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

Definitions, terminology and standards for reporting of births and deaths in the perinatal period: International Classification of Diseases (ICD-11)

Despite efforts to reduce stillbirths and neonatal deaths, inconsistent definitions and reporting practices continue to hamper global progress. Existing data frequently being limited in terms of quality and comparability across countries. This paper addresses this critical issue by outlining the new International Classification of Disease (ICD-11) recommendations for standardized recording and reporting of perinatal deaths to improve data accuracy and international comparison. Key advancements in ICD-11 include using gestational age as the primary threshold to for reporting, clearer guidance on measurement and recording of gestational age, and reporting mortality rates by gestational age subgroups to enable country comparisons to include similar populations (e.g., all births from 154 days [22+0 weeks] or from 196 days [28+0 weeks]). Furthermore, the revised ICD-11 guidance provides further clarification around the exclusion of terminations of pregnancy (induced abortions) from perinatal mortality statistics. Implementing standardized recording and reporting methods laid out in ICD-11 will be crucial for accurate global data on stillbirths and perinatal deaths. Such high-quality data would both allow appropriate regional and international comparisons to be made and serve as a resource to improve clinical practice and epidemiological and health surveillance, enabling focusing of limited programmatic and research funds towards ending preventable deaths and improving outcomes for every woman and every baby, everywhere.

Perinatal loss in Tanzania: Perspectives of maternal-child healthcare providers

Over 98% of stillbirths and neonatal deaths occur in Low- and Middle-Income Countries, such as Tanzania. Despite the profound burden of perinatal loss in these regions, access to facility or community-based palliative and psychosocial care is poor and understudied. In this study we explore perinatal loss through the lens of front-line healthcare providers, to better understand the knowledge and beliefs that guide their engagement with bereaved families. A Knowledge Attitudes and Practices survey addressing perinatal loss in Tanzania was developed, translated into Swahili, and administered over a 4-month period to healthcare professionals working at the Kilimanjaro Christian Medical Center (KCMC). Results were entered into REDCap and analyzed in R Studio. 74 providers completed the survey. Pediatric providers saw a yearly average of 5 stillbirths and 32.7 neonatal deaths. Obstetric providers saw an average of 11.5 stillbirths and 13.12 neonatal deaths. Most providers would provide resuscitation beginning at 28 weeks gestational age. Respondents estimated that a 50% chance of survival for a newborn occurred at 28 weeks both nationally and at KCMC. Most providers felt that stillbirth and neonatal mortality were not the mother's fault (78.4% and 81.1%). However, nearly half (44.6%) felt that stillbirth reflects negatively on the woman and 62.2% agreed that women are at higher risk of abuse or abandonment after stillbirth. A majority perceived that women wanted hold their child after stillbirth (63.0%) or neonatal death (70.3%). Overall, this study found that providers at KCMC perceived that women are at greater risk of psychosocial or physical harm following perinatal loss. How women can best be supported by both the health system and their community remains unclear. More research on perinatal loss and bereavement in LMICs is needed to inform patient-level and health-systems interventions addressing care gaps unique to resource-limited or non-western settings.

Customization and acceptability of the WHO labor care guide to improve labor monitoring among health workers in Uganda. An iterative development, mixed method study

Cognisant of persistently high maternal and perinatal mortality rates, WHO called for adoption and evaluation of new adaptable and context-specific solutions to improve labor monitoring and health outcomes. We aimed at customizing/refining the new WHO labour care guide (LCG) to suite health care provider needs (HCP) in monitoring labour in Uganda. We used mixed methods to customize/refine and pilot test the new WHO LCG using stakeholder perspectives. Between 1st July 2023 and 30th December 2023, we conducted; 1)30 stakeholder interviews to identify user needs/challenges that informed initial modifications of the WHO LCG; 2)15 HCP in-depth interviews to identify any further needs to modify the LCG; 3) Two focus group discussions and 4) Two exit expert panels to identify any further user needs to further refine proposed modifications into the final prototype. Questionnaires were administered to assess acceptability. We interviewed 125 stakeholders with median age of 36 years (IQR;26-48) exposed to the LCG for at least 12 months with 11.8(SD = 4.6) years of clinical practice. Simple useful modifications/customizations based on format, HCP's perceived function and role in improving decision making during monitoring labour included; 1) Customizing LCG by adding key socio-demographic data; 2) Adjusting observation ordering; 3) Modification of medication dosages and 4) Provision for recording key clinical notes/labour outcome data on reverse side of the same A4 paper. All HCPs found the modified WHO LCG useful, easy to use, appropriate, comprehensive, appealing and would recommend it to others for labour monitoring. It was implementable and majority took less than 2 minutes to completely record/fill observations on the LCG after each labour assessment. Active involvement of end-users improved inclusiveness, ownership, acceptability and uptake. The modified LCG prototype was found to be simple, appropriate and easy-to-use. Further research to evaluate large-scale use, feasibility and effectiveness is warranted.

Labour Care Guide implementation as a decision-making tool for monitoring labour among healthcare providers in Uganda: protocol for a mixed-methods study

INTRODUCTION

The new WHO Labour Care Guide (LCG), also regarded as the 'next-generation partograph', is a core component of 2018 WHO consolidated guidelines on intrapartum care for positive childbirth experience. The Ugandan Ministry of Health is in the process of adopting the new WHO LCG with no local context-specific data to inform this transition. We will explore potential barriers and facilitators to healthcare providers' (HCPs) sustained engagement in labour monitoring in Mbarara city, Southwestern Uganda, and use the data to refine the new WHO LCG and develop a suitable implementation strategy to effectively integrate LCG into routine maternity care in Uganda. We shall then assess effectiveness, validity and other preliminary implementation outcomes of using the new LCG in detecting prolonged labour.

METHODS AND ANALYSIS

The study will use a mixed-methods approach to identify key LCG user perspectives to refine and customise the WHO LCG among 120 HCPs and stakeholders involved in maternity care and labour monitoring within facilities in Southwestern Uganda. The refined prototype will be deployed and used to monitor labour in all 14 basic and comprehensive emergency obstetric and newborn care facilities in the study area. We will review labour outcomes of 520 patients monitored using the new LCG and compare these outcomes with a historical cohort of 520 patients monitored using the partograph. The main effectiveness outcome will be the proportion of women diagnosed with prolonged labour and/or obstructed labour.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Mbarara University of Science and Technology Research Ethics Committee (MUST-2023-808) and Uganda National Council for Science and Technology (HS2864ES). We shall obtain written informed consent from each participant. The results of this study will be published in international peer-reviewed journals and presented to the Ugandan Ministry of Health as policy briefs and at selected national/international conferences.

TRIAL REGISTRATION NUMBER

NCT05979194.

Ending preventable stillbirths and improving bereavement care: a scorecard for high- and upper-middle income countries

BACKGROUND

Despite progress, stillbirth rates in many high- and upper-middle income countries remain high, and the majority of these deaths are preventable. We introduce the Ending Preventable Stillbirths (EPS) Scorecard for High- and Upper Middle-Income Countries, a tool to track progress against the Lancet's 2016 EPS Series Call to Action, fostering transparency, consistency and accountability.

