Variation in classification of live birth with newborn period death versus fetal death at the local level may impact reported infant mortality rate.

BACKGROUND: To better understand factors that may impact infant mortality rates (IMR), we evaluated the consistency across birth hospitals in the classification of a birth event as either a fetal death or an early neonatal (infant) death using natality data from North Carolina for the years 1995-2000. METHODS: A database consisting of fetal deaths and infant deaths occurring within the first 24 hours after birth was constructed. Bivariate, followed by multivariable regression, analyses were used to control for relevant maternal and infant factors. Based upon hospital variances, adjustments were made to evaluate the impact of the classification on statewide infant mortality rate. RESULTS: After controlling for multiple maternal and infant factors, birth hospital remained a factor related to the classification of early neonatal versus fetal death. Reporting of early neonatal deaths versus fetal deaths consistent with the lowest or highest hospital strata would have resulted in an adjusted IMR varying from 7.5 to 10.64 compared with the actual rate of 8.95. CONCLUSIONS: Valid comparisons of IMR among geographic regions within and between countries require consistent classification of perinatal deaths. This study demonstrates that local variation in categorization of death events as fetal death versus neonatal death within the first 24 hours after delivery may impact a state-level IMR in a meaningful magnitude. The potential impact of this issue on IMRs should be examined in other state and national populations.

Stillbirth classification in population-based data and role of fetal growth restriction: the example of RECODE.

BACKGROUND: Stillbirth classifications use various strategies to synthesise information associated with fetal demise with the aim of identifying key causes for the death. RECODE is a hierarchical classification of death-related conditions, which grants a major place to fetal growth restriction (FGR). Our objective was to explore how placement of FGR in the hierarchy affected results from the classification. METHODS: In the Rhône-Alpes region, all stillbirths were recorded in a local registry from 2000 to 2010 in three districts (N = 969). Small for gestational age (SGA) was defined as a birthweight below the 10th percentile. We applied RECODE and then modified the hierarchy, including FGR as the penultimate category (RECODE-R). RESULTS: 49.0% of stillbirths were SGA. From RECODE to RECODE-R, stillbirths attributable to FGR decreased from 38% to 14%, in favour of other related conditions. Nearly half of SGA stillbirths (49%) were reclassified. There was a non-significant tendency toward moderate SGA, singletons and full-term stillbirths to older mothers being reclassified. CONCLUSIONS: The position of FGR in hierarchical stillbirth classification has a major impact on the first condition associated with stillbirth. RECODE-R calls less attention to monitoring SGA fetuses but illustrates the diversity of death-related conditions for small fetuses.

Stillbirth and fetal growth restriction.

OBJECTIVE: To confirm the role of fetal growth restriction (FGR) as a cause of stillbirth, and to compare diagnostic accuracy of customized fetal growth and population-based standards in identifying FGR within a pathological population of early and late stillbirths. METHODS: Retrospective study on a cohort of 189 stillbirths occurred in single pregnancy between January 2006 and September 2011. Unexplained stillbirths, defined by Aberdeen-Wigglesworth and ReCoDe classifications, were evaluated on the basis of fetal birthweight with both Tuscany population and Gardosi customized standards. Unexplained stillbirths have been classified as early or late depending on the gestational age of occurrence. RESULTS: Aberdeen-Wigglesworth classification, applied to the 189 cases of stillbirth, left 94 unexplained cases (49.7%), whereas the ReCoDe classification left only 40 (21%). By applying population standards to the 94 unexplained stillbirths we have identified 31 FGRs (33% of sample), while customized standards identified 54 FGRs (57%). Customised standards identified a larger number of FGRs with respect to population standards during the third trimester (i.e. 51% vs. 25% respectively) than in the second trimester (73% vs. 54% respectively) (p = 0.05). CONCLUSIONS: Customized standards have a higher diagnostic accuracy in identifying FGRs especially during the third trimester.

Reducing the proportion of stillborn babies classified as unexplained in Vietnam by application of the PSANZ clinical practice guideline.

BACKGROUND: Over 2.6 million babies are stillborn every year mostly in low- and middle-income countries, where cause of death remains often unexplained. AIM: To determine the applicability and utility of the Perinatal Society of Australia and New Zealand (PSANZ) Clinical Practice Guideline (CPG) for Perinatal Mortality in reducing the proportion of unexplained stillbirths in a hospital setting in Vietnam. METHODS: An analytic cross-sectional study of stillborn babies born at a major maternity facility in Vietnam. Maternal history, external physical examination of the baby and placental macroscopic examination were performed. Two experienced classifiers independently assigned PSANZ perinatal death classification (PDC). This was compared to cause of death documented in the hospital records. RESULTS: 107 stillborn babies were born to 105 mothers. The proportion of stillborn babies classified as unexplained was reduced from 52.3 to 24.3% (P < 0.01) using the PSANZ-PDC system. Causes of death were congenital abnormalities (35.6%), hypertension (8.4%), fetal growth restriction (8.4%), specific perinatal conditions (8.4%), spontaneous preterm (6.5%), maternal conditions (5.6%) and antepartum haemorrhage (3.7%). CONCLUSIONS: Application of the PSANZ-CPG and stillbirth classification system is effective and feasible in a low-income country facility setting and resulted in a reduction in the number of babies classified as unexplained stillbirth in Vietnam.

