Fig 1 - uploaded by Aleena M Wojcieszek
Content may be subject to copyright.
Percent of systems aligned with expert-identified characteristics for an effective global system. Note: Numbers in front of characteristics refer to sequence of characteristics in Table 1
Source publication
\textbf{Background:}$ To reduce the burden of 5.3 million stillbirths and neonatal deaths annually, an understanding of causes of deaths is critical. A systematic review identified 81 systems for classification of causes of stillbirth (SB) and neonatal death (NND) between 2009 and 2014. The large number of systems hampers efforts to understand and...
Citations
... The classification system helps to divide the causes of stillbirth into relevant groups to assist in counselling and the development of family planning. A number of classification systems have been applied to stillbirth in different countries [11,12], however, global comparisons are difficult because of the multiple classification systems used for perinatal death [12,13]. Better classification systems are needed to achieve accuracy and consistency in the reporting of causes of stillbirths. ...
Background
The causes of some stillbirths are unclear, and additional work must be done to investigate the risk factors for stillbirths.
Objective
To apply the International Classification of Disease-10 (ICD-10) for antepartum stillbirth at a referral center in eastern China.
Methods
Antepartum stillbirths were grouped according to the cause of death according to the International Classification of Disease-10 (ICD-10) criteria. The main maternal condition at the time of antepartum stillbirth was assigned to each patient.
Results
Antepartum stillbirths were mostly classified as fetal deaths of unspecified cause, antepartum hypoxia. Although more than half of the mothers were without an identified condition at the time of the antepartum stillbirth, where there was a maternal condition associated with perinatal death, maternal medical and surgical conditions and maternal complications during pregnancy were most common. Of all the stillbirths, 51.2% occurred between 28 and 37 weeks of gestation, the main causes of stillbirth at different gestational ages also differed. Autopsy and chromosomal microarray analysis (CMA) were recommended in all stillbirths, but only 3.6% received autopsy and 10.5% underwent chromosomal microarray analysis.
Conclusions
The ICD-10 is helpful in classifying the causes of stillbirths, but more than half of the stillbirths in our study were unexplained; therefore, additional work must be done. And the ICD-10 score may need to be improved, such as by classifying stillbirths according to gestational age. Autopsy and CMA could help determine the cause of stillbirth, but the acceptance of these methods is currently low.
... By one account, descriptions of 35 different classification systems have been published, mostly from high-income countries. 6,7 Few studies have addressed the cause of stillbirth in LMICs. Most of those that have commented on causes have not employed advanced methods to determine cause of stillbirth. ...
Objective
To examine internal organ tissues and placentas of stillbirths for various pathogens.
Design
Prospective, observational study.
Settings
Three study hospitals in India and a large maternity hospital in Pakistan.
Population
Stillborn infants delivered in a study hospital.
Methods
A prospective observational study.
Main outcome measures
Organisms identified by pathogen polymerase chain reaction (PCR) in internal organs and placental tissues of stillbirths.
Results
Of 2437 stillbirth internal tissues, 8.3% (95% CI 7.2–9.4) were positive. Organisms were most commonly detected in brain (12.3%), cerebrospinal fluid (CSF) (9.5%) and whole blood (8.4%). Ureaplasma urealyticum/parvum was the organism most frequently detected in at least one internal organ (6.4% of stillbirths and 2% of all tissues). Escherichia coli/Shigella was the next most common (4.1% one or more internal organ tissue sample and 1.3% of tissue samples), followed by Staphylococcus aureus in at least one internal organ tissue (1.9% and 0.9% of all tissues). None of the other organisms was found in more than 1.4% of the tissue samples in stillbirths or more than 0.6% of the internal tissues examined. In the placenta tissue, membrane or cord blood combined, 42.8% (95% CI 40.2–45.3) had at least one organism identified, with U. urealyticum/parvum representing the most commonly identified (27.8%).
Conclusions
In about 8% of stillbirths, there was evidence of a pathogen in an internal organ. Ureaplasma urealyticum/parvum was the most common organism found in the placenta and in the internal tissues, especially in the fetal brain.