METHODS

The Scorecard for EPS in High- and Upper-Middle Income Countries was adapted from the Scorecard for EPS in Low-Income Countries, which includes 20 indicators to track progress against the eight Call to Action targets. The Scorecard for High- and Upper-Middle Income Countries includes 23 indicators tracking progress against these same Call to Action targets. For this inaugural version of the Scorecard, 13 high- and upper-middle income countries supplied data. Data were collated and compared between and within countries.

RESULTS

Data were complete for 15 of 23 indicators (65%). Five key issues were identified: (1) there is wide variation in stillbirth rates and related perinatal outcomes, (2) definitions of stillbirth and related perinatal outcomes vary widely across countries, (3) data on key risk factors for stillbirth are often missing and equity is not consistently tracked, (4) most countries lack guidelines and targets for critical areas for stillbirth prevention and care after stillbirth and have not set a national stillbirth rate target, and (5) most countries do not have mechanisms in place for reduction of stigma or guidelines around bereavement care.

CONCLUSIONS

This inaugural version of the Scorecard for High- and Upper-Middle Income Countries highlights important gaps in performance indicators for stillbirth both between and within countries. The Scorecard provides a basis for future assessment of progress and can be used to help hold individual countries accountable, especially for reducing stillbirth inequities in disadvantaged groups.

Parents experiences of pregnancy following perinatal loss: An integrative review

BACKGROUND

Pregnancy following perinatal loss has a profound effect on parents and may contribute to intense psychological distress including grief, post-traumatic stress disorder, anxiety and depression. The subsequent pregnancy may also be perceived as more stressful due to the fear of recurrent loss. Midwives and other health care professionals need to be sensitive and empathetic to the needs of these parents when providing care in a pregnancy subsequent to a loss.

METHODOLOGY

The aim of this integrated literature review was to explore parents' experiences of pregnancy following a previous perinatal loss using a systematic approach. This is presented in a five-stage process that includes problem identification, literature search, data extraction and evaluation, data analysis and presentation of results. A systematic search of seven electronic databases was conducted (Jan 2009 -Jan 2023) to identify relevant primary research which addressed parents' experiences of pregnancy following a previous perinatal loss. Seven papers met the eligibility criteria and were assessed for quality using Crowe's Critical Appraisal Tool (CCAT). Thematic analysis identified two themes.

FINDINGS

The key themes identified from the literature were; the psychosocial needs and challenges faced by previously bereaved parents in subsequent pregnancies; and the need for specialist care and support in a subsequent pregnancy. Psychological needs and challenges included continued grief, depression, anxiety, and disparities in the grief process between men and women. The importance of specialist care with an increased level of support from competent, confident and compassionate health care providers was highlighted.

CONCLUSION

The experience of pregnancy following a perinatal loss can be a complex emotional experience for parents. The review identifies the need for post pregnancy loss debriefing and counselling and care pathways specific to caring for women and their partners in a pregnancy subsequent to a perinatal loss. Care in pregnancy subsequent to loss should be provided by empathetic, competent health care providers and include additional antenatal clinic appointments, pregnancy monitoring and psychological support in order to meet the needs of these expectant parents.

Stillbirth diagnosis and classification: comparison of ReCoDe and ICD-PM systems

OBJECTIVES

The identification of causes of stillbirth (SB) can be a challenge due to several different classification systems of SB causes. In the scientific literature there is a continuous emergence of SB classification systems, not allowing uniform data collection and comparisons between populations from different geographical areas. For these reasons, this study compared two of the most used SB classifications, aiming to identify which of them should be preferable.

METHODS

A total of 191 SBs were retrospectively classified by a panel composed by three experienced-physicians throughout the ReCoDe and ICD-PM systems to evaluate which classification minimizes unclassified/unspecified cases. In addition, intra and inter-rater agreements were calculated.

RESULTS

ReCoDe defined: the 23.6% of cases as unexplained, placental insufficiency in the 14.1%, lethal congenital anomalies in the 12%, infection in the 9.4%, abruptio in the 7.3%, and chorioamnionitis in the 7.3%. ICD-PM defined: the 20.9% of cases as unspecified, antepartum hypoxia in the 44%, congenital malformations, deformations, and chromosomal abnormalities in the 11.5%, and infection in the 11.5%. For ReCoDe, inter-rater was agreement of 0.58; intra-rater agreements were 0.78 and 0.79. For ICD-PM, inter-rater agreement was 0.54; intra-rater agreements were of 0.76 and 0.71.

CONCLUSIONS

There is no significant difference between ReCoDe and ICD-PM classifications in minimizing unexplained/unspecified cases. Inter and intra-rater agreements were largely suboptimal for both ReCoDe and ICD-PM due to their lack of specific guidelines which can facilitate the interpretation. Thus, the authors suggest correctives strategies: the implementation of specific guidelines and illustrative case reports to easily solve interpretation issues.

Cardiac ion channels associated with unexplained stillbirth - an immunohistochemical study

OBJECTIVES

Despite the use of post-mortem investigations, approximately 20% of stillbirths remain unexplained. Cardiac ion channelopathies have been identified as a cause of death in Sudden Infant Death Syndrome (SIDS) and could be associated with unexplained stillbirths. This study aimed to understand if the expression or localisation of cardiac ion channels associated with channelopathies were altered in cases of unexplained stillbirths.

METHODS

A case control study was conducted using formalin-fixed cardiac tissue from 20 cases of unexplained stillbirth and a control group of 20 cases of stillbirths from intrapartum hypoxia. 4 µm tissue sections were stained using haematoxylin and eosin, Masson's trichrome (MT) and Elastic van Gieson (EVG). Immunohistochemistry (IHC) was performed using antibodies against CACNA1G, KCNJ2, KCNQ1, KCNH2 and KCNE1. The cardiac conduction system in samples stained with MT and EVG could not be identified. Therefore, the levels of immunoperoxidase staining were quantified using QuPath software.

RESULTS

The nuclear-cytoplasmic ratio of sections stained with haematoxylin and eosin was higher for the hypoxia group (hypoxia median 0.13 vs. 0.04 unexplained, p < 0.001). CACNA1G (unexplained median 0.26 vs. hypoxia 0.30, p=0.009) and KCNJ2 (unexplained median 0.35 vs. hypoxia 0.41, p=0.001) had lower staining intensity in the unexplained stillbirth group. There were no statistically significant differences in the staining intensity of KCNQ1, KCNH2 and KCNE1.

CONCLUSIONS

Two ion channels associated with channelopathies demonstrated lower levels of expression in cases of unexplained stillbirth. Further genetic studies using human tissue should be performed to understand the association between channelopathies and otherwise unexplained stillbirths.

Insights on the differentiation of stillbirths and early neonatal deaths: A study from the Child Health and Mortality Prevention Surveillance (CHAMPS) network

Introduction

The high burden of stillbirths and neonatal deaths is driving global initiatives to improve birth outcomes. Discerning stillbirths from neonatal deaths can be difficult in some settings, yet this distinction is critical for understanding causes of perinatal deaths and improving resuscitation practices for live born babies.

Methods

We evaluated data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network to compare the accuracy of determining stillbirths versus neonatal deaths from different data sources and to evaluate evidence of resuscitation at delivery in accordance with World Health Organization (WHO) guidelines. CHAMPS works to identify causes of stillbirth and death in children <5 years of age in Bangladesh and 6 countries in sub-Saharan Africa. Using CHAMPS data, we compared the final classification of a case as a stillbirth or neonatal death as certified by the CHAMPS Determining Cause of Death (DeCoDe) panel to both the initial report of the case by the family member or healthcare worker at CHAMPS enrollment and the birth outcome as stillbirth or livebirth documented in the maternal health record.

