Stillbirths: the way forward in high-income countries.

Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has slowed or stalled over recent times. The present variation in stillbirth rates across and within high-income countries indicates that further reduction in stillbirth is possible. Large disparities (linked to disadvantage such as poverty) in stillbirth rates need to be addressed by providing more educational opportunities and improving living conditions for women. Placental pathologies and infection associated with preterm birth are linked to a substantial proportion of stillbirths. The proportion of unexplained stillbirths associated with under investigation continues to impede efforts in stillbirth prevention. Overweight, obesity, and smoking are important modifiable risk factors for stillbirth, and advanced maternal age is also an increasingly prevalent risk factor. Intensified efforts are needed to ameliorate the effects of these factors on stillbirth rates. Culturally appropriate preconception care and quality antenatal care that is accessible to all women has the potential to reduce stillbirth rates in high-income countries. Implementation of national perinatal mortality audit programmes aimed at improving the quality of care could substantially reduce stillbirths. Better data on numbers and causes of stillbirth are needed, and international consensus on definition and classification related to stillbirth is a priority. All parents should be offered a thorough investigation including a high-quality autopsy and placental histopathology. Parent organisations are powerful change agents and could have an important role in raising awareness to prevent stillbirth. Future research must focus on screening and interventions to reduce antepartum stillbirth as a result of placental dysfunction. Identification of ways to reduce maternal overweight and obesity is a high priority for high-income countries.

Using a Birth Defects Surveillance Program to Enhance Existing Surveillance of Stillbirth.

Objective: Fetal death certificates (FDCs) are the main source of stillbirth surveillance data in the United States, yet previous studies suggest FDCs have incomplete ascertainment. The objectives of this analysis were (1) to evaluate whether the use of an existing birth defects surveillance program (the Metropolitan Atlanta Congenital Defects Program [MACDP]) to conduct surveillance on stillbirths enhances case ascertainment, and (2) to compare stillbirth prevalence estimates in metropolitan Atlanta using data from MACDP and FDCs, independently and combined, from 2009-2015. Methods: Stillbirths were ascertained by MACDP and FDCs from 2009-2015. Capture-recapture methods were used to estimate the relative contributions of each data source. Prevalence estimates generated from each data source independently and combined were compared. Results: There were 3,031 stillbirths ascertained by FDCs and MACDP in metropolitan Atlanta from 2009-2015. It was assumed that 35% of FDCs unlinked to MACDP were misclassified as stillbirth. Under this assumption, an estimated 2,610 total stillbirths occurred. Accounting for potential misclassification in the FDC, the prevalence rate for stillbirth was 6.9 per 1,000 live births plus stillbirths for stillbirths captured only in FDC, and 6.2 per 1,000 live births plus stillbirths for stillbirths caught only in MACDP. Using both sources combined for casefinding, the prevalence rate was 10.0 per 1,000 live births plus stillbirths for all years combined. Conclusions: Expanding certain birth defects surveillance programs to conduct surveillance on stillbirths could potentially enhance existing surveillance data on stillbirths when linked to FDCs.

Using an Existing Birth Defects Surveillance Program to Enhance Surveillance Data on Stillbirths.

BACKGROUND: Fetal death certificates (FDCs) are the main source of stillbirth surveillance data in the United States, yet previous studies suggest FDCs have incomplete ascertainment. In 2005, the Centers for Disease Control and Prevention (CDC) funded 2 pilot programs to determine the feasibility of expanding existing birth defects surveillance systems employing active casefinding methods to conduct surveillance of stillbirths. The objectives of this analysis were to: 1) estimate the completeness of ascertainment of stillbirths identified through one of the pilot programs, the Metropolitan Atlanta Congenital Defects Program (MACDP), and 2) compare the prevalence of stillbirths obtained through active casefinding (MACDP) with data available from FDCs. METHODS: Stillbirths in metropolitan Atlanta were independently ascertained by both FDC and MACDP in 2006 and 2008. Capture-recapture methods were used to estimate the total number of stillbirths in the surveillance area. The sensitivities for capturing stillbirths were estimated for FDCs, MACDP, and both sources combined. Prevalence estimates for each data source and for the combined data sources were calculated using a denominator of live births plus FDC-identified stillbirths. RESULTS: An estimated 1,118 stillbirths occurred in metropolitan Atlanta. MACDP captured 863 and FDCs captured 862. There were 198 stillbirths captured by MACDP and not reported by FDC, and 197 stillbirths identified by FDCs that were not initially captured by MACDP. The estimated sensitivities were 77.1%, 77.2%, and 94.8% for FDCs, MACDP, and both sources combined, respectively. The stillbirth prevalences for 2006 and 2008 using FDC data alone were 8.2 and 7.4 per 1,000 live births plus stillbirths, respectively, and 9.9 and 9.3 per 1,000 live births plus stillbirths, respectively, using both data sources combined. CONCLUSIONS: Leveraging the resources of existing birth defects surveillance programs in combination with FDCs could improve population-based ascertainment of stillbirths.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Using an existing birth defects surveillance program to enhance surveillance data on stillbirths.

