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Asefa YA, Persson LÅ, Seale AC, Assefa N. Burden, causes, and risk factors of perinatal mortality in Eastern Africa: a protocol for systematic review and meta-analysis. Gates Open Res 2022. [DOI: 10.12688/gatesopenres.13915.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Although global mortality rates in children under 5 years have decreased substantially in the last 30 years, there remain around 2.6 million stillbirths and 2.9 million neonatal deaths each year. The majority of these deaths occur in Africa and South Asia. To reduce perinatal deaths in East Africa, knowledge of the burden, but also the risk factors and causes of perinatal deaths are crucial. To the best of our knowledge, reviews have previously focused on the burden of perinatal deaths; here we aim to synthesize evidence on the burden, causes, and risk factors for perinatal mortality in East Africa. Methods: We will conduct a systematic literature search in Medline, Web of Science, EMBASE, Global Health, SCOPUS, Cochrane Library, CINAHL, HINARI, African Index Medicus, African Journals Online (AJOL), and WHO African Regional Office (AFRO) Library. We will include studies from 2010 to 2022, and to facilitate the inclusion of up-to-date data, we will request recent data from ongoing surveillance in the region, such as the Child Health and Mortality Prevention Surveillance (CHAMPS) network and Health and Demographic Surveillance sites (HDSS sites). To assess the quality of included studies we will use the Joanna Briggs Institute quality assessment tool for observational and trial studies. We will analyze the data using STATA version 17 statistical software and assess heterogeneity and publication bias by Higgins’ I2 and funnel plot, respectively. Conclusions: This systematic review protocol will search for published studies, and seek unpublished data, on the burden, causes, and risk factors of perinatal mortality in East Africa. Findings will be reported and gaps in the evidence base identified, with recommendations, with the ultimate aim of reducing perinatal deaths.
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Risk factors and incidence of third trimester stillbirths in China. Sci Rep 2021; 11:12701. [PMID: 34135411 PMCID: PMC8209053 DOI: 10.1038/s41598-021-92106-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 06/04/2021] [Indexed: 11/08/2022] Open
Abstract
About 2.6 million third-trimester stillbirths occur annually worldwide, mostly in low- and middle-income countries. However, the causes of stillbirths are rarely investigated. We performed a retrospective, hospital-based study in Zhejiang Province, southern China, of the causes of third-trimester stillbirths. Causes of stillbirths were classified using the Relevant Condition at Death classification system. From January 1, 2013, to December 31, 2018, we enrolled 341 stillbirths (born to 338 women) from 111,275 perinatal fetuses (born to 107,142 women), as well as 293 control cases (born to 291 women). The total incidence of third-trimester stillbirths was 3.06/1000 (341/111,275). There were higher proportions of women with a high body mass index, twins, pregnancy-induced hypertension, assisted reproduction and other risk factors among the antepartum than the control cases. The antepartum stillbirth fetuses were of lower median birth weight and gestational age and had a smaller portion of translucent amniotic fluid than the control cases. The antepartum stillbirth fetuses had a higher frequency of abnormalities detected prenatally and of fetal growth restriction than the control cases. Of 341 cases (born to 338 mothers), the most common causes of stillbirth were fetal conditions [117 (34.3%) cases], umbilical cord [88 (25.8%)], maternal conditions [34 (10.0%)], placental conditions [31 (9.1%)], and intrapartum [28 (8.2%)]. Only eight (2.3%), three (0.9%), and two (0.6%) stillbirths were attributed to amniotic fluid, trauma, and uterus, respectively. In 30 (8.8%) cases, the cause of death was unclassified. In conclusion, targeted investigation can ascertain the causes of most cases of third-trimester stillbirths.
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Gulati N, Mackie FL, Cox P, Marton T, Heazell A, Morris RK, Kilby MD. Cause of intrauterine and neonatal death in twin pregnancies (CoDiT): development of a novel classification system. BJOG 2020; 127:1507-1515. [PMID: 32359214 DOI: 10.1111/1471-0528.16291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Twin pregnancies have a significantly higher perinatal mortality than singleton pregnancies. Current classification systems for perinatal death lack twin-specific categories, potentially leading to loss of important information regarding cause of death. We introduce and test a classification system designed to assign a cause of death in twin pregnancies (CoDiT). DESIGN Retrospective cross-sectional study. SETTING Tertiary maternity unit in England with a perinatal pathology service. POPULATION Twin pregnancies in the West Midlands affected by fetal or neonatal demise of one or both twins between 1 January 2005 and 31 December 2016 in which postmortem examination was undertaken. METHODS A multidisciplinary panel designed CoDiT by adapting the most appropriate elements of singleton classification systems. The system was tested by assigning cause of death in 265 fetal and neonatal deaths from 144 twin pregnancies. Cause of death was validated by another obstetrician blinded to the original classification. MAIN OUTCOME MEASURES Inter-rater, intra-rater, inter-disciplinary agreement and cause of death. RESULTS Cohen's Kappa demonstrated 'strong' (>0.8) inter-rater, intra-rater and inter-disciplinary agreement (95% CI 0.70-0.91). The commonest cause of death irrespective of chorionicity was the placenta; twin-to-twin transfusion syndrome (TTTS) was the commonest placental cause in monochorionic twins and acute chorioamnionitis in dichorionic twins. CONCLUSIONS This novel classification system records causes of death in twin pregnancies from postmortem reports with high inter-user agreement. We highlight differences in aetiology of death between monochorionic and dichorionic twins. TWEETABLE ABSTRACT New classification system for #twin cause of death 'CoDiT' shows high rater agreement.
