Care Around Stillbirth and Neonatal Death (CASaND) Clinical Practice Guideline

Section 7 references

  1. Sexton, J.K., et al., Prospective cohort study: Causes of stillbirth in Australia 2013–2018. Australian & New Zealand Journal of Obstetrics & Gynaecology, 2021. 61(5): p. 667-674 doi: 10.1111/ajo.13334.
  2. World Health Organization. Making every baby count: Audit and review of stillbirths and neonatal deaths. 2016; Available from: https://www.who.int/publications/i/item/9789241511223.
  3. Gondwe, M.J., et al., Approaches, enablers, barriers and outcomes of implementing facility-based stillbirth and neonatal death audit in LMICs: A systematic review. BMJ Open Quality, 2021. 10(1): p. e001266 doi: 10.1136/bmjoq-2020-001266.
  4. Gutman, A., et al., Perinatal mortality audits and reporting of perinatal deaths: Systematic review of outcomes and barriers. Journal of Perinatal Medicine, 2022. 50(6): p. 684–712 doi: 10.1515/jpm-2021-0363.
  5. Sauvegrain, P., et al., Understanding high rates of stillbirth and neonatal death in a disadvantaged, high-migrant district in France: A perinatal audit. Acta Obstetricia et Gynecologica Scandinavica, 2020. 99(9): p. 1163-1173 doi: 10.1111/aogs.13838.
  6. D’Aloja, P., et al., A nationwide surveillance system to reduce perinatal death cases in Italy: Implementing a population-based pilot project. Epidemiologia & Prevenzione, 2021. 45(5): p. 343–352 doi: 10.19191/ep21.5.A002.097.
  7. Po, G., et al., A regional audit system for stillbirth: A way to better understand the phenomenon. BMC Pregnancy & Childbirth, 2019. 19(1) doi: 10.1186/s12884-019-2432-2.
  8. Flenady, V., et al., Making every birth count: Outcomes of a perinatal mortality audit program. Australian & New Zealand Journal of Obstetrics & Gynaecology, 2021. 61(4): p. 540–547 doi: 10.1111/ajo.13325.
  9. Helps, Ä., et al., National perinatal mortality audits and resultant initiatives in four countries. European Journal of Obstetrics & Gynecology & Reproductive Biology, 2021. 267: p. 111-119 doi: 10.1016/j.ejogrb.2021.10.012.
  10. Tomlinson, A.J., et al., Improved management of stillbirth using a care pathway. International Journal of Health Governance, 2018. 23(1): p. 18-37 doi: 10.1108/IJHG-09-2017-0045.
  11. Lehner, C., et al., The feasibility of a clinical audit tool to investigate stillbirth in Australia – a single centre experience. Australian & New Zealand Journal of Obstetrics & Gynaecology, 2019. 59(1): p. 59-65 doi: 10.1111/ajo.12799.
  12. Vallely, L.M., et al., Perinatal death audit and classification of stillbirths in two provinces in Papua New Guinea: A retrospective analysis. International Journal of Gynecology and Obstetrics, 2021. 153(1): p. 160–168 doi: 10.1002/ijgo.13431.
  13. Vallely, L.M., et al., Early neonatal death review from two provinces in Papua New Guinea: A retrospective analysis. Journal of Paediatrics and Child Health, 2021. 57(6): p. 841–846 doi: 10.1111/jpc.15333.
  14. Perinatal and Maternal Mortality Review Committee. Fifteenth annual report of the Perinatal and Maternal Mortality review Committee. Te Pūrongo ā-Tau Tekau mā mā Rima o te Komiti Arotake Mate Pēpi, Mate Whaea Hoki: Reporting Mortality and Morbidity 2020. Te Tuku Pūrongo mō te Mate me te Whakamate 2020. 2022; Available from: https://www.hqsc.govt.nz/assets/Our-work/Mortality-review-committee/PMMRC/Publications-resources/15thPMMRC-report-final.pdf
  15. Draper ES, et al. MBRRACE-UK perinatal mortality surveillance report, UK perinatal deaths for births from January to December 2020. 2020; Available from: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/perinatal-surveillance-report-2020/MBRRACE-UK_Perinatal_Surveillance_Report_2020.pdf
  16. Eskes, M., et al., Term perinatal mortality audit in the Netherlands 2010–2012: A population-based cohort study. BMJ Open, 2014. 4(10): p. e005652 doi: 10.1136/bmjopen-2014-005652.
