The utility and validity of perinatal mortality rates (PNMR) as indicators of the quality of health care services are analysed. A major determinant of the PNMR is the birthweight distribution, and this may be determined in a large part through social factors rather than health care services. A means of standardizing the PNMR according to birthweight, in the same way that an SMR is standardized according to the age and sex distribution of a population, is proposed and demonstrated. The particular advantages and problems arising from the use of the method are presented. Means of further improvement are identified. The perinatal mortality rate (PNMR) is widely used as an indicator of the quality of obstetric and early neonatal care. Thus, the Court Committee1 based several of its conclusions upon the PNMR, making comparisons between different parts of the United Kingdom and between this and other countries. Unfortunately, usage of the PNMR fails to discriminate obstetric and paediatric factors on the one hand and socioeconomic factors on the other. Among other effects, the latter strongly influence the proportion of premature infants, which in turn strongly influences the stillbirth and neonatal death rates.2 In view of the caution with which other crude mortality data are generally treated both by clinicians and epidemiologists, it is perhaps surprising how often circumspection is discarded when the PNMR is considered. In its crude form it is less than incisive and fails to provide the medical officer, obstetrician or paediatrician with a tool capable of providing unambiguous comment about the quality of the health care services in his own area, or his own maternity hospital. To serve this purpose it would be necessary to exclude from it, so far as is possible, the main social, that is, non-service, effects. Our aim in the present study is to investigate the use of indirect standardization methods to provide a standardized perinatal mortality ratio (SPNMR), analogous with the standardized mortality ratio (SMR), except that the standardization is carried out according to the birthweight distribution instead of in terms of age and sex. We shall examine a number of technical issues relating to the reliability of the available data and the statistical stability of the SPNMR for populations of different sizes. In particular, we shall investigate the extent to which successive years must be aggregated in order to give sufficient numbers. This is especially relevant as the size of the studied geographical area is reduced, and as particular subsets of perinatal mortality are isolated for separate examination. We shall inquire also into the need, at these levels, for additional standardization procedures.
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