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Affiliation(s)
- N Gulati
- Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
| | - F L Mackie
- Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
| | - P Cox
- Cellular Pathology Department, Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - T Marton
- Cellular Pathology Department, Birmingham Women's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Aep Heazell
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK.,St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R K Morris
- Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK.,Institute of Applied Health Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - M D Kilby
- Institute of Metabolism & Systems Research, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK.,Fetal Medicine Centre, Birmingham Women's & Children's Foundation Trust, Birmingham, UK
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Relation of Pregnancy Loss to Risk of Cardiovascular Disease in Parous Postmenopausal Women (From the Women's Health Initiative). Am J Cardiol 2019; 123:1620-1625. [PMID: 30871746 DOI: 10.1016/j.amjcard.2019.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/05/2019] [Accepted: 02/11/2019] [Indexed: 01/06/2023]
Abstract
Women with history of pregnancy loss (PL) have higher burden of cardiovascular disease (CVD) later in life, yet it is unclear whether this is attributable to an association with established CVD risk factors (RFs). We examined whether PL is associated with CVD RFs and biomarkers in parous postmenopausal women in the Women's Health Initiative, and whether the association between PL and CVD RFs accounted for the association between PL and incident CVD. Linear and logistic regressions were used to estimate associations between baseline history of PL and CVD RFs. Cox proportional hazards regression models were used to estimate the associations between baseline history of PL and incident CVD after adjustment for baseline RFs. Of 79,121 women, 27,272 (35%) had experienced PL. History of PL was associated with higher body mass index (p < 0.0001), hypertension (p < 0.0001), diabetes (p = 0.003), depression (p < 0.0001), and lower income (p < 0.0001), physical activity (p = 0.01), poorer diet (p < 0.0001), smoking (p < 0.0001), and alcohol use (p < 0.0001). After adjustment for CVD RFs, PL was significantly associated with incident CVD over mean follow up of 16 years (hazard ratio 1.11, 95% confidence interval 1.06 to 1.16). In conclusion, several CVD RFs are associated with PL, but they do not entirely account for the association between PL and incident CVD.
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Kortekaas JC, Scheuer AC, de Miranda E, van Dijk AE, Keulen JKJ, Bruinsma A, Mol BWJ, Vandenbussche FPHA, van Dillen J. Perinatal death beyond 41 weeks pregnancy: an evaluation of causes and substandard care factors as identified in perinatal audit in the Netherlands. BMC Pregnancy Childbirth 2018; 18:380. [PMID: 30236080 PMCID: PMC6149052 DOI: 10.1186/s12884-018-1973-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 08/09/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Late- and postterm pregnancy are associated with adverse perinatal outcomes, like perinatal death. We evaluated causes of death and substandard care factors (SSFs) in term and postterm perinatal death. METHODS We used data from the Perinatal Audit Registry of the Netherlands (PARS). Women with a term perinatal death registered in PARS were stratified by gestational age into early-/full-term (37.0-40.6) and late-/postterm (≥41.0 weeks) death. Cause of death and SSFs ≥41 weeks were scored and classified by the local perinatal audit teams. RESULTS During 2010-2012, 947/479,097 (0.21%) term deaths occurred, from which 707 cases (75%) were registered and could be used for analyses. Five hundred ninety-eight early-/full-term and 109 late-/postterm audited deaths were registered in the PARS database. Of all audited cases of perinatal death in the PARS database, 55.2% in the early-/fullterm group occurred antepartum compared to 42.2% in the late-/postterm group, while intrapartum death occurred in 7.2% in the early-/full-term group compared to 19.3% in the late-/postterm group in the audited cases from the PARS database. According to the local perinatal audit, the most relevant causes of perinatal death ≥41 weeks were antepartum asphyxia (7.3%), intrapartum asphyxia (9.2%), neonatal asphyxia (10.1%) and placental insufficiency (10.1%). In the group with perinatal death ≥41 weeks there was ≥1SSF identified in 68.8%. The most frequent SSFs concerned inadequate cardiotocography (CTG) evaluation and/or classification (10.1%), incomplete registration or documentation in medical files (4.6%) or inadequate action on decreased foetal movements (4.6%). CONCLUSIONS In the Netherlands Perinatal Audit Registry, stillbirth occurred relatively less often antepartum and more often intrapartum in pregnancies ≥41 weeks compared to pregnancies at 37.0-40.6 weeks in the audited cases from the PARS database. Foetal, intrapartum and neonatal asphyxia were identified more frequently as cause of death in pregnancies ≥41 weeks. The most identified SSFs related to death in pregnancies ≥41 weeks concerned inadequate CTG monitoring (evaluation, classification, registration or documentation) and inadequate action on decreased foetal movements.
