Perinatal Death Classification Research Articles

Causes of in utero fetal deaths: 225 cases at Befelatanana Hospital, Madagascar

The high rate of in utero fetal death in our hospital led us to study its risk factors and causes. We conducted a case-control study from 1 January to 30 June, 2011, of all fetal deaths in utero in the Gynecology-Obstetrics University Hospital of Befelatanana. Risk factors were studied after comparison with a random sample of live births during the same period. The causes were classified according to the Perinatal Death Classification of the Perinatal Society of Australia and New Zealand. The rate of in utero fetal deaths was 5.22%. The risk factors statistically verified were: mother older than 34 years, parity of five or more, preterm, fewer than four prenatal consultations, previous fetal loss or hypertension disorders, and mother working in agriculture or commerce. The causes identified were hypertensive disorders (20.66%), prepartum hemorrhage (18.18%), fetal growth restriction (14.87%), premature rupture of the membrane (14.05%), hypoxia (12.39%), perinatal infection (11.57%), maternal conditions (3.30%), congenital abnormalities (3.30%), and specific perinatal conditions (1.65%). Screening for risk factors and close monitoring during pregnancy and labor are important to reduce fetal deaths.

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

Over 2.6 million babies are stillborn every year mostly in low- and middle-income countries, where cause of death remains often unexplained. 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. 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. 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%). 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.

The continuing dilemma of stillbirth

The continuing dilemma of stillbirth

Epidemiology of stillbirth and strategies for its prevention in Vietnam

Objective To describe major epidemiologic and placental findings regarding stillbirth in Vietnam. Methods A cross-sectional study of all stillbirths in a tertiary referral facility in Ho Chi Minh City, Vietnam, was performed. Detailed examination of each infant, placental pathology, and semi-structured maternal interviews were conducted according to the Perinatal Society of Australia and New Zealand Perinatal Death Classification guidelines. Maternal, fetal, and placental characteristics were examined. Results Between December 8, 2008, and January 9, 2009, there were 4694 live births and 122 stillbirths at the facility. In total, 107 (87.7%) cases were included in the study. Low education level was associated with a lack of prenatal care; induced abortion accounted for 34.6% of fetal deaths (gender selection was not the reason); 35.5% of infants were born at 22–28 weeks of gestation; 31.8% of stillbirths were small for gestational age; histologic evidence of chorioamnionitis was present in 40.2% of cases. Calcium supplements were less likely to have been taken in cases in which death from hypertension occurred. α-Thalassemia was the main cause of fetal hydrops (6.2%). Conclusion Improving access to prenatal care and prenatal calcium and iron supplementation, and screening for congenital abnormalities and α-thalassemia may help to reduce rates of perinatal death in Vietnam.

A comparison of the Perinatal Society of Australia and New Zealand‐Perinatal Death Classification system and relevant condition at death stillbirth classification systems

Stillbirths comprise two-thirds of all perinatal mortality. A classification system with low 'unexplained' stillbirth rates is important when developing prevention strategies. 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. 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. 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. 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.

Causes of death and associated conditions (Codac) – a utilitarian approach to the classification of perinatal deaths

A carefully classified dataset of perinatal mortality will retain the most significant information on the causes of death. Such information is needed for health care policy development, surveillance and international comparisons, clinical services and research. For comparability purposes, we propose a classification system that could serve all these needs, and be applicable in both developing and developed countries. It is developed to adhere to basic concepts of underlying cause in the International Classification of Diseases (ICD), although gaps in ICD prevent classification of perinatal deaths solely on existing ICD codes.We tested the Causes of Death and Associated Conditions (Codac) classification for perinatal deaths in seven populations, including two developing country settings. We identified areas of potential improvements in the ability to retain existing information, ease of use and inter-rater agreement. After revisions to address these issues we propose Version II of Codac with detailed coding instructions.The ten main categories of Codac consist of three key contributors to global perinatal mortality (intrapartum events, infections and congenital anomalies), two crucial aspects of perinatal mortality (unknown causes of death and termination of pregnancy), a clear distinction of conditions relevant only to the neonatal period and the remaining conditions are arranged in the four anatomical compartments (fetal, cord, placental and maternal).For more detail there are 94 subcategories, further specified in 577 categories in the full version. Codac is designed to accommodate both the main cause of death as well as two associated conditions. We suggest reporting not only the main cause of death, but also the associated relevant conditions so that scenarios of combined conditions and events are captured.The appropriately applied Codac system promises to better manage information on causes of perinatal deaths, the conditions associated with them, and the most common clinical scenarios for future study and comparisons.

