Trends In Stillbirth Research Articles

Global, Regional, and National Levels and Trends in Stillbirths from 2000 to 2019: A Systematic Assessment

Background: Stillbirths are a major public health issue and a sensitive marker of the quality of care around pregnancy and birth. The UN Global Strategy for Women’s, Children’s and Adolescents’ Health and the Every Newborn Action Plan (ENAP) call for ending preventable stillbirths. A first step to prevent stillbirths is obtaining standardized measurement of stillbirth levels and trends across countries. We estimated levels and trends in stillbirth rates at 28 weeks or more of gestation from 2000 to 2019 and assessed progress over time. Methods: Our dataset contained 2,800 country-year datapoints from 171 countries relevant to stillbirth rates, including data from registration systems, household-based surveys and population-based studies. We estimated country-specific stillbirth rates for all countries from 2000 to 2019 using a Bayesian hierarchical temporal sparse regression model. Our model combined covariates with a temporal smoothing process such that estimates were informed by data in country-periods with high-quality data and covariate-based for country-periods with limited or no data on stillbirth rates. Bias and additional uncertainty associated with observations using alternative stillbirth definitions, source types and observations that were subject to non-sampling errors were included in the model. Results: In 2019, an estimated 2.0 [90 percent uncertainty interval: 1.9, 2.2] million babies were stillborn at 28 weeks or more of gestation, with a global stillbirth rate of 13.9 [13.5, 15.4] stillbirths per 1,000 total births. Stillbirth rates varied widely across the world from 22.8 [19.8, 27.7] per 1,000 total births in West and Central Africa to 2.9 [2.7, 3.0] per 1,000 total births in Western Europe, with West and Central Africa, Eastern and Southern Africa and South Asia having the highest stillbirth rates in 2019. The global annual rate of reduction in the stillbirth rate was estimated at 2.3 [1.7, 2.7] per cent from 2000 to 2019, lower than the 2.9 [2.5, 3.2] percent reduction in the neonatal mortality rate and the 4.3 [3.8, 4.7] percent reduction in the mortality rate among children aged 1–59 months over the same period. Based on point estimates, 14 countries halved their stillbirth rate since 2000, and 115 countries reduced the stillbirth rate by more than 25 per cent. The remaining 80 countries for which we made estimates reduced their stillbirth rate by less than 25 percent since 2000, with the majority located in Sub-Saharan Africa. Interpretation: in reducing the stillbirth rate has been slow compared with declines in the mortality rate among children under 5 years of age. Accelerated improvements are most needed in the regions and countries with high stillbirth rates, particularly in sub-Saharan Africa where the increases in number of births has outpaced modest progress and declines in stillbirth rates, leading to a stagnation in the number of stillbirths since 2000. Increased efforts are needed to raise public awareness of stillbirths, to improve data collection and to prevent stillbirths. It’s not possible to assess progress going forward or understand public health priorities locally unless there is investment in gathering information about stillbirths. Funding Statement: UNICEF’s stillbirth estimation work was supported by the Bill & Melinda Gates Foundation (OPP1180460 OP190601 and INV-001395). We also acknowledge the Foreign, Commonwealth & Development Office (United Kingdom) for helping to initiate this work. Declaration of Interests: We declare that we have no conflicts of interest.

UK stillbirth trends in over 11 million births provide no evidence to support effectiveness of Growth Assessment Protocol program.