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Affiliation(s)
- Joep C. Kortekaas
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Anke C. Scheuer
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
| | - Esteriek de Miranda
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Judit K. J. Keulen
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Aafke Bruinsma
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Ben W. J. Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC Australia
| | - Frank P. H. A. Vandenbussche
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
| | - Jeroen van Dillen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6523 GA Nijmegen, the Netherlands
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Lannaman K, Romero R, Chaiworapongsa T, Kim YM, Korzeniewski SJ, Maymon E, Gomez-Lopez N, Panaitescu B, Hassan SS, Yeo L, Yoon BH, Kim CJ, Erez O. Fetal death: an extreme manifestation of maternal anti-fetal rejection. J Perinat Med 2017; 45:851-868. [PMID: 28862989 PMCID: PMC5848503 DOI: 10.1515/jpm-2017-0073] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 03/08/2017] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Kia Lannaman
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA
| | - Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Yeon Mee Kim
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Pathology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Steven J. Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
| | - Eli Maymon
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Immunology and Microbiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bogdan Panaitescu
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bo Hyun Yoon
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chong Jai Kim
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Offer Erez
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
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Reis AP, Rocha A, Lebre A, Ramos U, Cunha A. Perinatal mortality classification: an analysis of 112 cases of stillbirth. J OBSTET GYNAECOL 2017. [PMID: 28641024 DOI: 10.1080/01443615.2017.1323854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
This was a retrospective cohort analysis of stillbirths that occurred from January 2004 to December 2013 in our institution. We compared Tulip and Wigglesworth classification systems on a cohort of stillbirths and analysed the main differences between these two classifications. In this period, there were 112 stillbirths of a total of 31,758 births (stillbirth rate of 3.5 per 1000 births). There were 99 antepartum deaths and 13 intrapartum deaths. Foetal autopsy was performed in 99 cases and placental histopathological examination in all of the cases. The Wigglesworth found 'unknown' causes in 47 cases and the Tulip classification allocated 33 of these. Fourteen cases remained in the group of 'unknown' causes. Therefore, the Wigglesworth classification of stillbirths results in a higher proportion of unexplained stillbirths. We suggest that the traditional Wigglesworth classification should be substituted by a classification that manages the available information.
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Affiliation(s)
- Ana Paula Reis
- a Department of Obstetrics and Gynecology , Centro Hospitalar do Porto , Porto , Portugal
| | - Ana Rocha
- a Department of Obstetrics and Gynecology , Centro Hospitalar do Porto , Porto , Portugal
| | - Andrea Lebre
- a Department of Obstetrics and Gynecology , Centro Hospitalar do Porto , Porto , Portugal
| | - Umbelina Ramos
- b Department of Pathological Anatomy , Centro Hospitalar do Porto , Porto , Portugal
| | - Ana Cunha
- a Department of Obstetrics and Gynecology , Centro Hospitalar do Porto , Porto , Portugal
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Leisher SH, Teoh Z, Reinebrant H, Allanson E, Blencowe H, Erwich JJ, Frøen JF, Gardosi J, Gordijn S, Gülmezoglu AM, Heazell AEP, Korteweg F, Lawn J, McClure EM, Pattinson R, Smith GCS, Tunçalp Ӧ, Wojcieszek AM, Flenady V. Seeking order amidst chaos: a systematic review of classification systems for causes of stillbirth and neonatal death, 2009-2014. BMC Pregnancy Childbirth 2016; 16:295. [PMID: 27716090 PMCID: PMC5053068 DOI: 10.1186/s12884-016-1071-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 09/07/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Each year, about 5.3 million babies die in the perinatal period. Understanding of causes of death is critical for prevention, yet there is no globally acceptable classification system. Instead, many disparate systems have been developed and used. We aimed to identify all systems used or created between 2009 and 2014, with their key features, including extent of alignment with the International Classification of Diseases (ICD) and variation in features by region, to inform the World Health Organization's development of a new global approach to classifying perinatal deaths. METHODS A systematic literature review (CINAHL, EMBASE, Medline, Global Health, and PubMed) identified published and unpublished studies and national reports describing new classification systems or modifications of existing systems for causes of perinatal death, or that used or tested such systems, between 2009 and 2014. Studies reporting ICD use only were excluded. Data were independently double-extracted (except from non-English publications). Subgroup analyses explored variation by extent and region. RESULTS Eighty-one systems were identified as new, modifications of existing systems, or having been used between 2009 and 2014, with an average of ten systems created/modified each year. Systems had widely varying characteristics: (i) comprehensiveness (40 systems classified both stillbirths and neonatal deaths); (ii) extent of use (systems were created in 28 countries and used in 40; 17 were created for national use; 27 were widely used); (iii) accessibility (three systems available in e-format); (iv) underlying cause of death (64 systems required a single cause of death); (v) reliability (10 systems tested for reliability, with overall Kappa scores ranging from .35-.93); and (vi) ICD alignment (17 systems used ICD codes). Regional databases were not searched, so system numbers may be underestimated. Some non-differential misclassification of systems was possible. CONCLUSIONS The plethora of systems in use, and continuing system development, hamper international efforts to improve understanding of causes of death. Recognition of the features of currently used systems, combined with a better understanding of the drivers of continued system creation, may help the development of a truly effective global system.
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Affiliation(s)
- Susannah Hopkins Leisher
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia.
- International Stillbirth Alliance, Millburn, USA.
