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

Perinatal mortality is a major population health indicator

conveying important signals about the state of maternity

care and measures of the current and future health of

mothers and newborns. International comparisons are used

to encourage countries to improve their perinatal health

and health systems. However, extensive evidence highlights

methodological challenges to ensuring valid and robust

comparisons, as a lack of standardised criteria can lead to

bias and inappropriate inferences.

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.

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.

As the gestational age limit for initiation of neonatal care decreases, exclusion of these stillbirths limits the full evaluation of

care provision and outcomes at early gestational ages. Fur-

ther, it underestimates the burden of loss on parents’ men-

tal and physical health.