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Original Contribution
December 14, 2011

Causes of Death Among Stillbirths

Author Affiliations

The Stillbirth Collaborative Research Network Writing Group:Radek Bukowski, MD, PhD, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston; Marshall Carpenter, MD, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brown University School of Medicine, Providence, Rhode Island; Deborah Conway, MD, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio; Donald Coustan, MD, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brown University School of Medicine; Donald J. Dudley, MD, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio; Robert L. Goldenberg, MD, Department of Obstetrics and Gynecology, Drexel University School of Medicine, Philadelphia, Pennsylvania; Carol J. Rowland Hogue, PhD, MPH, Department of Epidemiology, Rollins School of Public Health, and Women's and Children's Center, Emory University; Matthew A. Koch, MD, PhD, Statistics and Epidemiology Unit, Health Sciences Division, RTI International, Research Triangle Park, North Carolina; Corette B. Parker, DrPH, Statistics and Epidemiology Unit, Health Sciences Division, RTI International; Halit Pinar, MD, Division of Perinatal and Pediatric Pathology, Department of Pathology and Laboratory Medicine, Brown University School of Medicine; Uma M. Reddy, MD, MPH, Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; George R. Saade, MD, Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston; Robert M. Silver, MD, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, and Maternal Fetal Medicine at Intermountain Healthcare, Salt Lake City; Barbara J. Stoll, MD, Emory University School of Medicine and Department of Pediatrics, Children's Healthcare Atlanta; Michael W. Varner, MD, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, and Maternal Fetal Medicine at Intermountain Healthcare, Salt Lake City; and Marian Willinger, PhD, Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development.

JAMA. 2011;306(22):2459-2468. doi:10.1001/jama.2011.1823
Abstract

Context Stillbirth affects 1 in 160 pregnancies in the United States, equal to the number of infant deaths each year. Rates are higher than those of other developed countries and have stagnated over the past decade. There is significant racial disparity in the rate of stillbirth that is unexplained.

Objective To ascertain the causes of stillbirth in a population that is diverse by race/ethnicity and geography.

Design, Setting, and Participants A population-based study from March 2006 to September 2008 with surveillance for all stillbirths at 20 weeks or later in 59 tertiary care and community hospitals in 5 catchment areas defined by state and county boundaries to ensure access to at least 90% of all deliveries. Termination of a live fetus was excluded. Standardized evaluations were performed at delivery.

Main Outcome Measures Medical history, fetal postmortem and placental pathology, karyotype, other laboratory tests, systematic assignment of causes of death.

Results Of 663 women with stillbirth enrolled, 500 women consented to complete postmortem examinations of 512 neonates. A probable cause of death was found in 312 stillbirths (60.9%; 95% CI, 56.5%-65.2%) and possible or probable cause in 390 (76.2%; 95% CI, 72.2%-79.8%). The most common causes were obstetric conditions (150 [29.3%; 95% CI, 25.4%-33.5%]), placental abnormalities (121 [23.6%; 95% CI, 20.1%-27.6%]), fetal genetic/structural abnormalities (70 [13.7%; 95% CI, 10.9%-17.0%]), infection (66 [12.9%; 95% CI, 10.2%-16.2%]), umbilical cord abnormalities (53 [10.4%; 95% CI, 7.9%-13.4%]), hypertensive disorders (47 [9.2%; 95% CI, 6.9%-12.1%]), and other maternal medical conditions (40 [7.8%; 95% CI, 5.7%-10.6%]). A higher proportion of stillbirths in non-Hispanic black women compared with non-Hispanic white and Hispanic ones was associated with obstetric complications (43.5% [50] vs 23.7% [85]; difference, 19.8%; 95% CI, 9.7%-29.9%; P < .001) and infections (25.2% [29] vs 7.8% [28]; difference, 17.4%; 95% CI, 9.0%-25.8%; P < .001). Stillbirths occurring intrapartum and early in gestation were more common in non-Hispanic black women. Sources most likely to provide positive information regarding cause of death were placental histology (268 [52.3%; 95% CI, 47.9%-56.7%]), perinatal postmortem examination (161 [31.4%; 95% CI, 27.5%-35.7%]), and karyotype (32 of 357 with definitive results [9%; 95% CI, 6.3%-12.5%]).

Conclusions A systematic evaluation led to a probable or possible cause in the majority of stillbirths. Obstetric conditions and placental abnormalities were the most common causes of stillbirth, although the distribution differed by race/ethnicity.

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