| | - Zheyi Teoh
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia
| | - Hanna Reinebrant
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia
- International Stillbirth Alliance, Millburn, USA
| | - Emma Allanson
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
- School of Women's and Infants' Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia
| | | | - Jan Jaap Erwich
- International Stillbirth Alliance, Millburn, USA
- The University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J Frederik Frøen
- Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway
- Center for Intervention Science for Maternal and Child Health, University of Bergen, Bergen, Norway
| | | | - Sanne Gordijn
- International Stillbirth Alliance, Millburn, USA
- The University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - A Metin Gülmezoglu
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Alexander E P Heazell
- International Stillbirth Alliance, Millburn, USA
- Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK
- St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Fleurisca Korteweg
- International Stillbirth Alliance, Millburn, USA
- Department of Obstetrics and Gynaecology, Martini Hospital, Groningen, The Netherlands
| | - Joy Lawn
- London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth M McClure
- International Stillbirth Alliance, Millburn, USA
- Research Triangle Institute, North Carolina, USA
| | - Robert Pattinson
- South Africa Medical Research Council Maternal and Infant Health Care Strategies Unit, University of Pretoria, Pretoria, South Africa
| | - Gordon C S Smith
- NIHR Biomedical Research Centre & Department of Obstetrics & Gynaecology, Cambridge University, Cambridge, UK
| | - Ӧzge Tunçalp
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Aleena M Wojcieszek
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia
- International Stillbirth Alliance, Millburn, USA
| | - Vicki Flenady
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia
- International Stillbirth Alliance, Millburn, USA
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Nappi L, Trezza F, Bufo P, Riezzo I, Turillazzi E, Borghi C, Bonaccorsi G, Scutiero G, Fineschi V, Greco P. Classification of stillbirths is an ongoing dilemma. J Perinat Med 2016; 44:837-843. [PMID: 26910736 DOI: 10.1515/jpm-2015-0318] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 01/18/2016] [Indexed: 11/15/2022]
Abstract
AIM To compare different classification systems in a cohort of stillbirths undergoing a comprehensive workup; to establish whether a particular classification system is most suitable and useful in determining cause of death, purporting the lowest percentage of unexplained death. METHODS Cases of stillbirth at gestational age 22-41 weeks occurring at the Department of Gynecology and Obstetrics of Foggia University during a 4 year period were collected. The World Health Organization (WHO) diagnosis of stillbirth was used. All the data collection was based on the recommendations of an Italian diagnostic workup for stillbirth. Two expert obstetricians reviewed all cases and classified causes according to five classification systems. RESULTS Relevant Condition at Death (ReCoDe) and Causes Of Death and Associated Conditions (CODAC) classification systems performed best in retaining information. The ReCoDe system provided the lowest rate of unexplained stillbirth (14%) compared to de Galan-Roosen (16%), CODAC (16%), Tulip (18%), Wigglesworth (62%). CONCLUSION Classification of stillbirth is influenced by the multiplicity of possible causes and factors related to fetal death. Fetal autopsy, placental histology and cytogenetic analysis are strongly recommended to have a complete diagnostic evaluation. Commonly employed classification systems performed differently in our experience, the most satisfactory being the ReCoDe. Given the rate of "unexplained" cases, none can be considered optimal and further efforts are necessary to work out a clinically useful system.
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Leisher SH, Teoh Z, Reinebrant H, Allanson E, Blencowe H, Erwich JJ, Frøen JF, Gardosi J, Gordijn S, Gülmezoglu AM, Heazell AEP, Korteweg F, Lawn J, McClure EM, Pattinson R, Smith GCS, Tunçalp Ӧ, Wojcieszek AM, Flenady V. Classification systems for causes of stillbirth and neonatal death, 2009-2014: an assessment of alignment with characteristics for an effective global system. BMC Pregnancy Childbirth 2016; 16:269. [PMID: 27634615 PMCID: PMC5025539 DOI: 10.1186/s12884-016-1040-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 08/11/2016] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Susannah Hopkins Leisher
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia. .,International Stillbirth Alliance, Millburn, USA.
| | - Zheyi Teoh
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia
| | - Hanna Reinebrant
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia.,International Stillbirth Alliance, Millburn, USA
| | - Emma Allanson
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland.,School of Women's and Infants' Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Perth, Australia
| | | | - Jan Jaap Erwich
- International Stillbirth Alliance, Millburn, USA.,University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
| | - J Frederik Frøen
- Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway.,Center for Intervention Science for Maternal and Child Health, University of Bergen, Bergen, Norway
| | | | - Sanne Gordijn
- International Stillbirth Alliance, Millburn, USA.,University Medical Center Groningen, The University of Groningen, Groningen, The Netherlands
| | - A Metin Gülmezoglu
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Alexander E P Heazell
- International Stillbirth Alliance, Millburn, USA.,Maternal and Fetal Health Research Centre, University of Manchester, Manchester, UK.,St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Fleurisca Korteweg
- International Stillbirth Alliance, Millburn, USA.,Department of Obstetrics and Gynaecology, Martini Hospital, Groningen, The Netherlands
| | - Joy Lawn
- London School of Hygiene & Tropical Medicine, London, UK
| | - Elizabeth M McClure
- International Stillbirth Alliance, Millburn, USA.,Research Triangle Institute, North Carolina, USA
| | - Robert Pattinson
- South Africa Medical Research Council Maternal and Infant Health Care Strategies Unit, University of Pretoria, Pretoria, South Africa
| | - Gordon C S Smith
- NIHR Biomedical Research Centre & Department of Obstetrics & Gynaecology, Cambridge University, Cambridge, UK
| | - Ӧzge Tunçalp
- Department of Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Aleena M Wojcieszek