Use of the Growth Assessment Protocol (GAP) has increased internationally under the assumption that it reduces the stillbirth rate. The evidence for this is limited and based largely on an ecological time-trend study. Discordance in the uptake of the GAP program between Scotland and England/Wales enabled us to assess the assertion that implementation of GAP leads to a reduced stillbirth rate. We analyzed data from the National Records for Scotland and the Office for National Statistics on the number of singleton maternities and stillbirths in Scotland and in England and Wales, respectively, from 1 January 2000 to 31 December 2015. National uptake of the GAP program over time in each of the regions was recorded. Stillbirth rate per 1000 maternities was calculated, according to year of delivery, and compared between Scotland and England/Wales. During the study period, there were 870 632 singleton maternities in Scotland, of which 4243 were stillbirths, and there were 10 469 120 singleton maternities in England and Wales, of which 51 562 were stillbirths. There was a marked difference in uptake of the GAP program between the two regions, with substantially fewer maternity units in Scotland implementing the program. Stillbirth rates were static up to 2010, with a decline thereafter in both regions, to 3.75 (95% CI, 3.25-4.30) per 1000 maternities in Scotland and 4.30 (95% CI, 4.15-4.46) per 1000 maternities in England and Wales in 2015. From 2010 onwards, the decline in Scotland was faster, equating to 48 (95% CI, 47.9-48.1) fewer stillbirths per 100 000 maternities in Scotland than in England and Wales from 2010 to 2015 compared with 2000 to 2009. We observed a decline in stillbirth rate in England and Wales, which coincided with implementation of the GAP program. However, a concurrent decline in stillbirth rate was observed in Scotland in the absence of increased implementation of GAP. The secular rates of change in stillbirth rate in England and Wales cannot be used to infer efficacy of the GAP program. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Trends and risk factors associated with stillbirths: A case study of the Navrongo War Memorial Hospital in Northern Ghana

Maternal and Child health remains at the core of global health priorities transcending the Millennium Development Goals into the current era of Sustainable Development Goals. Most low and middle-income countries including Ghana are yet to achieve the required levels of reduction in child and maternal mortality. This paper analysed the trends and the associated risk factors of stillbirths in a district hospital located in an impoverished and remote region of Ghana. Retrospective hospital maternal records on all deliveries conducted in the Navrongo War Memorial hospital from 2003-2013 were retrieved and analysed. Descriptive and inferential statistics were used to summarise trends in stillbirths while the generalized linear estimation logistic regression is used to determine socio-demographic, maternal and neonatal factors associated with stillbirths. A total of 16,670 deliveries were analysed over the study period. Stillbirth rate was 3.4% of all births. There was an overall decline in stillbirth rate over the study period as stillbirths declined from 4.2% in 2003 to 2.1% in 2013. Female neonates were less likely to be stillborn (Adjusted Odds ratio = 0.62 and 95%CI [0.46, 0.84]; p = 0.002) compared to male neonates; neonates with low birth weight (4.02 [2.92, 5.53]) and extreme low birth weight (18.9 [10.9, 32.4]) were at a higher risk of still birth (p<0.001). Mothers who had undergone Female Genital Mutilation had 47% (1.47 [1.04, 2.09]) increase odds of having a stillbirth compared to non FGM mothers (p = 0.031). Mothers giving birth for the first time also had a 40% increase odds of having a stillbirth compared to those who had more than one previous births (p = 0.037). Despite the modest reduction in stillbirth rates over the study period, it is evident from the results that stillbirth rate is still relatively high. Primiparous women and preterm deliveries leading to low birth weight are identified factors that result in increased stillbirths. Efforts aimed at impacting on stillbirths should include the elimination of outmoded cultural practices such as FGM.

Stillbirth in Greece during the years of economic crisis: a population-based study.

The recent economic crisis has been linked with declines in population health. Evidence on the impact of the crisis on stillbirth rates is scarce. The aim of this study was to assess trends of stillbirth rates in Greece during the pre-crisis (2004-2008) and crisis period (2009-2015) and explore risk factors. Nationwide data (n = 1,276,816 births; 5023 stillbirths) were used to assess rates and trends through Poisson and joinpoint regressions. Multivariable Poisson regressions by nationality were fitted. The overall annual stillbirth rate was 3.9/1000 births with higher rates among non-Greeks (5.0/1000) than Greeks (3.7/1000). Non-significant decreasing trends were noted for Greeks (- 0.5%, 95% confidence interval [CI] - 1.4, 0.4%) versus non-significant increasing trends in non-Greeks (1.4%, 95% CI - 0.5, 3.3%). After adjusting for possible confounders, the relative stillbirth risk (RR) increased during the crisis versus the pre-crisis period (RRGreeks 1.61, 95% CI 1.50, 1.74; RRnon-Greeks 1.92, 95% CI 1.64, 2.26). Multiplicity, birth order, birth size, maternal education, marital status, and parental age were risk factors.Conclusions: Bidirectional stillbirth trends were observed among Greeks and non-Greeks, whereas the RR increased by 2-fold during the crisis. Persisting disparities require tailored employment of preventive measures ensuring optimal quality of the child's and maternal health.What is Known:• Stillbirth rate is a key population health indicator reflecting economic development and health care services within a population.• The recent economic crisis has been linked with declines in population health.What is New:• Economic crisis, ethnic minorities, and several modifiable factors seem to be significant determinants of stillbirth risk.

