Fetal Death Reports Research Articles

Racial and Ethnic Disparities in Fetal Deaths - United States, 2015-2017.

The spontaneous death or loss of a fetus during pregnancy is termed a fetal death. In the United States, national data on fetal deaths are available for losses at ≥20 weeks' gestation.* Deaths occurring during this period of pregnancy are commonly known as stillbirths. In 2017, approximately 23,000 fetal deaths were reported in the United States (1). Racial/ethnic disparities exist in the fetal mortality rate; however, much of the known disparity in fetal deaths is unexplained (2). CDC analyzed 2015-2017 U.S. fetal death report data and found that non-Hispanic Black (Black) women had more than twice the fetal mortality rate compared with non-Hispanic White (White) women and Hispanic women. Fetal mortality rates also varied by maternal state of residence. Cause of death analyses were conducted for jurisdictions where >50% of reports had a cause of death specified. Still, even in these jurisdictions, approximately 31% of fetal deaths had no cause of death reported on a fetal death report. There were differences by race and Hispanic origin in causes of death, with Black women having three times the rate of fetal deaths because of maternal complications compared with White women. The disparities suggest opportunities for prevention to reduce the U.S. fetal mortality rate. Improved documentation of cause of death on fetal death reports might help identify preventable causes and guide prevention efforts.

Pregnancy, Birth, and Infant Outcomes Among Women Who Are Deaf or Hard of Hearing

Being deaf or hard of hearing can be marginalizing and associated with inequitable health outcomes. Until recently, there were no U.S. population-based studies of pregnancy outcomes among deaf or hard of hearing women. In light of inconsistent findings in the limited available literature, this study sought to conduct a more rigorous study using population-based, longitudinal linked data to compare pregnancy complications, birth characteristics, and neonatal outcomes between deaf or hard of hearing and non-deaf or hard of hearing women. Researchers conducted a retrospective cohort study in 2019 using the Massachusetts Pregnancy to Early Life Longitudinal data system. This system links all Massachusetts birth certificates, fetal death reports, and delivery- and nondelivery-related hospital discharge records for all infants and their mothers. The study included women with singleton deliveries who gave birth in Massachusetts between January 1998 and December 2013. The deaf or hard of hearing women had an increased risk of chronic medical conditions and pregnancy complications including pre-existing diabetes, gestational diabetes, pre-eclampsia and eclampsia, and placental abruption. Deliveries to deaf or hard of hearing women were significantly associated with adverse birth outcomes, including preterm birth, low birth weight or very low weight, and low 1-minute Apgar score or low 5-minute Apgar score. No significant differences were found in size for gestational age, fetal distress, or stillbirth among deaf or hard of hearing women. Findings from this 2019 study indicate that deaf or hard of hearing women are at a heightened risk for chronic conditions, pregnancy-related complications, and adverse birth outcomes and underscore the need for systematic investigation of the pregnancy- and neonatal-related risks, complications, costs, mechanisms, and outcomes of deaf or hard of hearing women.

Checking the pregnancy checkbox: Evaluation of a four-state quality assurance pilot.

The 2003 revision of the standard United States death certificate included a set of "pregnancy checkboxes" to ascertain whether a woman was pregnant at the time of her death or within the preceding year. Studies validating the pregnancy checkbox have indicated a potentially high number of errors, resulting in inflated maternal mortality rates. In response to concerns about pregnancy checkbox data quality, four state health departments implemented a quality assurance pilot project examining the accuracy of the pregnancy checkbox for 2016 deaths. State staff conducted searches for birth or fetal death reports that matched a death certificate, within a year of death. If a pregnancy checkbox was marked, but no match was found between certificates, confirmation of the pregnancy was attempted through active follow-up with the death certifier. From December 2017 to January 2018, the quality assurance pilot was evaluated through three focus groups with key stakeholders. The evaluation aimed to describe opportunities and challenges to implementation, sustainability, and lessons learned. Opportunities for implementing the pilot included written documentation of the quality assurance process, improved certifier response, improved data quality, and increased data timeliness for Maternal Mortality Review Committees. Challenges included initial delays in certifier response, staff turnover, high caseloads in relation to resources, and lack of pilot prioritization in the health department. All four pilot states plan to sustain the pregnancy checkbox quality assurance process in some capacity. Implementing quality assurance processes for the pregnancy checkbox may ultimately improve state and national maternal death data quality.

