Birth - Stillbirth and Perinatal Death

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The distorted world map above shows the relative distribution of early neonatal death by country. Note the over-representation of Africa and Asia compared with Europe, USA and Australia. [1]


The perinatal period is the early postnatal period relating to the birth, statistically it includes the period up to 7 days after birth. Neonatal period is the four weeks/month after birth. Stillbirth and perinatal death can be classified by a number of different systems, all still have "unexplained" or "other" as a potential option. in several systems contribute to many of these deaths. Neonatal deaths include a broader age range of infants who have also died after birth from various causes.

Stillbirths with a gestational age of 28 weeks or more are defined as "late fetal deaths".

There are several death classification systems used in different countries around the world, the most recent are the suggested ReCoDe (UK, 2005), the modified Whitfield (Australia/New Zealand, 2004), and the World Health Organization's International Classification of Disease (ICD-10) systems.

A common stillbirth classification is still "unexplained", with recent analysis of data showing fetal growth restriction is a common antecedent.

Australian categories perinatal and infant death graph.jpg
Australian Categories of Perinatal and Infant Death[2]
Birth Links: Introduction | Lecture - Birth | Caesarean | Preterm | Birth Weight | Birth Statistics | Australian Birth Data | Developmental Origins of Health and Disease | Macrosomia | Neonatal Diagnosis | Apgar test | Guthrie test | Neonatal Development | Stillbirth and Perinatal Death | ICD-10 Perinatal Period | Category:Birth

Some Recent Findings

Neonatal mortality rates 2009
  • Stillbirths in Germany 2003 - 2011[3] Searches in the international peer-reviewed literature, retrospective data collection of 168 stillbirths in 8 hospitals, (in the area of Bonn) with subsequent statistical evaluation (descriptive statistics, t-test and binominal test) were undertaken. This study shows considerable deficits in data documentation, interdisciplinary communication and postmortal examination. Only in 51.8% (87/168) of the cases was a certain or uncertain cause of death found (42.3% placental, 1.2% foetal, 3.6% chromosomal, 4.8% umbilical cord abnormalities). Severe foetal growth restriction (<5(th) percentile) was observed in 29.2%; 44.9% (22/49) of them died at the age of ≥36+0 weeks of gestation." Germany Statistics
  • Stillbirths in Australia 1991-2009[2] "In 2009, 2,341 babies were stillborn, accounting for almost three quarters of perinatal deaths. In Australia a 'stillbirth' is defined as the birth of a baby who shows no signs of life after a pregnancy of at least 20 weeks gestation or weighing 400 grams or more. Congenital anomalies, or birth defects, are the most common cause of stillbirth in Australia, accounting for 21% of all stillbirths. From 1991 to 2009, the stillbirth rate in Australia was between 6.4 and 7.8 per 1,000 births. The risk of stillbirth occurring between 28 and 41 weeks gestation dropped between 1991 and 2009, however there was an increase in the risk of stillbirths from 20-27 weeks." Reports Australian Statistics
  • Perinatal mortality following assisted reproductive technology treatment in Australia and New Zealand, a public health approach for international reporting of perinatal mortality.[4] "There is a need to have uniformed reporting of perinatal mortality for births following assisted reproductive technology (ART) treatment to enable international comparison and benchmarking of ART practice. ...We recommend that reporting of perinatal deaths following ART treatment, should be stratified for three gestation-specific perinatal periods of >= 20, >= 22 and >= 28 completed weeks to < 7 days post-birth; and include plurality specific rates by SET and DET." Assisted Reproductive Technology
  • Neonatal Mortality Levels for 193 Countries in 2009 with Trends since 1990: A Systematic Analysis of Progress, Projections, and Priorities.[5] " In 2009, an estimated 3.3 million babies died in the first month of life-compared with 4.6 million neonatal deaths in 1990-and more than half of all neonatal deaths occurred in five countries of the world (44% of global livebirths): India 27.8% (19.6% of global livebirths), Nigeria 7.2% (4.5%), Pakistan 6.9% (4.0%), China 6.4% (13.4%), and Democratic Republic of the Congo 4.6% (2.1%)."
  • Effect of screening and management of diabetes during pregnancy on stillbirths[6] "Diabetes during pregnancy is associated with significant risk of complications to the mother, fetus and newborn. We reviewed the potential impact of early detection and control of diabetes mellitus during pregnancy on stillbirths for possible inclusion in the Lives Saved Tool (LiST)."
  • UK study - Time of birth and risk of neonatal death at term [7] "The risk of neonatal death was 4.2 per 10 000 during the normal working week (Monday to Friday, 0900-1700) and 5.6 per 10 000 at all other times (out of hours) (unadjusted odds ratio 1.3, 95% confidence interval 1.1 to 1.6). Adjustment for maternal characteristics had no material effect. The higher rate of death out of hours was because of an increased risk of death ascribed to intrapartum anoxia (adjusted odds ratio 1.7, 1.2 to 2.3)." (See also Swedish study[8])
  • Stillbirth classification - executive summary of a National Institute of Child Health and Human Development workshop.[9] "Stillbirth is a major obstetric complication, with 3.2 million stillbirths worldwide and 26,000 stillbirths in the United States every year. The Eunice Kennedy Shriver National Institute of Child Health and Human Development held a workshop from October 22-24, 2007, to review the pathophysiology of conditions underlying stillbirth to define causes of death."
More recent papers  
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This table shows an automated computer PubMed search using the listed sub-heading term.