BACKGROUND: Fetal death certificates (FDCs) are the main source of stillbirth surveillance data in the United States, yet previous studies suggest FDCs have incomplete ascertainment. In 2005, the Centers for Disease Control and Prevention (CDC) funded 2 pilot programs to determine the feasibility of expanding existing birth defects surveillance systems employing active casefinding methods to conduct surveillance of stillbirths. The objectives of this analysis were to: 1) estimate the completeness of ascertainment of stillbirths identified through one of the pilot programs, the Metropolitan Atlanta Congenital Defects Program (MACDP), and 2) compare the prevalence of stillbirths obtained through active casefinding (MACDP) with data available from FDCs. METHODS: Stillbirths in metropolitan Atlanta were independently ascertained by both FDC and MACDP in 2006 and 2008. Capture-recapture methods were used to estimate the total number of stillbirths in the surveillance area. The sensitivities for capturing stillbirths were estimated for FDCs, MACDP, and both sources combined. Prevalence estimates for each data source and for the combined data sources were calculated using a denominator of live births plus FDC-identified stillbirths. RESULTS: An estimated 1,118 stillbirths occurred in metropolitan Atlanta. MACDP captured 863 and FDCs captured 862. There were 198 stillbirths captured by MACDP and not reported by FDC, and 197 stillbirths identified by FDCs that were not initially captured by MACDP. The estimated sensitivities were 77.1 percent, 77.2 percent, and 94.8 percent for FDCs, MACDP, and both sources combined, respectively. The stillbirth prevalences for 2006 and 2008 using FDC data alone were 8.2 and 7.4 per 1,000 live births plus stillbirths, respectively, and 9.9 and 9.3 per 1,000 live births plus stillbirths, respectively, using both data sources combined. CONCLUSIONS: Leveraging the resources of existing birth defects surveillance programs in combination with FDCs could improve population-based ascertainment of stillbirths.

Survey of knowledge, attitudes, and practice management patterns of Atlanta-area obstetricians regarding stillbirth.

OBJECTIVE: Existing surveillance data on fetal death certificates are suboptimal for conducting reliable epidemiologic studies on stillbirth. The objective of this survey was to better understand the factors potentially affecting the quality of data collected on stillbirths among a defined population. METHODS: A survey was mailed to all physicians (n = 661) listed in the July 2007 version of the American Medical Association master file with a primary specialty of obstetrics/gynecology and a mailing address within five counties in metropolitan Atlanta. RESULTS: A total of 487 physicians met eligibility criteria: 279 returned the survey, 179 did not return the survey, and 29 were returned as unable to locate. Two respondents returned incomplete surveys, leaving 277 participants for the final analysis. Respondents reported seeing an average of six stillbirths per year. A cause of death was not identified in two thirds of cases. Almost half (46.8%) of participants responded that 20 weeks was the minimum gestational age defining stillbirth, whereas 33.1% responded that it was 24 weeks. A majority (92.6%) responded that a standardized definition for stillbirth should be adopted. More than 80% agreed that a comprehensive evaluation was important to identify a cause of death, and 91.9% agreed that the use of a standardized protocol for post-mortem stillbirth evaluation would be helpful. A majority also agreed that ongoing surveillance of stillbirths and a national research agenda on causes of stillbirth are important. CONCLUSION: Comprehensive educational and awareness efforts for obstetricians and other related health care personnel are needed to further improve on the data collected for surveillance purposes on stillbirth.