  17. San Lazaro Campillo I, et al. Perinatal mortality national clinical audit in Ireland annual report 2020. 2022; Available from: https://www.ucc.ie/en/media/research/nationalperinatalepidemiologycentre/NPECPerinatalMortalityinIrelandannualreport2020.pdf.
  18. Perinatal and Maternal Mortality Review Committee. Fourteenth annual report of the Perinatal and Maternal Mortality Review Committee. 2021; Available from: www.hqsc.govt.nz/our-programmes/mrc/pmmrc.
  19. Queensland Maternal and Perinatal Quality Council. Queensland mothers and babies 2018–2019. 2021; Available from: https://clinicalexcellence.qld.gov.au/priority-areas/safety-and-quality/queensland-maternal-and-perinatal-quality-council.
  20. Centre for Epidemiology and Evidence. New South Wales mothers and babies 2020. 2021; Available from: https://www.health.nsw.gov.au/hsnsw/Publications/mothers-and-babies-2020.pdf
  21. Consultative Council on Obstetric and Paediatric Mortality and Morbidity. Victoria’s mothers, babies and children 2020. 2022; Available from: https://www.safercare.vic.gov.au/publications/victorias-mothers-babies-and-children-2020-report-and-presentations
  22. Fathima P, et al. The 16th report of the Perinatal and Infant Mortality Committee of Western Australia, 2014–2018. 2022; Available from: https://www.health.wa.gov.au/~/media/Corp/Documents/Reports-and-publications/Perinatal-infant-and-maternal/16-Report-of-the-Perinatal-and-Infant-Mortality-Committee.pdf.
  23. Maternal and Perinatal Mortality Committee. Maternal and perinatal mortality in South Australia 2020. 2023; Available from: https://www.wellbeingsa.sa.gov.au/assets/downloads/maternal-perinatal-mortality/Maternal-and-Perinatal-Mortality-in-South-Australia-2020.pdf.
  24. Council of Obstetric and Paediatric Mortality and Morbidity. Annual report 2020. 2021; Available from: https://www.health.tas.gov.au/publications/council-obstetric-and-paediatric-mortality-and-morbidity-copmm-2020-annual-report.
  25. Li, L. and L. O’Neil. Northern Territory midwives’ collection mothers and babies 2020 2023; Available from: https://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/12467/1/Northern%20Territory%20Midwives%20Collection%20Mothers%20and%20Babies%20Report%202020.pdf
  26. ACT Health. Perinatal mortality in the Australian Capital Territory, 2011–2015. 2017; Available from: https://www.health.act.gov.au/sites/default/files/2019-09/Number%2065%20-%20Perinatal%20Mortality%20in%20the%20ACT%202011-2015%20version%205.pdf.
  27. Australian Institute of Health and Welfare. Stillbirths and neonatal deaths in Australia 2017 and 2018. Perinatal statistics series no. 38. Cat. no. PER 115. 2021; Available from: https://www.aihw.gov.au/reports/mothers-babies/stillbirths-and-neonatal-deaths-in-australia-2017/summary.
  28. COAG Health Council Australian Government Department of Health. Woman-centred care: Strategic directions for Australian maternity services. 2019 August; Available from: https://www.health.gov.au/resources/publications/woman-centred-care-strategic-directions-for-australian-maternity-services?language=en.
  29. Sands UK. National Bereavement Care Pathway for Pregnancy and Baby Loss. Stillbirth: Full guidance document. 2022; Available from: https://www.nbcpathway.org.uk/pathways/stillbirth-bereavement-care-pathway/
  30. Smith, L.K., et al., Parents’ experiences of care following the loss of a baby at the margins between miscarriage, stillbirth and neonatal death: A UK qualitative study. BJOG: An International Journal of Obstetrics and Gynaecology, 2020. 127(7): p. 868–874 doi: 10.1111/1471-0528.16113.
  31. Helps, Ä., et al., Perinatal mortality audits and reviews: Past, present and the way forward. European Journal of Obstetrics & Gynecology & Reproductive Biology, 2020. 250: p. 24–30 doi: 10.1016/j.ejogrb.2020.04.054.
  32. Bakhbakhi, D., et al., Learning from deaths: Parents’ Active Role and ENgagement in The review of their Stillbirth/perinatal death (the PARENTS 1 study). BMC Pregnancy & Childbirth, 2017. 17: p. 1-6 doi: 10.1186/s12884-017-1509-z.
  33. Bakhbakhi, D., et al., PARENTS 2 Study: A qualitative study of the views of healthcare professionals and stakeholders on parental engagement in the perinatal mortality review – From ‘bottom of the pile’ to joint learning. BMJ Open, 2018. 8(11): p. e023792 doi: 10.1136/bmjopen-2018-023792.