  • Therefore the list of references do not reflect any editorial selection of material based on content or relevance.
  • References appear in this list based upon the date of the actual page viewing.

References listed on the rest of the content page and the associated discussion page (listed under the publication year sub-headings) do include some editorial selection based upon both relevance and availability.

Links: References | Discussion Page | Pubmed Most Recent | Journal Searches

Search term: Stillbirth

Keita Ebisu, Brian Malig, Sina Hasheminassab, Constantinos Sioutas, Rupa Basu Cause-specific stillbirth and exposure to chemical constituents and sources of fine particulate matter. Environ. Res.: 2017, 160;358-364 PubMed 29055831

Jan Jaap H M Erwich Uneasy to talk about costs of stillbirth? BJOG: 2017; PubMed 29055084

S J Bonner, O Asghar, A Roberts, S Vause, B Clarke, B Keavney Cardiovascular, obstetric and neonatal outcomes in women with previous fontan repair. Eur. J. Obstet. Gynecol. Reprod. Biol.: 2017, 219;53-56 PubMed 29054041

Lauren M Rossen, Katherine A Ahrens, Amy M Branum Trends in Risk of Pregnancy Loss Among US Women, 1990-2011. Paediatr Perinat Epidemiol: 2017; PubMed 29053188

Ramin Mozafari Kermani, Mansoureh Farhangniya, Seyed Abolhassan Shahzadeh Fazeli, Pezhman Bagheri, Mahnaz Ashrafi, Ahmad Vosough Taqi Dizaj Congenital Malformations in Singleton Infants Conceived by Assisted Reproductive Technologies and Singleton Infants by Natural Conception in Tehran, Iran. Int J Fertil Steril: 2018, 11(4);304-308 PubMed 29043707

Search term: Perinatal Death

Georgios Daskalakis, Dimitrios Zacharakis, Marianna Theodora, Panagiotis Antsaklis, Nikolaos Papantoniou, Dimitris Loutradis, Aris Antsaklis Safety and efficacy of the cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth. J Perinat Med: 2017; PubMed 29055173

Marise M Wagner, Jantien Visser, Harjo Verburg, Chantal W P M Hukkelhoven, Jan M M van Lith, Kitty W M Bloemenkamp Pregnancy prior to recurrent pregnancy loss more often complicated by post-term birth and perinatal death. Acta Obstet Gynecol Scand: 2017; PubMed 29055052

Marit C I Lier, Romana F Malik, Johannes C F Ket, Cornelis B Lambalk, Ivo A Brosens, Velja Mijatovic Spontaneous hemoperitoneum in pregnancy (SHiP) and endometriosis - A systematic review of the recent literature. Eur. J. Obstet. Gynecol. Reprod. Biol.: 2017, 219;57-65 PubMed 29054042

Kathleen Rice Simpson Sudden Unexpected Postnatal Collapse and Sudden Unexpected Infant Death. MCN Am J Matern Child Nurs: 2017, 42(6);368 PubMed 29049067

Veronica Mugarab-Samedi, Abhay Lodha, Adel ElSharkawy, Essa Al Awad Aplasia cutis congenita as a result of interstitial laser therapy for fetal reduction in monochorionic twins: Conservative approach and outcome. Int J Surg Case Rep: 2017, 41;68-70 PubMed 29040903

World High Rate Countries

World infant mortality 01.jpg

Graph shows the number of infant deaths / 1,000 live births for countries above 1%.

Classification Differences

  • World Health Organization - report stillbirths weighing 500g, or born at or after 22 weeks gestational age GA, or 25 cm crown-heel length (CRL), if neither birthweight nor gestational age is known. Restrict stillbirth used for international reporting to those weighing 1,000g (or born at or after 28 weeks gestational age or 35 cm CRL.
  • Australia - a baby who is stillborn must be of at least 20 weeks gestational age or weigh 400g or more.
  • New Zealand - include all fetal deaths from 20 week gestational age or 400g birthweight[10].
  • Canada - includes fetal deaths from 20 week gestational age or 500g birthweight in all provinces except Quebec where only the birthweight criterion applies. [11]
  • United States - states to report fetal deaths of 20 or more weeks gestation, but the definition of a ‘fetal death’ specifically excludes deaths that result from induced termination of pregnancy.[12]
  • United Kingdom - 24 weeks gestational age and includes all fetal deaths that meet this criterion.
  • Europe - the lower limit ranges from 16–26 weeks gestational age and member states vary in their capacity to include late termination of pregnancy that meet their gestation criterion for a stillbirth (Gissler 2012).