Understanding Perinatal Death: A Systematic Analysis of New York City Fetal and Neonatal Death Vital Record Data and Implications for Improvement, 2007–2011

We aimed to compare demographic, medical, and cause-of-death information reported for third-trimester fetal and neonatal death vital records collected in New York City (NYC) before and after implementation of the revised fetal death certificate to identify: (1) the limitations of combining fetal and neonatal death records for the purpose of perinatal death prevention; and (2) improvement opportunities for fetal death vital records registration. Using Chi squared tests, we compared data completeness and cause-of-death information between third-trimester NYC fetal (n = 1,930) and neonatal deaths (n = 735) from 2007 to 2011. We also compared fetal death data before and after the 2011 implementation of the 2003 United States (US) Standard Report of Fetal Death and an electronic reporting system. Compared with neonatal deaths, fetal death data were generally less complete (P < 0.0001). Fetal death data much more frequently reported an ill-defined cause of death (67 vs. 5 %). Most ill-defined reported causes of fetal death (73 %) were attributed to stillbirth synonyms (e.g., "fetal demise"). Ill-defined causes of fetal death decreased from 68 to 61 % (P < 0.01) after 2011. Both data completeness and ill-defined causes of death varied widely by hospital. In NYC, fetal deaths lack demographic, medical, and cause-of-death information compared with neonatal deaths, with implications for research that uses combined perinatal mortality data sets. Electronic implementation of the US Standard Report of Fetal Death minimally improved cause-of-death information. Substantial variability by hospital suggests opportunities for improvement exist.

Accounting for fetal death: Vital statistics and the medicalization of pregnancy in the United States

Recent reports by the Centers for Disease Control and Prevention have decried the high rate of fetal mortality in the contemporary United States. Much of the data about fetal and infant deaths, as well as other poor pregnancy outcomes, are tabulated and tracked through vital statistics. In this article, I demonstrate how notions of fetal death became increasingly tied to the surveillance of maternal bodies through the tabulating and tracking of vital statistics in the middle part of the twentieth century. Using a historical analysis of the revisions to the United States Standard Certificate of Live Birth, and the United States Standard Report of Fetal Death, I examine how the categories of analysis utilized in these documents becomes integrally linked to contemporary ideas about fetal and perinatal death, gestational age, and prematurity. While it is evident that there are relationships between maternal behavior and birth outcomes, in this article I interrogate the ways in which the surveillance of maternal bodies through vital statistics has naturalized these relationships.

Comparison of VAERS fetal-loss reports during three consecutive influenza seasons

The aim of this study was to compare the number of inactivated-influenza vaccine–related spontaneous abortion and stillbirth (SB) reports in the Vaccine Adverse Event Reporting System (VAERS) database during three consecutive flu seasons beginning 2008/2009 and assess the relative fetal death reports associated with the two-vaccine 2009/2010 season. The VAERS database was searched for reports of fetal demise following administration of the influenza vaccine/vaccines to pregnant women. Utilization of an independent surveillance survey and VAERS, two-source capture–recapture analysis estimated the reporting completeness in the 2009/2010 flu season. Capture–recapture demonstrated that the VAERS database captured about 13.2% of the total 1321 (95% confidence interval (CI): 815–2795) estimated reports, yielding an ascertainment-corrected rate of 590 fetal-loss reports per million pregnant women vaccinated (or 1 per 1695). The unadjusted fetal-loss report rates for the three consecutive influenza seasons beginning 2008/2009 were 6.8 (95% CI: 0.1–13.1), 77.8 (95% CI: 66.3–89.4), and 12.6 (95% CI: 7.2–18.0) cases per million pregnant women vaccinated, respectively. The observed reporting bias was too low to explain the magnitude increase in fetal-demise reporting rates in the VAERS database relative to the reported annual trends. Thus, a synergistic fetal toxicity likely resulted from the administration of both the pandemic (A-H1N1) and seasonal influenza vaccines during the 2009/2010 season.

Challenges and priorities for surveillance of stillbirths: a report on two workshops.

Stillbirths, those with and without birth defects, are an important public health topic. The National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention conducted two workshops during April and July 2005. Both workshops explored the challenges of conducting surveillance of stillbirths. Workshop participants considered an approach that added the surveillance of stillbirths, those with and without birth defects, as part of existing population-based birth defects surveillance programs in Iowa and Atlanta. The workshops addressed three key aspects for expanding birth defects programs to conduct active, population-based surveillance on stillbirths: (1) case identification and ascertainment, (2) data collection, and (3) data use and project evaluation. Participants included experts in pediatrics, obstetrics, epidemiology, maternal-fetal medicine, perinatology and pediatric pathology, midwifery, as well as practicing clinicians and pathologists. Expanding existing birth defects surveillance programs to include information of stillbirths could potentially enhance the data available on fetal death reports and also could benefit such programs by improving the ascertainment of birth defects.

Using active birth defects surveillance programs to supplement data on fetal death reports: Improving surveillance data on stillbirths

