Worth the paper it's written on- A cross-sectional study of Medical Certificate of Stillbirth accuracy in the UK

Rimmer, Michael P; Henderson, Ian; Parry-Smith, William; Raglan, Olivia; Tamblyn, Jennifer; Heazell, Alexander E P; Higgins, Lucy E; working group, the UKARCOG NESTT

Abstract

Background
The Medical Certificate of Stillbirth (MCS) records data about a baby’s death after 24 weeks of gestation but before birth. Major errors that could alter interpretation of the MCS were widespread in two UK-based regional studies.

Methods
A multicentre evaluation was conducted, examining MCS issued 1 January 2018 to 31 December 2018 in 76 UK obstetric units. A systematic case-note review of stillbirths was conducted by Obstetric and Gynaecology trainees, generating individual ‘ideal MCSs’ and comparing these to the actual MCS issued. Anonymized central data analysis described rates and types of error, agreement and factors associated with major errors.

Results
There were 1120 MCSs suitable for assessment, with 126 additional submitted data sets unsuitable for accuracy analysis (total 1246 cases). Gestational age demonstrated ‘substantial’ agreement [K = 0.73 (95% CI 0.70–0.76)]. Primary cause of death (COD) showed ‘fair’ agreement [K = 0.26 (95% CI 0.24–0.29)]. Major errors [696/1120; 62.1% (95% CI 59.3–64.9%)] included certificates issued for fetal demise at <24 weeks’ gestation [23/696; 3.3% (95% CI 2.2–4.9%)] or neonatal death [2/696; 0.3% (95% CI 0.1–1.1%)] or incorrect primary COD [667/696; 95.8% (95% CI 94.1–97.1%)]. Of 540/1246 [43.3% (95% CI 40.6–46.1%)] ‘unexplained’ stillbirths, only 119/540 [22.0% (95% CI 18.8–25.7%)] remained unexplained; the majority were redesignated as either fetal growth restriction [FGR: 195/540; 36.1% (95% CI 32.2–40.3%)] or placental insufficiency [184/540; 34.1% (95% CI 30.2–38.2)]. Overall, FGR [306/1246; 24.6% (95% CI 22.3–27.0%)] was the leading primary COD after review, yet only 53/306 [17.3% (95% CI 13.5–22.1%)] FGR cases were originally attributed correctly.

Conclusion
This study demonstrates widespread major errors in MCS completion across the UK. MCS should only be completed following structured case-note review, with particular attention on the fetal growth trajectory.

Citation

Rimmer, M. P., Henderson, I., Parry-Smith, W., Raglan, O., Tamblyn, J., Heazell, A. E. P., …working group, T. U. N. (2023). Worth the paper it's written on- A cross-sectional study of Medical Certificate of Stillbirth accuracy in the UK. International Journal of Epidemiology, 52(1), 295–308. https://doi.org/10.1093/ije/dyac100

• Journal Article Type: Article
• Acceptance Date: Apr 22, 2022
• Online Publication Date: Jun 20, 2022
• Publication Date: 2023-02
• Deposit Date: Mar 19, 2024
• Journal: International Journal of Epidemiology
• Print ISSN: 0300-5771
• Publisher: Oxford University Press
• Peer Reviewed: Peer Reviewed
• Volume: 52
• Issue: 1
• Pages: 295–308
• DOI: https://doi.org/10.1093/ije/dyac100
• Keywords: Stillbirth, perinatal death, cause of death, fetal growth restriction, placental insufficiency, accuracy, death certification, stillbirth certification
• Publisher URL: https://academic.oup.com/ije/article/52/1/295/6609214