Decreased Fetal Movements

Decreased fetal movements (DFM) can occur during the normal fetal period. Pregnancies with multiple occasions of decreased fetal movements are at increased risk of poor perinatal outcomes, including fetal death, intrauterine fetal growth restriction (IUFGR) or preterm birth. An evaluation of women presenting with DFM should involve a thorough history, examination and auscultation of fetal heart, cardiotocography (CTG) and ultrasound if indicated. There are guidelines and position statements available for DFM.

There have been studies using maternal recording of movements, that have limitations of non-compliance and initial analysis shows poor correlation.[9]

A population-based study has also been unable to link, except for some subgroups, maternally perceived DFM to placental pathology.[13]

Links: Fetal Development | Ultrasound | Australia RANZCOG Guideline 2013 PDF | Health 2011 | UK 2011 Guideline No. 57 | USA Reduced fetal movements 2011

Uterine Artery Pulsatility Index

Uterine Artery Pulsatility Index (UT-PI) is a clinical ultrasound technique used for monitoring placental and fetal function. Can be used in second trimester screening in combination with maternal factors and fetal biometry to predict stillbirths and in particular those associated with impaired placentation.[14] Maternal factors can include measurement of maternal serum placental growth factor (PLGF) levels.[15]

Australian Data

Australian Perinatal Deaths
Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Rate 10.1 10.4 9.8 9.8 9.9 10.6 9.2 8.8 8.4 9.0
Number 2,534 2,571 2,475 2,480 2,541 2,769 2,459 2,532 2,501 2,671
  • Perinatal deaths are all fetal deaths (at least 20 weeks gestation or at least 400 grams birth weight) plus all neonatal deaths (death of a live born baby within 28 completed days of birth).
  • Perinatal death rates are calculated per 1,000 all births for the calendar year.
  • Source: ABS Births, Australia, 2009 (cat. no. 3301.0); ABS Perinatal Deaths, Australia, 2009 (cat. no. 3304.0).


NSW perinatal mortality rate

In New South Wales (2002) 613 perinatal deaths were reported.

  • Unexplained antepartum deaths: 26.3% of perinatal deaths (or 39.2% of stillbirths)
  • Spontaneous preterm labour: 20.6% (less than 37 weeks gestation)
  • Congenital abnormality: 16.8%
  • Antepartum haemorrhage: 8.5%
  • Specific perinatal conditions: 7.3%, of which twin-twin transfusion accounted for 2.3% of deaths
  • Hypertension (high blood pressure): 5.5%
  • Perinatal infection: 4.4%
  • Maternal disease: 4.4%
  • Hypoxic peripartum death: 3.8%

Neonatal deaths (four weeks/month after birth)

  • extreme prematurity was most common cause (39.6%)
  • congenital abnormality (19.3%)
  • neurological disease (13.4%)
  • cardio-respiratory conditions (11.9%)
  • infection (8.4%)

Data: Report of the New South Wales Chief Health Officer, 2004 accessed 19Oct05

USA Data

Leading causes of infant death for 2005:[16]

  1. Congenital malformations, deformations and chromosomal abnormalities
  2. Disorders related to short gestation and low birthweight, not elsewhere classified
  3. Sudden infant death syndrome
  4. Newborn affected by maternal complications of pregnancy
  5. Newborn affected by complications of placenta, cord and membranes
  6. Accidents (unintentional injuries); Respiratory distress of newborn
  7. Bacterial sepsis of newborn
  8. Neonatal hemorrhage
  9. Necrotizing enterocolitis of newborn.

Fetal Death Information

Sample form - fetal death report
  • 2003 Revisions of the U.S. Standard Certificates of Live Birth and Death and the Fetal Death Report. The revision process is generally carried out every 10 to 15 years.
  • Maternal, Paternal and medical and health information is collected.