Trends in Stillbirths and Stillbirth Phenotypes in the United States: An Analysis of 131.5 Million Births.

We examined the trends in stillbirth across gestational age in the United States (US).We conducted a trend analysis using the U.S. Natality and Fetal Death datasets covering 1982 and 2017. We compared the incidence and rates of stillbirth for term, all preterm, moderate-to-late preterm, very preterm, and extreme preterm phenotypes. The incidence of stillbirth decreased for the entire birth cohort over the 36-year period. The rates of overall, term, all preterm, very preterm and moderate-to-late preterm stillbirth decreased from 1982 to 2017; however, the rates for extreme preterm stillbirth increased by about 7.6% over the same study period.

Secular trends in stillbirth by maternal socioeconomic status in Spain 2007-15: a population-based study of 4 million births.

IntroductionStillbirth, one of the urgent concerns of preventable perinatal deaths, has wide-reaching consequences for society. We studied secular stillbirth trends by maternal socioeconomic status (SES) in Spain.MethodsWe developed a population-based observational study, including 4 083 919 births during 2007–15. We estimate stillbirth rates and secular trends by maternal SES. We also evaluated the joint effect of maternal educational attainment and the Human Development Index (HDI) of women’s country of origin on the risk of stillbirth. The data and statistical analysis can be accessed for reproducibility in a GitHub repository: https://github.com/migariane/StillbirthResultsWe found a consistent pattern of socioeconomic inequalities in the risk of delivering a stillborn, mainly characterized by a persistently higher risk, over time, among women with lower SES. Overall, women from countries with low HDIs and low educational attainments had approximately a four times higher risk of stillbirth (RR: 4.44; 95%CI: 3.71–5.32). Furthermore, we found a paradoxical reduction of the stillbirth gap over time between the highest and the lowest SESs, which is mostly due to the significant and increasing trend of stillbirth risk among highly educated women of advanced maternal age.ConclusionOur findings highlight no improvement in stillbirth rates among women of lower SES and an increasing trend among highly educated women of advanced maternal age over recent years. Public health policies developing preventive programmes to reduce stillbirth rates among women with lower SES are needed as well as the necessity of further study to understand the growing trend of age-related stillbirths among highly educated women in Spain.

Trends and risk factors of stillbirth in Taiwan 2006-2013: a population-based study.

To examine temporal trends in stillbirth and its associated risk factors in Taiwan. This was a population-based cohort study. Data were extracted from the Birth Certificate Application database. Singleton births at 28 or more gestational weeks were included. A total of 1,536,796 births, including 3741 stillbirths, were analyzed from January 2006 to December 2013. The stillbirth rate was 2.4 per 1000 births and there was no change in the stillbirth rate during the study period. The adjusted odds ratio (aOR) for stillbirth was 1.28 for maternal age between 35 and 40years and 1.79 for maternal age ≥41years, with 21-34years as the reference. The risk for stillbirth increased in single women (aOR, 2.4), female baby (aOR, 1.08), small for gestational age (aOR, 6.34) and large for gestational age (aOR, 1.52) infants, and women with hypertension (aOR, 3.78), diabetes mellitus (aOR, 2.04), anemia (aOR, 1.65), and oligohydramnios or polyhydramnios (aOR, 2.46).Women with heart disease and maternal age ≤20years had no significant association with stillbirth after adjusting for various risk factors. Although the rate of stillbirth was stable during the study period, the incidence of risk factors associated with stillbirth, such as advanced maternal age, hypertension, diabetes mellitus, and anemia, had increased over time. Understanding about the risk factors might change protocols and allow for earlier detection of problems and prevention of stillbirths. Prevention or management of risk factors should be undertaken to reduce stillbirth rate.