Stillbirths: Where? When? Why? How to make the data count?

Despite increasing attention and investment for maternal, neonatal, and child health, stillbirths remain invisible-not counted in the Millennium Development Goals, nor tracked by the UN, nor in the Global Burden of Disease metrics. At least 2·65 million stillbirths (uncertainty range 2·08 million to 3·79 million) were estimated worldwide in 2008 (≥1000 g birthweight or ≥28 weeks of gestation). 98% of stillbirths occur in low-income and middle-income countries, and numbers vary from 2·0 per 1000 total births in Finland to more than 40 per 1000 total births in Nigeria and Pakistan. Worldwide, 67% of stillbirths occur in rural families, 55% in rural sub-Saharan Africa and south Asia, where skilled birth attendance and caesarean sections are much lower than that for urban births. In total, an estimated 1·19 million (range 0·82 million to 1·97 million) intrapartum stillbirths occur yearly. Most intrapartum stillbirths are associated with obstetric emergencies, whereas antepartum stillbirths are associated with maternal infections and fetal growth restriction. National estimates of causes of stillbirths are scarce, and multiple (>35) classification systems impede international comparison. Immediate data improvements are feasible through household surveys and facility audit, and improvements in vital registration, including specific perinatal certificates and revised International Classification of Disease codes, are needed. A simple, programme-relevant stillbirth classification that can be used with verbal autopsy would provide a basis for comparable national estimates. A new focus on all deaths around the time of birth is crucial to inform programmatic investment.

[The problem of study of unexplainable antenatal fetal death].

The paperpresents the data on the causes ofperinatal mortality. Particular emphasis is placed on unexplainable antenatal fetal death, the absence of uniform terminology or a consensus classification of the causes of antenatal fetal death, and the principles in placental studies and stillborn baby autopsy. Various aspects of sophisticated relations in the mother-placenta-fetus system are considered. It is pointed out that the number of unexplainable antenatal fetal deaths can be reduced when the placenta is meticulously studied. A conventional protocol for stillborn baby autopsy and placental studies is noted to be elaborated.

Making stillbirths count, making numbers talk - issues in data collection for stillbirths.

BACKGROUND: Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care. DISCUSSION: In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings. SUMMARY: Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.

Stillbirth classification--developing an international consensus for research: executive summary of a National Institute of Child Health and Human Development workshop.

Stillbirth is a major obstetric complication, with 3.2 million stillbirths worldwide and 26,000 stillbirths in the United States every year. The Eunice Kennedy Shriver National Institute of Child Health and Human Development held a workshop from October 22-24, 2007, to review the pathophysiology of conditions underlying stillbirth to define causes of death. The optimal classification system would identify the pathophysiologic entity initiating the chain of events that irreversibly led to death. Because the integrity of the classification is based on available pathologic, clinical, and diagnostic data, experts emphasized that a complete stillbirth workup should be performed. Experts developed evidence-based characteristics of maternal, fetal, and placental conditions to attribute a condition as a cause of stillbirth. These conditions include infection, maternal medical conditions, antiphospholipid syndrome, heritable thrombophilias, red cell alloimmunization, platelet alloimmunization, congenital malformations, chromosomal abnormalities including confined placental mosaicism, fetomaternal hemorrhage, placental and umbilical cord abnormalities including vasa previa and placental abruption, complications of multifetal gestation, and uterine complications. In all cases, owing to lack of sufficient knowledge about disease states and normal development, there will be a degree of uncertainty regarding whether a specific condition was indeed the cause of death.

The Stockholm classification of stillbirth.

OBJECTIVE: To design and validate a classification system for audit groups working with stillbirth. The classification includes well-defined primary and associated conditions related to fetal death. DESIGN: Descriptive. SETTING: All delivery wards in Stockholm. POPULATION: Stillbirths from 22 completed weeks in Stockholm, Sweden. METHODS: Parallel to audit work, the Stockholm stillbirth group has developed a classification of conditions related to stillbirth. The classification has been validated. MAIN OUTCOME MEASURE: The classification and the results of the validation are presented. RESULT: The classification with 17 groups identifying underlying conditions related to stillbirth (primary diagnoses) and associated factors which may have contributed to the death (associated diagnoses) is described. The conditions are subdivided into definite, probable and possible relation to the death. An evaluation of 382 cases of stillbirth during 2002-2005 resulted in 382 primary diagnoses and 132 associated diagnoses. The most common conditions identified were intrauterine growth restriction/placental insufficiency (23%), infection (19%), malformations/chromosomal abnormalities (12%). The 'unexplained' group together with the 'unknown' group comprised 18%. Validation was done by reclassification of 95 cases from 2005 by six investigators. The overall agreement regarding primary diagnosis was substantial (kappa=0.70). CONCLUSIONS: The Stockholm classification of stillbirth consists of 17 diagnostic groups allowing one primary diagnosis and if needed, associated diagnoses. Diagnoses are subdivided according to definite, probable and possible relation to stillbirth. Validation showed high degree of agreement regarding primary diagnosis. The classification can provide a useful tool for clinicians and audit groups when discussing cause and underlying conditions of fetal death.

