A regional audit system for stillbirth: a way to better understand the phenomenon

Abstract

Background Implementation of high-quality national audits for perinatal mortality are needed to improve the registration of all perinatal deaths and the identification of the causes of death. This study aims to evaluate the implementation of a Regional Audit System for Stillbirth in Emilia-Romagna Region, Italy. Methods For each stillbirth (≥ 22 weeks of gestation, ≥ 500 g) occurred between January 1, 2014 to December 1, 2016 ( n = 332), the same diagnostic workup was performed and a clinical record with data about mother and stillborn was completed. Every case was discussed in a multidisciplinary local audit to assess both the cause of death (ReCoDe classification) and the quality of care. Data were reviewed by the Regional Audit Group. Stillbirth rates, causes of death and the quality of care were established for each case. Results Total stillbirth rate was 3.09 per 1000 births (332/107,528). Late stillbirth rate was 2.3 per 1000 (251/107,087). Sixteen stillbirths were not registered by the Regional Birth Register. The most prevalent cause of death was placental disorder (33.3%), followed by fetal (17.6%), cord (14.2%) and maternal disorders (7.6%). Unexplained cases were 14%. Compared to local audits, the regional group attributed different causes of death in 17% of cases. At multivariate analysis, infections were associated with early stillbirths (OR 3.38, CI95% 1.62–7.03) and intrapartum cases (OR 6.64, CI95% 2.61–17.02). Placental disorders were related to growth restriction (OR 1.89, CI95% 1.06–3.36) and were more frequent before term (OR 1.86, CI95% 1.11–3.15). Stillbirths judged possibly/probably preventable with a different management (10.9%) occurred more frequently in non-Italian women and were mainly related to maternal disorders (OR 6.64, CI95% 2.61–17.02). Conclusions Regional Audit System for Stillbirth improves the registration of stillbirth and allows to define the causes of death. Moreover, sub-optimal care was recognized, allowing to identify populations which could benefit from preventive measures.

Could a multidisciplinary regional audit identify avoidable factors and delays that contribute to stillbirths? A retrospective cohort study

“…There was an overrepresentation of women born in Africa in the stillbirth group. This is also in line with previous reports, both in a Swedish register-based study on stillbirths and in an Italian audit on stillbirths [ 17 , 31 ]. It is also possible, even if we could not control for it in this study, that women from Africa are in a more socioeconomic vulnerable situation.…”

“…The audit was carried out on behalf of the Swedish National Board of Health and Welfare and was performed by a multidisciplinary team consisting of three obstetricians, one midwife and one neonatologist. A combination of different protocols used internationally in similar projects was used [ 17 , 18 , 26 , 28 ]. The WHO’s “Making every baby count: audit and review of stillbirths and neonatal deaths” suggests that the audit of medical records may be a tool when trying to identify modifiable factors or avoidable patterns [ 29 ].…”

“…Using audits has been suggested as a way to map the circumstances surrounding a stillbirth. Previous studies suggest that the implementation of regional audits can improve the registration of stillbirths and causes of death, help identify the cases with suboptimal care and possibly help decrease the number of preventable stillbirths [17,18], even though more evidence for this in high-income settings is needed [19].…”

Assessing Implementation of Maternal and Perinatal Death Surveillance and Response in Rwanda

“…Findings from other settings suggested that for many cases of perinatal mortality the cause of death is never established [17,26,27], suggesting that perinatal death audits are probably not done. Also, a few high-income countries have an active national program of stillbirth audits [28]. Although facility-based deaths were easily identified, the findings showed that only a third of the health centers assessed and tracked deaths within the community, and yet the information was identified as key in avoiding preventable deaths [29][30][31].…”

Vigilância do óbito evitável: comparação entre fetal e neonatal precoce

“…A vigilância do óbito infantil fornece informações do perfil da mortalidade perinatal e das falhas na assistência, subsidiando o planejamento de ações que visem evitar a ocorrência de mortes preveníveis 11,12,18,19 .…”