Re‐conceptualising stillbirth and revisiting birth surveillance

The increased focus on stillbirth-related issues in recent years has brought several previously neglected issues 'out of the shadows'1 and highlighted the need for greater preventive efforts and better care for bereaved mothers and families. Some issues (such as the option of caesarean delivery for fetal death at late gestation,2 viewing the fetus following pregnancy termination for a fetal anomaly3, 4 and acknowledgement of paternal grief and anxiety5) reflect a substantial shift from previous traditions in clinical practice. At a conceptual level as well, there are challenges that may lead to a break with tradition. These include definitional aspects related to fetal death and stillbirth, and considerations related to the surveillance of pregnancy outcomes. Is fetal death or (still)birth following fetal demise the central event of medical concern? Should fetal deaths due to iatrogenic pregnancy termination be excluded from the definition of fetal death? What viability criteria should be used to distinguish between early pregnancy loss and fetal death at later gestation? Should surveillance of pregnancy outcomes be restricted to viable fetuses or should surveillance be more comprehensive? Do fetal deaths resulting from iatrogenic pregnancy termination constitute private events to be recorded in medical charts or do they require registration and publicly accessible documentation? In this commentary, we briefly review such concerns,6, 7 with the hope of initiating an international discussion and consensus. In 1950, the World Health Organization (WHO), in its International Statistical Classification of Diseases and Related Health Problems (ICD), proposed the now widely used definition of fetal death. Fetal death is death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles.8 Whereas the decades-long survival of this definition is a testament to its careful formulation, the requirement for absent vital signs at birth for inferring fetal death in utero has become superfluous given the current status of imaging and related technology. Typically, fetal death and stillbirth are distinct events, temporally separated by hours or days. In the case of fetal reduction or the spontaneous death of one fetus in a multi-fetal pregnancy, the time that elapses between fetal death and stillbirth can extend to several months. Although both fetal death and stillbirth represent devastating events for mothers and families, fetal death is the seminal event from an aetiological and prognostic perspective. Clearly, there is a medical rationale for public health surveillance shifting focus from stillbirth to fetal death. Whereas the clinical care and imaging technology required for ascertaining the gestational age at fetal death may not be available to women in some less industrialised countries and even to some women in industrialised countries, this does not justify the narrow focus on stillbirth alone. Birth registration requirements should include collection of information on both the gestational age at stillbirth and the best estimate of gestational age at fetal death. In the absence of clinical, imaging or other information on the timing of fetal death, the gestational age at stillbirth should be used as the best estimate of the gestational age at fetal death. Although the WHO definition of fetal death is widely accepted, several countries exclude iatrogenic pregnancy termination from their counts of fetal death. In fact, countries such as the USA have retained the WHO fetal death definition, while adding a clause that specifically excludes fetal deaths due to iatrogenic pregnancy termination.9, 10 Despite the semantic arbitrariness of such an exclusion (arbitrary, as such pregnancy terminations do cause fetal death), the separate categorisation of spontaneous fetal death and fetal death due to iatrogenic pregnancy termination serves an important surveillance purpose. Combining these two subtypes of fetal death can obfuscate frequency patterns and prevention strategies. Temporal trends in stillbirth rates in Canada (which does not distinguish between spontaneous stillbirths and stillbirths due to iatrogenic pregnancy terminations in its vital records), show a steadily increasing rate in recent years, due to increases in late pregnancy termination following prenatal diagnosis of a serious congenital anomaly.11 Yet another widespread deviation from WHO recommendations relates to viability criteria for the reporting of fetal deaths. Although the definition of fetal death does not include any birthweight or gestational age criteria, WHO recommends reporting of all fetal deaths with a birthweight of at least 500 g. This singular criterion is supplemented by alternative cut-offs (namely, 22 completed weeks' gestation or 25 cm crown-heel length) to be used in instances where birthweight is not available. Unfortunately, current reporting of stillbirth statistics internationally remains unstandardised with large variations in reporting criteria (e.g. ≥400 g birthweight or ≥20 weeks' gestation in Australia, ≥20 weeks or ≥500 g in Canada, and ≥24 weeks' gestation in the UK). Equally problematic is the use of dual criteria (as opposed to the singular birthweight criterion proposed by the WHO). Dual criteria such as ≥400 g birthweight or ≥20 weeks' gestation reveal a lack of conceptual clarity because the first criterion restricts reporting to stillbirths at ≥400 g birthweight, whereas the second criterion requires the registration of stillbirths with a birthweight of <400 g at 20–24 weeks' gestation. The lack of concordance between the birthweight and gestational age criteria used in countries such as Canada (≥20 weeks' gestation or ≥500 g) compounds this problem. Although a standard viability criterion for reporting stillbirth rates is a prerequisite for preventive benchmarking and meaningful international comparisons, proposing a specific gestational age criterion for reporting fetal death will require appreciation of the steadily falling threshold of viability and an international consensus. Gestational age (or birthweight) cut-offs for the registration of fetal deaths are closely related to viability criteria for national reporting of fetal deaths. Surveillance principles suggest that complete reporting of pregnancy outcomes at and beyond any specific gestational age threshold requires registration of events at a lower threshold. Thus, if the goal is complete reporting of spontaneous fetal deaths at ≥20 weeks' gestation, registration requirements should specify 16 or 18 weeks' gestation as the cut-off for fetal death registration. Norway, which requires registration of all pregnancy outcomes ≥16 weeks' gestation, offers a paradigm worthy of consideration (some US states, where all products of conception require registration, represent a more extreme requirement). Acknowledgement of the significance of fetal loss and stillbirth to mothers and families should extend to include recognition of privacy issues. Some sociologists and anthropologists have argued that vital statistics related to fetal death have been used to medicalise pregnancy and as a means for the social surveillance of women's bodies.12 Whereas this contention is debatable, it is not difficult to see how requirements for registration that create a publicly accessible record of fetal deaths due to iatrogenic pregnancy termination, disregard the privacy of women who have had a pregnancy termination. This is especially consequential, as commercial enterprises increasingly access vital records for creating family trees and ancestral lineages. In conclusion, conceptual and definitional rigour is needed to identify and accurately define the issues of concerns with regard to fetal death and stillbirth. The current definition of fetal death, first proposed more than 50 years ago, needs to be updated in the light of improvements in diagnosis, and increasing survival at early gestation calls for a reconsideration of viability criteria for reporting preventable fetal death. Public health surveillance and prevention are best served if the registration and reporting of fetal death make a clear distinction between spontaneous fetal death and iatrogenic pregnancy termination. Accurate reporting of fetal death requires careful consideration of the cut-off for registration of fetal deaths in order to ensure complete ascertainment of all reportable events. Finally, there is a need to review requirements for the registration of fetal deaths following iatrogenic pregnancy termination in order to respect the privacy rights of women. Although these questions are likely to generate debate and discussion, both within the medical and lay communities, they involve fundamental issues that need to be standardised if there is to be international progress in understanding issues related to fetal death. The movement to bring stillbirth out of the shadows provides an opportunity to simultaneously address conceptual, clinical care, surveillance and prevention issues with regard to fetal death and stillbirth. KSJ's work is supported by the Canadian Institutes of Health Research (APR126338). None declared. Completed disclosure of interests form available to view online as supporting information. KSJ, MB, CD and LL discussed the issues presented in the Commentary. KSJ wrote the draft manuscript and all authors contributed to its revision. The final manuscript has been approved by all authors. Not applicable. No funding. 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