Results

Of 1967 deaths ultimately classified as stillbirth, only 28 (1.4%) were initially reported as livebirths. Of 845 cases classified as very early neonatal death, 33 (4%) were initially reported as stillbirth. Of 367 cases with post-mortem examination showing delivery weight >1000g and no maceration, the maternal clinical record documented that resuscitation was not performed in 161 cases (44%), performed in 14 (3%), and unknown or data missing for 192 (52%).

Conclusion

This analysis found that CHAMPS cases assigned as stillbirth or neonatal death after DeCoDe expert panel review were generally consistent with the initial report of the case as a stillbirth or neonatal death. Our findings suggest that more frequent use of resuscitation at delivery and improvements in documentation around events at birth could help improve perinatal outcomes.

Intra-urban differentials of fetal mortality in clusters of social vulnerability in São Paulo Municipality, Brazil

This study aimed to analyze the distribution of stillbirths by birth weight, type of death, the trend of Stillbirth Rate (SBR), and avoidable causes of death, according to social vulnerability clusters in São Paulo Municipality, 2007-2017. Social vulnerability clusters were created with the k-means method. The Prais-Winsten generalized linear regression was used in the trend of SBR by < 2500 g,  ≥ 2500 g, and total deaths analysis. The Brazilian list of avoidable causes of death was adapted for stillbirths. There was a predominance of antepartum stillbirths (70%). There was an increase in SBR with the growth of social vulnerability from the center to the outskirts of the city. The cluster with the highest vulnerability presented SBR 69% higher than the cluster with the lowest vulnerability. SBR ≥ 2500 g was decreasing in the clusters with the high vulnerability. There was an increase in SBR of avoidable causes of death of the cluster from the lowest to the highest vulnerability. Ill-defined causes of death accounted for 75% of deaths in the highest vulnerability area. Rates of fetal mortality and avoidable causes of death increased with social vulnerability. The trend of reduction of SBR ≥ 2500 g may suggest improvement in prenatal care in areas of higher vulnerability.

[Avoidability of fetal deaths: reflections on the Brazilian List of Avoidable Causes of Deaths through interventions by the Brazilian Unified National Health System]

Although the Brazilian List of Avoidable Causes of Deaths (LBE in Portuguese), in its version for children under 5 years of age (LBE < 5), does not include stillbirths, some studies have used the list with or without adaptations. We present a proposal for adaptation of the LBE for stillbirths (LBE-OF in Portuguese) and the results of its application to stillbirths in the State of Rio de Janeiro, Brazil, in 2018, compared to the results with LBE < 5. We reviewed the categories from the 10th revision of the International Classification of Diseases (ICD-10) in the LBE < 5 and reassigned them in the avoidability groups, according to time of death in relation to delivery and the causes consistent with stillbirths. Conditions that did not elucidate the determinants of death were allocated as ill-defined causes. Stillbirths in the State of Rio de Janeiro, selected from the databases of the Mortality Information System (SIM in Portuguese), were classified according to LBE-OF and LBE < 5. When classifying the 2,585 stillbirths that occurred in the State of Rio de Janeiro in 2018, we found that according to LBE < 5, there were predominantly causes "reducible by adequate care in labor and delivery" (42.9%), while according to LBE-OF, the most frequent causes were "reducible by adequate care for during pregnancy" (43.6%). Ill-defined causes ranked second according to the LBE-OF (35.4%) and third according to LBE < 5. Some 30% of stillbirths changed groups and subgroups of avoidability, showing greater consistency with the profile of obstetric care. Although identifying a higher percentage of ill-defined causes, the LBE-OF is more consistent with the pathophysiology of fetal deaths. The inclusion of stillbirths in the SIM would be a positive step in monitoring and upgrading the investigation of causes of fetal death.

[Contributions by the investigation of fetal deaths for improving the definition of underlying cause of death in the city of São Paulo, Brazil]

This study aimed to analyze the time trend in stillbirth rate (SBR) and the contribution by investigation to improving the definition of underlying cause of stillbirth in the city of São Paulo, Brazil, according to the place where the death certificate was issued. An ecological approach was used to analyze the trend in SBR by weight stratum (< 2,500g and ≥ 2,500g) and total deaths in the city in 2007-2017. Prais-Winsten generalized linear regression was used. The study of cases analyzed the underlying causes of stillbirth from 2012 to 2014, before and after the investigation, time of conclusion of the investigation, and redefinition of the underlying cause of stillbirths by type of issuer. In deaths with < 2,500g, there was an upward trend in SBR of 1.5% per year and a reduction (-1.3% per year) in stillbirths ≥ 2,500g. Total deaths presented a stable trend. In 2012-2014, 90% of deaths with ≥ 2,500g were investigated. After investigation, the underlying cause of death was redefined in 15% of the deaths, and not otherwise specified stillbirth (P95) represented 25% of the causes of death. The highest proportion of changes in the underlying cause of death occurred in deaths for which the death certificate was issued by the death certification review service (17%), while in health services the proportion was 10.6%. In conclusion, the SBR in deaths with ≥ 2,500g showed a downward trend. There was a significant redefinition of underlying causes, especially in those attested by the death certification review service. However, the redefinition was insufficient to expand the proportion of causes of death that would allow a better understanding of the mortality conditions.

Neonatal mortality burden and trends in UNHCR refugee camps, 2006-2017: a retrospective analysis

Background

More than 100 million people were forcibly displaced over the last decade, including millions of refugees displaced across international borders. Although refugee health and well-being has gained increasing attention from researchers in recent years, few studies have examined refugee birth outcomes or newborn health on a regional or global scale. This study uses routine health information system data to examine neonatal mortality burden and trends in refugee camps between 2006 and 2017.

Methods

Refugee population and mortality data were exported from the United Nations High Commissioner for Refugees (UNHCR) Health Information System (HIS) database. Tableau was used to export the data. Stata was used for data cleaning and statistical analysis. Neonatal mortality burdens and trends in refugee camps were analyzed and compared to national and subnational neonatal mortality rates captured by household surveys.

Findings

One hundred fifty refugee camps in 21 countries were included in this study, with an average population of 1,725,433 between 2006 and 2017. A total of 663,892 live births and 3382 neonatal deaths were captured during this period. Annual country-level refugee camp neonatal mortality rates (NMR) ranged from 12 to 56 neonatal deaths per 1000 live births. In most countries and years where national population-based surveys are available, refugee camp NMR as reported in the UNHCR HIS was lower than that of the immediate host community.

Conclusion

The UNHCR HIS provides insights into the neonatal mortality burden among refugees in camp settings and issues to consider in design and use of routine health information systems to monitor neonatal health in sub-national populations. Increased visibility of neonatal deaths and stillbirths among displaced populations can drive advocacy and inform decisions needed to strengthen health systems. Efforts to count every stillbirth and neonatal death are critical, as well as improvements to reporting systems and mechanisms for data review within broader efforts to improve the quality of neonatal care practices within and outside of health facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10343-5.

The effect of antenatal care on perinatal outcomes in Ethiopia: A systematic review and meta-analysis

BACKGROUND

The estimated annual global perinatal and neonatal death is four million. Stillbirths are almost equivalent to neonatal mortality, yet they have not received the same attention. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but its effectiveness as a means of reducing perinatal mortality has not been evaluated in Ethiopia. Therefore, we will identify the pooled effect of antenatal care on perinatal outcomes in Ethiopia.