  • WEIGHT OF FETUS (grams preferred, specify unit)

Links: 2003 Revisions of the U.S. Standard Certificates of Live Birth and Death and the Fetal Death Report

Conditions Associated with Stillbirth

Based upon the 2007 National Institute of Child Health and Human Development workshop. [9]


  • Severe maternal illness
  • Placental infection leading to hypoxemia
  • Fetal infection leading to congenital deformity
  • Fetal infection leading damage of a vital organ
  • Precipitating preterm labor with the fetus dying in labor

Maternal medical conditions

  • Hypertensive disorders
  • Diabetes mellitus
  • Thyroid disease
  • Renal disease
  • Liver disease
  • Connective tissue disease (systemic lupus erythematosus)
  • Cholestasis


  • Antiphospholipid syndrome
  • Heritable thrombophilias
  • Red cell alloimmunization
  • Platelet alloimmunization
  • Congenital anomaly and malformations
  • Chromosomal abnormalities including confined placental mosaicism
  • Fetomaternal hemorrhage
  • Fetal growth restriction
  • Placental abnormalities including vasa previa and placental abruption
  • Umbilical cord pathology including velamentous insertion, prolapse, occlusion and entanglement
  • Multifetal gestation including twin–twin transfusion syndrome and twin reverse arterial perfusion
  • Amniotic band sequence
  • Central nervous system lesions


  1. Danny Dorling Worldmapper: the human anatomy of a small planet. PLoS Med.: 2007, 4(1);e1 PubMed 17411312 | PLoS
  2. 2.0 2.1 AIHW: Hilder L, Li Z, Zeki R & Sullivan EA 2014. Stillbirths in Australia 1991-2009. Perinatal statistics series no. 29. Cat. no. PER 63. Canberra: AIHW.
  3. J Hübner, A-S Gast, A M Müller, P Bartmann, U Gembruch [Stillbirths in Germany: Retrospective Analysis of 168 Cases between 2003 and 2011]. [Totgeburten in Deutschland: Retrospektive Datenanalyse von 168 Fällen zwischen 2003 und 2011.] Z Geburtshilfe Neonatol: 2015, 219(2);73-80 PubMed 25901868
  4. Elizabeth A Sullivan, Yueping A Wang, Robert J Norman, Georgina M Chambers, Abrar Ahmad Chughtai, Cynthia M Farquhar Perinatal mortality following assisted reproductive technology treatment in Australia and New Zealand, a public health approach for international reporting of perinatal mortality. BMC Pregnancy Childbirth: 2013, 13;177 PubMed 24044524
  5. Mikkel Zahle Oestergaard, Mie Inoue, Sachiyo Yoshida, Wahyu Retno Mahanani, Fiona M Gore, Simon Cousens, Joy E Lawn, Colin Douglas Mathers, United Nations Inter-Agency Group for Child Mortality Estimation and the Child Health Epidemiology Reference Group Neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. PLoS Med.: 2011, 8(8);e1001080 PubMed 21918640 | PLoS Med.
  6. Madiha Syed, Hasan Javed, Mohammad Yawar Yakoob, Zulfiqar A Bhutta Effect of screening and management of diabetes during pregnancy on stillbirths. BMC Public Health: 2011, 11 Suppl 3;S2 PubMed 21501437
  7. Dharmintra Pasupathy, Angela M Wood, Jill P Pell, Michael Fleming, Gordon C S Smith Time of birth and risk of neonatal death at term: retrospective cohort study. BMJ: 2010, 341;c3498 PubMed 20634347
  8. Z C Luo, J Karlberg Timing of birth and infant and early neonatal mortality in Sweden 1973-95: longitudinal birth register study. BMJ: 2001, 323(7325);1327-30 PubMed 11739216
  9. 9.0 9.1 9.2 Uma M Reddy, Robert Goldenberg, Robert Silver, Gordon C S Smith, Richard M Pauli, Ronald J Wapner, Jason Gardosi, Halit Pinar, Marjorie Grafe, Michael Kupferminc, Ingela Hulthén Varli, Jan Jaap H M Erwich, Ruth C Fretts, Marian Willinger Stillbirth classification--developing an international consensus for research: executive summary of a National Institute of Child Health and Human Development workshop. Obstet Gynecol: 2009, 114(4);901-14 PubMed 19888051 Cite error: Invalid <ref> tag; name "PMID19888051" defined multiple times with different content
  10. Perinatal and Maternal Mortality Review Committee (PMMRC). 2013. Seventh Annual Report of the Perinatal and Maternal Mortality Review Committee: Reporting mortality 2011. Wellington: Health Quality & Safety Commission
  11. Public Health Agency of Canada (PHAC). 2008. Canadian Perinatal Health Report, 2008 Edition. Ottawa.
  12. Kowaleski J. 1997. State definitions and reporting requirements for live births, fetal deaths, and induced terminations of pregnancy (1997 revision). Hyattsville, Maryland: National Center for Health Statistics.
  13. Brita Askeland Winje, Borghild Roald, Nina Petrov Kristensen, J Frederik Frøen Placental pathology in pregnancies with maternally perceived decreased fetal movement--a population-based nested case-cohort study. PLoS ONE: 2012, 7(6);e39259 PubMed 22723978
  14. Melonie Heron, Betzaida Tejada-Vera Deaths: leading causes for 2005. Natl Vital Stat Rep: 2009, 58(8);1-97 PubMed 20361522



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