Time to change focus? Transitioning from higher neonatal to higher stillbirth mortality in São Paulo State, Brazil.

BackgroundDifferential trends in mortality suggest that stillbirths may dominate neonatal mortality in the medium to long run. Brazil has made major efforts to improve data collection on health indicators at granular geographic levels, and provides an ideal environment to test this hypothesis. Our goals were to examine levels and trends in stillbirths and neonatal deaths and the extent to which the mortality burden caused by stillbirths dominates neonatal mortality at the municipality- and state-level.MethodsWe used data from the Brazilian Ministry of Health’s repository on births, fetal, and neonatal deaths (2010–2014) to calculate stillbirth and neonatal mortality rates for São Paulo state’s 645 municipalities.ResultsAt the state level, 7.9 per 1000 pregnancies ended in stillbirth (fetal death >22 weeks gestation or fetal weight >500g), but this varied from 0.0 to 28.4 per 1000 across municipalities. 7.9 per 1000 live births also died within the first 28 days. 42% of municipalities had a higher stillbirth rate than neonatal mortality rate, and in 61% of areas with low neonatal mortality (<8.0 per 1000), stillbirth rates exceeded neonatal mortality rates.ConclusionsThis analysis suggests large variability and inequality in mortality outcomes at the sub-national level. The results also imply that stillbirth mortality may exceed neonatal mortality in Brazil and similar settings in the next few decades, which suggests a need for a shift in policy. This work further underscores the importance of continued research into causes and prevention of stillbirth.

Temporal Trends in Stillbirth in the United States, 1992-2004

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Stillbirth in an Anglophone minority of Canada

We assessed trends in stillbirth over time for Francophones and Anglophones of Quebec, a large Canadian province with publically funded health care and an English-speaking minority. We calculated stillbirth rates for Francophones and Anglophones, and estimated hazard ratios (HR) by decade from 1981 to 2010, adjusting for maternal characteristics. We analyzed temporal trends by gestational interval and cause of fetal death. Stillbirth rates decreased in Quebec during the three decades, due to improved rates in Francophones. Rates decreased for Anglophones in 1991-2000, but increased in 2001-2010 at term, during the second trimester, and for most causes of fetal death. In the 2000s, the hazard of stillbirth for Anglophones was nearly the same as the hazard for Francophones in the 1980s (HR 0.93, 95 % confidence interval 0.82, 1.05). Stillbirth rates declined in both Francophones and Anglophones before the turn of the century, but increased thereafter for Anglophones, suggesting that linguistic inequalities in stillbirth may be emerging in Quebec. Linguistic status may be a useful marker for surveillance of inequalities in stillbirth.

PPO.14 A 5 Year Retrospective Analysis of Stillbirth Trends in a Large Obstetric Unit – will lives be saved with increasing resources towards identification of and intervention in small for gestational age foetuses?

Recent guidelines suggest intensive monitoring and consideration for delivery at 37 weeks for all small for gestational age (SGA) foetuses.1 Adopting such an approach has considerable resource implications. This study...

Temporal trends in stillbirth in the United States, 1992–2004: a population‐based cohort study