  34. Bakhbakhi, D., et al., PARENTS 2 study: Consensus report for parental engagement in the perinatal mortality review process. Ultrasound in Obstetrics & Gynecology, 2019. 54(2): p. 215–224 doi: 10.1002/uog.20139.
  35. Burke, B., et al., Barriers to attendance at a tertiary hospital’s perinatal mortality meeting. Irish Journal of Medical Science, 2023. 192: p. 1265–1270 doi: 10.1007/s11845-022-03137-0.
  36. Mukinda, F.K., et al., Practice of death surveillance and response for maternal, newborn and child health: A framework and application to a South African health district. BMJ Open, 2021. 11(5): p. e043783 doi: 10.1136/bmjopen-2020-043783.
  37. Knight, M., Strengths and weaknesses of national confidential case reviews of maternal and newborn morbidity and mortality. Early Human Development, 2019. 138: p. 104848 doi: 10.1016/j.earlhumdev.2019.104848.
  38. Bartlett, K., et al., Rethinking placental pathology in the PSANZ classification of unexplained stillbirth at term. Australian and New Zealand Journal of Obstetrics and Gynaecology, 2017. 57(3): p. 248–252 doi: 10.1111/ajo.12492.
  39. Higgins, L.E., A.E.P. Heazell, and M.K. Whitworth, Persistent inaccuracies in completion of medical certificates of stillbirth: A cross-sectional study. Paediatric & Perinatal Epidemiology, 2018. 32(5): p. 474–481 doi: 10.1111/ppe.12501.
  40. Heazell, A.E.P., et al., Stillbirths: Economic and psychosocial consequences. The Lancet, 2016. 387(10018): p. 604–616 doi: 10.1016/S0140-6736(15)00836-3.
  41. Flenady, V., et al., Clinical practice guideline for care around stillbirth and neonatal death. Vol. 3.4. 2020, Brisbane: NHMRC Centre of Research Excellence.
  42. Burden, C., et al., Parents’ Active Role and ENgagement in the review of their Stillbirth/perinatal death 2 (PARENTS 2) study: A mixed-methods study of implementation. BMJ Open, 2021. 11(3): p. e044563 doi: 10.1136/bmjopen-2020-044563.
  43. Boyle, F.M., et al., Parent engagement in perinatal mortality reviews: An online survey of clinicians from six high-income countries. BJOG: An International Journal of Obstetrics and Gynaecology, 2021. 128(4): p. 696–703 doi: 10.1111/1471-0528.16529.
  44. Kurinczuk, J.J., et al. Learning from standardised reviews when babies die. National perinatal mortality review tool: Second annual report. 2020; Available from: https://www.npeu.ox.ac.uk/assets/downloads/pmrt/reports/report-2020/PMRT_Report_2020_-_Full_report__10_12_2020_V10_FINAL.pdf.
  45. Australian Commission on Safety and Quality in Health Care. Stillbirth clinical care standard. 2022 November; Available from: https://www.safetyandquality.gov.au/publications-and-resources/resource-library/stillbirth-clinical-care-standard-2022.
  46. Angell, J.N., et al., Determining the cause of stillbirth in Kumasi, Ghana. International Journal of Gynecology & Obstetrics, 2019. 147(2): p. 173–178 doi: 10.1002/ijgo.12930.
  47. Lewkowitz, A.K., et al., Association between stillbirth at 23 weeks of gestation or greater and severe maternal morbidity. Obstetrics & Gynecology, 2019. 134(5): p. 964–973 doi: 10.1097/aog.0000000000003528.
  48. Gulati, N., et al., Cause of intrauterine and neonatal death in twin pregnancies (CoDiT): Development of a novel classification system. BJOG: An International Journal of Obstetrics and Gynaecology, 2020. 127(12): p. 1507–1515 doi: 10.1111/1471-0528.16291.
  49. Aminu, M., et al., Cause of and factors associated with stillbirth: A systematic review of classification systems. Acta Obstetricia et Gynecologica Scandinavica, 2017. 96(5): p. 519–528 doi: 10.1111/aogs.13126.
  50. Fabrizio, D., et al., A comparison of three classification systems for stillbirth. Journal of Maternal-Fetal and Neonatal Medicine, 2022. 35(19): p. 3722–3728 doi: 10.1080/14767058.2020.1839749.
