Call for reform in stillbirth recording as study finds major errors

3 out of 5 Medical Certificates of Stillbirth have major errors, study finds
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The accuracy of the way stillbirths are reported has been called into question by an analysis of Medical Certificates of Stillbirth from across the UK.

When a baby dies during pregnancy or birth, parents are left asking why. A Tommy’s survey in 2019, found that without an answer or reason for their baby’s death, the majority of parents felt guilt, and 82% blamed themselves for their loss. This makes it harder for families to come to terms with their loss and can lead to long-term mental health issues and greater anxiety and stress during pregnancies after loss. 

Around 1 in 250 pregnancies in the UK end in stillbirth. 

Researchers led by the University of Manchester and University of Edinburgh, including Tommy’s Stillbirth Research Centre scientists, have reassessed 1,120 certificates, studying case notes in detail for each stillborn baby and comparing them with the cause of death recorded at the time.

In nearly half of these cases, the baby’s death had been registered as unexplained, leaving parents without the answers they deserve to help them understand their loss. 

Yet when reassessed, the research team found that almost 75% of stillbirths certified as being of unknown or unexplained cause of death did have an identifiable cause. Of 540 stillbirths originally certified as unexplained, only 119 remained unexplained following the analysis. 

195 deaths were redesignated as fetal growth restriction - a condition where a baby is smaller than expected or when a baby’s growth slows or stops during pregnancy. 

184 deaths were redesignated as placental insufficiency – when the placenta has not worked as well as it should, resulting in a baby being unable to get as much oxygen or nutrients as it needs to grow and develop well. 
 
Identified as the cause of death in 306 babies overall, fetal growth restriction was the leading cause of death after review. Only 53 of these cases were correctly identified before the researchers’ work. 

Tommy’s believes that parents deserve to be told why their baby has died or has been born prematurely. That’s why we fund research into miscarriage, stillbirth and preterm birth and campaign to increase the amount of research happening in reproductive health and pregnancy care. 

As well as ending the cycle of self-blame and guilt, this research continues to improve our understanding of the biological processes at work and helps to tackle the myth that baby loss is ‘just one of those things’ and can’t be prevented – finding answers prevents babies from dying before, during and after birth.

What does this mean? 

Co-author Professor Alex Heazell, Director of the Tommy’s Stillbirth Research Centre at the University of Manchester says: 

“Data from Medical Certificates of Stillbirth inform healthcare service strategy, funding, research and public health initiatives. It is vital that we identify preventable stillbirths to make sure we can develop future strategies to reduce deaths." 

Lead author Dr Lucy Higgins, a Senior Lecturer in obstetrics at the University of Manchester and consultant obstetrician, urged full case reviews following a stillbirth which focused on accurately identifying and recording cause of death: 

“This study demonstrate widespread major errors in the way Medical Certificates of Stillbirth are completed across the UK. We argue these documents should only be completed following a structured case note review, with particular attention to fetal growth trajectory.” 

What else did the study show?

Writing in the International Journal of Epidemiology, the research team explain that over 80% of the Medical Certificates of Stillbirths they reviewed contained errors. Just under 56% had a major error that would change their interpretation.

Inaccuracies were recorded across the UK, but hospitals in regions where audits had previously been carried out were less likely to contain major errors, possibly due to increased error awareness. 

The training and seniority of the healthcare professional filling in the certificate was unrelated to the chances of making an error.
 
The team evaluated Medical Certificates of Stillbirth issued across the year 2018 in 76 UK obstetric units. Case note reviews were carried out by a network of Obstetrics and Gynaecology non-consultant grade doctors, who work jointly on large audit and research projects, called UK ARCOG. 
  
The study did not examine the standard of care received prior to a baby’s death but looked only at whether the data reported on the Medical Certificate of Stillbirth accurately reflected the facts surrounding death. 

Kath Abrahams, Tommy’s Chief Executive, says: 

“With every baby loss, devastated parents most commonly ask ‘why?’. They want to know why their baby died and what could be done in future to reduce the risk of it happening again.

“Without an accurate cause of death, parents are left without an explanation and researchers working to find the causes of stillbirth and how to prevent it are left without the information they need to make progress. It is not always possible to know why a stillbirth happened, but this review shows that ‘unexplained’ should not be the norm. Accuracy alongside compassion should be prioritised when certifying stillbirth.” 

Amina Hatia, Tommy’s Midwifery Manager, says: 

“Losing a baby at any point in pregnancy is devastating, but when a baby dies late in pregnancy without a given reason, families are more likely to experience guilt and self-blame. This makes grieving their loss difficult, and this can also impact on future pregnancies. 

“When the cause of death is known, we can support families to understand the reasons for their loss and the risks of it happening again. This means we can give them the right advice and support if they become pregnant again and work closely with their clinical teams to reduce their risks.”