METHODS

Medline, Embase, Cinahl, African journal online and Google Scholar was searched for articles published in English language between January 1990 and May 2020. Two independent assessors selected studies and extracted data from eligible articles. The Risk of Bias Assessment tool for Non-Randomized Studies was used to assess the quality of each included study. Data analysis was performed using RevMan 5.3. Heterogeneity and publication bias were assessed using I2 test statistical significance and Egger's test for small-study effects respectively. The random effect model was employed, and forest plot was used to present the risk ratio (RR) with 95% confidence interval (CI).

RESULTS

Thirteen out of seventeen included studies revealed antenatal care utilization had a significant association with perinatal outcomes. The pooled risk ratio by the random-effects model for perinatal death was 0.42 (95% CI: 0.34, 0.52); stillbirth 0.34 (95% CI: 0.25, 0.46); early neonatal death 0.85 (95% CI: 0.21. 3.49).

CONCLUSION

Women who attended at least one antenatal care visit were more likely to give birth to an alive neonate that survives compared to their counterpart. Therefore, the Ethiopian Ministry of health and other stakeholders should design tailored interventions to increase antenatal care utilization since it has been shown to reduce perinatal mortality.

The application of WHO ICD-PM: Feasibility for the classification of timing and causes of perinatal deaths in a busy birth centre in a low-income country

OBJECTIVE

To assess the feasibility of the application of International Classification of Diseases-10-to perinatal mortality (ICD-PM) in a busy low-income referral hospital and determine the timing and causes of perinatal deaths, and associated maternal conditions.

DESIGN

Prospective application of ICD-PM.

SETTING

Referral hospital of Mnazi Mmoja Hospital, Zanzibar, United Republic of Tanzania.

POPULATION

Stillbirths and neonatal deaths with a birth weight above 1000 grams born between October 16th 2017 to May 31st 2018.

METHODS

Clinical information and an adapted WHO ICD-PM interactive excel-based system were used to capture and classify the deaths according to timing, causes and associated maternal complications. Descriptive analysis was performed.

MAIN OUTCOME MEASURES

Timing and causes of perinatal mortality and their associated maternal conditions.

RESULTS

There were 661 perinatal deaths of which 248 (37.5%) were neonatal deaths and 413 (62.5%) stillbirths. Of the stillbirths, 128 (31%) occurred antepartum, 129 (31%) intrapartum and for 156 (38%) the timing was unknown. Half (n = 64/128) of the antepartum stillbirths were unexplained. Two-thirds (67%, n = 87/129) of intrapartum stillbirths followed acute intrapartum events, and 30% (39/129) were unexplained. Of the neonatal deaths, 40% died after complications of intrapartum events.

CONCLUSION

Problems of documentation, lack of perinatal death audits, capacity for investigations, and guidelines for the unambiguous objective assignment of timing and primary causes of death are major threats for accurate determination of timing and specific primary causes of perinatal deaths.

A comparison of three classification systems for stillbirth

BACKGROUND

Understanding the causes of perinatal death can provide relevant information to couples, caregivers, and society. Classification systems play a crucial role in identifying the most relevant conditions suggesting preventive measures for decreasing stillbirth (SB). In 2016 the International Classification of Disease to Deaths during the Perinatal Period (ICD-PM) was released with the aim to suggest a universally accepted classification.

METHODS

This is a prospective cohort study that enrolled all SBs occurred in Emilia-Romagna, from 2014 to 2017. We prospectively applied ReCoDe classification and retrospectively used Simplified CODAC classification and ICD-PM. The aim of this study is to compare different classification systems on a cohort of SBs, undergoing a comprehensive workup, to establish what classification minimizes rates of unexplained SB.

RESULTS

We registered 443 SBs. According to ReCoDe the largest category of SB was "placental insufficiency/infarction" (16.9%), followed by "abruptio placentae" (14.2%). Unexplained cases are 16.7%. Gestational age <37 weeks is less frequent in the group of women with unclassified SB (OR 0.50, OR95%CI [0.3-0.8]) against women with classified SB. Considering CODAC the two largest categories are "infarctions or thrombi" (16.3%) and "abruption or retro-placental haematoma" (15.1%), instead only 17.2% of cases remained unexplained.

CONCLUSIONS

Comparing ReCoDe and CODAC we found no real difference in any category. ReCoDe and CODAC better underlines the primary cause of death. ICD-PM reveals to be easily applicable to clinical practice. ICD-PM has the lowest rate of unexplained SBs (9.3%) due to the structure itself and not to a deeper comprehension of death.

Stillbirth 2010-2018: a prospective, population-based, multi-country study from the Global Network

BACKGROUND

Stillbirth rates are high and represent a substantial proportion of the under-5 mortality in low and middle-income countries (LMIC). In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented cause of stillbirths or the trends in rate of stillbirth over time.

METHODS

We undertook a prospective, population-based multi-country research study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, Democratic Republic of Congo, India, Pakistan, and Guatemala). Staff collected demographic and health care characteristics with outcomes obtained at delivery. Cause of stillbirth was assigned by algorithm.

RESULTS

From 2010 through 2018, 573,148 women were enrolled with delivery data obtained. Of the 552,547 births that reached 500 g or 20 weeks gestation, 15,604 were stillbirths; a rate of 28.2 stillbirths per 1000 births. The stillbirth rates were 19.3 in the Guatemala site, 23.8 in the African sites, and 33.3 in the Asian sites. Specifically, stillbirth rates were highest in the Pakistan site, which also documented a substantial decrease in stillbirth rates over the study period, from 56.0 per 1000 (95% CI 51.0, 61.0) in 2010 to 44.4 per 1000 (95% CI 39.1, 49.7) in 2018. The Nagpur, India site also documented a substantial decrease in stillbirths from 32.5 (95% CI 29.0, 36.1) to 16.9 (95% CI 13.9, 19.9) per 1000 in 2018; however, other sites had only small declines in stillbirth over the same period. Women who were less educated and older as well as those with less access to antenatal care and with vaginal assisted delivery were at increased risk of stillbirth. The major fetal causes of stillbirth were birth asphyxia (44.0% of stillbirths) and infectious causes (22.2%). The maternal conditions that were observed among those with stillbirth were obstructed or prolonged labor, antepartum hemorrhage and maternal infections.

CONCLUSIONS

Over the study period, stillbirth rates have remained relatively high across all sites. With the exceptions of the Pakistan and Nagpur sites, Global Network sites did not observe substantial changes in their stillbirth rates. Women who were less educated and had less access to antenatal and obstetric care remained at the highest burden of stillbirth.

STUDY REGISTRATION

Clinicaltrials.gov (ID# NCT01073475).

Retrospective study 2005-2015 of all cases of fetal death occurred at ≥23 gestational weeks, in Friuli Venezia Giulia, Italy

Background

Intrauterine fetal death (IUFD) is a tragic event and, despite efforts to reduce rates, its incidence remains difficult to reduce. The objective of the present study was to examine the etiological factors that contribute to the main causes and conditions associated with IUFD, over an 11-year period in a region of North-East Italy (Friuli Venezia Giulia) for which reliable data in available.

