Pregnancy outcomes of women presenting with stage 1 hypertension during the first prenatal clinic visit before 20 gestational weeks.

OBJECTIVE: To determine the pregnancy outcomes of women who had 2017 American College of Cardiologists stage 1 hypertension during the first prenatal clinic visit before 20 gestational weeks in a tertiary hospital in South Africa. STUDY DESIGN: A retrospective cohort study involving the review of medical records of 127 participants with stage 1 hypertension and 128 control with blood pressure (BP) less than stage 1 hypertension before 20 weeks' gestation. MAIN OUTCOME MEASURES: The primary outcome measure was progression to stage 2 hypertension (BP ≥ 140/90 mmHg). Secondary outcome measures were a combination of maternal variables (postpartum BP ≥ 140/90 mmHg, use of antihypertensives within 24 h postpartum, pulmonary oedema, and maternal death within 24 h postpartum) and perinatal variables (fetal growth restriction, gestational age at delivery, fetal compromise, abruptio placenta, birth weight, Apgar score in 1 and 5 min). RESULTS: The study and control arms were similar in age, parity, and comorbidities (p > 0.05). The following maternal outcomes were worse (p < 0.001) in the study compared to control arm: progression to stage 2 hypertension (46 % vs 1.6 %), postpartum systolic BP ≥ 140 mmHg (33.9 % vs 1.6 %), postpartum diastolic BP ≥ 90 mmHg (22.1 % vs 1.6 %) and use of antihypertensives within 24 h postpartum (27.6 % vs 0.8 %). Other outcome measures did not differ between the two groups (p > 0.05). CONCLUSIONS: Stage 1 hypertension occurring before 20 weeks' gestation increases the risk of progression to stage 2 hypertension in pregnancy and the use of antihypertensive drug therapy within 24 h postpartum.

Profile and outcomes of management of patients admitted to obstetric high care unit in a tertiary academic hospital in Gauteng Province, South Africa.

The aim of this study was to describe maternal characteristics and pregnancy outcomes of women admitted in a dedicated obstetric high care unit (OHCU) in a tertiary hospital in Gauteng province, South Africa. The study involved review of clinical records of women admitted to OHCU between January and June 2016. Data collected included maternal demographic data, indication for admission, management and outcomes. A total of 4 637 of women gave birth and 114 (2.5%) were admitted to the OHCU during this period. Majority (90, 78.9%) were younger than 35 (mean 29.6) years with 32(28.1%), in their first pregnancy. Obstetric related indications for OHCU admission were mainly, pre-eclampsia and related complications (89, 78.1%), followed by obstetric haemorrhage (32, 28.1%). Cardiac disease, 14(12.3%) and pneumonia 6(5.3%) were the most common non-obstetrics indications for admission. Majority of patients stayed in OHCU for an average of 24-48 hours and were discharged alive (99.86.8%). Only 11(9.6%) were transferred to ICU and complications related to cardiac diseases were the most common reason for the transfer. Preeclampsia, obstetric hemorrhage and cardiac related complications are the most common reasons for OHCU and ICU admissions however most of these condition can be successfully managed in OHCU.

Diagnosis and management of a pelvic solitary fibrous tumor in a postmenopausal woman - a case report.

Background: Solitary fibrous tumors, previously known as hemangiopericytomas, originate from mesenchymal tissue and can occur at many body sites, such as the thorax, head and neck, retroperitoneal space and abdomen. These tumors are generally rare and pelvic location is extremely uncommon. Consequently, pelvic solitary tumors could be mistaken for ovarian cancer in menopausal women. This report presents a case of pelvic solitary tumor to highlight the importance of considering this diagnosis in a postmenopausal woman presenting with a solid pelvic mass, normal tumor markers and no ascites. Case: A 54-year-old woman presented with amenorrhea, abdominal pain, constipation, nausea, vomiting, and frequency of urination. On examination she had a pelvic mass of approximately 20-24 weeks in size. Ultrasound and computed tomography imaging showed a well-defined, round, centrally hypodense, irregular thick and peripheral, enhancing solid mass originating from the left ovary. Carcinoembryonic antigen, carbohydrate antigen-125, and carcinoembryonic antigen 19-9 were all normal. Intraoperatively the tumor was attached to the peritoneum and mesentery. Part of the large bowel, including the sigmoid colon, were attached to it. The exact origin of the tumor could not be ascertained during surgery. The tumor was successfully excised, and specimen sent for histology and immunochemistry analysis. The definitive diagnosis was confirmed with immunochemistry. The patient had an uneventful postsurgical course and was discharged on day 4 after surgery for routine gynecological follow-up. Conclusion: Solitary fibrous tumor is very rare; however, the diagnosis should be considered in a postmenopausal woman with solid pelvic mass, normal tumor markers and no ascites.