  51. Jayaratnam, S., et al., A prospective review of perinatal mortality at Hospital Nacional Guido Valadares (HNGV). Australian & New Zealand Journal of Obstetrics & Gynaecology, 2020. 60(1): p. 70–75 doi: 10.1111/ajo.12991.
  52. Reinebrant, H.E., et al., Making stillbirths visible: A systematic review of globally reported causes of stillbirth. BJOG: An International Journal of Obstetrics and Gynaecology, 2018. 125(2): p. 212–224 doi: 10.1111/1471-0528.14971.
  53. Auger, N., et al., Decreasing use of autopsy for stillbirths and infant deaths: Missed opportunity. Journal of Perinatology, 2018. 38(10): p. 1414–1419 doi: 10.1038/s41372-018-0191-y.
  54. Wijs, L.A., et al., Causes of stillbirth in a socioeconomically disadvantaged urban Australian population – A comprehensive analysis. Journal of Maternal-Fetal & Neonatal Medicine, 2017. 30(23): p. 2851–2857 doi: 10.1080/14767058.2016.1265933.
  55. Goldenberg, R.L., et al., Criteria for assigning cause of death for stillbirths and neonatal deaths in research studies in low-middle income countries. Journal of Maternal-Fetal & Neonatal Medicine, 2019. 32(11): p. 1915-1923 doi: 10.1080/14767058.2017.1419177.
  56. Breiman, R.F., et al., Postmortem investigations and identification of multiple causes of child deaths: An analysis of findings from the Child Health and Mortality Prevention Surveillance (CHAMPS) network. PLoS Medicine, 2021. 18(9): p. 1-19 doi: 10.1371/journal.pmed.1003814.
  57. Jones, F., et al., Practice of pathological examinations in stillbirths: A 10-year retrospective study. Journal of Gynecology Obstetrics and Human Reproduction, 2017. 46(1): p. 61–67 doi: 10.1016/j.jgyn.2016.06.004.
  58. Taweevisit, M. and P.S. Thorner, Placental findings contributing to perinatal death: A 15-year retrospective review from a teaching hospital in Thailand. Fetal and Pediatric Pathology, 2022. 41(1): p. 18-28 doi: 10.1080/15513815.2020.1747121.
  59. Page, J.M. and R.M. Silver, Stillbirth: Evaluation and follow-up. Obstetrics and Gynecology Clinics of North America, 2020. 47(3): p. 439-451 doi: 10.1016/j.ogc.2020.04.008.
  60. Man, J., et al., Stillbirth and intrauterine fetal death: Role of routine histopathological placental findings to determine cause of death. Ultrasound in Obstetrics & Gynecology, 2016. 48(5): p. 579–584 doi: 10.1002/uog.16019.
  61. Wojcik, M.H., et al., Mortality in the neonatal intensive care unit: improving the accuracy of death reporting. Journal of Perinatology, 2022. 42(5): p. 671-676 doi: 10.1038/s41372-021-01214-3.
  62. Royal College of Pathologists of Australasia Autopsy Working Party, The decline of the hospital autopsy: A safety and quality issue for healthcare in Australia. Medical Journal of Australia, 2004. 180(6): p. 281-285 doi: 10.5694/j.1326-5377.2004.tb05926.x.
  63. Bezhenar, V.F., L.A. Ivanova, and D.O. Ivanov, Legal aspects of perinatal loss. Journal of Obstetrics and Women’s Diseases, 2021. 70(3): p. 143–150 doi: 10.17816/JOWD64324.
  64. American College of Obstetricians and Gynecologists, ACOG Committee Opinion No. 748: The importance of vital records and statistics for the obstetrician-gynecologist. Obstetrics & Gynecology, 2018. 132(2): p. e78–e81 doi: 10.1097/aog.0000000000002759.
  65. Knight, M., Strengths and weaknesses of national confidential case reviews of maternal and newborn morbidity and mortality. Early Human Development, 2019. 138 doi: 10.1016/j.earlhumdev.2019.104848.
  66. Willcox, M.L., et al., Maternal and perinatal death surveillance and response: A systematic review of qualitative studies. Bulletin of the World Health Organization, 2023. 101(1): p. 62–75G doi: 10.2471/blt.22.288703.
  67. Flenady, V., et al., Classification of causes and associated conditions for stillbirths and neonatal deaths. Seminars in Fetal & Neonatal Medicine, 2017. 22(3): p. 176-185 doi: 10.1016/j.siny.2017.02.009.
  68. Prüst, Z.D., et al., The global use of the International Classification of Diseases to Perinatal Mortality (ICD-PM): A systematic review. Journal of Global Health, 2022. 12: p. 04069 doi: 10.7189/jogh.12.04069.