... A LBE, como outras classificações 14 , está alinhada à Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde (CID-10) 3 , e abrange óbitos nas faixas de 5 a 75 anos e em crianças menores de 5 anos, sem incluir óbitos fetais 9,10 . Atualmente, é uma das classificações propostas no módulo de investigação de óbitos infantis e fetais do SIM. ...
... Outras características da LBE, além do alinhamento à CID-10, que a tornam particularmente útil, são: (1) diferentes níveis de complexidade, com grupos e subgrupos de causas; (2) regras claras e facilmente aplicáveis; (3) fácil acesso aos dados, por estar disponível no SIM. Uma das limitações, no entanto, é não ser aplicável a óbitos fetais 14 . ...
... A LBE é a classificação mais usada no país 11,12,13,21,22,23,24 e tem muitas características que a habilitam como um "sistema global de classificação" 14 . Contextualizada ao perfil de atendimento do SUS, pode ser usada também como parâmetro em avaliações de intervenções de saúde 24 . ...
Although the Brazilian List of Avoidable Causes of Deaths (LBE in Portuguese), in its version for children under 5 years of age (LBE < 5), does not include stillbirths, some studies have used the list with or without adaptations. We present a proposal for adaptation of the LBE for stillbirths (LBE-OF in Portuguese) and the results of its application to stillbirths in the State of Rio de Janeiro, Brazil, in 2018, compared to the results with LBE < 5. We reviewed the categories from the 10th revision of the International Classification of Diseases (ICD-10) in the LBE < 5 and reassigned them in the avoidability groups, according to time of death in relation to delivery and the causes consistent with stillbirths. Conditions that did not elucidate the determinants of death were allocated as ill-defined causes. Stillbirths in the State of Rio de Janeiro, selected from the databases of the Mortality Information System (SIM in Portuguese), were classified according to LBE-OF and LBE < 5. When classifying the 2,585 stillbirths that occurred in the State of Rio de Janeiro in 2018, we found that according to LBE < 5, there were predominantly causes "reducible by adequate care in labor and delivery" (42.9%), while according to LBE-OF, the most frequent causes were "reducible by adequate care for during pregnancy" (43.6%). Ill-defined causes ranked second according to the LBE-OF (35.4%) and third according to LBE < 5. Some 30% of stillbirths changed groups and subgroups of avoidability, showing greater consistency with the profile of obstetric care. Although identifying a higher percentage of ill-defined causes, the LBE-OF is more consistent with the pathophysiology of fetal deaths. The inclusion of stillbirths in the SIM would be a positive step in monitoring and upgrading the investigation of causes of fetal death.
... Foi analisado o alinhamento dos sistemas com os princípios gerais da CID-10, constatando a sua utilização limitada para a classificação de natimortos, com apenas 21% dos sistemas usando códigos da CID-10. Identificou-se que a maioria dos sistemas foi aplicado apenas nas regiões em que foram desenvolvidos, tornando incompatíveis os dados produzidos e dificultando a compreensão da dimensão de causas específicas de mortes perinatais no mundo 30 . ...
... Em reconhecimento à necessidade de classificar com precisão as causas dessas mortes, a Organização Mundial da Saúde (OMS) lançou em 2016 uma nova abordagem para a classificação de mortes perinatais para uso mundial, a "Aplicação da CID-10 da OMS às mortes perinatais" (CID-Mortalidade Perinatal ou CID-PM) 30 . Esse sistema globalmente aplicável exige o registro do tempo das mortes (intraparto e anteparto) e as condições maternas que contribuíram para a morte perinatal. ...