Research prioritisation on prevention and management of preterm birth in low and middle-income countries (LMICs) with a special focus on Bangladesh using the Child Health and Nutrition Research Initiative (CHNRI) method.

Background: Fifteen million babies are born preterm globally each year, with 81% occurring in low- and middle-income countries (LMICs). Preterm birth complications are the leading cause of newborn deaths and significantly impact health, quality of life, and costs of health services. Improving outcomes for newborns and their families requires prioritising research for developing practical, scalable solutions, especially in low-resource settings such as Bangladesh. We aimed to identify research priorities related to preventing and managing preterm birth in LMICs for 2021-2030, with a special focus on Bangladesh. Methods: We adopted the Child Health and Nutrition Research Initiative (CHNRI) method to set research priorities for preventing and managing preterm birth. Seventy-six experts submitted 490 research questions online, which we collated into 95 unique questions and sent for scoring to all experts. A hundred and nine experts scored the questions using five pre-selected criteria: answerability, effectiveness, deliverability, maximum potential for burden reduction, and effect on equity. We calculated weighted and unweighted research priority scores and average expert agreement to generate a list of top-ranked research questions for LMICs and Bangladesh. Results: Health systems and policy research dominated the top 20 identified priorities for LMICs, such as understanding and improving uptake of the facility and community-based Kangaroo Mother Care (KMC), promoting breastfeeding, improving referral and transport networks, evaluating the impact of the use of skilled attendants, quality improvement activities, and exploring barriers to antenatal steroid use. Several of the top 20 questions also focused on screening high-risk women or the general population of women, understanding the causes of preterm birth, or managing preterm babies with illnesses (jaundice, sepsis and retinopathy of prematurity). There was a high overlap between research priorities in LMICs and Bangladesh. Conclusions: This exercise, aimed at identifying priorities for preterm birth prevention and management research in LMICs, especially in Bangladesh, found research on improving the care of preterm babies to be more important in reducing the burden of preterm birth and accelerating the attainment of Sustainable Development Goal 3 target of newborn deaths, by 2030.

The role of the placenta in perinatal asphyxia, neonatal encephalopathy, and neurodevelopmental outcome: A review.

Perinatal asphyxia contributes significantly to neonatal deaths globally. This may occur due to the effects of various phenomena like uterine rupture, infections, maternal hemodynamic compromise (amniotic fluid embolus), placenta, and umbilical cord (umbilical cord knot, placental abruption, or compression). Perinatal asphyxia is the term used for interrupted blood flow or the exchange of gases in the fetus during the prenatal period. The reduced oxygenation induces a cascade of brain injuries, resulting in long-term damage to the infant's brain. Some infants exposed to perinatal hypoxia-ischemia will make an immediate recovery and have normal survival, while others may suffer from an evolving clinical encephalopathy. This review article focuses on the relationship between the placenta, neonatal encephalopathy, and neurodevelopmental outcome. It also aims to identify possible interventions and drive the focus of policymakers towards issues that evolve around perinatal asphyxia, neonatal encephalopathy, and neonatal care and that have a high impact on infant morbidity in sub-Saharan Africa.

Prevalence, Pattern, and Outcome of Congenital Anomalies Admitted to a Neonatal Unit in a Low-Income Country-a Ten-Year Retrospective Study.