Unexplained fetal death: Are women with a history of fetal loss at higher risk?

To identify factors, including the loss of a previous pregnancy before 20 weeks gestation, which are associated with increased risk of singleton antepartum unexplained fetal death (UFD) in Western Australia (WA) using information recorded in routine data collections. All fetal deaths in WA from 1990 to 1999 that underwent thorough post-mortem investigations were classified using the Perinatal Society of Australia and New Zealand Perinatal Death Classification System. All UFDs were selected as cases and unmatched controls were randomly drawn from all live births in WA occurring during the study period. Demographic and clinical information on cases and controls was obtained from the WA Midwives' Notification System. Multivariable logistic regression was carried out to determine the independent effect of risk factors and calculate odds ratios. Almost one quarter (22%) of stillbirths were unexplained. Primigravid and primiparous women with a history of pregnancy loss before 20 weeks were at higher risk of UFD than multiparous women who had not experienced any loss. Women with a history of fetal death (after 20 weeks) had the highest risk of UFD. The current practice of closely monitoring pregnant women with a history of fetal loss or death should continue as this study suggests they may have a higher risk of poor obstetric outcome. Larger studies are needed to confirm the association between previous pregnancy loss and UFD.

Classification and description of stillbirths in New South Wales, 2002–2004

To describe the pattern of stillbirths by cause and gestation period in New South Wales since the introduction of the Perinatal Society of Australia and New Zealand perinatal death classification (PSANZ-PDC); and to assess the agreement between classifications on cause of death between local hospital committees and the Perinatal Outcomes Working Party (POWP - a subgroup of the NSW Department of Health Ministerial Maternal and Perinatal Committee). Population-based retrospective cohort study of all 258 045 births in NSW and all 1264 stillbirths classified by the POWP in 2002-2004, based on linked data on perinatal deaths from the NSW Midwives Data Collection and the NSW Ministerial Maternal and Perinatal Committee. Pattern of stillbirths by cause and gestation period; and interobserver agreement on classification of cause of death (according to the PSANZ-PDC) between local hospital review committees and the POWP. The most common classification was unexplained antepartum death, comprising 41.5% of the cohort and 60% of stillbirths of > or = 37 weeks' gestation. These unexplained stillbirths were more likely to have had an autopsy performed than the explained stillbirths (45% v 36%; x2 = 10.1; df = 1; P = 0.001). Agreement on cause of death differed by cause of death classification, with an overall kappa statistic of 0.638. Unexplained antepartum death is the most common classification of stillbirths near term, and these stillbirths are more likely to have had an autopsy. Although reported interobserver agreement is high for PSANZ-PDC, in practice it is relatively low between hospital mortality review committees and the POWP.

Fetal growth restriction and other risk factors for stillbirth in a New Zealand setting

Stillbirth affects almost 1% of pregnant women in the Western world but is still not a research priority. To assess in a cohort of stillbirths: the demographic risk factors, the prevalence of small for gestational age (SGA) by customised and population centiles, and the classification of death using the Perinatal Society of Australia and New Zealand Perinatal Death Classification (PSANZ-PDC). The study population comprised 437 stillborn babies (born from 1993 to 2000 at National Women's Hospital, Auckland, New Zealand) and their mothers. The referent population for demographic factors was live births n=69 173. After multivariable analysis, risk factors for stillbirths were: Indian (odds ratio (OR) 1.85, 95%CI (1.18, 2.91)), or Pacific Islander (OR 1.65, 95%CI (1.27, 2.14)); smoking (OR 1.33, 95%CI (0.99, 1.79)) or unknown smoking status (OR 2.87, 95%CI (2.30, 3.58)); nulliparity (OR 1.42, 95%CI (1.10, 1.83)), and para 2 (OR 1.36, 95%CI (1.01, 1.83)). One hundred and twenty-nine (46%) stillbirths born>or=24 weeks (n=278) were SGA by customised, and 94 (34%) by population centiles. Customised SGA was more common in preterm versus term stillbirths (101 of 198 (51%) vs 28 of 80 (35%), respectively, P=0.02) but rates of population SGA did not differ (72 of 198 (36%) vs 22 of 80 (28%) P=0.16). 'Spontaneous preterm' was the most common cause of stillbirth at <28 weeks and 'unexplained' at >or=28 weeks using PSANZ-PDC classification. This study again emphasises the importance of suboptimal fetal growth as an important risk factor for stillbirth. Customised centiles identified more stillborn babies as SGA than population centiles especially preterm.

