Objective To compare provider assessment of fetal maceration with death-to-delivery interval to evaluate the reliability of appearance as a proxy for time of death. Methods Cohort chart abstraction was performed for all stillbirth deliveries at or above 28 weeks of gestation during a 1-year period in a teaching hospital in Ghana. Results Of 470 stillborn infants, 337 had adequate data for analysis. Of 47 fetuses alive on admission with death-to-delivery intervals estimated to be less than 8 hours (expected to be reported as fresh), 14 (30%) were actually reported as macerated. Of 94 cases in which the fetus was deceased on admission with death-to-delivery interval of more than 8 hours (expected to be macerated), 17 (18%) were described as fresh. Conclusion Provider description of fetal appearance may be an unreliable indicator for time since fetal death. The findings have significant implications for stillbirth prevention and assessment.