OBJECTIVE: The incidence of congenital abnormalities is highest in low-and-middle-income countries. However, the prevalence, spectrum, trends of neonatal congenital anomalies and their admission outcomes have not been well explored. This study was a 10 year retrospective hospital-based research in a low-income country to address the above. METHODS: All infants hospitalized in the Special Care Baby Unit at the Cape Coast Teaching Hospital in Ghana, between 1st January 2010 and 31st December 2019, had their demographic, obstetric, and clinical data recorded. RESULTS: Over the decade, 236 neonates with congenital abnormalities were admitted to the unit, accounting for 2.8% of total neonatal admissions and 8.6 per 1000 births. Mortality occurred in 33.2% of neonates with congenital abnormalities, corresponding to 4.6% of all neonatal deaths. Mortality was significantly associated with place of delivery and gravidity of more than five. The commonest anomalies were in the nervous system, particularly neural tube defects, followed by suspected chromosomal abnormalities and then cardiac defects. Neonates with cardiac defects had a higher chance of dying. Health center/clinic delivery proffered a better survival than hospital delivery, but this should be interpreted with caution. CONCLUSION: Neural tube defects were the most predominant anomalies; hence, intensification of preconception and antenatal folic acid supplementation is pivotal towards their reduction. Making prenatal screening for early detection of fetal anomalies an integral part of routine antenatal care is also essential. This research was conducted in a single center and did not include stillbirths and abortions so cannot give an accurate estimation of the number of congenital abnormalities in the population. A national registry of congenital anomalies is recommended.

Interventions for the prevention of spontaneous preterm birth: a scoping review of systematic reviews.

BACKGROUND: Globally, 11% of babies are born preterm each year. Preterm birth (PTB) is a leading cause of neonatal death and under-five mortality and morbidity, with lifelong sequelae in those who survive. PTB disproportionately impacts low/middle-income countries (LMICs) where the burden is highest. OBJECTIVES: This scoping review sought to the evidence for interventions that reduce the risk of PTB, focusing on the evidence from LMICs and describing how context is considered in evidence synthesis. DESIGN: We conducted a scoping review, to describe this wide topic area. We searched five electronic databases (2009-2020) and contacted experts to identify relevant systematic reviews of interventions to reduce the risk of PTB. We included published systematic reviews that examined the effectiveness of interventions and their effect on reducing the risk of PTB. Data were extracted and is described narratively. RESULTS: 139 published systematic reviews were included in the review. Interventions were categorised as primary or secondary. The interventions where the results showed a greater effect size and consistency across review findings included treatment of syphilis and vaginal candidiasis, vitamin D supplementation and cervical cerclage. Included in the 139 reviews were 1372 unique primary source studies. 28% primary studies were undertaken in LMIC contexts and only 4.5% undertaken in a low-income country (LIC) Only 10.8% of the reviews sought to explore the impact of context on findings, and 19.4% reviews did not report the settings or the primary studies. CONCLUSION: This scoping review highlights the lack of research evidence derived from contexts where the burden of PTB globally is greatest. The lack of rigour in addressing contextual applicability within systematic review methods is also highlighted. This presents a risk of inappropriate and unsafe recommendations for practice within these contexts. It also highlights a need for primary research, developing and testing interventions in LIC settings.

Role of genetic factors in recurrent miscarriages - A review.

Recurrent miscarriage is classically defined as three or more consecutive pregnancy losses in about 1-5% of couples trying to conceive. However, several researchers have amended this to two or more because of the recent increase in childless miscarriages. Recurrent miscarriage is a clinical challenge for clinicians because there are many possible causes, and diagnostic testing is expensive and time-consuming. Established causes of recurrent miscarriage are antiphospholipid antibodies, uterine anomalies, and abnormal chromosomes in either partner, particularly translocations. Uterine anatomical abnormalities, endocrine abnormalities, infections, immunologic factors, environmental factors, metabolic or hormonal disorders, sperm quality, and maternal and paternal age have each been linked. Among them, the genetic factor plays a significant role in recurrent miscarriage. Approximately 70% of miscarriage conceptions with sporadic spontaneous miscarriage reveal some chromosome abnormality. Specifically, recurrent miscarriage can be caused by a structural or numerical defect in the parents' or fetus' chromosomes. Recurrent miscarriage has been linked to several genes, including those involved in oxidative stress, angiogenesis, clotting, and inflammation. Despite several well-known etiologic factors, the etiology of recurrent miscarriage is unknown in over half of all instances. The current review aims to analyse the role of the genetic basis of recurrent miscarriages.

Maternal mortality from COVID 19 among South African pregnant women.

