Stillbirths including intrapartum timing: EN-BIRTH multi-country validation study

Kimberly Peven,En-Birth Study Group ,Ashish Kc,Hannah Blencowe,Qazi Sadeq-Ur Rahman,Joy E Lawn,Tazeen Tahsina,Shafiqul Ameen,Louise T Day,Josephine Shabani,Harriet Ruysen,Omkar Basnet,Stefanie Kong,Rajib Haider

doi:10.1186/s12884-020-03238-7

Abstract

BackgroundAn estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording.MethodsThe EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017–2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity, percent agreement). We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission.Results23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was > 90%. The observed study stillbirth rate ranged from 3.8 (95%CI = 2.0,7.0) to 50.3 (95%CI = 43.6,58.0)/1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9–0.7). Specificity of register-recorded birth outcomes was > 99% and sensitivity varied between hospitals, ranging from 77.7–86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (> 98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use.ConclusionsOur results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths.

Highlights

An estimated >2 million babies stillborn around the world each year lack visibility
Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths
The magnitude of global stillbirths is similar to neonatal deaths [3], stillbirths are not included in the sustainable development goals [4] and are absent from many health metrics including quality-adjusted life-years (QALYs), and disability-adjusted life-years (DALYs) [5, 6]

Summary

Introduction

An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middleincome countries carry 84% of the burden yet have the least data. An estimated >2 million babies are stillborn each year, of which 84% are in low- and middle-income countries (LMICs), notably in south Asia and sub-Saharan Africa [1, 2]. International Classification of Diseases (ICD) recommends collecting data on all babies showing no signs of life with a birthweight of 500 g or more [10]. Where birthweight is not known, ICD recommends using a gestational age threshold of 22 or more weeks for recording and 28 or more weeks for international comparisons. A review of these definitions is currently underway and, in line with recent global stillbirth estimates, the use of gestational age at birth in preference to birthweight criteria is likely to be recommended [2]. Whilst systematic global reviews found stillbirth rate data for over 147 countries, often these data are not used in national or global policy and planning [11]

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