The burden of and factors associated with misclassification of intrapartum stillbirth: Evidence from a large scale multicentric observational study

Abstract

Introduction Global estimates suggest 2.6 million stillbirths and 2.5 million neonatal deaths occur annually worldwide. The majority of these deaths occur in low resource settings where analysis of health metrics and outcomes measurements may be challenging. We examined the misclassification of documented intrapartum stillbirth and factors associated with misclassification. Material and methods A prospective observational study was performed in 12 public hospitals in Nepal. Data were extracted from the medical records of all births that occurred during the 6‐month period of the study. For the study purpose, we classified birth outcome based on the presence of fetal heart sound (FHS) at admission and use of neonatal resuscitation. The health worker‐documented intrapartum stillbirths were considered potentially misclassified when there were FHS present at admission and no resuscitation initiated after birth. The association between potentially misclassified intrapartum stillbirth and complications during labor, birthweight and gestational age was assessed using Pearson’s chi‐square test, bivariate and multivariate logistic regression. Results A total of 39 562 mother‐infant dyads were enrolled in the study, all of whom had FHS at admission. Among the 391 intrapartum stillbirths recorded during the study, 180 (46.0%) of them had FHS at admission with no resuscitation initiated after birth and were considered potentially misclassified intrapartum stillbirths. Among these potentially misclassified intrapartum stillbirths, 170 (43.5%) had FHS present 15 minutes before birth and 10 had no FHS 15 minutes before birth Among the potentially misclassified intrapartum stillbirths, 23.3% had complications during labor, 93.3% had birthweight less than 2500 g and 90.0% were born preterm. The risk of intrapartum misclassification was nearly four times higher among low birthweight babies (adjusted odds ratio [aOR] 3.5, 95% confidence interval [CI] 1.8 to 7.0, P < 0.001) and five times higher among preterm babies (aOR 5.3, 95% CI 3.0 to 9.3, P < 0.001). Conclusions We estimate that 46% of intrapartum stillbirths were potentially misclassified intrapartum stillbirths. Improving quality of both FHS monitoring and neonatal resuscitation as well as measurement of the care will reduce the risk of potentially misclassified intrapartum stillbirth and consequently intrapartum stillbirth.

Improved obstetric management after implementation of a scaled‐up quality improvement intervention: A nested before‐after study in three public hospitals in Nepal

“…Although the NePeriQIP intervention mainly focused on high‐quality neonatal resuscitation of nonbreathing newborns 27,28,32,33 and not obstetric management, our study demonstrates that many aspects of obstetric management improved. In line with an intervention study involving assessment, feedback, and training of doctors and program managers in 44 public health facilities in India that reported improved intrapartum fetal surveillance from 9% before the intervention to 48% at the end of the intervention, 26 our most consistent and prominent finding is the improvement in FHRM.…”

The burden of misclassification of antepartum stillbirth in Nepal

“…Our Nepal study from the same cohort has found that more than 45% of the intrapartum stillbirth were potentially misclassified who would have been a liveborn if resuscitated at birth 28…”

Provider-mother interactions are associated with birth outcome misclassifications in household surveys: A case-control study in Guinea-Bissau

“…In addition, accidental or purposive clinical misclassification, e.g. due to poor training, high workload, lack of equipment, and avoidance of blame or extra work [ 9 , 22 , 25 , 34 , 35 ], may have modified our results. Related differences as well as differences in the socio-cultural importance assigned to the distinction between stillbirths and neonatal deaths across settings may also compromise the transferability of findings.…”