To examine temporal trends in stillbirth and its risk factors in the United States (US), and to assess the contribution of labour induction and caesarean delivery to the stillbirth rate. Population-based cohort study based on linked birth-infant death and fetal death data files from the US National Vital Statistics System. Complete data were available for 44 states and the District of Columbia. Singleton births from 1992 to 2004. We assessed changes in stillbirth rates from 1992-1994 to 2002-2004 before and after adjustment for changes in maternal characteristics including maternal age, education, smoking, and medical risk factors, using Cox regression models. We also carried out an ecological study, using states as the units of analysis, to assess the impact on the stillbirth rate of increasing induction and caesarean delivery. Race-specific subgroup analyses were performed and included non-Hispanic Whites and non-Hispanic Blacks. Stillbirth rate. The stillbirth rate among non-Hispanic White singleton births decreased 11.5% from 1992-1994 (5.2 per 1000) to 2002-2004 (4.6 per 1000). After adjustment for maternal risk factors, the hazard ratio (HR) for 2002-2004 was 1.01 (0.99, 1.03) for gestational age (GA) ≤39 weeks, but 0.92 (0.86, 0.99) at 40 or more weeks. The ecologic analysis revealed a nonsignificant negative correlation of -0.17 (-0.44, 0.13) between state-level changes in stillbirth at GA ≥40 weeks and labour induction. A nonsignificant positive correlation of 0.23 (-0.07, 0.49) was observed between changes in stillbirth at all GAs and caesarean delivery and did not differ at GA ≤39 versus ≥40 weeks. Results were similar among non-Hispanic Blacks. Changes in maternal risk factors explained the reduction in stillbirth at GA ≤39 weeks but not at ≥40 weeks. The rise in labour induction and caesarean delivery rates did not explain the reduction in stillbirth ≥40 weeks of gestation.

Temporal trends in neonatal outcomes following iatrogenic preterm delivery

BackgroundPreterm birth rates have increased substantially in the recent years mostly due to obstetric intervention. We studied the effects of increasing iatrogenic preterm birth on temporal trends in perinatal mortality and serious neonatal morbidity in the United States.MethodsWe used data on singleton and twin births in the United States, 1995-2005 (n = 36,399,333), to examine trends in stillbirths, neonatal deaths, and serious neonatal morbidity (5-minute Apgar ≤3, assisted ventilation ≥30 min and neonatal seizures). Preterm birth subtypes were identified using an algorithm that categorized live births <37 weeks into iatrogenic preterm births, births following premature rupture of membranes and spontaneous preterm births. Temporal changes were quantified using odds ratios (OR) and 95% confidence intervals (CI).ResultsAmong singletons, preterm birth increased from 7.3 to 8.8 per 100 live births from 1995 to 2005, while iatrogenic preterm birth increased from 2.2 to 3.7 per 100 live births. Stillbirth rates declined from 3.4 to 3.0 per 1,000 total births from 1995-96 to 2004-05, and neonatal mortality rates declined from 2.4 to 2.1 per 1,000 live births. Temporal declines in neonatal mortality/morbidity were most pronounced at 34-36 weeks gestation and larger among iatrogenic preterm births (OR = 0.75, CI 0.73-0.77) than among spontaneous preterm births (OR = 0.82, CI 0.80-0.84); P < 0.001. Similar patterns were observed among twins, with some notable differences.ConclusionIncreases in iatrogenic preterm birth have been accompanied by declines in perinatal mortality. The temporal decline in neonatal mortality/serious neonatal morbidity has been larger among iatrogenic preterm births as compared with spontaneous preterm births.

Impact of Pregnancy-induced Hypertension on Stillbirth and Neonatal Mortality

Hypertensive disorders of pregnancy are more frequent in primiparous women, but may be more severe in multiparas. We examined trends in stillbirth and neonatal mortality related to pregnancy-induced hypertension (PIH), and explored whether mortality varied by parity and maternal race. We carried out a population-based study of 57 million singleton live births and stillbirths (24-46 weeks' gestation) in the United States between 1990 and 2004. We estimated rates and adjusted odds ratios (ORs) of stillbirth and neonatal death in relation to PIH, comparing births in 1990-1991 with 2003-2004. PIH increased from 3.0% in 1990-1991 to 3.8% in 2003-2004. In both periods, PIH was associated with a higher risk of stillbirth and neonatal death. We explored this in more detail in 2003-2004, and observed that the increased risk of PIH-related stillbirth was higher in women having their second or higher-order births (OR = 2.2 [95% confidence interval = 2.1-2.4]) compared with women having their first birth (1.5 [1.4-1.6]). Patterns were similar for neonatal death (1.3 [1.2-1.4] in first and 1.6 [1.5-1.8] in second or higher-order births). Among multiparas, the association between PIH and stillbirth was stronger in black women (2.9 [2.7-3.2]) than white women (2.0 [1.8-2.1]). A substantial burden of stillbirth and neonatal mortality is associated with PIH, especially among multiparous women, which may be due to more severe PIH, or to a higher burden of underlying disease.