Methods

Retrospective analysis of all 278 IUFD cases occurred between 2005 and 2015 in pregnancies with gestational age ≥ 23 weeks.

Results

The incidence of IUFD was 2.8‰ live births. Of these, 30% were small for gestational age (SGA), with immigrant women being significantly over-represented. The share of SGA reached 35% in cases in which a maternal of fetal pathological condition was present, and dropped to 28% in the absence of associated pathology. In 78 pregnancies (28%) no pathology was recorded that could justify IUFD. Of all IUFDs, 11% occurred during labor, and 72% occurred at a gestational age above 30 weeks.

Conclusion

The percentage of IUFD cases for which no possible cause can be identified is quite high. Only the adoption of evidence-based diagnostic protocols, with integrated immunologic, genetic and pathologic examinations, can help reduce this diagnostic gap, contributing to the prevention of future IUFDs.

Women's Choice to Deliver at Home: Understanding the Psychosocial and Cultural Factors Influencing Birthing Choices for Unskilled Home Delivery among Women in Southwestern Uganda

BACKGROUND

Utilization of perinatal services in Uganda remains low, with correspondingly high rates of unskilled home deliveries, which can be life-threatening. We explored psychosocial and cultural factors influencing birthing choices for unskilled home delivery among postpartum women in rural southwestern Uganda.

METHODS

We conducted in-depth qualitative face-to-face interviews with 30 purposively selected women between December 2018 and March 2019 to include adult women who delivered from their homes and health facility within the past three months. Women were recruited from 10 villages within 20 km from a referral hospital. Using the constructs of the Health Utilization Model (HUM), interview topics were developed. Interviews were conducted and digitally recorded in a private setting by a native speaker to elicit choices and experiences during pregnancy and childbirth. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive categories using inductive content analytic approach.

RESULTS

Eighteen women (60%) preferred to deliver from home. Women's referent birth location was largely intentional. Overall, the data suggest women choose home delivery (1) because of their financial dependency and expectation for a "natural" and normal childbirth, affecting their ability and need to seek skilled facility delivery; (2) as a means of controlling their own birth processes; (3) out of dissatisfaction with facility-based care; (4) out of strong belief in fate regarding birth outcomes; (5) because they have access to alternative sources of birthing help within their communities, perceived as "affordable," "supportive," and "convenient"; and (6) as a result of existing gender and traditional norms that limit their ability and freedom to make family or health decisions as women.

CONCLUSION

Women's psychosocial and cultural understandings of pregnancy and child birth, their established traditions, birth expectations, and perceptions of control, need, and quality of maternity care at a particular birthing location influenced their past and future decisions to pursue home delivery. Interventions to address barriers to healthcare utilization through a multipronged approach could help to debunk misconceptions, increase perceived need, and motivate women to seek facility delivery.

A missense mutation of ErbB2 produces a novel mouse model of stillbirth associated with a cardiac abnormality but lacking abnormalities of placental structure

Background

In humans, stillbirth describes the death of a fetus before birth after 28 weeks gestation, and accounts for approximately 2.6 million deaths worldwide annually. In high-income countries, up to half of stillbirths have an unknown cause and are described as “unexplained stillbirths”; this lack of understanding impairs efforts to prevent stillbirth. There are also few animal models of stillbirth, but those that have been described usually have significant placental abnormalities. This study describes a novel mutant murine model of fetal death with atrial conduction block due to an ErbB2 missense mutation which is not associated with abnormal placental morphology.

Methods

Phenotypic characterisation and histological analysis of the mutant mouse model was conducted. The mRNA distribution of the early cardiomyocyte marker Nkx2-5 was assessed via in situ hybridisation. Cardiac structure was quantified and cellular morphology evaluated by electron microscopy. Immunostaining was employed to quantify placental structure and cell characteristics on matched heterozygous and homozygous mutant placental samples.

Results

There were no structural abnormalities observed in hearts of mutant embryos. Comparable Nkx2-5 expression was observed in hearts of mutants and controls, suggesting normal cardiac specification. Additionally, there was no significant difference in the weight, placenta dimensions, giant cell characteristics, labyrinth tissue composition, levels of apoptosis, proliferation or vascularisation between placentas of homozygous mutant mice and controls.

Conclusion

Embryonic lethality in the ErbB2 homozygous mutant mouse cannot be attributed to placental pathology. As such, we conclude the ErbB2^M802R mutant is a model of stillbirth with a non-placental cause of death. The mechanism of the atrial block resulting from ErbB2 mutation and its role in embryonic death is still unclear. Studying this mutant mouse model could identify candidate genes involved in stillbirth associated with structural or functional cardiac defects.

Genetic innovations and our understanding of stillbirth

Stillbirth after 20 weeks gestation happens in 1 in 200 pregnancies and occurs more commonly than neonatal loss and sudden infant death syndrome (SIDs) combined. The stillbirth rate is several times greater in low as opposed to high-resource countries. However, among high-resource countries, although a lower overall stillbirth rate exists, there has been little change for several decades. Molecular genetic technologies are emerging as important contributors to our understanding of stillbirth. Initially, genetic etiologies included alterations in chromosome number or structure such as aneuploidy and microduplications and deletions. More recently, next-generation sequencing analysis in two genetic conditions, Smith Lemli Optiz Syndrome (SLOs) and the channelopathy disorders (such as long QT syndrome (LQTS)) provide examples into the association of pathogenic gene variants with stillbirth. Although these specific conditions individually account for only a small number of stillbirths, investigating these disorders provides a new and innovative approach for further understanding genetic contributors to adverse pregnancy outcomes. Our knowledge of the role of genetic disease as an etiology for stillbirth is elementary. Genomic interrogation of maternal-fetal genotypes, gene-gene, and genotype-environment interaction is lacking in stillbirth research. At the DNA sequence level, further investigation of variants of unknown significance is an opportunity for exploration of biologic pathways of importance to pregnancy loss. This review concentrates on SLO as an example of a single gene disorder with a high carrier but low affected liveborn proband rate. The channelopathy disorders are included as initial examples of genetic conditions with variable presentation including an association with sudden infant death syndrome. Highlighted are the challenges when numerous genes and variants are involved, and the task of assigning pathogenicity. The advantages and limitations of genetic evaluations are presented and avenues for further research considered.

Review of the evidence for interventions to reduce perinatal mortality in low- and middle-income countries

Low- and middle-income countries contribute to the overwhelming majority of the global perinatal and neonatal mortality. There is a growing amount of literature focused on interventions aimed at reducing the healthcare gaps and thereby reducing perinatal and neonatal mortality in low- and middle-income countries. The current review synthesizes available evidence for interventions that have shown to improve perinatal and neonatal outcomes. Reduction in important gaps in the availability and utilization of perinatal care practices is needed to end preventable deaths of newborns.

A simple classification of peritoneal contamination in perforated appendicitis predicts surgery-related complications

AIM

Perforated appendicitis has poorer clinical outcomes compared to non-perforated appendicitis. However, accurate outcome comparisons in research and clinical audits are challenged by its wide spectrum of manifestation. Previous attempts at the classification of severity have been complex and difficult to reproduce. In our study, we used another institution's (Jones et al., TX, USA) previously described simple classification system of peritoneal contamination and examined its usefulness in predicting outcomes.