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia.,International Stillbirth Alliance, Millburn, USA
| | - Vicki Flenady
- Mater Research Institute, The University of Queensland (MRI-UQ), Brisbane, Australia.,International Stillbirth Alliance, Millburn, USA
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McClure EM, Bose CL, Garces A, Esamai F, Goudar SS, Patel A, Chomba E, Pasha O, Tshefu A, Kodkany BS, Saleem S, Carlo WA, Derman RJ, Hibberd PL, Liechty EA, Hambidge KM, Krebs NF, Bauserman M, Koso-Thomas M, Moore J, Wallace DD, Jobe AH, Goldenberg RL. Global network for women's and children's health research: a system for low-resource areas to determine probable causes of stillbirth, neonatal, and maternal death. Matern Health Neonatol Perinatol 2015; 1:11. [PMID: 27057328 PMCID: PMC4823684 DOI: 10.1186/s40748-015-0012-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 03/09/2015] [Indexed: 01/01/2023] Open
Abstract
Background Determining cause of death is needed to develop strategies to reduce maternal death, stillbirth, and newborn death, especially for low-resource settings where 98% of deaths occur. Most existing classification systems are designed for high income settings where extensive testing is available. Verbal autopsy or audits, developed as an alternative, are time-intensive and not generally feasible for population-based evaluation. Furthermore, because most classification is user-dependent, reliability of classification varies over time and across settings. Thus, we sought to develop classification systems for maternal, fetal and newborn mortality based on minimal data to produce reliable cause-of-death estimates for low-resource settings. Results In six low-resource countries (India, Pakistan, Guatemala, DRC, Zambia and Kenya), we evaluated data which are collected routinely at antenatal care and delivery and could be obtained with interview, observation, or basic equipment from the mother, lay-health provider or family to inform causes of death. Using these basic data collected in a standard way, we then developed an algorithm to assign cause of death that could be computer-programmed. Causes of death for maternal (trauma, abortion, hemorrhage, infection and hypertensive disease of pregnancy), stillbirth (birth trauma, congenital anomaly, infection, asphyxia, complications of preterm birth) and neonatal death (congenital anomaly, infection, asphyxia, complications of preterm birth) are based on existing cause of death classifications, and compatible with the World Health Organization International Classification of Disease system. Conclusions Our system to assign cause of maternal, fetal and neonatal death uses basic data from family or lay-health providers to assign cause of death by an algorithm to eliminate a source of inconsistency and bias. The major strengths are consistency, transparency, and comparability across time or regions with minimal burden on the healthcare system. This system will be an important contribution to determining cause of death in low-resource settings.
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Affiliation(s)
| | - Carl L Bose
- University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | | | - Fabian Esamai
- Moi University Medical Teaching Hospital, Eldoret, Kenya
| | | | - Archana Patel
- Latta Medical Research Foundation, Indira Gandhi Medical School, Nagpur, India
| | | | | | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | | | | | | | | | | | | | | | | | | | | | | | | | - Alan H Jobe
- Cincinnati Children's Hospital, Cincinnati, OH USA
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12
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Barona-Vilar C, López-Maside A, Bosch-Sánchez S, Pérez-Panadés J, Melchor-Alós I, Mas-Pons R, Zurriaga Ó. Inequalities in perinatal mortality rates among immigrant and native population in Spain, 2005-2008. J Immigr Minor Health 2015; 16:1-6. [PMID: 23054547 DOI: 10.1007/s10903-012-9730-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We compared perinatal mortality rates (PMRs) and the risk from certain causes among immigrant and native population in the Valencian Community (Spain). Using data from the Perinatal Mortality Registry, crude and age standardized mortality ratios were obtained in the different groups of mothers. Mortality rate ratios were calculated to compare the causes of death resulting from prematurity, congenital anomalies, infectious diseases and Sudden Infant Death Syndrome between Spanish and foreign women. PMRs were higher among all the immigrant groups compared with the native population, with a statistical significance in Eastern European and sub-Saharan mothers. Neonatal mortality rates in North African and Latin American mothers were similar to those of native women. Babies of immigrant mothers were at a significant higher risk of dying from late infectious diseases and from causes resulting from being premature. More research is needed on the risk factors which contribute to generating differences in our setting.
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Affiliation(s)
- Carmen Barona-Vilar
- Direcció General d'Investigació i Salut Pública, Conselleria de Sanitat, Avda Catalunya, 21, 46020, Valencia, Spain,
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13
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Stillbirth in an Anglophone minority of Canada. Int J Public Health 2015; 60:353-62. [PMID: 25588815 DOI: 10.1007/s00038-015-0650-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/17/2014] [Accepted: 01/05/2015] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES We assessed trends in stillbirth over time for Francophones and Anglophones of Quebec, a large Canadian province with publically funded health care and an English-speaking minority. METHODS We calculated stillbirth rates for Francophones and Anglophones, and estimated hazard ratios (HR) by decade from 1981 to 2010, adjusting for maternal characteristics. We analyzed temporal trends by gestational interval and cause of fetal death. RESULTS Stillbirth rates decreased in Quebec during the three decades, due to improved rates in Francophones. Rates decreased for Anglophones in 1991-2000, but increased in 2001-2010 at term, during the second trimester, and for most causes of fetal death. In the 2000s, the hazard of stillbirth for Anglophones was nearly the same as the hazard for Francophones in the 1980s (HR 0.93, 95 % confidence interval 0.82, 1.05). CONCLUSIONS Stillbirth rates declined in both Francophones and Anglophones before the turn of the century, but increased thereafter for Anglophones, suggesting that linguistic inequalities in stillbirth may be emerging in Quebec. Linguistic status may be a useful marker for surveillance of inequalities in stillbirth.