Aetiology of stillbirth: unexplored is not unexplained

To describe the rate of and demographic factors associated with fetal postmortem investigation and to classify the cause of all fetal deaths that underwent postmortem investigation. To compare the proportion of deaths remaining unexplained after postmortem investigation with estimates derived from death certificates. All fetal deaths in Western Australia (WA) from 1990 to 1999 were identified. These data were used to calculate postmortem rates and describe the characteristics of women consenting to postmortems. A multidisciplinary team classified the cause of all deaths that underwent postmortem investigation using the Perinatal Society of Australia and New Zealand Perinatal Death Classification System. The proportion of deaths that were unexplained was compared with estimates based on death certificates. Of the 1,619 fetal deaths recorded for 1990 to 1999, 49% (n=789) underwent complete postmortem investigation. Based on investigations, 22% of the 789 fetal deaths were unexplained and a further 18% were identified as having fetal growth restriction. Based on death certificates, 42% were unexplained and 65% were later explained by postmortem investigation. Postmortem investigation rates are low. They reveal a cause of death for the majority of cases that are unexplained clinically. Epidemiological investigations of unexplained fetal death based on cases not subject to complete postmortem investigation may lead to inaccurate conclusions. A standardised definition for unexplained fetal deaths that distinguishes between cases with detailed investigation and those with limited or no investigation is needed.

Analysis of Perinatal Mortality at a Teaching Hospital in Dar es Salaam, Tamania, 1999-2003

We conducted a retrospective analysis of perinatal mortality at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania 1999-2003 in order to categorise/classify perinatal deaths as well as to identify key factors in perinatal care that could be improved. Data were retrieved from the MNH obstetric database and causes of early neonatal deaths were traced from the neonatal ward register. The study includes all foetuses weighing =500g. A modified Nordic-Baltic classification was used for classification of perinatal deaths. Over a 5-year period there were 77,815 babies born with a perinatal mortality rate of 124 per 1000 births, 78% of which was labour related stillbirth. The PMR was 913/1000 for singleton births and 723/1000 for multiple births for babies weighing less than 1500 grams and 65/1000 for singleton births and 116/1000 for multiple births for babies weighing 2500 grams or more. Babies weighing less than 1500 grams contributed 26% of PMR, whereas 41% occurred in babies weighing 2500 grams or more. The majority (79%) of neonatal deaths had Apgar score <7 at 5 minutes and the most common causes of neonatal mortality were birth asphyxia (37%) and prematurity (29%). Labour related deaths were more common in multiple pregnancies. The majority of the perinatal deaths should be essentially avoidable through improved quality of intrapartum care. Establishment of perinatal audit at MNH can help identify key actions for improved care.

Audit of perinatal deaths in a tertiary level hospital in Latvia (1995–1999) using the Nordic-Baltic perinatal death classification: Evidence of suboptimal care