METHODS

With ethical approval, we retrospectively reviewed the records of all paediatric patients operated at our institution for perforated appendicitis from 2016 to 2017. Patient demographics, intra-operative and histological findings, post-operative outcomes and length of stay were collected. Patients were categorised into group 1 (purulence in right lower quadrant only) and group 2 (contamination in two or more quadrants). Post-operative complications were defined as procedure-related (e.g. post-operative ileus, intra-abdominal abscess, visceral injury) and non-procedure-related (e.g. bronchospasm). Statistical analysis using χ² tests for categorical data and Mann-Whitney U-tests for non-parametric continuous variables was performed, with a significance of P < 0.05.

RESULTS

There were 134 eligible patients. We excluded 19 with incomplete data, leaving 115 for analysis, of which 69 (60%) were in group 2. Those in group 2 had a longer stay (P = 0.005) and more post-operative complications (P = 0.001), particularly procedure-related events (P = 0.006). There were no differences in age (P = 0.182), gender (P = 0.876), readmission rate (P = 0.317) and non-procedure-related post-operative complications (0.152).

CONCLUSION

This simple classification of perforated appendicitis appears to differentiate clinical outcomes well, particularly for iatrogenic morbidity, making it useful for operative preparation and outcomes research.

Application of the International Classification of Diseases for Perinatal Mortality (ICD-PM) to vital statistics records for the purpose of classifying perinatal deaths in Antioquia, Colombia

Objective

To describe perinatal mortality in the Department of Antioquia based on the WHO International Classification of Diseases (ICD-PM) and determine the feasibility of applying this classification system to the official records on vital statistics.

Materials and methods

Descriptive study of the causes of perinatal death according to the time of death in relation to the time of delivery and associated maternal conditions. The primary source was the official database of vital statistics for the period between 2013 and 2016. The variables measured were maternal age, gestational age and weight at the time of birth, area of residence, type of delivery, and causes of death, including direct and associated causes, and other pathological conditions. A descriptive analysis is performed, causes are presented in terms of absolute numbers and percentages, and distributed according to the timing of death in relation to childbirth and birthweight.

Results

Of 3901 perinatal deaths occurring in fetuses 22 weeks or more of gestational age or a minimum weight of 500 g, and up to 28 days of life, 1404 (36.0%) occurred before delivery, 378 (9.7%) during the intrapartum period, 1760 (45.1%) during the neonatal period, and 359 (9.2%) cases had no information regarding the time of death in relation to the time of delivery. The main causes of death of the neonates weighing 1000 g or more were congenital malformations, deformities and chromosomal abnormalities (30.2%), antepartum and intrapartum hypoxia (29.3%), and infection (12.3%). In 69.5% of cases, no associated maternal causes were identified and in those in which there were related causes, the most frequent was placenta, cord and membrane complications (16.8%).

Conclusion

The ICD-PM is a system globally applicable to records of vital statistics, enabling the characterization of perinatal mortality in the Department.

Newborn Resuscitation in Settings Without Access to Supplemental Oxygen

Low- and middle-income countries and resource-limited regions are major contributors to perinatal and infant mortality. Oxygen is widely used for resuscitation in high- and middle-income settings. However, oxygen supplementation is not available in resource-limited regions. Oxygen supplementation for resuscitation at birth has adverse effects in human/animal model studies. There has been a change with resultant recommendations for restrictive oxygen use in neonatal resuscitation. Neonatal resuscitation without supplemental oxygen decreases mortality and morbidities. Oxygen in resource-limited settings for neonatal resuscitation is ideal as a backup for selected resuscitations but should not be a limiting factor for implementing basic life-saving efforts.

A regional audit system for stillbirth: a way to better understand the phenomenon

Background

Implementation of high-quality national audits for perinatal mortality are needed to improve the registration of all perinatal deaths and the identification of the causes of death. This study aims to evaluate the implementation of a Regional Audit System for Stillbirth in Emilia-Romagna Region, Italy.

Methods

For each stillbirth (≥ 22 weeks of gestation, ≥ 500 g) occurred between January 1, 2014 to December 1, 2016 (n = 332), the same diagnostic workup was performed and a clinical record with data about mother and stillborn was completed. Every case was discussed in a multidisciplinary local audit to assess both the cause of death (ReCoDe classification) and the quality of care. Data were reviewed by the Regional Audit Group. Stillbirth rates, causes of death and the quality of care were established for each case.

Results

Total stillbirth rate was 3.09 per 1000 births (332/107,528). Late stillbirth rate was 2.3 per 1000 (251/107,087). Sixteen stillbirths were not registered by the Regional Birth Register. The most prevalent cause of death was placental disorder (33.3%), followed by fetal (17.6%), cord (14.2%) and maternal disorders (7.6%). Unexplained cases were 14%. Compared to local audits, the regional group attributed different causes of death in 17% of cases. At multivariate analysis, infections were associated with early stillbirths (OR 3.38, CI95% 1.62–7.03) and intrapartum cases (OR 6.64, CI95% 2.61–17.02). Placental disorders were related to growth restriction (OR 1.89, CI95% 1.06–3.36) and were more frequent before term (OR 1.86, CI95% 1.11–3.15). Stillbirths judged possibly/probably preventable with a different management (10.9%) occurred more frequently in non-Italian women and were mainly related to maternal disorders (OR 6.64, CI95% 2.61–17.02).

Conclusions

Regional Audit System for Stillbirth improves the registration of stillbirth and allows to define the causes of death. Moreover, sub-optimal care was recognized, allowing to identify populations which could benefit from preventive measures.

Applying the international classification of diseases to perinatal mortality data, South Africa

Objective

To examine the feasibility of applying the International Classification of Diseases-perinatal mortality (ICD-PM) coding to an existing data set in the classification of perinatal deaths.

Methods

One author, a researcher with a non-clinical public health background, applied the ICD-PM coding system to South Africa’s national perinatal mortality audit system, the Perinatal Problem Identification Program. The database for this study included all perinatal deaths (n = 26 810), defined as either stillbirths (of birth weight > 1000 g and after 28 weeks of gestation) or early neonatal deaths (age 0–7 days), that occurred between 1 October 2013 and 31 December 2016. A clinical obstetrician verified the coding.

Findings

The South African classification system does not include the timing of death; however, under the ICD-PM system, deaths could be classified as antepartum (n = 15 619; 58.2%), intrapartum (n = 3725; 14.0%) or neonatal (n = 7466; 27.8%). Further, the South African classification system linked a maternal condition to only 40.3% (10 802/26 810) of all perinatal deaths; this proportion increased to 68.9% (18 467/26 810) under the ICD-PM system.

Conclusion

The main benefit of using the clinically relevant and user-friendly ICD-PM system was an enhanced understanding of the data, in terms of both timing of death and maternal conditions. We have also demonstrated that it is feasible to convert an existing perinatal mortality classification system to one which is globally comparable and can inform policy-makers internationally.

Interventions for investigating and identifying the causes of stillbirth

BACKGROUND

Identification of the causes of stillbirth is critical to the primary prevention of stillbirth and to the provision of optimal care in subsequent pregnancies. A wide variety of investigations are available, but there is currently no consensus on the optimal approach. Given their cost and potential to add further emotional burden to parents, there is a need to systematically assess the effect of these interventions on outcomes for parents, including psychosocial outcomes, economic costs, and on rates of diagnosis of the causes of stillbirth.

