Interventions to improve rates of post-mortem examination after stillbirth

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Abstract

Objective

Despite recognition of the value of post-mortem examination following stillbirth, worldwide rates have declined since the early 1990s. There is a paucity of published evidence relating to factors that can improve post-mortem uptake. The aim of this study was to assess post-mortem rates following stillbirth and identify trends in the past 18 years that may have affected acceptance of the investigation.

Results

Sharp declines in post-mortems coincided with publicity surrounding unlawful organ retention. Although nationally post-mortem rates have continued to fall, in our unit there was recovery in post-mortem rates. This increase was associated with implementation of policies to promote the uptake of perinatal post-mortem, including availability of specialist perinatal pathologists, education in the value of post-mortem, and senior staff involvement in counselling regarding the procedure.

Conclusion

The need to improve uptake of post-mortem examination following stillbirth is internationally recognized. The results of this study suggest that increased local availability of specialist perinatal pathologists, who can support education in the value of post-mortem, along with senior staff obtaining consent, may help achieve this goal.

Introduction

The value of post-mortem examination following stillbirth is well documented [1]. Post-mortem is important for accurately determining cause of stillbirth and directing management of subsequent pregnancy, as well as audit and death certification. Perinatal autopsy provides additional information to clinical findings in up to 65% of cases of intrauterine death at greater than 20 weeks’ gestation [2], [3], [4]. It may also alleviate parental anxiety about antenatal care and is essential for research to investigate the aetiology of stillbirth and improve preventative strategies. Nevertheless, worldwide the number of perinatal post-mortems performed has declined in the past 30 years [5], [6], [7]. Improving rate of post-mortems is a goal supported by both professional bodies [8], [9], [10] and consumer groups [11], [12] but there is little published evidence of good practice to help achieve this.

In 2005, in response to the perception of declining rates of post-mortem, we performed an audit of post-mortems following stillbirth in a tertiary referral centre with over 6500 deliveries a year. The aim of this was to identify trends in uptake over time and investigate factors affecting consent. Unit guidelines for management after stillbirth were then changed, and we instituted an education policy on the value of post-mortem examination. Unlike national rates, which have continued to decline, uptake of post-mortem following stillbirth in our unit has since increased. Here we report the results of the completed audit cycle, and trends in post-mortem uptake over an 18-year period. We present this to highlight factors that may improve rates of uptake of post-mortem following stillbirth and emphasize the importance of local perinatal pathology services in maintaining good post-mortem rates.

Section snippets

Materials and methods

We examined post-mortem reports and/or obstetric records of all stillbirths delivered at the Simpson Centre for Reproductive Health (SCRH) at the Royal Infirmary, Edinburgh, between January 1991 and December 2008 (589 births; 582 pregnancies). The UK definition of stillbirth was used [7], namely infants born without signs of life at greater than 24 weeks gestation, with exclusion of fetus papyraceous (where there is demise of one twin confirmed at less than 24 weeks, but born after 24 weeks).

Trends in uptake of post-mortem

The pattern of post-mortem uptake following stillbirth in our unit is shown in Fig. 1. UK rates are shown for comparison. There was a steady decline in all post-mortem examinations from 91.7% (86.0–97.4) in 1991–1993, to 76.1% (67.1–85.1) in 2000–2002 (p < 0.001). The proportion of full post-mortem examinations also fell, with full post-mortem rates declining from 85.6% (78.5–92.7) to 57.9% (47.6–68.2; p < 0.001). In 2003–2005 post-mortem examination rates increased to 80.6% (73.1–88.1), but this

Comment

Multiple factors may have contributed to the declining perinatal post-mortem rates seen worldwide. Our data show sharp declines in uptake of post-mortem after the disclosures of unlawful organ retention, and there is little doubt that the negative media attention was damaging both nationally and internationally [5]. However, if this were the only cause, some recovery in rates would be expected as public memory faded, but national rates have not shown this. In contrast, in our unit, since 2003

Conflict of interest

None.

Role of the funding source

None.

Acknowledgements

Support for this project was provided by Dr Corinne Love and Allyn Dick (Lothian University Healthcare Trust Obstetrics and Gynaecology Quality Improvement Team). Kim Rolfe kindly provided data from the All-Wales perinatal survey, Lorraine Adamson provided SSBIDs data and CEMACH provided UK data.

References (14)

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