OBJECTIVE: To determine the COVID 19 related maternal deaths among South African pregnant women at Ekurhuleni health district in South Africa and to compare with similar studies. STUDY DESIGN: Retrospective review of all maternal deaths from all health care facilities from April to September 2020 were conducted using COVID registers and maternity case records. Human Research Ethics Committee of the University of Witwatersrand approved the study. Data included total live births, maternal mortality ratio (MMR), age, ethnicity, place of admission, parity, pregnancy status, antenatal complications, gestational age (GA) at delivery, GA at COVID 19 diagnosis, GA at death, symptoms, comorbidity, investigations (HIV, platelets, lymphocytes and LDH), and fetal outcome. Descriptive statistics (mean ± standard deviation, number and percentages) were calculated. RESULTS: Six women died from COVID. All were African. Mean age was 33.5 (SD ± 4.3) years majority (83%) were multiparous. The mean GA at the time of diagnosis was 35 (± 5.8) weeks. All had dyspnea at presentation. All had hypertension. HIV rate (50%) was higher than the national rate. High lactic dehydrogenase was the commonest laboratory abnormality. Rate of macerated stillborn (66%) was very high. CONCLUSION: To date, there are no African studies reporting on maternal mortality from COVID 19. This study provided valuable insight into maternal deaths due to COVID among South African women. COVID 19 is a novel cause of maternal death that has increased the death rate among South African pregnant women. Hypertensive women are at increased risk of death. They should be routinely tested for COVID. Women are at risk of death during the third trimester of pregnancy. High rate of stillborn is a concern. Decision to deliver earlier should be an option. High HIV rate and LDH count should alert health care workers to perform these tests among all COVID positive mothers.

"Suction Tube Uterine Tamponade" for treatment of refractory postpartum hemorrhage: Internal feasibility and acceptability pilot of a randomized clinical trial.

OBJECTIVE: To assess feasibility and acceptability of a novel, low-cost "Suction Tube Uterine Tamponade" (STUT) treatment for refractory postpartum hemorrhage (PPH). METHODS: We allocated patients with refractory PPH by randomly ordered envelopes to STUT or routine uterine balloon tamponade (UBT, Ellavi free-flow system) in 10 hospitals in South Africa. In the STUT group, a 24FG Levin stomach tube was inserted into the uterine cavity and vacuum created with a vacuum pump or manual vacuum aspiration syringe. RESULTS: For this internal pilot study, 12 participants were allocated to STUT and 12 to UBT. Insertion failed in one of each group and was recorded as difficult in 3/10 STUT and 4/9 UBT insertions respectively (five missing data). There were two laparotomies and one intensive care unit admission in the UBT group. Pain during STUT insertion was graded as none/mild in 9/10 and severe in 1/10. The experience of the STUT procedure was graded as fine in 4/11 and "uncomfortable but acceptable" in 7/11. CONCLUSION: STUT is feasible and acceptable, justifying continuation of our trial. These data will also inform a large World Health Organization trial to test effectiveness of uterine tamponade methods. The numbers are too small to support any clinical recommendation.

Maternal characteristics and pregnancy outcomes of hospitalized pregnant women with SARS-CoV-2 infection in South Africa: An International Network of Obstetric Survey Systems-based cohort study.

OBJECTIVE: To describe risk factors and outcomes of pregnant women infected with SARS-CoV-2 admitted to South African healthcare facilities. METHODS: A population-based cohort study was conducted utilizing an amended International Obstetric Surveillance System protocol. Data on pregnant women with SARS-CoV-2 infection, hospitalized between April 14, 2020, and November 24, 2020, were analyzed. RESULTS: A total of 36 hospitals submitted data on 673 infected hospitalized pregnant women; 217 (32.2%) were admitted for COVID-19 illness and 456 for other indications. There were 39 deaths with a case fatality rate of 6.3%: 32 (14.7%) deaths occurred in women admitted for COVID-19 illness compared to 7 (1.8%) in women admitted for other indications. Of the women, 106 (15.9%) required critical care. Maternal tuberculosis, but not HIV co-infection or other co-morbidities, was associated with admission for COVID-19 illness. Rates of cesarean delivery did not differ significantly between women admitted for COVID-19 and those admitted for other indications. There were 179 (35.4%) preterm births, 25 (4.7%) stillbirths, 12 (2.3%) neonatal deaths, and 162 (30.8%) neonatal admissions. Neonatal outcomes did not differ significantly from those of infected women admitted for other indications. CONCLUSION: The maternal mortality rate was high among women admitted with SARS-CoV-2 infection and higher in women admitted primarily for COVID-19 illness with tuberculosis being the only co-morbidity associated with admission.

