Perinatal deaths: relevance of Wigglesworth's classification

Perinatal mortality in preterm births: an analysis of causes, presence of substandard care and avoiding mortality in three Dutch regions

OBJECTIVE

To analyze the causes and underlying events in cases of perinatal mortality (PNM) in preterm children.

SETTING

Three regions within the Netherlands.

STUDY DESIGN

For this study, we combined data of a PNM audit over a 1-year (2003-2004) with the corresponding data of its source population (n=22,189). In the perinatal audit, all cases of perinatal death have been assessed by multi disciplinary teams of professionals in perinatal care in a consensus model for cause of death and the presence of substandard care factors (SSF). In this article, we restricted our analysis to children born between 22+0 and 37+0 weeks of pregnancy (≥154 and <259 days). We also evaluated avoidability of preterm birth and avoidability of preterm perinatal mortality (PPM) in cases with and without SSF.

RESULTS

Of 1885 preterm children, 166 died perinatally (8.81%). The two most important determinants were small-for-gestational-age;ib47.6% of all cases with gestational age (GA) ≥25 weeks;ic and previous PNM (21.1%). In addition, PPM was substantially increased in mothers of non-Dutch origin (PPM 12.1% vs. 6.6% in children of Dutch mothers relative risk (RR)=1.88, 95% confidence interval=1.46-2.43) and in mothers in the age group 20-26 years (PPM 13.4% vs. <9% in all other categories, RR=1.69, 95% confidence interval=1.21-2.38). In 22.6% of the cases perinatal death was considered to be avoidable while in 17.0% perinatal death was related to SSF by caregivers.

CONCLUSIONS

Immediate and appropriate actions by both caregivers and care receivers in case of early signals of possible preterm labor may reduce PNM in this category in the Netherlands by more than 20%. Improvement in surveillance of fetal growth may reduce mortality significantly in the preterm gestational period.

Mortes perinatais e avaliação da assistência ao parto em maternidades do Sistema Único de Saúde em Belo Horizonte, Minas Gerais, Brasil, 1999

Este trabalho analisa a associação entre a morte perinatal e o processo de assistência hospitalar ao parto, considerando-se que grande parte das mortes perinatais pode ser prevenível pela atenção qualificada de saúde e que a avaliação da qualidade da assistência perinatal ao parto é necessária para a redução da morbi-mortalidade perinatal. Realizou-se estudo caso-controle de base populacional dos óbitos perinatais (n = 118) e nascimentos (n = 492), ocorridos em maternidades do Sistema Único de Saúde (SUS) de Belo Horizonte, Minas Gerais, Brasil. Sexo masculino, prematuridade, doenças na gravidez, baixo peso ao nascer, doenças do recém-nascido, não realização de pré-natal, não utilização de partograma e menos de uma avaliação fetal por hora durante o trabalho de parto apresentaram associação estatisticamente significativa com o óbito perinatal. No modelo de regressão logística múltipla, não utilização do partograma durante o trabalho de parto e tipo de maternidade apresentaram-se como fatores de risco independentes para a morte perinatal. O estudo indica que é deficiente a qualidade da assistência hospitalar ao parto e que aspectos da estrutura dos serviços e do processo de assistência relacionam-se com a mortalidade perinatal por causas evitáveis.

Classification of perinatal deaths: development of the Australian and New Zealand classifications

Classifications of perinatal deaths have been undertaken for surveillance of causes of death, but also for auditing individual deaths to identify suboptimal care at any level, so that preventive strategies may be implemented. This paper describes the history and development of the paired obstetric and neonatal Perinatal Society of Australia and New Zealand (PSANZ) classifications in the context of other classifications. The PSANZ Perinatal Death Classification is based on obstetric antecedent factors that initiated the sequence of events leading to the death, and was developed largely from the Aberdeen and Whitfield classifications. The PSANZ Neonatal Death Classification is based on fetal and neonatal factors associated with the death. The classifications, accessible on the PSANZ website (http://www.psanz.org), have definitions and guidelines for use, a high level of agreement between classifiers, and are now being used in nearly all Australian states and New Zealand.

[Perinatal mortality and evitability: a review]

This is a literature review onperinatal mortality focusing its evitability. A Medline and Lilacs (Latin-America and Caribbean) search was conducted for the 90s. There are few research studies on this subject in Brazil due to the great number of underreported fetal deaths and the low quality information provided in death certificates. Different proposals for perinatal death classification are presented. Most are based on grouping the underlying causes of deaths in a functional system in order to facilitate the analysis. In the Wigglesworth classification system, one of the most recommended methods, deaths are related to the different stages of care for pregnant women and children, evidencing the possibilities of their prevention. The evitability approach of perinatal deaths in Brazil is highly recommended, as mortality rates are still very high and most of the deaths are considered avoidable. Premature deaths could be avoided improving the quality of health care. Besides improving the medical assistance, the organization of health care regarding pre-natal, birth and neonatal care must also be better developed to ensure access to qualified assistance.

Use of Wigglesworth pathophysiological classification for perinatal mortality in Malaysia

A one year prospective study of perinatal deaths was conducted to test the feasibility of using the Wigglesworth pathophysiological classification in the Malaysian health service. Four regions with high perinatal mortality rates were selected. Deaths were actively identified. Nursing staff were trained to use the classification and every death was reviewed by a clinician. A total of 26,198 births and 482 perinatal deaths were reported. The perinatal mortality rate was 18.4. Only 14 (2.9%) deaths had their Wigglesworth category reclassified. Most deaths were in the normally formed macerated stillbirths (34.4%), asphyxial conditions (26.8%), and immaturity (20.1%) subgroups. The results were compared with data from other countries that used this classification. This study has shown that the Wigglesworth pathophysiological classification can be applied to perinatal deaths in the existing Malaysian health service.