Objective. The objective of this study was to explore applicability of the Nordic-Baltic perinatal death (PND) classification in a single hospital via evaluation of changes of the preventability of PND over the time period in a tertiary level perinatal care center in Latvia.Method. All PND cases during the period 1995–1999 at a tertiary referral perinatal care center, the Riga Maternity Hospital (RMH), were analyzed using the common Nordic-Baltic PND classification.Results. The total perinatal mortality rate (PNMR) did not decline at the RMH over the study period. The rate of antenatal and intrapartum deaths at <28 weeks of gestation increased (p < 0.01). Early neonatal deaths at 28–33 weeks of gestation with a low 5-minute Apgar score became less frequent (p < 0.05). There was a trend towards more cases of probably suboptimal care (p < 0.005) and the proportion of preventable PND cases increased from 14.7% in 1995 to 36.4% in 1999 (p = 0.01).Conclusion. The perinatal audit performed at the RMH using the Nordic-Baltic PND classification disclosed a requirement for further improvement of perinatal care in the hospital. The classification can be used to evaluate the preventability of perinatal death cases in a single hospital, and its application in other hospitals in Latvia could provide information necessary for the improvement of perinatal care in the country.

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.

Classification of perinatal death in a developing country

Objectives: To evaluate and compare the three most commonly used perinatal death classification systems: (1) the Nordic–Baltic; (2) the Aberdeen; and (3) the Wigglesworth, and assess their applicability in a developing country (Sudan) with a high perinatal mortality rate, and their justification for practical use in quality assurance and audit activities. Methods: At Omdurman Maternity Hospital (OMH), Khartoum, Sudan, 166 perinatal deaths were prospectively assessed during a 3-month period (May–August 2000) with a total of 2260 births. Narratives of 166 perinatal deaths were prepared for the purpose of audit. A panel of two Danish and one Sudanese obstetrician categorized the cases according to: (1) the Nordic–Baltic; (2) the Aberdeen; and (3) the Wigglesworth classification. Results: By all three classifications a similar fraction of cases (approx. 85%) were allocated to one category only, and in 15% of cases the assessors were in doubt into which of two categories the cases should be allocated. The necessary information is often not available, giving at least 40% classified as ‘unknown’ in the Aberdeen classification, whereas the Wigglesworth classification results in an even larger group of unspecified asphyxia. Conclusion: Classification of perinatal deaths in developing countries is associated with problems regarding application, validity and usefulness. The Nordic–Baltic classification seems to be most suitable for appropriate stratification using routinely recorded variables and providing categories associated with specific levels of care.

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.

Evaluation of 239 cases of perinatal death using a fundamental classification system

Objective: To classify 239 cases of perinatal death in a newly introduced classification system for underlying causes of perinatal death. Design: Prospective, descriptive. Setting: Dutch healthcare region Delft–Westland–Oostland (DWO). Materials and methods: In 10 years (1983–1992), all cases of perinatal death with a birthweight above 500 g ( n=239) were included into the study. We used a classification model based upon the underlying cause of death using simple principles of obstetrical and neonatal pathology. A team consisting of a gynaecologist, neonatologist and pathologist classified all cases of perinatal death into seven groups to determine the “most-probable” cause of death. Results: Birth trauma was seen in two cases (0.8%). Infections were seen in 16 cases (6.8%). Acute/subacute placental pathology in 77 cases (32.2%) and chronic placental pathology in 50 cases (21%). Bloodtype antagonism was seen in two cases (0.8%). Lethal congenital malformations in 55 cases (23%). Complications of pre-viable delivery in 20 cases (8.4%). Unclassifiable were 17 cases (7%): two cases could not be classified despite thorough investigation (1%) and 15 cases were lost for follow-up (6%). Conclusions: Classification of perinatal death causes by using our fundamental classification system gives insight in the possible underlying causes of death. The results of such a classification can be used as guidelines for preventive measures in the future.

Fundamental classification of perinatal death: Validation of a new classification system of perinatal death