Trends in stillbirths, early and late neonatal mortality in rural Bangladesh: the role of public health interventions

Trends were examined in a cohort study of stillbirths and early and late neonatal deaths in Matlab, a rural area of Bangladesh between 1975 and 2002, using routinely collected demographic surveillance data. Main outcome measures were stillbirths per 1000 births, early neonatal deaths per 1000 livebirths, and late neonatal deaths per 1000 children surviving after 1 week. We performed a logistic regression examining trends over time and between two areas in the three outcome measures, controlling for the effects of parental education, religion, time, geography, parity, maternal age and birth spacing. There was a marked decline in stillbirths, early and late neonatal mortality over time in both areas, though the pace of decline was somewhat faster in the ICDDR,B (International Centre for Diarrhoeal Disease Research, Bangladesh) service area. Stillbirths declined by 24% overall in the ICDDR,B service area (crude OR comparing 1996-2002 with 1975-81: 0.76 [95% CI 0.68, 0.84]), compared with 15% in the Government service area (crude OR comparing 1996-2002 with 1975-81: 0.85 [0.76, 0.94]). The overall reduction in early and late neonatal mortality comparing the same periods was 39% and 73%, respectively, in the ICDDR,B area, compared with 30% and 63%, respectively, in the Government service area. Adjusting for socio-economic or demographic factors did not substantially alter the time or area differentials. The dramatic decline in neonatal mortality was, in large part, due to a fall in deaths from neonatal tetanus. The pace of decline was faster in the area receiving intense maternal and child health and family planning interventions, but stillbirths, early and late neonatal deaths also declined in the area not receiving such intense attention, suggesting that factors outside the formal health sector play an important role.

Stillbirths in the United States, 1981–2000: An Age, Period, and Cohort Analysis

We examined age, period, and cohort (APC) effects on temporal trends in stillbirths among Black and White women in the United States. We conducted a cohort study of Black and White women who delivered a singleton live-born or stillborn infant during 1981 through 2000. We analyzed stillbirth rates at 20 or more weeks of gestation within 7 age groups, 4 periods, and 10 "central" birth cohorts after adjusting for confounders. In both racial groups, women younger than 20 years or 35 years or older were at increased risk of stillbirth; risks decreased over successive periods in all age groups. Birth cohort had no impact on stillbirth trends among Blacks and only a small, nonsignificant effect among Whites. Analyses of various APC combinations showed that Blacks were at a 1.2- to 2.9-fold increased risk for stillbirth relative to Whites. Attributable fractions for stillbirth because of age, period, and cohort effects were 16.5%, 24.9%, and 0.1%, respectively, among Black women and 14.5%, 36.2%, and 2.1%, respectively, among White women. Strong effects of age and period were observed in stillbirth trends, but these factors do not explain the persistent stillbirth disparity between Black and White women.

Trends in stillbirths and neonatal deaths for very pre-term infants (< 32 weeks' gestation) born in Victoria, 1986-1993.

We have examined the trends in stillbirth rates and neonatal mortality rates of infants of 20-31 weeks' gestational born in Victoria during 1986-1993 (n = 6,462), using data from the Victorian Perinatal Data Collection Unit. Seventy four percent of all infants and 83% of all liveborn infants were born in level 3 hospitals. Both stillbirth and neonatal mortality rates were lower for infants of higher gestational ages, and those born in level 3 hospitals. During 1986-1993, annual stillbirth rates remained steady, with mean values of 61.2%, 40.2%, 24.7%, 16.0%, and 11% for infants of gestational ages 20-23, 24-25, 26-27, 28-29, and 30-31 weeks, respectively. The neonatal mortality rates decreased from 76.1 to 38.6%, 42.3 to 17.6%, 12.9 to 6.0%, and 8.4 to 3.7% for liveborn infants of gestational ages 24-25, 26-27, 28-29, and 30-31 weeks, respectively. The time-related falls in neonatal mortality were not due to changes in Caesarean section rates, intubation rates, or the proportions of infants born in, or transferred to, level 3 hospitals. They probably reflect continuing improvements in perinatal care.

