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

Abstract

Background The annual rate of stillbirth in Sweden has remained largely unchanged for the past 30 years. In Sweden, there is no national audit system for stillbirths. The aim of the study was to determine if a regional multidisciplinary audit could help in identifying avoidable factors and delays associated with stillbirths. Methods Population-based retrospective cohort study. Settings: Six labour wards in Stockholm County. Participants: Women delivering a stillbirth > 22 weeks of gestation in Stockholm during 2017. Intervention: A multidisciplinary team was convened. Each team member independently assessed the medical chart of each case of stillbirth regarding causes and preventability, level of delay, the standard of healthcare provided, the investigation of maternal/foetal diseases and if any recommendations were given for the next pregnancy. A decision was based on the agreement of all five members. If no agreement was reached, a reassessment of the case was done and the medical record was scrutinized again until a mutual decision was made. Primary outcomes: The frequency of probably/possibly preventable factors associated with a stillbirth and the level of delay (patient/caregiver). Secondary outcomes: The causes of death, the standard of antenatal/intrapartum/postpartum care, whether a summary of possible causes of the stillbirth was made and if any plans for future pregnancies were noted. Results Thirty percent of the stillbirths were assessed as probably/possibly preventable. More frequent ultrasound/clinical check-ups, earlier induction of labour and earlier interventions in line with current guidelines were identified as possibly preventable factors. A possibly preventable stillbirth was more common among non-Swedish-speaking women (p = 0.03). In 15% of the cases, a delay by the healthcare system was identified. Having multiple caregivers, absence of continuity in terms of attending the antenatal clinic and not following the basic monitoring program for antenatal care were also identified as risk factors for a delay. Conclusion A national/regional multidisciplinary audit group retrospectively identified factors associated with stillbirth. Access to good translation services or a more innovative approach to the problem regarding communication with mothers could be an important factor to decrease possible patient delays contributing to stillbirths. Trial registration NCT04281368.

Determinants of stillbirth among reviewed perinatal deaths in Ethiopia

“…Besides, a positive dose-response relation was observed between a score of delay three and stillbirth outcomes. The finding was parallel with studies conducted in Nigeria ( 89 ), Jordan ( 90 ), Brazil ( 91 ), and Sweden ( 92 ). This might be explained by the level of health service providers' capacity of identifying and managing obstetrics emergencies.…”

Facility-based stillbirth review processes used in different countries across the world: a systematic review

“…For 29 out of 68 studies (43%), Government agencies (15 studies 3 , 14 , 17 , 18 , 24 , 25 , 30 , 32 , 34 , 35 , 36 , 38 , 39 , 72 , 75 ) or other funding bodies such as non-governmental organisations (9 studies 19 , 20 , 22 , 23 , 51 , 62 , 67 , 69 , 73 ), universities or professional associations (2 studies 26 , 47 ), and research grants (3 studies 10 , 11 , 77 ) were solely responsible for commissioning the review process. Fifteen studies 12 , 15 , 27 , 33 , 43 , 46 , 48 , 50 , 58 , 60 , 63 , 66 , 70 , 71 out of 68 received funding from two or more organisations (22%), but 24 out of the 68 studies (35%) received no funding or did not list any funding information for the stillbirth review process.…”

“…Routine data was used as at least one of the data sources to identify eligible stillbirths for review in 44 out of 68 included studies (65%). 10 , 11 , 12 , 16 , 19 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 38 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 50 , 52 , 55 , 57 , 59 , 61 , 62 , 63 , 64 , 65 , 67 , 69 , 71 , 72 , 73 , 74 , 75 , 77 Routine data included birth or death registry, hospital records, social care organisations' records, and obstetric records. Four studies (6%) used interviews with care providers as a supplementary source of data, in addition to routine records to identify stillbirths for review.…”

“…This means there was no interview or further additional information sought; 36 out of 68 studies (53%) used this method for data collection. 12 , 13 , 18 , 19 , 21 , 23 , 24 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 36 , 37 , 38 , 42 , 43 , 44 , 45 , 47 , 48 , 52 , 55 , 56 , 61 , 67 , 71 , 73 , 74 , 75 , 77 Twenty-six studies (38%) collected additional data for the purpose of the review 3 , 10 , 11 , 14 , 15 , 16 , 17 , 25 , 35 , 39 , 41 , 46 , 49 , 50 , 57 , 58 , 59 , 60 , 62 , 63 , 64 , 65 , 66 , 69 , 70 , 72 ; for example, by conducting interviews with mothers, health care providers, and family members, by requesting contextual background information about the facilities and mothers, and by carrying out additional tests (e.g. macroscopically examining placenta and cords) th...…”

“…Please see Supplementary material: Appendix 5 for the detailed review methods/tools used for each study. These included questions related to: reviewers being trained in the review process 18 , 24 , 50 ; data needed for the review being delivered to the reviewers prior to the review process to help with their preparation 12 , 18 , 36 , 61 , 52 ; structured forms or checklists to fill in during the review 3 , 17 , 18 , 24 , 37 , 49 , 50 , 51 , 52 , 53 , 66 , 67 , 68 , 69 , 71 , 73 versus discussion oriented process 64 ; no review meetings (chart review only) 22 , 26 , 29 , 41 , 46 , 49 , 69 , 73 versus two stage review process; individual judgement (case review) then a collective judgement after a panel discussion to reach a consensus 11 , 18 , 19 , 27 , 34 , 47 , 51 , 55 , 61 , 70 , 74 versus review meetings only 15 , 24 ; cause of death recorded using well-known classifications and/or selected contributory factors from a framework 14 , 15 , 16 , 17 , 18 , 19 , 21 , 24 ,…”