Changes in cause of neonatal death over a decade.

AIMS: To classify neonatal deaths at Wellington Hospital (Wellington, New Zealand) over a 10-year period and assess changes in cause of death over time. METHODS: Retrospective audit from 1995-2004 of live-born infants > or = 20 weeks gestation dying before 28 days of age. Deaths were classified according to the PSANZ-NDC Classification guideline. The years 1995-1999 and 2000-2004 were compared to analyse for changes in cause of death. RESULTS: There were 219 neonatal deaths: 67(31%) of these were term infants and 154 preterm; 109 infants from 1995-1999 and 110 from 2000-2004. The autopsy rate was 62% and highest in term infants (76%). Deaths due to congenital anomaly and extreme prematurity decreased over time and deaths due to infection increased. CONCLUSIONS: Use of the PSANZ-NDC death classification system enables an accurate cause of death to be established for most neonatal deaths and allows monitoring of mortality rates over time.

[Early pregnancy: revision of the Dutch terminology for clinical and ultrasound findings]. / De jonge zwangerschap: revisie van de Nederlandse benamingen voor klinische en echoscopische bevindingen.

The nomenclature used to describe findings during early pregnancy in The Netherlands needs to be revised. Various terms, like 'abortion' and 'miscarriage', are used to describe the same phenomenon, which is confusing for both patients and doctors. In addition, the meaning of some terms, like 'missed abortion', has changed over time. In accordance with the revision of the European nomenclature in the English language by the Special Interest Group for Early Pregnancy of the European Society for Human Reproduction and Embryology (ESHRE), a revision of the nomenclature in the Dutch language is needed as well. An unambiguous Dutch terminology pertaining to early pregnancy is recommended that corresponds to the English terminology; this includes the Dutch terms 'embryo' [embryo], 'foetus' [foetus], 'biochemische zwangerschap' [biochemical pregnancy], 'zwangerschap met onbekende lokalisatie' [pregnancy of unknown location], 'miskraam' [miscarriage], 'lege vruchtzak' [empty sac], 'gestopte hart-activiteit' [fetal loss], 'herhaalde miskraam' [recurrent miscarriage], 'extra-uteriene zwangerschap' [ectopic pregnancy], and 'trofoblast-ziekte' [gestational trophoblastic disease], because these are based on well-defined clinical and ultrasonographic concepts.

[Legal and practical aspects of perinatal death]. / Overleden pasgeborenen: wet en praktijk.

There is some debate as to whether the Dutch Burial Act applies to neonatal deaths after a gestation of less than 24 weeks. It is recommended that the Act be considered applicable in these situations, leading to a compulsory (external) post mortem examination, the issue of an official death certificate, and registration of the birth and death at the official registry office, followed by burial or cremation according to the law. The Act should be amended to this effect. It is also recommended that the Burial Act no longer apply in cases of known intra-uterine death before 24 weeks of gestation where birth takes place after 24 weeks. The stipulated cut-off point in the Act for defining a miscarriage as opposed to a birth or stillbirth, i.e. 24 weeks of gestation, should preferably be replaced by the international (WHO) criterion of a birth weight of 500 g, as this will lead to less ambiguity and a better comparison of Dutch and international data concerning perinatal mortality.

Certificado médico de defunción como instrumento de certificación de muerte fetal, análisis en hospitales de La Paz y El Alto durante la gestión 2004 / Medical death certificate as instrument of certificatión of death fetal, analysis in hospitals of La PAz and The High during the management 2004

El estudio y certificación de las muertes ocurridas durante la etapa perinatal, y por ende de las muertes fetales, es diferente al de otras etapas de la vida, ya que los componenetes materno y placentario juegan un papel importante en las causas de muerte. Entonces es lógico pensar que al momento de realizar un estudio o certificar una muerte fetal, se tiene que indagar en los componentes señalados. El objeto del presente estudio fue establecer que el Certificado Médico Unico de Defunción (CEMEUD), no recolecta datos necesarios para un estudio y registro adecuado de la muerte fetal intrauterina. se realizó un estudio descriptivo retrospectivo, donde se realizó al CEMEUD como instrumento captador de información y certificador de la muerte fetal intrauterina...

Updated and revised nomenclature for description of early pregnancy events.

The nomenclature used to describe clinical events in early pregnancy has been criticized for lack of clarity and promoting confusion. There is no agreed glossary of terms or consensus regarding important gestational milestones. In particular there are old and poorly descriptive terms such as 'missed abortion' and 'blighted ovum', which have persisted since their introduction many years ago (Robinson, 1975) and have not undergone revision despite the widespread application of ultrasound for accurate clinical assessment and diagnosis. The authors are aware of these shortcomings in terminology and are keen to provide an updated glossary. We hope that this paper will facilitate the introduction of a revised terminology in an attempt to provide clarity and to enhance uptake and use in the literature as well as clinical assessment and documentation.