Trends in perinatal mortality and cerebral palsy in Western Australia, 1967 to 1985.

To analyse the trends in stillbirths, neonatal deaths, and cerebral palsy in all infants born in Western Australia from 1967 to 1985. To relate these trends to changes in perinatal care, particularly in relation to avoidance of intrapartum asphyxia in term infants and the increased survival of low birthweight infants. Descriptive epidemiological study calculating population rates for perinatal deaths and cerebral palsy according to year of birth and birth weight. Western Australia. All infants born after 20 weeks' gestation or weighing at least 400 g (live and stillborn). Stillbirths, neonatal deaths (from perinatal death certificates), and cerebral palsy (from a population based register). Overall stillbirth rates fell from 12.1/1000 total births in 1967-70 to 8.1 in 1983-5. Early neonatal mortality fell from 13.0/1000 live births to 4.4 over the same period whereas total cerebral palsy rates remained at around 2-2.5/1000 live births. Death rates fell in all birth weight categories, particularly in low birthweight infants between 1975 and 1985, the period when birthweight data were available. In contrast, cerebral palsy rates in infants under 1500 g rose significantly over this period (from 12.1 in 1968 to 64.9 in 1985). The rise was seen in all spastic categories, including severely and multiply handicapped children. Large increases in the use of interventions aimed at reducing birth asphyxia and handicaps had not (by 1985) resulted in lower rates of cerebral palsy. This suggests that birth asphyxia is not a major cause. The increased survival of low birthweight infants has resulted in more cerebral palsy in this group, due either to postnatal complications of immaturity or prenatal damage to the fetal brain. These findings have implications for planning perinatal care and for litigation for putative obstetric malpractice in cerebral palsy cases.

Five-Decade International Trends in the Relation of Perinatal Mortality and Congenital Malformations: Stillbirth and Neonatal Death Compared

The relation between long-term temporal trends in stillbirth and neonatal death rates and the congenital malformation frequencies in such deaths were analysed, using data from hospital-based European, USA, and Canadian reports published from 1950. In the last 50 years the overall perinatal mortality rate has fairly steadily improved, decreasing by 65-80%. This was accomplished by the control of some serious problems of early life. However, lingering disorders form an ever larger proportion of the causes of perinatal mortality. Among the prominent of these are congenital malformations, accounting for nearly 30% of perinatal deaths at present. However, this figure conceals important differences between stillbirths and early neonatal deaths. For example, although stillbirth and early neonatal mortality rates have decreased to similar extents during these years, congenital malformations, which were almost equally frequent causes of death in both of them at the beginning of this period, are now about twice as common in early neonatal (one week) deaths as in stillbirths. Other differences between them are in birthweight-related malformation frequencies and in characteristic arrays of malformations. The significance of these patterns and of some geographical variations, and the likelihood of continuing improvement in the stillbirth and early neonatal mortality rates are discussed.

Maternal cohort, time of stillbirth, and maternal age effects in Italian stillbirth mortality.

The aim of the study was to investigate factors in stillbirth mortality in Italy. Italian stillbirth data from 1955 to 1979 were analysed using a log-linear Poisson model with arbitrary constraints on the parameters to identify the effects of maternal birth cohort, calendar period of stillbirth and maternal age. Stillbirth data for the whole of Italy were obtained from the Italian Central Institute of Statistics for the years under examination. During this period the criteria for defining stillbirth did not change and the quality of birth registration was similar. Decreases in stillbirth mortality were marked and steady, starting for the generations born since 1920. A period effect in stillbirth trends was shown, but this was apparently smaller than the cohort trend. The cohort trend suggests that long term improvements in socioeconomic and general health conditions may be important factors in the diminishing stillbirth rates, as well as short term advances in obstetric care. Alternatively the cohort effect could be attributed, at least in part, to an age-period interaction, since the downward trends were more pronounced in younger women.