O objetivo desta pesquisa foi analisar a evolução temporal da taxa de mortalidade fetal (TMF) e a contribuição da investigação para a melhoria da definição da causa básica do óbito fetal no Município de São Paulo, Brasil, segundo local de emissão da declaração de óbito. Na abordagem ecológica, analisou-se a tendência da TMF por estrato de peso (< 2.500g e ≥ 2.500g) e óbitos totais no Município de São Paulo entre 2007-2017. Utilizou-se a regressão linear generalizada de Prais-Winsten. No estudo de casos, foram analisadas as causas básicas de óbito fetal de 2012 a 2014, antes e após a investigação, o tempo de conclusão da investigação e a redefinição da causa básica por tipo de atestante. Houve tendência de aumento (1,5% ao ano) da TMF dos óbitos com < 2.500g e de redução (-1,3% ao ano) naqueles com ≥ 2.500g. Os óbitos totais apresentaram tendência estacionária. Entre 2012-2014, cerca de 90% dos óbitos com ≥ 2.500g foram investigados. Após a investigação, houve redefinição da causa básica de morte em 15% dos casos, e a morte fetal não especificada (P95) representou 25% das causas de óbito. A proporção mais elevada de alteração da causa de morte ocorreu nos casos cuja Declaração de Óbito foi emitida pelos serviços de verificação de óbito (17%), ao passo que nos serviços de saúde foi de 10,6%. Concluiu-se que a TMF dos óbitos com ≥ 2.500g apresentou tendência de redução. Houve redefinição significativa das causas básicas, sobretudo naquelas atestadas pelo serviços de verificação de óbito. Entretanto, foi insuficiente para ampliar a proporção de causas de morte que permitissem maior compreensão das condições de mortalidade.
... Obtaining reliable statistics is challenging since stillbirths are often poorly documented by the vital registry [4][5][6][7]. A literature review [8] revealed that, between 2009 and 2014, more than 81 systems were in place to classify causes of perinatal deaths, complicating cross-country comparison [8]. In response, the WHO developed a universal classification system, the International Classification of Disease 10 Perinatal-Mortality (ICD-PM) to harmonise classifications and facilitate global data comparison on causes of perinatal deaths [9]. ...
... Obtaining reliable statistics is challenging since stillbirths are often poorly documented by the vital registry [4][5][6][7]. A literature review [8] revealed that, between 2009 and 2014, more than 81 systems were in place to classify causes of perinatal deaths, complicating cross-country comparison [8]. In response, the WHO developed a universal classification system, the International Classification of Disease 10 Perinatal-Mortality (ICD-PM) to harmonise classifications and facilitate global data comparison on causes of perinatal deaths [9]. ...
Background
Suriname has one of the highest stillbirth rates in Latin America and the Caribbean. To facilitate data comparison of perinatal deaths, the World Health Organization developed the International Classification of Diseases-10 Perinatal Mortality (ICD-PM).
Objective
We aimed to (1) assess characteristics and risk indicators of women with a stillbirth, (2) determine the timing and causes of stillbirths according to the ICD-PM with critical evaluation of its application and (3) propose recommendations for the reduction of stillbirths in Suriname.
Methods
A hospital-based, nation-wide, cross-sectional study was conducted in all hospitals within Suriname during one-year (2017). The medical files of stillbirths (gestation ≥28 weeks/birth weight ≥1000 grams) were reviewed and classified using ICD-PM. We used descriptive statistics and multiple logistic regression analyses.
Results
The stillbirth rate in Suriname was 14.4/1000 births (n=131 stillbirths, n=9089 total births). Medical files were available for 86% (n=113/131) of stillbirths. Women of African descent had the highest stillbirth rate and two times the odds of stillbirth (OR 2.1, 95%CI 1.4–3.1) compared to women of other ethnicities. One third (33%, n=37/113) of stillbirths occurred after hospital admission. The timing was antepartum in 85% (n=96/113), intrapartum in 11% (n=12/113) and unknown in 4% (n=5/113). Antepartum stillbirths were caused by hypoxia in 46% (n=44/96). In 41% (n=39/96) the cause was unspecified. Maternal medical and surgical conditions were present in 50% (n=57/113), mostly hypertensive disorders.
Conclusion
Stillbirth reduction strategies in Suriname call for targeting ethnic disparities, improving antenatal services, implementing perinatal death audits and improving diagnostic post-mortem investigations. ICD-PM limited the formulation of recommendations due to many stillbirths of ‘unspecified’ causes. Based on our study findings, we also recommend addressing some challenges with applying the ICD-PM.
Abbreviations
CTG: Cardiotocography; ENAP: Every Newborn Action Plan (ENAP); ICD-PM: The WHO application of ICD-10 to deaths during the perinatal period – perinatal mortality; SBR: Stillbirth rate; SGA: Small for gestational age; WHO: World Health Organization; LMIC: Low- and middle-income countries; FHR: foetal heart rate.