OBJECTIVES

To assess the effect of different tests, protocols or guidelines for investigating and identifying the causes of stillbirth on outcomes for parents, including psychosocial outcomes, economic costs, and rates of diagnosis of the causes of stillbirth.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (31 August 2017), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (15 May 2017).

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. We planned to include studies published as abstract only, provided there was sufficient information to allow us to assess study eligibility. We planned to exclude cross-over trials.Participants included parents (including mothers, fathers, and partners) who had experienced a stillbirth of 20 weeks' gestation or greater.This review focused on interventions for investigating and identifying the causes of stillbirth. Such interventions are likely to be diverse, but could include:* review of maternal and family history, and current pregnancy and birth history;* clinical history of present illness;* maternal investigations (such as ultrasound, amniocentesis, antibody screening, etc.);* examination of the stillborn baby (including full autopsy, partial autopsy or noninvasive components, such as magnetic resonance imaging (MRI), computerised tomography (CT) scanning, and radiography);* umbilical cord examination;* placental examination including histopathology (microscopic examination of placental tissue); and* verbal autopsy (interviews with care providers and support people to ascertain causes, without examination of the baby).We planned to include trials assessing any test, protocol or guideline (or combinations of tests/protocols/guidelines) for investigating the causes of stillbirth, compared with the absence of a test, protocol or guideline, or usual care (further details are presented in the Background, see Description of the intervention).We also planned to include trials comparing any test, protocol or guideline (or combinations of tests/protocols/guidelines) for investigating the causes of stillbirth with another, for example, the use of a limited investigation protocol compared with a comprehensive investigation protocol.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility independently.

MAIN RESULTS

We excluded five studies that were not RCTs. There were no eligible trials for inclusion in this review.

AUTHORS' CONCLUSIONS

There is currently a lack of RCT evidence regarding the effectiveness of interventions for investigating and identifying the causes of stillbirth. Seeking to determine the causes of stillbirth is an essential component of quality maternity care, but it remains unclear what impact these interventions have on the psychosocial outcomes of parents and families, the rates of diagnosis of the causes of stillbirth, and the care and management of subsequent pregnancies following stillbirth. Due to the absence of trials, this review is unable to inform clinical practice regarding the investigation of stillbirths, and the specific investigations that would determine the causes.Future RCTs addressing this research question would be beneficial, but the settings in which the trials take place, and their design, need to be given careful consideration. Trials need to be conducted with the utmost care and consideration for the needs, concerns, and values of parents and families. Assessment of longer-term psychosocial variables, economic costs to health services, and effects on subsequent pregnancy care and outcomes should also be considered in any future trials.

Time to change focus? Transitioning from higher neonatal to higher stillbirth mortality in São Paulo State, Brazil

BACKGROUND

Differential trends in mortality suggest that stillbirths may dominate neonatal mortality in the medium to long run. Brazil has made major efforts to improve data collection on health indicators at granular geographic levels, and provides an ideal environment to test this hypothesis. Our goals were to examine levels and trends in stillbirths and neonatal deaths and the extent to which the mortality burden caused by stillbirths dominates neonatal mortality at the municipality- and state-level.

METHODS

We used data from the Brazilian Ministry of Health's repository on births, fetal, and neonatal deaths (2010-2014) to calculate stillbirth and neonatal mortality rates for São Paulo state's 645 municipalities.

RESULTS

At the state level, 7.9 per 1000 pregnancies ended in stillbirth (fetal death >22 weeks gestation or fetal weight >500g), but this varied from 0.0 to 28.4 per 1000 across municipalities. 7.9 per 1000 live births also died within the first 28 days. 42% of municipalities had a higher stillbirth rate than neonatal mortality rate, and in 61% of areas with low neonatal mortality (<8.0 per 1000), stillbirth rates exceeded neonatal mortality rates.

CONCLUSIONS

This analysis suggests large variability and inequality in mortality outcomes at the sub-national level. The results also imply that stillbirth mortality may exceed neonatal mortality in Brazil and similar settings in the next few decades, which suggests a need for a shift in policy. This work further underscores the importance of continued research into causes and prevention of stillbirth.

Making stillbirths visible: a systematic review of globally reported causes of stillbirth

BACKGROUND

Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention.

OBJECTIVES

To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM.

SEARCH STRATEGY

We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016.

SELECTION CRITERIA

Reports of stillbirth causes in unselective cohorts.

DATA COLLECTION AND ANALYSIS

Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC).

MAIN RESULTS

Eighty-five reports from 50 countries (489 089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes.

CONCLUSIONS

There is a paucity of quality information on causes of stillbirth globally. Improving investigation of stillbirths and standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings.

FUNDING

HR, SH, SHL, and AW were supported by an NHMRC-CRE grant (APP1116640). VF was funded by an NHMRC-CDF (APP1123611).

TWEETABLE ABSTRACT

Urgent need to improve data on causes of stillbirths across all settings to meet global targets.

PLAIN LANGUAGE SUMMARY

Background and methods Nearly three million babies are stillborn every year. These deaths have deep and long-lasting effects on parents, healthcare providers, and the society. One of the major challenges to preventing stillbirths is the lack of information about why they happen. In this study, we collected reports on the causes of stillbirth from high-, middle-, and low-income countries to: (1) Understand the causes of stillbirth, and (2) Understand how to improve reporting of stillbirths. Findings We found 85 reports from 50 different countries. The information available from the reports was inconsistent and often of poor quality, so it was hard to get a clear picture about what are the causes of stillbirth across the world. Many different definitions of stillbirth were used. There was also wide variation in what investigations of the mother and baby were undertaken to identify the cause of stillbirth. Stillbirths in all income settings (low-, middle-, and high-income countries) were most frequently reported as Unexplained, Other, and Haemorrhage (bleeding). Unexplained and Other are not helpful in understanding why a baby was stillborn. In low-income countries, stillbirths were often attributed to Infection and Complications during labour and birth. In middle- and high-income countries, stillbirths were often reported as Placental complications. Limitations We may have missed some reports as searches were carried out in English only. The available reports were of poor quality. Implications Many countries, particularly those where the majority of stillbirths occur, do not report any information about these deaths. Where there are reports, the quality is often poor. It is important to improve the investigation and reporting of stillbirth using a standardised system so that policy makers and healthcare workers can develop effective stillbirth prevention programs. All stillbirths should be investigated and reported in line with the World Health Organization standards.

Fetal death: an extreme manifestation of maternal anti-fetal rejection

OBJECTIVE

The aim of this study was to determine the association between chronic placental inflammation and amniotic fluid (AF) markers of maternal anti-fetal rejection as well as the presence of microorganisms in the AF fluid of patients with fetal death.

STUDY DESIGN

This cohort study included 40 patients with fetal death whose placentas were examined for chronic inflammatory lesions and whose AF chemokine ligand (CXCL)10 and interleukin (IL)-6 concentrations were determined by immunoassays. AF was processed for bacteria, mycoplasmas and viruses using cultivation and molecular microbiologic techniques (i.e. PCR-ESI/MS).

RESULTS

(1) The most prevalent placental findings were maternal vascular underperfusion (63.2%, 24/38), followed by chronic inflammatory lesions (57.9%, 22/38); (2) chronic chorioamnionitis (18/38) was three times more frequent than villitis of unknown etiology (6/38); (3) an elevated AF CXCL10 concentration (above the 95th centile) was present in 60% of the cases, and a receiver operating characteristics (ROC)-derived cut-off of 2.9 ng/mL had a sensitivity of 73% and a specificity of 75% in the identification of chronic placental inflammatory lesions; (4) only five cases had microbial invasion of the amniotic cavity, and the presence of microorganisms did not correlate with chronic placental inflammation.

