Research Article: Application of the ICD-PM classification system to stillbirth in four sub-Saharan African countries

Date Published: May 9, 2019

Publisher: Public Library of Science

Author(s): Mamuda Aminu, Matthews Mathai, Nynke van den Broek, Rakhi Dandona.


To identify the causes and categories of stillbirth using the Application of ICD-10 to Deaths during the Perinatal Period (ICD-PM).

Prospective, observational study in 12 hospitals across Kenya, Malawi, Sierra Leone and Zimbabwe. Healthcare providers (HCPs) assigned cause of stillbirth following perinatal death audit. Cause of death was classified using the ICD-PM classification system.

1267 stillbirths met the inclusion criteria. The stillbirth rate (per 1000 births) was 20.3 in Malawi (95% CI: 15.0–42.8), 34.7 in Zimbabwe (95% CI: 31.8–39.2), 38.8 in Kenya (95% CI: 33.9–43.3) and 118.1 in Sierra Leone (95% CI: 115.0–121.2). Of the included cases, 532 (42.0%) were antepartum deaths, 643 (50.7%) were intrapartum deaths and 92 cases (7.3%) could not be categorised by time of death. Overall, only 16% of stillbirths could be classified by fetal cause of death. Infection (A2 category) was the most commonly identified cause for antepartum stillbirths (8.6%). Acute intrapartum events (I3) accounted for the largest proportion of intrapartum deaths (31.3%). In contrast, for 76% of stillbirths, an associated maternal condition could be identified. The M1 category (complications of placenta, cord and membranes) was the most common category assigned for antepartum deaths (31.1%), while complications of labour and delivery (M3) accounted for the highest proportion of intrapartum deaths (38.4%). Overall, the proportion of cases for which no fetal or maternal cause could be identified was 32.6% for antepartum deaths, 8.1% for intrapartum deaths and 17.4% for cases with unknown time of death.

Clinical care and documentation of this care require strengthening. Diagnostic protocols and guidelines should be introduced more widely to obtain better data on cause of death, especially antepartum stillbirths. Revision of ICD-PM should consider an additional category to help accommodate stillbirths with unknown time of death.

Partial Text

Stillbirth is a major public health problem, with an estimated 2.6 million deaths occurring annually worldwide, 98% of which occur in low- and middle-income countries (LMIC) [1]. Many LMIC have stillbirth rates above 30 per 1,000 births which is at least three times higher than in high-income countries.

Overall, 1267 stillbirths were included: 321 in Kenya, 299 in Malawi, 340 in Sierra Leone and 307 in Zimbabwe. The hospital stillbirth rate varied among countries: facilities in Malawi had the lowest rate (20.3 per 1000 births, 95% CI: 15.0–42.8), followed by those in Zimbabwe (34.7 per 1000 births, 95% CI: 31.8–39.2), Kenya (38.8 per 1000 births, 95% CI: 33.9–43.3) and Sierra Leone (118.1 per 1000 births, 95% CI: 115.0–121.2).

Healthcare providers in LMIC should be aware of the need and supported to improve clinical care and documentation of care for all mothers, including those who experience stillbirth as well as the stillborn babies. Diagnostic protocols and guidelines for the application of these need to be introduced. In the interim, it is recommended that an additional category is added to the ICD-PM to accommodate stillbirths with unknown time of death.




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