Objective: To validate a newly introduced classification system for the registration of perinatal mortality. Design: Descriptive. Setting: Dutch Healthcare region Delft-Westland-Oostland (DWO). Material and methods: In a 10-years period (1983–1992), all cases of perinatal death with a birthweight above 500 g ( n=239) were included into the study. Six assessors: four gynaecologists and two paediatricians were asked to classify all cases using a classification model proposed by the authors. This model is based on the underlying cause of death using simple principles of obstetrical and neonatal pathology: birth trauma, infection, placenta or cord pathology, pathology of immune tolerance of mother and fetus, congenital malformation of the fetus and complications of a pre-viable delivery. Therefore, we used the term fundamental classification. The six assessors worked independently of each other in classifying all cases of perinatal death, were not involved in the original development of the system and were unaware of the results of the classification of their colleagues. Agreement beyond chance between assessors was calculated using kappa’s coefficient for multiple observers and multiple test results. Results: Overall kappa was 0.70 (95% confidence interval (C.I.) 0.68–0.72). Reproducibility was poor for the categories trauma and unclassifiable, fair for the categories infections and placental/cord pathology, and very good to excellent for the categories maternal immune system pathology, congenital malformations and complications of prematurity. Conclusions: The proposed system showed a good level of agreement and appeared to be simply applicable. It offers a good insight in the underlying cause of death with the possibility for recognising preventive factors in future pregnancies and will enable (inter)national comparisons in causes of perinatal death. A reliable uniform registration of perinatal death based on the underlying causes should be the basis for improvement of the quality of perinatal care.

Using the Nordic–Baltic perinatal death classification to assess perinatal care in Ukraine

Objective: To identify health care issues important to reduce the perinatal mortality rate (PMR) in Ukraine. Study Design: Perinatal deaths in the Donetsk region (Ukraine) in 1997–1998 were compared with those in Denmark in 1996 by using the Nordic–Baltic classification for perinatal deaths. Clinical guidelines, use of technology and rates of interventions in the two regions were described. Results: A two-fold increase in PMR was found in Ukraine compared to Denmark, mainly explained by higher rates of antenatal deaths of growth restricted fetuses, intrapartum deaths, and neonatal deaths due to asphyxia. Vacuum extraction is rarely used in Ukraine. The clinical guidelines for care differ significantly between the two regions. Conclusion: Appropriate use of technology and implementation of evidence-based guidelines should be a matter of high priority in the Donetsk region, Ukraine.

Perinatal deaths and insufficient antenatal care in Latvia.

A national audit on perinatal deaths was performed to assess the quality of antenatal care, and to suggest measures for improved antenatal care. Medical records of all the perinatal deaths in Latvia in the years 1995-1996 have been studied. Non-attenders and attenders of antenatal care were characterized by socio-economic and medical variables: maternal age, parity, history of perinatal outcome, health status and behavioral hazards during the index pregnancy, length of gestation and birth weight. The Nordic-Baltic perinatal death classification was used. In 85 of 442 cases (19%) of perinatal deaths women had not taken advantage of antenatal care provided for them. Non-attenders were more likely to be smokers (p<0.001) and alcohol abusers (p<0.005), above 35 years of age (p<0.005), and had higher parity (p<0.001). Non-attenders more often had systemic diseases and pregnancy complications. Neonatal complications, such as congenital syphilis (p<0.05) and other infections (p<0.05), were more common among non-attenders. There was no difference in rates of preterm birth and low birth weight between attenders and non-attenders. One fifth of mothers with perinatal death did not attend ANC, and in some women who attended ANC, lack of intervention was related to the perinatal death.

Propuesta de un certificado de defunción para mejorar el registro y reporte de la muerte en el periodo perinatal

To analyze perinatal births and deaths recording at the Mexican Institute of Social Security (MISS), and to evaluate the correct classification of perinatal deaths. From January to March 2000, data were collected from the 37 MISS districts on the total number of births and deaths occurring during 1999, deaths occurring before the seventh day of life, and gestational age and weight at birth. Early neonatal and infant mortality rates were analyzed including or separating newborns with < 1,000 g and < 28 weeks of gestational age. During 1999 there were 634,892 live births--whose gestational age and birth weight are unknown- and 3,984 stillbirths > or = 28 gestation weeks. There were 4,556 newborns who died before the seventh day of extrauterine life; 1,385 of them (30.4%) weighted less than 1,000 g and had a gestational age < 28 weeks. The analysis of mortality with and without these newborns shows a decrease of two points in early neonatal and infant mortality rates. This study shows that classification and reporting of perinatal mortality are inappropriate. A proposal is made to develop information systems that include weight and gestational age of all births. A new perinatal death certificate replacing current fetal and general death certificates would allow proper mortality classification and comparisons between countries.