Abstract
The archaic definition and registration processes for stillbirth currently prevalent in Canada impede both clinical care and public health. The situation is fraught because of definitional problems related to the inclusion of induced abortions at ≥20 weeks’ gestation as stillbirths: widespread uptake of prenatal diagnosis and induced abortion for serious congenital anomalies has resulted in an artefactual temporal increase in stillbirth rates in Canada and placed the country in an unfavourable position in international (stillbirth) rankings. Other problems with the Canadian stillbirth definition and registration processes extend to the inclusion of fetal reductions (for multi-fetal pregnancy) as stillbirths, and the use of inconsistent viability criteria for reporting stillbirth. This paper reviews the history of stillbirth registration in Canada, provides a rationale for updating the definition of fetal death and recommends a new definition and improved processes for fetal death registration. The recommendations proposed are intended to serve as a starting point for reformulating issues related to stillbirth, with the hope that building a consensus regarding a definition and registration procedures will facilitate clinical care and public health.
Highlights
Current definition the global movement to bring stillbirth ‘out of the shadows’ has gained substantial traction (Mullan and Horton 2011), little effort has been made towards rationalizing the definition of stillbirth in Canada
The situation is fraught because of definitional problems related to the inclusion of induced abortions at ≥20 weeks’ gestation as stillbirths: widespread uptake of prenatal diagnosis and induced abortion for serious congenital anomalies has resulted in an artefactual temporal increase in stillbirth rates in Canada and placed the country in an unfavourable position in international rankings
In 1959, the Canadian stillbirth definition was aligned with the World Health Organization’s (WHO) definition of ‘fetal death’, namely, “death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles” (WHO 2004)
Summary
The global movement to bring stillbirth ‘out of the shadows’ has gained substantial traction (Mullan and Horton 2011), little effort has been made towards rationalizing the definition of stillbirth in Canada. During most of the twentieth century, Canadian vital records defined stillbirth as “the birth of a fetus, after at least 28 weeks’ pregnancy, which, after complete separation from the mother, does not show any sign of life” (Statistics Canada 2020). Modeled on the WHO’s definition of fetal death, the Canadian stillbirth definition included a (new) gestational age cut-off of ≥20 weeks (Statistics Canada 2020). With the exception of Quebec, all provinces/territories in Canada currently define stillbirth as the birth of a fetus at ≥20 weeks’ gestation or with a birth weight ≥500 g, which shows no signs of life at birth (Statistics Canada 2020). These definitions differ from those used elsewhere (Joseph et al 2015), e.g., Australia (≥20 weeks’ gestation or ≥400 g birth weight) and the United Kingdom (≥ 24 weeks’ gestation)
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