Charles W Duke

Fetal death certificates (FDCs) are the main source of stillbirth surveillance data in the United States, yet previous studies suggest FDCs have incomplete ascertainment. In 2005, the Centers for Disease Control and Prevention (CDC) funded 2 pilot programs to determine the feasibility of expanding existing birth defects surveillance systems employing active casefinding methods to conduct surveillance of stillbirths. The objectives of this analysis were to: 1) estimate the completeness of ascertainment of stillbirths identified through one of the pilot programs, the Metropolitan Atlanta Congenital Defects Program (MACDP), and 2) compare the prevalence of stillbirths obtained through active casefinding (MACDP) with data available from FDCs. Stillbirths in metropolitan Atlanta were independently ascertained by both FDC and MACDP in 2006 and 2008. Capture-recapture methods were used to estimate the total number of stillbirths in the surveillance area. The sensitivities for capturing stillbirths were estimated for FDCs, MACDP, and both sources combined. Prevalence estimates for each data source and for the combined data sources were calculated using a denominator of live births plus FDC-identified stillbirths. An estimated 1,118 stillbirths occurred in metropolitan Atlanta. MACDP captured 863 and FDCs captured 862. There were 198 stillbirths captured by MACDP and not reported by FDC, and 197 stillbirths identified by FDCs that were not initially captured by MACDP. The estimated sensitivities were 77.1 percent, 77.2 percent, and 94.8 percent for FDCs, MACDP, and both sources combined, respectively. The stillbirth prevalences for 2006 and 2008 using FDC data alone were 8.2 and 7.4 per 1,000 live births plus stillbirths, respectively, and 9.9 and 9.3 per 1,000 live births plus stillbirths, respectively, using both data sources combined. Leveraging the resources of existing birth defects surveillance programs in combination with FDCs could improve population-based ascertainment of stillbirths.

Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care.

A carefully classified dataset of perinatal mortality will retain the most significant information on the causes of death. Such information is needed for health care policy development, surveillance and international comparisons, clinical services and research. For comparability purposes, we propose a classification system that could serve all these needs, and be applicable in both developing and developed countries. It is developed to adhere to basic concepts of underlying cause in the International Classification of Diseases (ICD), although gaps in ICD prevent classification of perinatal deaths solely on existing ICD codes.