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Observational Study
. 2021 Mar 26;21(Suppl 1):226.
doi: 10.1186/s12884-020-03238-7.

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

Collaborators, Affiliations
Observational Study

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

Kimberly Peven et al. BMC Pregnancy Childbirth. .

Abstract

Background: An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording.

Methods: The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017-2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity, percent agreement). We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission.

Results: 23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was > 90%. The observed study stillbirth rate ranged from 3.8 (95%CI = 2.0,7.0) to 50.3 (95%CI = 43.6,58.0)/1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9-0.7). Specificity of register-recorded birth outcomes was > 99% and sensitivity varied between hospitals, ranging from 77.7-86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (> 98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use.

Conclusions: Our results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths.

Keywords: Birth; Health management information systems; Hospital records; Maternal; Neonatal; Stillbirth; Survey; Validity.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Stillbirth: validation design, EN-BIRTH study. EN-BIRTH validation design comparing observation gold standard with register-recorded and women’s report on exit survey; EN-BIRTH data collection tools (observation checklist, register data extraction tool and exit survey tool) are published separately [22]
Fig. 2
Fig. 2
Flow diagram for stillbirths, EN-BIRTH study (n = 23,072)
Fig. 3
Fig. 3
Stillbirth rates measured by observation and registers (95%CI), EN-BIRTH study (n = 23,072). *Random effects; Observed births n = 23,072; Register-recorded births n = 21,401; BD = Bangladesh, NP = Nepal, TZ = Tanzania
Fig. 4
Fig. 4
Routine register design and data quality dimensions for stillbirths by site, EN-BIRTH study. Observed births n = 23,072; Register-recorded births n = 21,401
Fig. 5
Fig. 5
Proportion of stillbirths misclassified as deaths, proportion of labour ward neonatal deaths misclassified as stillbirths. BD = Bangladesh, NP = Nepal, TZ = Tanzania
Fig. 6
Fig. 6
Percent distribution of stillbirths by birthweight (n = 482) and gestational age at admission (n = 550), EN-BIRTH study. From observation data; BD = Bangladesh, NP = Nepal, TZ = Tanzania
Fig. 7
Fig. 7
Register-recorded birth outcome for confirmed intrapartum stillbirths (n = 334), EN-BIRTH study. BD = Bangladesh, NP = Nepal, TZ = Tanzania
Fig. 8
Fig. 8
Gap analysis for coverage and measurement by birth outcome, EN-BIRTH study. Observed: live births (n = 22,464), fresh stillbirths (n = 230), macerated stillbirths (n = 277); Survey: live births (n = 20,050), fresh stillbirths (n = 157), macerated stillbirths (n = 200); BD = Bangladesh, NP = Nepal, TZ = Tanzania

References

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