... 8 Currently there are more than 80 stillbirth classification systems in the world. 9 Designed and developed as a facility-based audit tool in South Africa in the 1990s, the Perinatal Problem Identification Program (PPIP) system has been adopted nationally since 2012, and applied in LMICs 7 as a means to classify deaths and understand potential avoidable factors associated with perinatal death. 10 Papua New Guinea (PNG), an LMIC in the Asia-Pacific region, has one of the highest maternal and perinatal mortality rates in the world. ...
Objective
To undertake a retrospective perinatal death audit and assessment of avoidable factors associated with stillbirths among a cohort of women in two provinces in Papua New Guinea.
Methods
We used data from an ongoing cluster‐randomized crossover trial in 10 sites among 4600 women in Papua New Guinea (from 2017 to date). The overarching aim is to improve birth outcomes. All stillbirths from July 2017 to January 2020 were identified. The Perinatal Problem Identification Program was used to analyze each stillbirth and review associated avoidable factors.
Results
There were 59 stillbirths among 2558 births (23 per 1000 births); 68% (40/59) were classified “fresh” and 32% as “macerated”. Perinatal cause of death was identified for 63% (37/59): 30% (11/37) were due to intrapartum asphyxia and traumatic breech birth and 19% (7/37) were the result of pre‐eclampsia. At least one avoidable factor was identified for 95% (56/59) of stillbirths. Patient‐associated factors included lack of response to reduced fetal movements and delay in seeking care during labor. Health personnel‐associated factors included poor intrapartum care, late diagnosis of breech presentation, and prolonged second stage with no intervention.
Conclusion
Factors associated with stillbirths in this setting could be avoided through a package of interventions at both the community and health‐facility levels.
... All rights reserved surveillance for those who need it and would potentially reduce anxiety and unnecessary intervention in women with a low risk of recurrence. 24,25 Current, common systems include Aberdeen, 26 Wigglesworth,27 ReCoDe (Classification of stillbirth by Relevant Condition at Death), 28 ...
Key content
Pregnancies following stillbirth have an increased risk of adverse outcome, including a 4.8‐fold increased risk of stillbirth.
Risk factors for stillbirth include obesity, smoking, advanced maternal age, fetal growth restriction, hypertension and diabetes.
Increased risk of medical problems may result from recurrent placental pathologies or genetic conditions or persistent maternal disease; thus, care for a subsequent pregnancy should commence with investigation of the index stillbirth.
Parents also require additional psychological support to navigate mixed emotions, particularly anxiety, about the development of pregnancy complications.
Antenatal care in a subsequent pregnancy after stillbirth should ideally be delivered by a multidisciplinary team to provide continuity of physical and psychological care.
Learning objectives
To improve understanding of the importance of a preconception/early pregnancy appointment and the key information to be covered in such an appointment in a pregnancy after stillbirth.
To know what information can be gained from postnatal investigations and the placental histology report and the relationship between this information and a subsequent pregnancy after stillbirth.
To be able to describe an example of a model of care used to address medical and psychological needs of parents in subsequent pregnancy.
Ethical issues
Failing to appreciate the medical and psychological significance of a history of stillbirth may lead to suboptimal antenatal care that does not meet women’s needs.
Lack of robust evidence may lead to prescription of medication without clear evidence of benefit.
... b Non-reassuring fetal status. resource limitations.14,16 The PSANZ Perinatal Death Classification system was updated in March 2018, and a working group through the International Stillbirth Alliance is developing a new, standardized stillbirth classification system which will likely have some similarity to PSANZ-PDC.24 ...
Objective
To classify cause‐of‐death (COD) for stillbirths occurring in a major referral hospital in Kumasi, Ghana.
Methods
In a retrospective review conducted between June 8, 2011, and June 12, 2012, detailed information was collected on all stillbirths delivered at Komfo Anokye Teaching Hospital in Kumasi, Ghana. Patient records were independently reviewed by investigators using the Perinatal Society of Australia and New Zealand's Perinatal Death Classification system to determine COD for each case.
