Causes of death in stillbirth and quality of care—an example of a local audit

Abstract

Abstract Introduction Neonatal deaths have decreased steadily in Sweden since the 1960s, but the stillbirth rate has been stable at around 4 per 1000 births, for the last 40 years. Risk factors of stillbirth are well studied; however, the cause of death is unclear in many cases. The purpose of this study was to examine causes of death in stillbirth using a classification system. In addition, we aimed to assess substandard care factors and identify areas for quality improvement. Materials and Methods We performed a retrospective clinical audit of all stillbirths delivered between January 2006 and December 2019. We performed a detailed investigation of medical records and classified the causes of death according to ‘The Stockholm classification of stillbirth’. Unclear cases were discussed in a multidisciplinary local audit group. Substandard care factors were identified and classified as probable, possible, or unlikely, with respect to the cause of death. Results In total, there were 64 cases of stillbirth. It was possible to determine a cause of death in 91% (95% confidence interval [CI]: 81.02–95.63) of the cases. The leading cause of death was intrauterine growth restriction (IUGR)/placental insufficiency (45%) (95% CI: 33.73–57.43), followed by infection (13%) (95% CI: 6.47–22.8) and placental abruption (9%) (95% CI: 4.37–18.98). Factors of substandard care were identified in 49% (95% CI: 37.06–61.4) of the cases, but in only 10% the substandard care factor had a probable association with the cause of death. Conclusion Introducing a local audit group and using a validated classification system made it possible to find a cause of death in about 90% of the cases of stillbirth. Since IUGR/placental insufficiency is the leading cause of death, it is important to improve current strategies to identify pregnancies at risk for IUGR, antenatally. Our results suggest that there is a possibility to improve the quality of care in many areas, particularly regarding symphysis‐fundus measurements. Tweetable Abstract A validated classification system and local audits are valuable tools to determine the causes of IUFD. This enables directed preventive actions toward IUFD.

Keywords

• causes of death
• classification
• clinical audit
• foetal death
• stillbirth
• substandard care