Stillbirth outcome capture and classification in population-based surveys: EN-INDEPTH study

Abstract

Background Household surveys remain important sources of stillbirth data, but omission and misclassification are common. Classifying adverse pregnancy outcomes as stillbirths requires accurate reporting of vital status at birth and gestational age or birthweight for every pregnancy. Further categorisation, e.g. by sex, or timing (intrapartum/antepartum) improves data to understand and prevent stillbirth. Methods We undertook a cross-sectional population-based survey of women of reproductive age in five health and demographic surveillance system sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda (2017–2018). All women answered a full birth history with pregnancy loss questions (FBH+) or a full pregnancy history (FPH). A sub-sample across both groups were asked additional stillbirth questions. Questions were evaluated using descriptive measures. Using an interpretative paradigm and phenomenology methodology, focus group discussions with women exploring barriers to reporting birthweight for stillbirths were conducted. Thematic analysis was guided by an a priori codebook. Results Overall 69,176 women reported 98,483 livebirths (FBH+) and 102,873 pregnancies (FPH). Additional questions were asked for 1453 stillbirths, 1528 neonatal deaths and 12,620 surviving children born in the 5 years prior to the survey. Completeness was high (> 99%) for existing FBH+/FPH questions on signs of life at birth and gestational age (months). Discordant responses in signs of life at birth between different questions were common; nearly one-quarter classified as stillbirths on FBH+/FPH were reported born alive on additional questions. Availability of information on gestational age (weeks) (58.1%) and birthweight (13.2%) was low amongst stillbirths, and heaping was common. Most women (93.9%) were able to report the sex of their stillborn baby. Response completeness for stillbirth timing (18.3–95.1%) and estimated proportion intrapartum (15.6–90.0%) varied by question and site. Congenital malformations were reported in 3.1% stillbirths. Perceived value in weighing a stillborn baby varied and barriers to weighing at birth a nd knowing birthweight were common. Conclusions Improving stillbirth data in surveys will require investment in improving the measurement of vital status, gestational age and birthweight by healthcare providers, communication of these with women, and overcoming reporting barriers. Given the large burden and effect on families, improved data must be made available to end preventable stillbirths.

Neonatal and perinatal mortality in the urban continuum: a geospatial analysis of the household survey, satellite imagery and travel time data in Tanzania

“…Misclassification in household surveys has been reported in several studies. 10 35–37 That this pattern appears largely confined to urban areas in our study warrants further investigation. We would expect better differentiation between these outcomes in an urban setting where higher quality services and more skilled personnel are available.…”

“…A second issue for research to understand in the association between neonatal mortality and urbanicity is the potential misclassification between stillbirths and neonatal deaths due to challenges with establishing whether there were signs of life after birth. 10 The combination of omission of stillbirths, potential misclassification of birth outcomes (neonatal deaths and stillbirths), misclassification or oversimplification of urbanicity and residual confounding may mask the true direction and strength of the association between urbanicity and neonatal mortality.…”

Stillbirths including intrapartum timing: EN-BIRTH multi-country validation study

“…In our sample, 385 mothers of stillborn babies out of 412 approached for interview consented to participate. The Every Newborn-INDEPTH multi-country study similarly investigated survey-reported data on stillbirth, including the feasibility of capturing information on timing of stillbirth [13,53].…”

Neonatal and perinatal mortality in the urban continuum: A geospatial analysis of the household survey, satellite imagery and travel time data in Tanzania

“…The high degree of underreporting of stillbirths in the core urban area points to potential misclassification of stillbirths as neonatal deaths or general underreporting of stillbirths in these contexts. Misclassification in household surveys has been reported in several studies 13 47-49 and is related to factors such as how well vital status is assessed at birth and birth attendant’s ability to distinguish stillbirths from early neonatal deaths, socio-cultural perceptions of pregnancy loss that might affect disclosure, or intentional misclassification or underreporting to avoid blame or additional investigation depending on requirements in the context. That this pattern appears confined only to urban areas in our study warrants further investigation.…”

“…In addition to the misclassification of urban areas, the outcome - neonatal mortality - may also be subject to misclassification with stillbirth due to challenges with establishing whether there were signs of life after birth. 13 To date, the DHS data does not include full data on stillbirths. Instead, pregnancy history is collected in the contraceptive calendar, and perinatal mortality (i.e., stillbirths and neonatal deaths) can be assessed.…”