Results
COD was analyzed in 465 stillbirth cases. The leading causes of death were hypoxic interpartum death (105, 22.6%), antepartum hemorrhage (67, 14.4%), hypertension (52, 11.2%), and perinatal infection (32, 6.9%). One hundred and fifty seven (33.8%) stillbirths were classified as unexplained antepartum deaths.
Conclusions
This evaluation of stillbirth in a busy, tertiary care hospital in Kumasi, Ghana provides crucial insight into the high volume of stillbirth in Ghana as well as its medical causes. The study demonstrated the high rate of stillbirth attributed to hypoxic intrapartum events, placental abruption, pre‐eclampsia, and unspecified bacterial infections. Yet, our rate of unexplained stillbirths underscores the need for a stillbirth classification system that thoughtfully integrates the needs and limitations of low‐resource settings as unexplained stillbirth rates are a common indicator of the effectiveness of a classification system.
... 2,8 Third, the AMANHI mortality study group collected information about the probable cause of death through physician-coded verbal autopsy interviews. The results for causes of stillbirths are valuable, especially given challenges with multiple classification systems, 9 and show the prominence of antepartum stillbirths due to hypertensive disorders of pregnancy (south Asia) and infections (sub-Saharan Africa), with many intrapartum stillbirths in both regions attributed to complications of labour and delivery. Among neonatal deaths, complications of prematurity as a cause of death were less common as in global estimates, and perinatal asphyxia and severe neonatal infections were the leading causes of death. ...
... Suboptimal systems exclude important information and result in a high proportion of deaths being classified incorrectly as "unexplained", hampering efforts to achieve the goals of classification stated above [8]. Despite decades of work, the ideal system remains elusive [9]. With 98% of perinatal deaths occurring in low-and middle-income countries (LMICs) [10], a classification system relevant to these settings is vital. ...
... These are that "a global system must be": (1) easy to use, and produce data that are easily understood and valued by users; (2) have clear guidelines for use and definitions for all terms used; use rules to ensure valid assignment of cause of death categories; (3) be able to work with all levels of data (from both low-and high-income countries), including minimal levels; (4) ensure cause of death categories are relevant in all settings; and (5) produce data that can be used to inform strategies to prevent perinatal deaths. In an evaluation of the contemporary systems, none met all these features [9]. Overall, 82% of systems met fewer than five of the 17 characteristics. ...
... It is difficult to evaluate ICD-PM against the Delphi criteria for a good global system (according to users) as the system has not yet been implemented. ICD-PM currently satisfies five of 17 Delphi panel characteristics using the same methodology as Leisher et al. [9]. The strengths of ICD-PM against the expert user criteria include that it incorporates both stillbirths and neonatal deaths; it distinguishes between antepartum and intrapartum conditions; that associated factors are recorded and clearly distinguished from causes of death; that it has clear guidelines for use and definitions for all terms used; and that it has rules to ensure valid assignment of cause of death categories. ...
Accurate and consistent classification of causes and associated conditions for perinatal deaths is essential to inform strategies to reduce the five million which occur globally each year. With the majority of deaths occurring in low- and middle-income countries (LMICs), their needs must be prioritised. The aim of this paper is to review the classification of perinatal death, the contemporary classification systems including the World Health Organization's International Classification of Diseases – Perinatal Mortality (ICD-PM), and next steps. During the period from 2009 to 2014, a total of 81 new or modified classification systems were identified with the majority developed in high-income countries (HICs). Structure, definitions and rules and therefore data on causes vary widely and implementation is suboptimal. Whereas system testing is limited, none appears ideal. Several systems result in a high proportion of unexplained stillbirths, prompting HICs to use more detailed systems that require data unavailable in low-income countries. Some systems appear to perform well across these different settings. ICD-PM addresses some shortcomings of ICD-10 for perinatal deaths, but important limitations remain, especially for stillbirths. A global approach to classification is needed and seems feasible. The new ICD-PM system is an important step forward and improvements will be enhanced by wide-scale use and evaluation. Implementation requires national-level support and dedicated resources. Future research should focus on implementation strategies and evaluation methods, defining placental pathologies, and ways to engage parents in the process.
