60
views
0
recommends
+1 Recommend
0 collections
    0
    shares
      • Record: found
      • Abstract: found
      • Article: found
      Is Open Access

      An evaluation of classification systems for stillbirth

      research-article

      Read this article at

      Bookmark
          There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

          Abstract

          Background

          Audit and classification of stillbirths is an essential part of clinical practice and a crucial step towards stillbirth prevention. Due to the limitations of the ICD system and lack of an international approach to an acceptable solution, numerous disparate classification systems have emerged. We assessed the performance of six contemporary systems to inform the development of an internationally accepted approach.

          Methods

          We evaluated the following systems: Amended Aberdeen, Extended Wigglesworth; PSANZ-PDC, ReCoDe, Tulip and CODAC. Nine teams from 7 countries applied the classification systems to cohorts of stillbirths from their regions using 857 stillbirth cases. The main outcome measures were: the ability to retain the important information about the death using the InfoKeep rating; the ease of use according to the Ease rating (both measures used a five-point scale with a score <2 considered unsatisfactory); inter-observer agreement and the proportion of unexplained stillbirths. A randomly selected subset of 100 stillbirths was used to assess inter-observer agreement.

          Results

          InfoKeep scores were significantly different across the classifications ( p ≤ 0.01) due to low scores for Wigglesworth and Aberdeen. CODAC received the highest mean (SD) score of 3.40 (0.73) followed by PSANZ-PDC, ReCoDe and Tulip [2.77 (1.00), 2.36 (1.21), 1.92 (1.24) respectively]. Wigglesworth and Aberdeen resulted in a high proportion of unexplained stillbirths and CODAC and Tulip the lowest. While Ease scores were different ( p ≤ 0.01), all systems received satisfactory scores; CODAC received the highest score. Aberdeen and Wigglesworth showed poor agreement with kappas of 0.35 and 0.25 respectively. Tulip performed best with a kappa of 0.74. The remainder had good to fair agreement.

          Conclusion

          The Extended Wigglesworth and Amended Aberdeen systems cannot be recommended for classification of stillbirths. Overall, CODAC performed best with PSANZ-PDC and ReCoDe performing well. Tulip was shown to have the best agreement and a low proportion of unexplained stillbirths. The virtues of these systems need to be considered in the development of an international solution to classification of stillbirths. Further studies are required on the performance of classification systems in the context of developing countries. Suboptimal agreement highlights the importance of instituting measures to ensure consistency for any classification system.

          Related collections

          Most cited references61

          • Record: found
          • Abstract: found
          • Article: not found

          Classification of stillbirth by relevant condition at death (ReCoDe): population based cohort study.

          To develop and test a new classification system for stillbirths to help improve understanding of the main causes and conditions associated with fetal death. Population based cohort study. West Midlands region. 2625 stillbirths from 1997 to 2003. Categories of death according to conventional classification methods and a newly developed system (ReCoDe, relevant condition at death). By the conventional Wigglesworth classification, 66.2% of the stillbirths (1738 of 2625) were unexplained. The median gestational age of the unexplained group was 237 days, significantly higher than the stillbirths in the other categories (210 days; P < 0.001). The proportion of stillbirths that were unexplained was high regardless of whether a postmortem examination had been carried out or not (67% and 65%; P = 0.3). By the ReCoDe classification, the most common condition was fetal growth restriction (43.0%), and only 15.2% of stillbirths remained unexplained. ReCoDe identified 57.7% of the Wigglesworth unexplained stillbirths as growth restricted. The size of the category for intrapartum asphyxia was reduced from 11.7% (Wigglesworth) to 3.4% (ReCoDe). The new ReCoDe classification system reduces the predominance of stillbirths currently categorised as unexplained. Fetal growth restriction is a common antecedent of stillbirth, but its high prevalence is hidden by current classification systems. This finding has profound implications for maternity services, and raises the question whether some hitherto "unexplained" stillbirths may be avoidable.
            Bookmark
            • Record: found
            • Abstract: found
            • Article: not found

            Stillbirth.

