Producing valid statistics when legislation, culture, and medical practices differ for births at or before the threshold of survival: Report of a European workshop

<div>Perinatal mortality is a major population health indicator</div><div>conveying important signals about the state of maternity</div><div>care and measures of the current and future health of</div><div>mothers and newborns. International comparisons are used</div><div>to encourage countries to improve their perinatal health</div><div>and health systems. However, extensive evidence highlights</div><div>methodological challenges to ensuring valid and robust</div><div>comparisons, as a lack of standardised criteria can lead to</div><div>bias and inappropriate inferences.</div><div>One major issue is the wide international variation in the criteria for classification and registration of deaths as a stillbirth or neonatal death at the threshold of survival.</div><div>Standard practice is to minimise this problem by using a gestational age cut-off of 24 or even 28 weeks for mortality rate calculations. However, this strategy excludes a significant number of stillbirths, at least one in five deaths before 24 weeks of gestation and over one in three deaths before 28 weeks.</div><div>As the gestational age limit for initiation of neonatal care decreases, exclusion of these stillbirths limits the full evaluation of</div><div>care provision and outcomes at early gestational ages. Fur-</div><div>ther, it underestimates the burden of loss on parents’ men-</div><div>tal and physical health.</div>