Worth the paper it's written on? A cross-sectional study of Medical Certificate of Stillbirth accuracy in the UK

Abstract

Background: The Medical Certificate of Stillbirth (MCS) records data about a baby's death after 24 weeks of gestation but before birth. Major errors that could alter interpretation of the MCS were widespread in two UK-based regional studies.

Methods: A multicentre evaluation was conducted, examining MCS issued 1 January 2018 to 31 December 2018 in 76 UK obstetric units. A systematic case-note review of stillbirths was conducted by Obstetric and Gynaecology trainees, generating individual 'ideal MCSs' and comparing these to the actual MCS issued. Anonymized central data analysis described rates and types of error, agreement and factors associated with major errors.

Results: There were 1120 MCSs suitable for assessment, with 126 additional submitted data sets unsuitable for accuracy analysis (total 1246 cases). Gestational age demonstrated 'substantial' agreement [K = 0.73 (95% CI 0.70-0.76)]. Primary cause of death (COD) showed 'fair' agreement [K = 0.26 (95% CI 0.24-0.29)]. Major errors [696/1120; 62.1% (95% CI 59.3-64.9%)] included certificates issued for fetal demise at <24 weeks' gestation [23/696; 3.3% (95% CI 2.2-4.9%)] or neonatal death [2/696; 0.3% (95% CI 0.1-1.1%)] or incorrect primary COD [667/696; 95.8% (95% CI 94.1-97.1%)]. Of 540/1246 [43.3% (95% CI 40.6-46.1%)] 'unexplained' stillbirths, only 119/540 [22.0% (95% CI 18.8-25.7%)] remained unexplained; the majority were redesignated as either fetal growth restriction [FGR: 195/540; 36.1% (95% CI 32.2-40.3%)] or placental insufficiency [184/540; 34.1% (95% CI 30.2-38.2)]. Overall, FGR [306/1246; 24.6% (95% CI 22.3-27.0%)] was the leading primary COD after review, yet only 53/306 [17.3% (95% CI 13.5-22.1%)] FGR cases were originally attributed correctly.

Conclusion: This study demonstrates widespread major errors in MCS completion across the UK. MCS should only be completed following structured case-note review, with particular attention on the fetal growth trajectory.

Keywords: Stillbirth; accuracy; cause of death; death certification; fetal growth restriction; perinatal death; placental insufficiency; stillbirth certification.

Figure 1

Typical timeline for reporting post-mortem investigation results in the UK. Reporting timeline based on full uptake of all recommended investigations, including autopsy, and average reporting times; days since delivery are shown along the bottom with territory-specific legal registration deadlines in brackets [Northern Ireland deadline for registration (365 days) not pictured in displayed timeline]. In practice, legal registration of stillbirth must be complete before burial or cremation; therefore, it is commonly completed within a week of delivery (indicated by bold arrow). The National Health Service aims to report 60% of autopsy investigations within 42 days of examination and 90% within 56 days, longer where specialist opinions are required. Accounting for processing time and delays, many autopsy examinations can take up to 12 weeks for reporting; placental histopathology without autopsy is often reported by 6 weeks post-delivery. Similar timescales are anticipated in other international healthcare settings. In practice the true time from death to delivery is unknown and may, particularly in cases of co-twin demise, take several weeks. However, diagnosis-to-delivery intervals of >1 week are unusual in singleton pregnancies. * indicates investigations that are not always indicated. Autopsy consent is optional (^$) and not required under Coronial jurisdiction in the UK.

Figure 2

Flow of cases through the study. Cases were assessed against study inclusion and exclusion criteria [all births where a Medical Certificate of Stillbirth (MCS) was issued or should have been issued including cases where an MCS was issued in error including death prior to 24 weeks’ gestation or neonatal deaths]. Cases were included/not included according to whether at least some/no accuracy data were reported. FDIU, fetal death in utero; MCS, Medical Certificate of Stillbirth (the document issued by registered medical or midwifery practitioners to the parents of a stillborn infant for the purposes of legally registering the stillbirth); NND, neonatal death (death after being born with signs of life, even if not capable of supporting life).

Figure 3

Incidence and grade of error categories in Medical Certificates of Stillbirth (N = 1120). Of all Medical Certificates of Stillbirth (MCSs) that could be assessed for accuracy, 79.8% contained at least one error; 29.6% of MCSs contained compound errors. Major errors (defined as those that would materially affect the interpretation of the certificate by the family, healthcare professionals and healthcare statisticians) were present in 62.2% of MCSs. These comprised (i) MCS issued pertaining to an infant proven to have demised prior to 24 completed weeks' gestation or an infant born with signs of life (regardless of gestation or whether capable of sustaining life), (ii) incorrect primary cause of death on MCS. Minor errors (defined as errors without significant impact on interpretation of the MCS) occurred in 47.3% of MCSs. These comprised inaccuracies in documented (i) sex, (ii) date of delivery, (iii) gestational age (falling short of major error), (iv) birthweight or (v) timing in relation to the onset of labour. Data are presented as numbers and expressed as a percentage (with 95% CI) of the proportion of cases where accuracy could be assessed. Certificates containing errors are subdivided in the right-hand bar according to error category.