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15
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Stormdal Bring H, Hulthén Varli IA, Kublickas M, Papadogiannakis N, Pettersson K. Causes of stillbirth at different gestational ages in singleton pregnancies. Acta Obstet Gynecol Scand 2013; 93:86-92. [PMID: 24117104 DOI: 10.1111/aogs.12278] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 10/04/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare causes of stillbirth in preterm and term pregnancies. DESIGN Cohort study. SETTING All delivery wards in Stockholm, 1998-2009. POPULATION Stillbirths from singleton pregnancies of gestational age ≥22(+0) (n = 1089) extracted from a web-based database including all stillbirths in the major Stockholm area since 1998. METHODS The parents of the stillborns were all offered an extensive standardized investigation. The causes of death were assigned in a perinatal audit using the Stockholm classification of stillbirth. Singleton stillbirths were divided into preterm (gestational week 22(+0) -36(+6) ) and term/post-term (gestational week ≥37(+0) ). The term/post-term group was subdivided into term (gestational week 37(+0) -40(+6) ) and post-term stillbirths (gestational week ≥41(+0) ). MAIN OUTCOME MEASURE Causes of stillbirth at different gestational ages. RESULTS A higher proportion of placental abruption and preeclampsia/hypertension was seen in preterm stillbirths compared with term/post-term stillbirths, which instead had a higher proportion of umbilical cord complications and infection. Infection was more common in post-term than term stillbirths (46.5 vs. 19.8%, p < 0.001). CONCLUSION Increased knowledge of causes of stillbirth in different gestational ages may be valuable in developing strategies for prevention of fetal death. The high proportion of infection in post-term stillbirths could be clinically important and warrants further studies.
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Affiliation(s)
- Hanna Stormdal Bring
- Department of Obstetrics and Gynecology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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16
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Ego A, Zeitlin J, Batailler P, Cornec S, Fondeur A, Baran-Marszak M, Jouk PS, Debillon T, Cans C. Stillbirth classification in population-based data and role of fetal growth restriction: the example of RECODE. BMC Pregnancy Childbirth 2013; 13:182. [PMID: 24090495 PMCID: PMC3850812 DOI: 10.1186/1471-2393-13-182] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 09/26/2013] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Anne Ego
- The RHEOP (Registre des Handicaps de l'Enfant et Observatoire Périnatal Isère, Savoie et Haute-Savoie), Grenoble, France.
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17
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Stampfel C, Kroelinger CD, Dudgeon M, Goodman D, Ramos LR, Barfield WD. Developing a standard approach to examine infant mortality: findings from the State Infant Mortality Collaborative (SIMC). Matern Child Health J 2012; 16 Suppl 2:360-9. [PMID: 23108735 PMCID: PMC4301426 DOI: 10.1007/s10995-012-1167-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
States can improve pregnancy outcomes by using a standard approach to assess infant mortality. The State Infant Mortality Collaborative (SIMC) developed a series of analyses to describe infant mortality in states, identify contributing factors to infant death, and develop the evidence base for implementing new or modifying existing programs and policies addressing infant mortality. The SIMC was conducted between 2004 and 2006 among five states: Delaware, Hawaii, Louisiana, Missouri, and North Carolina. States used analytic strategies in an iterative process to investigate contributors to infant mortality. Analyses were conducted within three domains: data reporting (quality, reporting, definitional criteria, and timeliness), cause and timing of infant death (classification of cause and fetal, neonatal, and postneonatal timing), and maturity and weight at birth/maturity and birth weight-specific mortality. All states identified the SIMC analyses as useful for examining infant mortality trends. In each of the three domains, SIMC results were used to identify important direct contributors to infant mortality including disparities, design or implement interventions to reduce infant death, and identify foci for additional analyses. While each state has unique structural, political, and programmatic circumstances, the SIMC model provides a systematic approach to investigating increasing or static infant mortality rates that can be easily replicated in all other states and allows for cross-state comparison of results.
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Affiliation(s)
- Caroline Stampfel
- Association of Maternal and Child Health Programs, 2030 M Street NW, Washington, DC 20036, USA.
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18
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van Diem MT, Timmer A, Bergman KA, Bouman K, van Egmond N, Stant DA, Ulkeman LHM, Veen WB, Erwich J. The implementation of unit-based perinatal mortality audit in perinatal cooperation units in the northern region of the Netherlands. BMC Health Serv Res 2012; 12:195. [PMID: 22776712 PMCID: PMC3506548 DOI: 10.1186/1472-6963-12-195] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 06/20/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Perinatal (mortality) audit can be considered to be a way to improve the careprocess for all pregnant women and their newborns by creating an opportunity to learn from unwanted events in the care process. In unit-based perinatal audit, the caregivers involved in cases that result in mortality are usually part of the audit group. This makes such an audit a delicate matter. METHODS The purpose of this study was to implement unit-based perinatal mortality audit in all 15 perinatal cooperation units in the northern region of the Netherlands between September 2007 and March 2010. These units consist of hospital-based and independent community-based perinatal caregivers. The implementation strategy encompassed an information plan, an organization plan, and a training plan. The main outcomes are the number of participating perinatal cooperation units at the end of the project, the identified substandard factors (SSF), the actions to improve care, and the opinions of the participants. RESULTS The perinatal mortality audit was implemented in all 15 perinatal cooperation units. 677 different caregivers analyzed 112 cases of perinatal mortality and identified 163 substandard factors. In 31% of cases the guidelines were not followed and in 23% care was not according to normal practice. In 28% of cases, the documentation was not in order, while in 13% of cases the communication between caregivers was insufficient. 442 actions to improve care were reported for 'external cooperation' (15%), 'internal cooperation' (17%), 'practice organization' (26%), 'training and education' (10%), and 'medical performance' (27%). Valued aspects of the audit meetings were: the multidisciplinary character (13%), the collective and non-judgmental search for substandard factors (21%), the perception of safety (13%), the motivation to reflect on one's own professional performance (5%), and the inherent postgraduate education (10%). CONCLUSION Following our implementation strategy, the perinatal mortality audit has been successfully implemented in all 15 perinatal cooperation units. An important feature was our emphasis on the delicate character of the caregivers evaluating the care they provided. However, the actual implementation of the proposed actions for improving care is still a point of concern.