Surveillance of stillbirths using fetal death reports (FDRs) has been challenging because of under-reporting of fetal deaths and missing data on the FDRs. Using active case finding and chart abstraction within the infrastructure of established birth defect surveillance programs could potentially enhance the data from FDRs. The data collection form for the Metropolitan Atlanta Congenital Defects Program, an active, population-based birth defects surveillance system, was modified to collect additional information on stillbirths from medical records. The study population was a 25% simple random sample of stillbirths recorded on FDRs in 2004 (n = 125) by residents in the five central counties of metropolitan Atlanta. Stillbirth was defined as a fetal death at > or =20 weeks gestation or > or =350 g if age was unknown. Data on demographic characteristics and risk factors collected from the two sources were compared for completeness and agreement, as well as causes of and conditions associated with the fetal death. Combining data sources provided more information. Demographic and risk factor variables in the two data sources showed strong agreement (categorical variable, kappa range = 0.79-1.00; continuous variable, correlation coefficient range = 0.61-1.00). The actively ascertained data provided more complete information for causes and conditions of fetal death. Data from the FDRs yielded 42% of cases with no listed cause of death or associated condition compared with 10% using Metropolitan Atlanta Congenital Defects Program data. Expanding the potential of existing active birth defects surveillance programs to include stillbirth surveillance could potentially improve the quantity and quality of available data on fetal deaths. Ongoing studies are needed to corroborate these findings and to assess completeness of case ascertainment.

Congenital cytomegalovirus infection in pregnancy: a case report of fetal death in a CMV-infected woman

The human cytomegalovirus (CMV) is universally distributed among human populations as one of the most common cause of congenital infection with an incidence of about 0.15-2.0% in developed countries. However, controversial data concerning intrauterine fetal death caused by CMV infection exist. A case report. In this case report we present a stillbirth in the 18th week of pregnancy, caused by a maternal serological and fetal histological congenital CMV infection. Every attending physician and obstetrician should be aware of the possibility of a primary or even recurrent congenital CMV infection that could be a reason for sudden unknown congenital fetal death.

Congenital cytomegalovirus infection in pregnancy – A case report of fetal death in a CMV- infected woman

The human cytomegalovirus (CMV) is universally distributed among human populations and one of the most common causes of congenital infections with an incidence of about 0.15%–2.0% in developed countries. However, controversial data concerning intrauterine fetal death caused by CMV infection exist. In this case report we present a still birth in the 18th week of pregnancy, caused by a maternal serological and fetal histological congenital CMV infection. Therefore, every attending physician and obstetrician should be aware of the possibility of a primary or even recurrent congenital CMV infection could be a reason for sudden unknown congenital fetal death.

The national fetal death file

The most comprehensive source of US data on fetal deaths of 20 gestational weeks or greater is available through the National Vital Statistics System (NVSS). The NVSS is a collaborative effort between the independent reporting areas (the individual States and the territories), and the federal government or its agent, the Centers for Disease Control, and Prevention's National Center for Health Statistics (NCHS). The federal government has no authority to register vital events. The registration of births, deaths, fetal deaths, marriages, and divorces is solely a state responsibility. However, NCHS is mandated by law to produce national data based on vital events. To promote the uniformity necessary to create a national file from this decentralized system, NCHS attempts to influence state systems via the development of certain standards, primarily, The Model State Vital Statistics Act and Regulations (The Model Law), and the Standard Certificates and Reports. The Model Law definitions for live birth, fetal death and induced termination of pregnancy are based on international standards set by The World Health Organization. All states have definitions of fetal death consistent with the Model Law. The Model Law also recommends reporting requirements for fetal death, but state requirements vary. This variation results in differences in reporting of fetal deaths among areas. Other limitations to the national fetal death file include: the under-reporting of fetal deaths incidence, higher than acceptable levels of missing data for some items, and the accuracy of the data reported. Also of concern is the potential misclassification of fetal deaths and short-lived live births. These limitations are amenable to improvement. The upcoming revision of the US Standard Report of Fetal Death addresses these issues and offers an opportunity to strengthen the quality of fetal death data. The development of worksheets, detailed specifications and instruction manuals, and a reformatted cause of death section should importantly enhance the quality of national fetal death file and ultimately reduce the incidence of these tragic events.

The 1989 revisions of the US Standard Certificates of Live Birth and Death and the US Standard Report of Fetal Death.

The US Standard Certificates and Reports are models used by state vital statistics offices to develop documents for the collection of data about vital events. The 1989 revisions incorporate some major modifications to previous versions. Both the Standard Certificate of Live Birth and the Standard Report of Fetal Death utilize a checkbox format to elicit information on medical and other risk factors affecting the pregnancy, complications of labor and/or delivery, obstetric procedures, method of delivery, congenital anomalies, and abnormal conditions of the newborn. Revisions to the Standard Certificate of Death include modifications to the medical certification section and the addition of decedent's educational attainment. Items requesting information about Hispanic origin are added to all of these documents. The rationale behind these changes and their intended use are discussed.

Birthplace and attendants: Oregeon's alternative experience, 1977.

In October of 1977 an article entitled "Birthplace Alternatives" appeared in the Oregon State Health Bulletin. This article presented a narrative based on facts taken from the data on birth certificates of all births occurring outside of a hospital in the State of Oregon in 1976. Tabulations were compiled to show where the infants were being born, who was delivering them, the educational level of the parents, and the prenatal care given. Insofar as was possible--from complications listed on the birth certificates, information from matched infant death reports, and full term fetal death reports--the outcome of these deliveries was explored. Due to the tremendous response to that article, this update of 1977 data on out-of-hospital births was prepared.