Stillbirth in Canada: anachronistic definition and registration processes impede public health surveillance and clinical care

Abstract

The archaic definition and registration processes for stillbirth currently prevalent in Canada impede both clinical care and public health. The situation is fraught because of definitional problems related to the inclusion of induced abortions at ≥20 weeks’ gestation as stillbirths: widespread uptake of prenatal diagnosis and induced abortion for serious congenital anomalies has resulted in an artefactual temporal increase in stillbirth rates in Canada and placed the country in an unfavourable position in international (stillbirth) rankings. Other problems with the Canadian stillbirth definition and registration processes extend to the inclusion of fetal reductions (for multi-fetal pregnancy) as stillbirths, and the use of inconsistent viability criteria for reporting stillbirth. This paper reviews the history of stillbirth registration in Canada, provides a rationale for updating the definition of fetal death and recommends a new definition and improved processes for fetal death registration. The recommendations proposed are intended to serve as a starting point for reformulating issues related to stillbirth, with the hope that building a consensus regarding a definition and registration procedures will facilitate clinical care and public health.

Pregnancy Outcomes During the COVID-19 Pandemic in Canada, March to August 2020

“…Late pregnancy terminations were not included in the study. However, the inclusion of such induced abortions in stillbirth counts is an anachronism 28 and the numbers of spontaneous stillbirths in our study appear to be accurate. The stillbirth rate at ≥28 weeks' gestation in our study (3.1 per 1000 total births, Table 3) is consistent with previous publications 29,30 which have reported a stillbirth rate of 3.0 per 1000 for stillbirths ≥28 weeks' or ≥1000 g for Canada (excluding Quebec), 2013-17.…”

Analgesic Efficacy of Paracervical Block for Manual Vacuum Aspiration of Incomplete Abortions: A Randomized Controlled Trial

“…The use of misoprostol to prime the cervix in those studies, is a factor which is usually associated with lower abdominal pain and could have aggravated the pains in addition, the studies described above were induced abortions in which the cervix is closed, it is necessary to dilate the cervix through mechanical procedures; this is the most painful part of the procedure [10] [19] unlike the focus of this present study (incomplete abortions), with open cervix and does not require dilation, also the technique of paracervical block injections of two sites and 10mls of lidocaine used in those studies is totally different from this study in which 20mls of lignocaine concentration was used and injected into four sites. The above explanation also probably explain that of the outcome of Gomez et al which revealed no statistically significant differences between the pain reported by the patient nor in the degree of pain evaluated by the observer, even though a greater percentage of patients in group 2 (placebo group) was said to have experienced severe pain, both in the external observer's evaluation and in the patient's own evaluation and of course, it further explains, the Cochrane review performed in 2013 that identified no clear evidence of superiority or inferiority using paracervical blocks over other methods for pain control during procedures involving cervical dilation and uterine instrumentation [5]. But this review was not specifically directed toward the use of paracervical blocks during surgical abortions, let alone incomplete abortions, it therefore does not provide a strong basis to compare this finding with the target population of the current study.…”

“…The cervix is dilated and the products of conception may be protruding through the cervical os [2] [4] [10]. Pregnancy test and ultrasonography are helpful in making diagnosis, especially in the very early gestational age as they distinguish it from other causes of abnormal uterine bleeding [5].…”

“…Pain control during gynecologic procedures including first trimester surgical abortion, especially mva for incomplete abortion is particularly a significant issue for women [5]. An effective pain control must be able to block or prevent transmission of sensation from the parasympathetic fibers of s2 to s4 which innervate the cervix and the lower uterine segment and sympathetic fibers from t10 to l1 which innervate the uterine fundus [6] [7] [8] [9].…”

“…While a variety of options are available for analgesia, evidence elucidating the efficacy of these options is limited. Currently, selection of analgesia for first trimester surgical abortion is primarily guided by literature on other gynecological procedures involving dilation of the cervix in conscious patients [5] while these studies provide useful insight, the issue of pain control during abortion is complicated not only by the psychosocial aspects of pain (especially if the pregnancy is wanted), but also by the context of a procedure so deeply stigmatized as abortion. Unfortunately, guidelines for appropriate pain management during treatment of incomplete abortions are few, not usually very clear and not even available in most of our centres.…”