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Affiliation(s)
- Mariet Th van Diem
- Department of Obstetrics and Gynaecology, CB22, University Medical Centre Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - Albertus Timmer
- Department of Pathology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Klasien A Bergman
- Department of Neonatology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Katelijne Bouman
- Department of Genetics, University Medical Centre Groningen, Groningen, The Netherlands
| | - Nico van Egmond
- General Practitioners Practice “De Kompe”, Gorredijk, The Netherlands
| | - Dennis A Stant
- Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Lida H M Ulkeman
- Department of Obstetrics and Gynaecology, CB22, University Medical Centre Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
| | - Wenda B Veen
- Legal Department, University Medical Centre Groningen, Groningen, The Netherlands
| | - JanJaapHM Erwich
- Department of Obstetrics and Gynaecology, CB22, University Medical Centre Groningen, P.O. Box 30001, 9700 RB, Groningen, The Netherlands
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Abstract
AIM The aim of this study was to identify the risk factors for perinatal deaths in Pakistan, where perinatal mortality is still very high. MATERIALS AND METHODS This prospective cohort study was conducted in Sindh Government Lyari General Hospital, Karachi from 1 May 2006 to 30 April 2008. During this period, all perinatal deaths and each live infant delivered following every perinatal death (which were taken as controls) were enrolled. Demographic information, birthweight, booking status, associated obstetric risk factors, stillbirth or neonatal death and the cause of death were recorded. Univariate logistic regression was used to determine the effect of categorized weight, booking status, sex and the obstetric risk factors on perinatal death. RESULTS A total of 1103 deliveries were conducted during this period with 119 perinatal deaths. Stillbirths constituted 68.9% while there were early neonatal deaths in 31.1% cases. Booking status, gestational age, weight of fetus and the presence of obstetric risk factors were found to have significant (P-value < 0.05) association with perinatal deaths. Among the obstetric risk factors, abruptio placentae was the commonest (13.4%) and the commonest cause of death was identified as birth asphyxia (44.5%). There was a strong association between birthweight and perinatal death. CONCLUSIONS The high perinatal death rate in this study is comparable to other hospital-based studies and indicates the poor health status, inadequate prenatal and intranatal care and lack of services in our setup. In order to achieve the Millennium Development Goals-4, much work is needed to improve the quality of care, to identify high-risk cases and to carry out their proper management.
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Hirst JE, Ha LTT, Jeffery HE. Reducing the proportion of stillborn babies classified as unexplained in Vietnam by application of the PSANZ clinical practice guideline. Aust N Z J Obstet Gynaecol 2011; 52:62-6. [PMID: 21923842 DOI: 10.1111/j.1479-828x.2011.01363.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Jane E Hirst
- Department of Obstetrics & Gynaecology, Sydney Medical School, University of Sydney, Royal North Shore Hospital, Australia.
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Abstract
In this first paper of The Lancet's Stillbirths Series we explore the present status of stillbirths in the world-from global health policy to a survey of community perceptions in 135 countries. Our findings highlight the need for a strong call for action. In times of global focus on motherhood, the mother's own aspiration of a liveborn baby is not recognised on the world's health agenda. Millions of deaths are not counted; stillbirths are not in the Global Burden of Disease, nor in disability-adjusted life-years lost, and they are not part of the UN Millennium Development Goals. The grief of mothers might be aggravated by social stigma, blame, and marginalisation in regions where most deaths occur. Most stillborn babies are disposed of without any recognition or ritual, such as naming, funeral rites, or the mother holding or dressing the baby. Beliefs in the mother's sins and evil spirits as causes of stillbirth are rife, and stillbirth is widely believed to be a natural selection of babies never meant to live. Stillbirth prevention is closely linked with prevention of maternal and neonatal deaths. Knowledge of causes and feasible solutions for prevention is key to health professionals' priorities, to which this Stillbirths Series paper aims to contribute.
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Affiliation(s)
- J Frederik Frøen
- Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway.
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Abstract
OBJECTIVE To describe the methods for assigning the cause of death for stillbirths enrolled in the Stillbirth Collaborative Research Network (SCRN). METHODS A complete evaluation, including postmortem examination, placental pathology, medical record abstraction, and maternal interview was available on 512 stillbirths among 500 women. These 512 stillbirths were evaluated for cause of death using the definitions outlined in this report. Using the best available evidence, SCRN investigators developed a new methodology to assign the cause of death of stillbirths using clinical, postmortem, and placental pathology data. This new tool, designated the Initial Causes of Fetal Death, incorporates known causes of death and assigns them as possible or probable based on strict diagnostic criteria, derived from published references and pathophysiologic sequences that lead to stillbirth. RESULTS Six broad categories of causes of death are accounted for, including maternal medical conditions; obstetric complications; maternal or fetal hematologic conditions; fetal genetic, structural, and karyotypic abnormalities; placental infection, fetal infection, or both; and placental pathologic findings. Isolated histologic chorioamnionitis and small for gestational age were not considered causes of death. CONCLUSION A new system, Initial Causes of Fetal Death, to assign cause of death in stillbirths was developed by the SCRN investigators for use in this study but has broader applicability. Initial Causes of Fetal Death is a standardized method to assign probable and possible causes of death of stillbirths based on information routinely collected during prenatal care and the clinical evaluation of fetal death.
