The Italian Perinatal Surveillance System SPItOSS: insights from Confidential Enquiries
Authors: Salvatore Michele Antonio , Salvi Silvia , D’Aloja Paola , Vergani Patrizia , Bellù Roberto , Dani Carlo , Mecacci Federico , D’Anna Maria Rosa , Ferrazzani Sergio , Battagliarin Giuseppe , Paolillo Piermichele , Picone Simonetta , Ramenghi Luca , Vento Giovanni , Donati Serena ,   The Italian Perinatal Surveillance System-SPItOSS Working Group, Albolino Sara , Rossi Flavia Alessandra , Bulfamante Gaetano , Cassata Nicola , Castiglione Francesca , Dagliana Giulia , Dardanoni Gabriella , Ettore Giuseppe , Ferlazzo Giuseppe , Ferraro Sebastiana , Gagliardi Luigi , Gitto Eloisa , Goretti Paola , Gramaglia Giuseppe , Grismondi Ester , Iannuzzi Laura , Lalatta Faustina , Lo Lucia , Mannone Tommaso , Marconi Anna Maria , Maresi Emiliano , Micaglio Massimo , Moretto Alessandra , Mosca Fabio , Murolo Giuseppe , Pelo Elisabetta , Piccione Maria , Pratesi Simone , Scarpuzza Emanuele , Serena Caterina , Severi Filiberto Maria , Strigini Francesca , Strobelt Nicola , Tagliabue Paolo Emilio , Taverna Rosaria , Tomasini Barbara , Vitaliti Marcello , Voller Fabio , Bartoloni Giovanni 
Published: December 2024

Abstract
Background
An effective strategy to reduce perinatal mortality requires an active surveillance system. This includes monitoring cases, organizing multidisciplinary local audits, conducting Confidential Enquiries, identifying avoidable factors, and facilitating changes in the healthcare system. In 2017, the Italian Obstetric Surveillance System launched the SPItOSS pilot Perinatal Surveillance System. The aim of this paper is to describe the results of the SPItOSS Confidential Enquiries on perinatal deaths focusing on the emergent critical aspects in obstetric and neonatal care, as well as on the healthcare facilities organization.

Methods
SPItOSS, a population-based surveillance system, collected and analysed incident perinatal deaths from July 2017 to June 2019 in three Regions encompassing 32.3% of Italian births. Cases were defined according to WHO definition as fetuses born dead ≥ 28 weeks of gestation and live newborn died within 7 days from birth. The International Statistical Classification of Diseases and related Health Problem-Perinatal Mortality was adopted for coding causes of death and contributing maternal and placenta-related conditions. Confidential Enquiries, prioritized according to perinatal deaths preventability, were conducted by expert committees at Regional and National level.

Results
A total of 830 incident perinatal deaths were notified, with 58.3% classified as antepartum, 4.3% as intrapartum, and 37.3% as neonatal deaths. According to the SPItOSS protocol, Confidential Enquiries evaluated only the most preventable deaths, including 19 intrapartum and 70 neonatal deaths. Of these, 43.8% were assessed as unavoidable with appropriate care; 29.2% as unavoidable with improvable care, and 15.7% as avoidable due to inappropriate care. Most intrapartum deaths were attributed to intrauterine hypoxia, while neonatal deaths recognized a multifactorial aetiology. Different aspects of inappropriate care were highlighted, such as failure to recognise maternal or fetal problems before labour, delayed or inappropriate neonatal resuscitation, and poor or suboptimal neonatal monitoring.

Conclusions
The SPItOSS Confidential Enquires provided insights for improving maternity and perinatal services. By targeting key areas of obstetric and neonatal care, the surveillance can generate recommendations and actions to prevent avoidable perinatal deaths.