CONCLUSION

In women with unexplained fetal death, there is an association between elevated AF CXCL10 and chronic placental inflammatory lesions. Therefore, we conclude that a subset of patients with fetal death may have endured a breakdown of maternal-fetal tolerance, which cannot be attributed to microorganisms in the amniotic cavity.

Cause of and factors associated with stillbirth: a systematic review of classification systems

INTRODUCTION

An estimated 2.6 million stillbirths occur worldwide each year. A standardized classification system setting out possible cause of death and contributing factors is useful to help obtain comparative data across different settings. We undertook a systematic review of stillbirth classification systems to highlight their strengths and weaknesses for practitioners and policymakers.

MATERIAL AND METHODS

We conducted a systematic search and review of the literature to identify the classification systems used to aggregate information for stillbirth and perinatal deaths. Narrative synthesis was used to compare the range and depth of information required to apply the systems, and the different categories provided for cause of and factors contributing to stillbirth.

RESULTS

A total of 118 documents were screened; 31 classification systems were included, of which six were designed specifically for stillbirth, 14 for perinatal death, three systems included neonatal deaths and two included infant deaths. Most (27/31) were developed in and first tested using data obtained from high-income settings. All systems required information from clinical records. One-third of the classification systems (11/31) included information obtained from histology or autopsy. The percentage where cause of death remained unknown ranged from 0.39% using the Nordic-Baltic classification to 46.4% using the Keeling system.

CONCLUSION

Over time, classification systems have become more complex. The success of application is dependent on the availability of detailed clinical information and laboratory investigations. Systems that adopt a layered approach allow for classification of cause of death to a broad as well as to a more detailed level.

Early neonatal death: A challenge worldwide

Early neonatal death (ENND), defined as the death of a newborn between zero and seven days after birth, represents 73% of all postnatal deaths worldwide. Despite a 50% reduction in childhood mortality, reduction of ENND has significantly lagged behind other Millennium Developmental Goal achievements and is a growing contributor to overall mortality in children aged <5 years. The etiology of ENND is closely related to the level of a country's industrialization. Hence, prematurity and congenital anomalies are the leading causes in high-income countries. Furthermore, sudden unexpected early neonatal deaths (SUEND) and collapse have only recently been identified as relevant and often preventable causes of death. Concomitantly, perinatal-related events such as asphyxia and infections are extremely relevant in Africa, South East Asia, and Latin America and, together with prematurity, are the principal contributors to ENND. In high-income countries, according to current research evidence, survival may be improved by applying antenatal and perinatal therapies and immediate newborn resuscitation, as well as by centralizing at-risk deliveries to centers with appropriate expertise available around the clock. In addition, resources should be allocated to the close surveillance of newborn infants, especially during the first hours of life. Many of the conditions leading to ENND in low-income countries are preventable with relatively easy and cost-effective interventions such as contraception, vaccination of pregnant women, hygienic delivery at a hospital, training health care workers in resuscitation practices, simplified algorithms that allow for early detection of perinatal infections, and early initiation of breastfeeding and skin-to-skin care. The future is promising. As initiatives undertaken in previous decades have led to substantial reduction in childhood mortality, it is expected that new initiatives targeting the perinatal/neonatal periods are bound to reduce ENND and provide these babies with a better future.

Classification of causes and associated conditions for stillbirths and neonatal deaths

Accurate and consistent classification of causes and associated conditions for perinatal deaths is essential to inform strategies to reduce the five million which occur globally each year. With the majority of deaths occurring in low- and middle-income countries (LMICs), their needs must be prioritised. The aim of this paper is to review the classification of perinatal death, the contemporary classification systems including the World Health Organization's International Classification of Diseases - Perinatal Mortality (ICD-PM), and next steps. During the period from 2009 to 2014, a total of 81 new or modified classification systems were identified with the majority developed in high-income countries (HICs). Structure, definitions and rules and therefore data on causes vary widely and implementation is suboptimal. Whereas system testing is limited, none appears ideal. Several systems result in a high proportion of unexplained stillbirths, prompting HICs to use more detailed systems that require data unavailable in low-income countries. Some systems appear to perform well across these different settings. ICD-PM addresses some shortcomings of ICD-10 for perinatal deaths, but important limitations remain, especially for stillbirths. A global approach to classification is needed and seems feasible. The new ICD-PM system is an important step forward and improvements will be enhanced by wide-scale use and evaluation. Implementation requires national-level support and dedicated resources. Future research should focus on implementation strategies and evaluation methods, defining placental pathologies, and ways to engage parents in the process.

Understanding Misclassification between Neonatal Deaths and Stillbirths: Empirical Evidence from Malawi

Improving the counting of stillbirths and neonatal deaths is important to tracking Sustainable Development Goal 3.2 and improving vital statistics in low- and middle-income countries (LMICs). However, the validity of self-reported stillbirths and neonatal deaths in surveys is often threatened by misclassification errors between the two birth outcomes. We assessed the extent and correlates of stillbirths being misclassified as neonatal deaths by comparing two recent and linked population surveys conducted in Malawi, one being a full birth history (FBH) survey, and the other a follow-up verbal/social autopsy (VASA) survey. We found that one-fifth of 365 neonatal deaths identified in the FBH survey were classified as stillbirths in the VASA survey. Neonatal deaths with signs of movements in the last few days before delivery reported were less likely to be misclassified stillbirths (OR = 0.08, p<0.05). Having signs of birth injury was found to be associated with higher odds of misclassification (OR = 6.17, p<0.05). We recommend replicating our study with larger sample size in other settings. Additionally, we recommend conducting validation studies to confirm accuracy and completeness of live births and neonatal deaths reported in household surveys with events reported in a full birth history and the extent of underestimation of neonatal mortality resulting from misclassifications. Questions on fetal movement, signs of life at delivery and improved probing among older mother may be useful to improve accuracy of reported events.

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.

Characteristics of a global classification system for perinatal deaths: a Delphi consensus study

BACKGROUND

Despite the global burden of perinatal deaths, there is currently no single, globally-acceptable classification system for perinatal deaths. Instead, multiple, disparate systems are in use world-wide. This inconsistency hinders accurate estimates of causes of death and impedes effective prevention strategies. The World Health Organisation (WHO) is developing a globally-acceptable classification approach for perinatal deaths. To inform this work, we sought to establish a consensus on the important characteristics of such a system.

METHODS

A group of international experts in the classification of perinatal deaths were identified and invited to join an expert panel to develop a list of important characteristics of a quality global classification system for perinatal death. A Delphi consensus methodology was used to reach agreement. Three rounds of consultation were undertaken using a purpose built on-line survey. Round one sought suggested characteristics for subsequent scoring and selection in rounds two and three.

RESULTS

The panel of experts agreed on a total of 17 important characteristics for a globally-acceptable perinatal death classification system. Of these, 10 relate to the structural design of the system and 7 relate to the functional aspects and use of the system.

CONCLUSION

This study serves as formative work towards the development of a globally-acceptable approach for the classification of the causes of perinatal deaths. The list of functional and structural characteristics identified should be taken into consideration when designing and developing such a system.