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Lu JR, McCowan L. A comparison of the Perinatal Society of Australia and New Zealand-Perinatal Death Classification system and relevant condition at death stillbirth classification systems. Aust N Z J Obstet Gynaecol 2010; 49:467-71. [PMID: 19780727 DOI: 10.1111/j.1479-828x.2009.01066.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Stillbirths comprise two-thirds of all perinatal mortality. A classification system with low 'unexplained' stillbirth rates is important when developing prevention strategies. AIMS This study aims to (i) determine whether the proportion of stillbirths classified as 'unexplained' is reduced, by using the relevant condition at death (ReCoDe) stillbirth classification system, compared with the Perinatal Society of Australia and New Zealand - Perinatal Death Classification (PSANZ-PDC) system; and (ii) compare the proportion of stillbirths attributed to fetal growth restriction and other causes by each system. METHODS The ReCoDe stillbirth classification system was applied to the National Women's Health's stillbirth database for years 2004-2007. The proportion of stillbirths classified as 'unexplained' and as a result of fetal growth restriction was compared between the ReCoDe and the PSANZ-PDC systems using the chi(2) test. RESULTS The proportion of stillbirths classified as unexplained was less with ReCoDe compared with PSANZ-PDC (8.5% (n = 26) vs 14.1% (n = 43) P = 0.04). The proportion with the primary cause attributed to fetal growth restriction was increased with ReCoDe compared with PSANZ-PDC (23.2% (n = 71) vs 8.2% (n = 25) P < 0.0001). However, 44.8% (n = 137) of all stillbirths were small for gestational age (birthweight < 10th customised centile). The most common primary cause or condition at death by both systems was congenital abnormalities. CONCLUSION The proportion of stillbirths classified as unexplained was less with ReCoDe compared with PSANZ-PDC but rates with either method were low compared with earlier classification systems. Fetal growth restriction was listed as the primary condition more commonly with ReCoDe compared with PSANZ-PDC because of different definitions.
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Affiliation(s)
- Jye Ru Lu
- National Women's Health, Auckland City Hospital, Level 9, Auckland City Hospital, 2, Park Road, Grafton, Auckland, New Zealand.
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24
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Frøen JF, Gordijn SJ, Abdel-Aleem H, Bergsjø P, Betran A, Duke CW, Fauveau V, Flenady V, Hinderaker SG, Hofmeyr GJ, Jokhio AH, Lawn J, Lumbiganon P, Merialdi M, Pattinson R, Shankar A. Making stillbirths count, making numbers talk - issues in data collection for stillbirths. BMC Pregnancy Childbirth 2009; 9:58. [PMID: 20017922 PMCID: PMC2805601 DOI: 10.1186/1471-2393-9-58] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 12/17/2009] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- J Frederik Frøen
- Department of Genes and Environment, Division of Epidemiology, Norwegian Institute of Public Health, P.O. Box 4404 Nydalen, N-0403 Oslo, Norway
| | - Sanne J Gordijn
- Department of Obstetrics and Gynaecology, University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Hany Abdel-Aleem
- Department of Obstetrics and Gynaecology, University Hospital, Assiut, Egypt
| | - Per Bergsjø
- Department of Chronic Diseases, Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Ana Betran
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Charles W Duke
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Vincent Fauveau
- Reproductive Health Branch, United Nations Population Fund, Geneva, Switzerland
| | - Vicki Flenady
- Department of Obstetrics and Gynaecology, University of Queensland
- Mater Mothers' Research Centre, Mater Health Services, Brisbane, Australia
| | | | - G Justus Hofmeyr
- Effective Care Research Unit, Eastern Cape Department of Health, Universities of the Witwatersrand and Fort Hare, South Africa
| | - Abdul Hakeem Jokhio
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Joy Lawn
- Saving Newborn Lives, Cape Town, South Africa
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynecology, Faculty of Medicine and Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - Mario Merialdi
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Robert Pattinson
- Department of Obstetrics and Gynaecology, University of Pretoria School of Medicine, Pretoria, South Africa
| | - Anuraj Shankar
- Department of Nutrition, Harvard School of Public Health, Harvard University, Boston, USA
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25
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Abstract
OBJECTIVE To estimate the occurrence of placental causes of fetal death in relation to different gestational ages and their clinical manifestations during pregnancy. METHODS In a prospective cohort study conducted from 2002 to 2006, we studied 750 couples with singleton intrauterine fetal death after 20 weeks of gestation. Cause of death was classified according to the Dutch Tulip cause of death classification for perinatal mortality. Differences between groups for categorical data were evaluated by the Fisher exact test or chi test. RESULTS The main causes were placental pathology (64.9%), congenital anomaly (5.3%), infection (1.9%), other (4.8%), and unknown (23.1%). The contribution of causes differed over gestational age periods. At lower gestational age, placental and unknown were the most dominant causes of death (34.8% and 41.7%, respectively); at higher gestational age, the relative importance of an unknown cause decreased and a placental cause increased (16.5% and 77.6%) (P<.001). Placental bed pathology was observed in 33.6% of all fetal deaths, with the highest occurrence between 24 0/7 and 31 6/7 weeks and a strong decline after 32 weeks. In contrast, contribution of developmental placental pathology (17.6%) increased after 32 weeks of gestation (P<.001), as did umbilical cord complications (5.2%) and combined placental pathology (5.4%). Solitary placental parenchyma pathology was less frequent (3.1%). Hypertension-related disease was observed in 16.1% (95% confidence interval [CI] 13.6-19.0) of the cohort, small for gestational age fetuses in 37.9% (95% CI 34.1-41.7), and diabetes-related disease in 4.1% (95% CI 2.8-5.8). CONCLUSION Most fetal deaths were caused by a variety of placental pathologies. These were related to gestational age, and their clinical manifestations varied during pregnancy. LEVEL OF EVIDENCE II.
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