Clinical Features and Outcomes of COVID-19 Infection among Pregnant Women in South Africa.

BACKGROUND AND OBJECTIVE: Studies among COVID positive pregnant women are limited. Previous studies reported high rate of symptoms, comorbidities and poor fetal/neonatal outcome among women of different ethnicity. To date, no study was reported among pregnant African women. This study was conducted to determine the clinical features and outcomes of COVID-19 positive pregnant women in Ekurhuleni District in South Africa. METHODS: Retrospective record review of 103 COVID-19 infected pregnant women during the period of April to September 2020 was done. Clinical features, symptoms, comorbidities, laboratory results, maternal and neonatal outcomes were analyzed. Descriptive statistics (mean + standard deviation, number and percentages) and inferential statistics (Chi-square test) were calculated. Ethical clearance was obtained from the Human Research Ethics Committee of the University of Witwatersrand, South Africa. RESULTS: Majority (90%) were of African ethnicity and symptomatic (53%). The commonest symptom, comorbidity and laboratory abnormality was cough (62%), hypertension (23%) and high LDH (20%), respectively. Thrombocytopenia and lymphocytopenia occurred among 9% and 15% of the women, respectively. Although association was not significant, symptoms were more common among comorbid, HIV positive and women with abnormal results. Commonest complications were preterm labor (8%) and macerated stillbirths (6%). Six (6%) mothers died. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: COVID positive pregnant South African women were commonly symptomatic but incidence of adverse fetal outcomes was low. High rate of preterm labor, macerated stillbirths and maternal deaths was a concern. This study has several strengths. It included all COVID positive women over a 6 months' period at all level of healthcare facilities such as clinics, community health centers/midwifery units, and district, regional and tertiary hospitals, conducted in an African country. Previous studies included mainly hospitals raising a high probability of including mainly severely ill women. The study might benefit the health care workers in other African countries.

Pregnancy in women with cardiac disease: a one-year retrospective review of management and maternal and neonatal outcomes in a tertiary hospital in Johannesburg, South Africa.

INTRODUCTION: In South Africa, cardiac disease continues to be the most important non-obstetric cause of maternal death. METHODS: A record review of 74 pregnant women with cardiac disease was performed to determine the prevalence and outcomes of cardiac disease at Charlotte Maxeke Johannesburg Academic Hospital between January and December 2017. RESULTS: Rheumatic heart disease was the most common cardiac diagnosis (n = 21, 28.4%), followed by pulmonary hypertension (n = 13, 17.6%) and congenital heart disease (n = 12, 16.2%). There were one (1.4%) maternal and two (2.7%) perinatal deaths. Neonatal complications included pre-term delivery (n = 20, 32.3%) and small-for-gestational-age infants (n = 10, 16.1%). Cardiac complications (n = 30, 40.5%) included heart failure (n = 15, 20.3%), pulmonary hypertension (n = 11, 14.9%) and blood transfusions (n = 8, 10.8%). CONCLUSIONS: Cardiac disease in pregnancy was associated with a high risk of maternal and neonatal complications. Pre-conceptual counselling and managing pregnant women at a dedicated centre by a multidisciplinary team could, however, improve outcomes.

Pregnancy-related venous thromboembolism and HIV infection.

OBJECTIVE: To assess risk factors for venous thromboembolism (VTE) in African women in order to guide thromboprophylaxis. METHODS: A case-control study was performed at a specialist obstetric unit in South Africa from July 1, 2017 to June 30, 2020. We identified 128 cases with VTE and 640 controls, matched for gestation. RESULTS: Prepartum risk factors associated with VTE included; medical comorbidities (odds ratios [OR] 5.32, 95% confidence intervals [CI] 1.82-15.56), human immunodeficiency virus (HIV) (OR 2.84, 95% CI 1.50-5.41), and hospital admission or immobility (OR 5.33, 95% CI 1.17-24.22). Postpartum, the following were identified as significant risk factors; medical comorbidities (OR 23.72, 95% CI 8.75-64.27), hospital admission or immobility (OR 13.18, 95% CI 5.04-34.49), systemic infection (OR 4.48, 95% CI 1.28-15.68), HIV (OR 3.20, 95% CI 1.49-6.87), pre-eclampsia and fetal growth restriction (OR 2.74, 95% CI 1.18-6.36), and postpartum hemorrhage (OR 4.38, 95% CI 1.75-10.97). Antiretroviral therapy, opportunistic infections, and viral load >50 copies/ml, however, were not associated with VTE risk among HIV-infected participants. CONCLUSION: HIV was a significant risk factor for pregnancy-related thrombosis. This was independent of traditional HIV risk factors. As such, future studies are recommended to explore the mechanisms of thrombosis associated with HIV infection.