  69. Lupariello, F., G. Di Vella, and G. Botta, Stillbirth diagnosis and classification: Comparison of ReCoDe and ICD-PM systems. Journal of Perinatal Medicine, 2022. 50(6): p. 713–721 doi: 10.1515/jpm-2022-0014.
  70. Leisher, S.H., et al., Classification systems for causes of stillbirth and neonatal death, 2009–2014: An assessment of alignment with characteristics for an effective global system. BMC Pregnancy and Childbirth, 2016. 16(1): p. 269 doi: 10.1186/s12884-016-1040-7.
  71. Boyer, M.M., Root cause analysis in perinatal care: Health care professionals creating safer health care systems. The Journal of Perinatal & Neonatal Nursing, 2001. 15(1): p. 40-54 doi: 10.1097/00005237-200106000-00006.
  72. Nicolini, D., J. Waring, and J. Mengis, Policy and practice in the use of root cause analysis to investigate clinical adverse events: Mind the gap. Social Science and Medicine, 2011. 73(2): p. 217-225 doi: 10.1016/j.socscimed.2011.05.010.
  73. Rimmer, M.P., et al., Worth the paper it’s written on? A cross-sectional study of Medical Certificate of Stillbirth accuracy in the UK. International Journal of Epidemiology, 2022. 52(1): p. 295–308 doi: 10.1093/ije/dyac100.
  74. Taweevisit, M., P. Nimitpanya, and P.S. Thorner, Classification of stillbirth by the International Classification of Diseases for Perinatal Mortality using a sequential approach: A 20-year retrospective study from Thailand. Journal of Obstetrics and Gynaecology Research, 2022 doi: 10.1111/jog.15189.
  75. South Australian Community Health Research Unit and Department of Human Services South Australia. Performance indicators in community health: Development of a process, March 2000-October 2001: Final project report. 2002 Available from: https://catalogue.nla.gov.au/Record/198240.
  76. Australian Commission on Safety and Quality in Health Care. Clinical governance and quality improvement to support effective communication. Action 6.02: Applying quality improvement systems. 2023; Available from: https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/clinical-governance-and-quality-improvement-support-effective-communication/action-602.
  77. Zulfeen, M., et al., What do the numbers say? – Introduction of the WHO ICD-PM classification and fetuses-at risk approach in perinatal audit, South India. Clinical and Experimental Obstetrics and Gynecology, 2021. 48(1): p. 144-150 doi: 10.31083/j.ceog.2021.01.5466.
  78. Joseph, K.S., et al., Stillbirth in Canada: Anachronistic definition and registration processes impede public health surveillance and clinical care. Canadian Journal of Public Health, 2021. 112(4): p. 766-772 doi: 10.17269/s41997-021-00483-x.
  79. Helps, A., et al., Perinatal mortality audits and reviews: Past, present and the way forward. European Journal of Obstetrics & Gynecology & Reproductive Biology, 2020. 250: p. 24-30 doi: 10.1016/j.ejogrb.2020.04.054.
  80. de Graaff, E.C., et al., Ending preventable stillbirths and improving bereavement care: A scorecard for high- and upper-middle income countries. BMC Pregnancy and Childbirth, 2023. 23(1): p. 480 doi: 10.1186/s12884-023-05765-5.
  81. World Health Organization. Improving maternal and newborn health and survival and reducing stillbirth: Progress report 2023. Licence: CC BY-NC-SA 3.0 IGO, 2023; Available from: https://www.who.int/publications/i/item/9789240073678.
  82. Smith, L.K., et al., Quantifying the burden of stillbirths before 28 weeks of completed gestational age in high-income countries: A population-based study of 19 European countries. Lancet, 2018. 392(10158): p. 1639-1646 doi: 10.1016/s0140-6736(18)31651-9.
  83. Australian Institute of Health and Welfare. Australia’s mothers and babies: Stillbirths and neonatal deaths. 2022; Available from: https://www.aihw.gov.au/reports/mothers-babies/stillbirths-and-neonatal-deaths.
Part B: 8-step audit cycle
Section 7 appendices
Western Pacific Regional Office of the International Stillbirth Alliance
Coordinating Centre, Stillbirth and Neonatal Death Alliance, Perinatal Society of Australia and New Zealand

Level 3, Aubigny Place
Mater Research Institute
Raymond Terrace,
South Brisbane QLD 4101
The University of Queensland Faculty of Medicine

Copyright © Stillbirth CRE