Worth the paper it’s written on? A cross-sectional study of Medical Certificate of Stillbirth accuracy in the UK
Authors: Rimmer Michael P , Henderson Ian , Parry-Smith William , Raglan Olivia , Tamblyn Jennifer , Heazell Alexander E P , Higgins Lucy E ,   the UKARCOG NESTT working group authors, Aadan H , Ajoku K F , Asim S , Badger E J , Barfi L E , Bevington L M , Bhat M , Black N , Black R E , Boughey S A , Brewster C B , Buchanan C E , Bullough S H , Byrne V , Carpenter C C , Carron S A , Conti-Ramsden F , Cordell V C , Craggs S , Creswell L C , Cury Fernandes A , Dalton J A , Dracocardos D V , Dunlop C E , Egan J K , Ejiofor C I , Elderfield C H J , Faluyi D , Geddes-Barton D M , Giacchino T , Giles S E , Goodier E A , Goodman J K , Govil M , Grainger R , Guyett E A , Haken A J , Harrison R C , Hartley J L , Hogg F S , Hutchinson E , Jamie H S , Jamison L A C , Jaufuraully S , Jethwani G , Jones C M , Karapanos I , Karavadra B , Kasaven L S , Kaur R , Kermack A J , King A , Lallemant C L B , Lattey K R , Layden E A , MacMahon C A , Maddy L R , Magee S M , Mahilchi Sudar L , Mahmud A , Marks K J , McNally A , Medford E S , Milliken S V I , Mogekwu O M , Mohamed H E , Moorhouse S S , Mouhajer M , Mumtaz H , Murphy L L , Navaratnam K , Neville A E , Nijjar S K , O’Brien S , Obeysekera M H , Odonde R I , Ofodile O , Okagbue N , Parnell L , Pearce M D , Petrovic M , Picart S R , Plant C L , Powell H M , Powell S E , Preston L , Raglan O , Ramcharn M , Reilly K M , Riaz N , Riches J M , Rutherford D R , Sathyendran P , Shamsudin F , Simonian M , Smith K E , Sohal-Burnside J K , Standing L J , Stirrat L I , Stocker L J , Subba K , Summerhill C , Taylor C J , Thomson S , Thyne K C A , Tomlinson F , Troko J , Verasingam N , Welch H E , Whittle K M , Williams S G , Wilson K J , Wilson S F , Wilson-Theaker W P , Wyeth C L M 
Published: April 2022

Abstract

Background
The Medical Certificate of Stillbirth (MCS) records data about a baby’s death after 24 weeks of gestation but before birth. Major errors that could alter interpretation of the MCS were widespread in two UK-based regional studies.

Methods
A multicentre evaluation was conducted, examining MCS issued 1 January 2018 to 31 December 2018 in 76 UK obstetric units. A systematic case-note review of stillbirths was conducted by Obstetric and Gynaecology trainees, generating individual ‘ideal MCSs’ and comparing these to the actual MCS issued. Anonymized central data analysis described rates and types of error, agreement and factors associated with major errors.

Results
There were 1120 MCSs suitable for assessment, with 126 additional submitted data sets unsuitable for accuracy analysis (total 1246 cases). Gestational age demonstrated ‘substantial’ agreement [K = 0.73 (95% CI 0.70–0.76)]. Primary cause of death (COD) showed ‘fair’ agreement [K = 0.26 (95% CI 0.24–0.29)]. Major errors [696/1120; 62.1% (95% CI 59.3–64.9%)] included certificates issued for fetal demise at &lt;24 weeks’ gestation [23/696; 3.3% (95% CI 2.2–4.9%)] or neonatal death [2/696; 0.3% (95% CI 0.1–1.1%)] or incorrect primary COD [667/696; 95.8% (95% CI 94.1–97.1%)]. Of 540/1246 [43.3% (95% CI 40.6–46.1%)] ‘unexplained’ stillbirths, only 119/540 [22.0% (95% CI 18.8–25.7%)] remained unexplained; the majority were redesignated as either fetal growth restriction [FGR: 195/540; 36.1% (95% CI 32.2–40.3%)] or placental insufficiency [184/540; 34.1% (95% CI 30.2–38.2)]. Overall, FGR [306/1246; 24.6% (95% CI 22.3–27.0%)] was the leading primary COD after review, yet only 53/306 [17.3% (95% CI 13.5–22.1%)] FGR cases were originally attributed correctly.

Conclusion
This study demonstrates widespread major errors in MCS completion across the UK. MCS should only be completed following structured case-note review, with particular attention on the fetal growth trajectory.