the lack of alignment with “ease of use” among all systems, including even the most-aligned. A system which meets the needs of users would have the potential to become the first truly globally effective classification system.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1040-7) contains supplementary material, which is available to authorized users.

Towards reducing variations in infant mortality and morbidity: a population-based approach

Background

Our aims were (1) to improve understanding of regional variation in early-life mortality rates and the UK’s poor performance in international comparisons; and (2) to identify the extent to which late and moderately preterm (LMPT) birth contributes to early childhood mortality and morbidity.

Objective

To undertake a programme of linked population-based research studies to work towards reducing variations in infant mortality and morbidity rates.

Design

Two interlinked streams: (1) a detailed analysis of national and regional data sets and (2) establishment of cohorts of LMPT babies and term-born control babies.

Setting

Cohorts were drawn from the geographically defined areas of Leicestershire and Nottinghamshire, and analyses were carried out at the University of Leicester.

Data sources

For stream 1, national data were obtained from four sources: the Office for National Statistics, NHS Numbers for Babies, Centre for Maternal and Child Enquiries and East Midlands and South Yorkshire Congenital Anomalies Register. For stream 2, prospective data were collected for 1130 LMPT babies and 1255 term-born control babies.

Main outcome measures

Detailed analysis of stillbirth and early childhood mortality rates with a particular focus on factors leading to biased or unfair comparison; review of clinical, health economic and developmental outcomes over the first 2 years of life for LMPT and term-born babies.

Results

The deprivation gap in neonatal mortality has widened over time, despite government efforts to reduce it. Stillbirth rates are twice as high in the most deprived as in the least deprived decile. Approximately 70% of all infant deaths are the result of either preterm birth or a major congenital abnormality, and these are heavily influenced by mothers’ exposure to deprivation. Births at < 24 weeks’ gestation constitute only 1% of all births, but account for 20% of infant mortality. Classification of birth status for these babies varies widely across England. Risk of LMPT birth is greatest in the most deprived groups within society. Compared with term-born peers, LMPT babies are at an increased risk of neonatal morbidity, neonatal unit admission and poorer long-term health and developmental outcomes. Cognitive and socioemotional development problems confer the greatest long-term burden, with the risk being amplified by socioeconomic factors. During the first 24 months of life each child born LMPT generates approximately £3500 of additional health and societal costs.

Conclusions

Health professionals should be cautious in reviewing unadjusted early-life mortality rates, particularly when these relate to individual trusts. When more sophisticated analysis is not possible, babies of < 24 weeks’ gestation should be excluded. Neonatal services should review the care they offer to babies born LMPT to ensure that it is appropriate to their needs. The risk of adverse outcome is low in LMPT children. However, the risk appears higher for some types of antenatal problems and when the mother is from a deprived background.

Future work

Future work could include studies to improve our understanding of how deprivation increases the risk of mortality and morbidity in early life and investigation of longer-term outcomes and interventions in at-risk LMPT infants to improve future attainment.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Stillbirths: recall to action in high-income countries

Variation in stillbirth rates across high-income countries and large equity gaps within high-income countries persist. If all high-income countries achieved stillbirth rates equal to the best performing countries, 19,439 late gestation (28 weeks or more) stillbirths could have been avoided in 2015. The proportion of unexplained stillbirths is high and can be addressed through improvements in data collection, investigation, and classification, and with a better understanding of causal pathways. Substandard care contributes to 20-30% of all stillbirths and the contribution is even higher for late gestation intrapartum stillbirths. National perinatal mortality audit programmes need to be implemented in all high-income countries. The need to reduce stigma and fatalism related to stillbirth and to improve bereavement care are also clear, persisting priorities for action. In high-income countries, a woman living under adverse socioeconomic circumstances has twice the risk of having a stillborn child when compared to her more advantaged counterparts. Programmes at community and country level need to improve health in disadvantaged families to address these inequities.

Socioeconomic inequalities in stillbirth rates in Europe: measuring the gap using routine data from the Euro-Peristat Project

BACKGROUND

Previous studies have shown that socioeconomic position is inversely associated with stillbirth risk, but the impact on national rates in Europe is not known. We aimed to assess the magnitude of social inequalities in stillbirth rates in European countries using indicators generated from routine monitoring systems.

METHODS

Aggregated data on the number of stillbirths and live births for the year 2010 were collected for three socioeconomic indicators (mothers' educational level, mothers' and fathers' occupational group) from 29 European countries participating in the Euro-Peristat project. Educational categories were coded using the International Standard Classification of Education (ISCED) and analysed as: primary/lower secondary, upper secondary and postsecondary. Parents' occupations were grouped using International Standard Classification of Occupations (ISCO-08) major groups and then coded into 4 categories: No occupation or student, Skilled/ unskilled workers, Technicians/clerical/service occupations and Managers/professionals. We calculated risk ratios (RR) for stillbirth by each occupational group as well as the percentage population attributable risks using the most advantaged category as the reference (post-secondary education and professional/managerial occupations).