Improving prenatal detection of congenital hand defects through collaborative goal-directed antenatal care: a case report on symbrachydactyly.

BACKGROUND: Prenatal ultrasonography for the detection of fetal structural anomaly is an important component of antenatal care. During the assessment, proximal limb deformities are readily diagnosed. Distal limb, especially digit, abnormalities, however, may be difficult to detect, particularly if the ultrasonography is performed in the third trimester, and the deformity is unilateral and isolated. CASE: A 24-year-old primigravida booked for antenatal care with a general practitioner had threatened miscarriage at 12 weeks of gestation, and at 34 weeks was referred to an obstetrician for further care and delivery. The growth ultrasonographic examination was normal but at 40 weeks of gestation she developed antepartum haemorrhage of unknown origin. She had a caesarean delivery and a female baby with "rudimentary" left fingers ("isolated symbrachydactyly") was delivered. The parents were counselled and they declined further assessment of the baby by a hand surgeon and a clinical geneticist. At 3 years of age, the baby had normal development and "is using her hand even without fingers," according to the mother. CONCLUSION: Collaborative goal-directed antenatal care that involves different categories of healthcare professionals, but particularly a certified sonologist who performs fetal anomaly ultrasonography, is essential for the detection of congenital hand defects. Adequate counselling is essential for the satisfaction of the baby's family.

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.

An evaluation of classification systems for stillbirth.

BACKGROUND: Audit and classification of stillbirths is an essential part of clinical practice and a crucial step towards stillbirth prevention. Due to the limitations of the ICD system and lack of an international approach to an acceptable solution, numerous disparate classification systems have emerged. We assessed the performance of six contemporary systems to inform the development of an internationally accepted approach. METHODS: We evaluated the following systems: Amended Aberdeen, Extended Wigglesworth; PSANZ-PDC, ReCoDe, Tulip and CODAC. Nine teams from 7 countries applied the classification systems to cohorts of stillbirths from their regions using 857 stillbirth cases. The main outcome measures were: the ability to retain the important information about the death using the InfoKeep rating; the ease of use according to the Ease rating (both measures used a five-point scale with a score <2 considered unsatisfactory); inter-observer agreement and the proportion of unexplained stillbirths. A randomly selected subset of 100 stillbirths was used to assess inter-observer agreement. RESULTS: InfoKeep scores were significantly different across the classifications (p < or = 0.01) due to low scores for Wigglesworth and Aberdeen. CODAC received the highest mean (SD) score of 3.40 (0.73) followed by PSANZ-PDC, ReCoDe and Tulip [2.77 (1.00), 2.36 (1.21), 1.92 (1.24) respectively]. Wigglesworth and Aberdeen resulted in a high proportion of unexplained stillbirths and CODAC and Tulip the lowest. While Ease scores were different (p < or = 0.01), all systems received satisfactory scores; CODAC received the highest score. Aberdeen and Wigglesworth showed poor agreement with kappas of 0.35 and 0.25 respectively. Tulip performed best with a kappa of 0.74. The remainder had good to fair agreement. CONCLUSION: The Extended Wigglesworth and Amended Aberdeen systems cannot be recommended for classification of stillbirths. Overall, CODAC performed best with PSANZ-PDC and ReCoDe performing well. Tulip was shown to have the best agreement and a low proportion of unexplained stillbirths. The virtues of these systems need to be considered in the development of an international solution to classification of stillbirths. Further studies are required on the performance of classification systems in the context of developing countries. Suboptimal agreement highlights the importance of instituting measures to ensure consistency for any classification system.