            In the UK, about one in 200 infants is stillborn, and rates of stillbirth have recently slightly increased. This recent rise might reflect increasing frequency of some important maternal risk factors for stillbirth, including nulliparity, advanced age, and obesity. Most stillbirths are related to placental dysfunction, which in many women is evident from the first half of pregnancy and is associated with fetal growth restriction. There is no effective screening test that has clearly shown a reduction in stillbirth rates in the general population. However, assessments of novel screening methods have generally failed to distinguish between effective identification of high-risk women and successful intervention for such women. Future research into stillbirth will probably focus on understanding the pathophysiology of impaired placentation to establish screening tests for stillbirth, and assessment of interventions to prevent stillbirth in women who screen positive.
              Bookmark
              • Record: found
              • Abstract: found
              • Article: not found

              Maternal mortality, stillbirth and measures of obstetric care in developing and developed countries.

              Maternal mortality and stillbirths are important adverse pregnancy outcomes, especially in developing countries. Because underlying causes of both outcomes appeared similar, the relationship between maternal mortality, stillbirth and three measures of obstetrical care were studied. Using data provided by the World Health Organization from 188 developed and developing countries, correlations and linear regression analyses between maternal mortality and stillbirth rates and cesarean section rates, skilled delivery attendance, and >or=4 prenatal visits) were developed. Stillbirth and maternal mortality rates were strongly correlated, with about 5 stillbirths for each maternal death. However, the ratio increased from about 2 to 1 in least developed countries to 50 to 1 in the most developed countries. In developing countries, as the cesarean section rates increased from 0 to about 10%, both maternal mortality and stillbirth rates decreased sharply. Skilled delivery attendance was not associated with significant reductions in maternal mortality or stillbirth rates until coverage rates of about 40% were achieved. Four or more antenatal visits were not associated with significant reductions in maternal deaths until about 60% coverage was achieved. The same measure was associated with only modest decreases in stillbirth. Across countries, stillbirth was significantly associated with maternal mortality. Both stillbirth and maternal mortality were similarly related to all three measures of obstetric care. An increase in cesarean section rates from 0 to 10% was associated with sharp decreases in both maternal mortality and stillbirths.
                Bookmark

                Author and article information

                Journal
                BMC Pregnancy Childbirth
                BMC Pregnancy and Childbirth
                BioMed Central
                1471-2393
                2009
                19 June 2009
                : 9
                : 24
                Affiliations
                [1 ]Mater Mothers' Research Centre, Mater Health Services, Brisbane, Australia
                [2 ]Department of Obstetrics and Gynecology, University of Queensland, Brisbane, Australia
                [3 ]Department of Genes and Environment, Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
                [4 ]Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA
                [5 ]Department of Pathology and Laboratory Medicine, Brown University Medical School, Providence, RI, USA
                [6 ]Department of Midwifery, Faculty of Nursing Education, Arkeshus University College, Lillestrøm, Norway
                [7 ]Alberta Perinatal Health Program, Edmonton, Canada
                [8 ]Division of Anatomical Pathology, Department of Laboratory Medicine & Pathology, University of Alberta Hospitals, University of Alberta, Edmonton, Canada
                [9 ]Department of Paediatric and Perinatal Pathology, King Edward Memorial Hospital, Perth, Australia
                [10 ]Department of Obstetrics and Gynaecology, University of Pretoria School of Medecine, Pretoria, South Africa
                [11 ]Division of Family Health Development, Ministry of Health Malaysia, Putrajaya, Malaysia
                [12 ]Department of Obstetrics, Karolinska University Hospital, Stockholm, Sweden
                [13 ]Department of Neonatal Medicine, Royal Prince Alfred Hospital, Sydney, Australia
                Article
                1471-2393-9-24
                10.1186/1471-2393-9-24
                2706223
                19538759
                00973eff-381c-4b7d-8265-f24258972cc1
                Copyright © 2009 Flenady et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 26 August 2008
                : 19 June 2009
                Categories
                Research Article

                Obstetrics & Gynecology
                Obstetrics & Gynecology

                Comments

                Comment on this article