RESULTS

Data on stillbirth rates by mothers' education were available in 19 countries and by mothers' and fathers' occupations in 13 countries. In countries with these data, the median RR of stillbirth for women with primary and lower secondary education compared to women with postsecondary education was 1.9 (interquartile range (IQR): 1.5 to 2.4) and 1.4 (IQR: 1.2 to 1.6), respectively. For mothers' occupations, the median RR comparing outcomes among manual workers with managers and professionals was 1.6 (IQR: 1.0-2.1) whereas for fathers' occupations, the median RR was 1.4 (IQR: 1.2-1.8). When applied to the entire set of countries with data about mothers' education, 1606 out of 6337 stillbirths (25 %) would not have occurred if stillbirth rates for all women were the same as for women with post-secondary education in their country.

CONCLUSIONS

Data on stillbirths and socioeconomic status from routine systems showed widespread and consistent socioeconomic inequalities in stillbirth rates in Europe. Further research is needed to better understand differences between countries in the magnitude of the socioeconomic gradient.

Ethnic variation in stillbirth risk and the role of maternal obesity: analysis of routine data from a London maternity unit

BACKGROUND

Approximately 5 in 1,000 deliveries in England and Wales result in stillbirth, with little improvement in figures over the last few decades. The aim of this study was to investigate the association between clinical and socio-demographic factors and stillbirth, with a particular focus on ethnicity and obesity.

METHODS

Analysis of routine maternity data on 53,293 singleton births occurring in a large London teaching hospital between 2004 and 2012. Logistic regression was used to investigate risk factors for stillbirth and to explore potential effect modification.

RESULTS

53,293 deliveries occurred during the time period, of which 329 resulted in a stillbirth (6.2 per 1,000 births). Compared to White women, non-White ethnicity was associated with a doubling of the odds of stillbirth (aOR for Black women 2.15, 95% CI 1.56-2.97; aOR for South Asian women 2.33, 95% CI 1.42-3.83). Obese women had a trend towards higher odds of stillbirth compared to women of recommended BMI (aOR 1.38, 95% CI 0.98-1.96), though this was not significant (p 0.07). Both higher parity (≥2 compared to para 1) and hypertension were associated with a higher odds of stillbirth (parity ≥2 aOR 1.65, 95% CI 1.13-2.39; hypertension aOR 1.84, 95% CI 1.22-2.78) but there was no evidence that area deprivation or maternal age were independently associated with stillbirth in this population. There was some evidence of effect modification between ethnicity and obesity (p value for interaction 0.06), with obesity a particularly strong risk factor for stillbirth in South Asian women (aOR 4.64, 95% CI 1.84-11.70).

CONCLUSIONS

There was a high prevalence of stillbirth in this multi-ethnic urban population. The increased risk of stillbirth observed in non-White women remains after adjusting for other factors. Our finding of possible effect modification between ethnicity and obesity suggests that further research should be conducted in order to improve understanding of the interplay between ethnicity, obesity and stillbirth.

Exploration and confirmation of factors associated with uncomplicated pregnancy in nulliparous women: prospective cohort study

OBJECTIVE

To identify factors at 15 and 20 weeks' gestation associated with a subsequent uncomplicated pregnancy.

DESIGN

Prospective international multicentre observational cohort study.

SETTING

Auckland, New Zealand and Adelaide, Australia (exploration and local replication dataset) and Manchester, Leeds, and London, United Kingdom, and Cork, Republic of Ireland (external confirmation dataset).

PARTICIPANTS

5628 healthy nulliparous women with a singleton pregnancy.

MAIN OUTCOME MEASURE

Uncomplicated pregnancy, defined as a normotensive pregnancy delivered at >37 weeks' gestation, resulting in a liveborn baby not small for gestational age, and the absence of any other significant pregnancy complications. In a stepwise logistic regression the comparison group was women with a complicated pregnancy.

RESULTS

Of the 5628 women, 3452 (61.3%) had an uncomplicated pregnancy. Factors that reduced the likelihood of an uncomplicated pregnancy included increased body mass index (relative risk 0.74, 95% confidence intervals 0.65 to 0.84), misuse of drugs in the first trimester (0.90, 0.84 to 0.97), mean diastolic blood pressure (for each 5 mm Hg increase 0.92, 0.91 to 0.94), and mean systolic blood pressure (for each 5 mm Hg increase 0.95, 0.94 to 0.96). Beneficial factors were prepregnancy fruit intake at least three times daily (1.09, 1.01 to 1.18) and being in paid employment (per eight hours' increase 1.02, 1.01 to 1.04). Detrimental factors not amenable to alteration were a history of hypertension while using oral contraception, socioeconomic index, family history of any hypertensive complications in pregnancy, vaginal bleeding during pregnancy, and increasing uterine artery resistance index. Smoking in pregnancy was noted to be a detrimental factor in the initial two datasets but did not remain in the final model.

CONCLUSIONS

This study identified factors associated with normal pregnancy through adoption of a novel hypothesis generating approach, which has shifted the emphasis away from adverse outcomes towards uncomplicated pregnancies. Although confirmation in other cohorts is necessary, this study implies that individually targeted lifestyle interventions (normalising maternal weight, increasing prepregnancy fruit intake, reducing blood pressure, stopping misuse of drugs) may increase the likelihood of normal pregnancy outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12607000551493.