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Medical certificates of stillbirth should record the likely cause of death for babies who died in the womb. However, research found major errors in most certificates. Many (43%) certificates had no recorded cause of death, even where the cause was identifiable.

These certificates are intended to give parents information about why their baby died. For review boards, they may suggest steps that could have prevented the death. Following this study, researchers call for an independent review of the process of medical certification of stillbirth.

This UK-wide study found numerous errors in the documents. Around 1 in 4 deaths were caused by the baby not gaining weight as expected (fetal growth restriction). This was the leading cause of death, but was rarely documented on certificates.

A full review is carried out for every stillbirth; this takes time and includes test results that could not be known when the certificate is issued. The researchers recommend that every stillbirth should, in addition, have a rapid review, before the certificate is produced. They also recommend additional training for clinicians on completing the certificates.

These measures would improve the accuracy of the causes of stillbirths on certificates, the researchers say. This would enable individual Trusts, and national policy makers, to target resources to improve the care provided by maternity services.  

More information about stillbirth is available on the NHS website.

The issue: how accurate are certificates of stillbirth?

A stillbirth is when a baby dies in the womb after 24 weeks of pregnancy. In 2020, around 3 in 1000 pregnancies in the UK ended in stillbirth. Recently published stillbirth statistics from 2021 have shown the first increase in stillbirth rates in many years.

A medical certificate of stillbirth should record the most likely cause of death and the stage of pregnancy when death occurred. These certificates are needed for burial and cremation, and most are issued within days of the baby’s death.

Data from the certificates are used to show how common stillbirths are, and to identify stillbirths that might have been prevented. It is intended to inform future strategies to improve maternity services, and to reduce deaths.

However, a 2015 review in North West England, found that almost half of all certificates had major errors. The cause of death was frequently documented as unexplained, even though few deaths remained unexplained after review of other hospital records by an audit team.

In this study, researchers investigated medical certificates of stillbirth issued throughout the UK in 2018. They also explored whether the accuracy of the certificate was related to the experience level or profession of the person who wrote it.

What’s new?

Certificates of stillbirth were collected by a network of doctors called the UK Audit and Research Collaborative in Obstetrics and Gynaecology (UKARCOG). This study was an analysis of 1,246 certificates of stillbirth, from 76 hospitals in 2018.

The researchers formed a network of 115 trainee doctors (UKARCOG’s NESTT or National Evaluation of Accuracy of Stillbirth Certificates Working Group). The trainees used the mother’s hospital records to create ‘ideal’ stillbirth certificates. They used only the information that would have been available to the professional who issued the certificate. The trainees compared the accuracy of actual medical certificates of stillbirth with their ‘ideal’ version.  

Major errors were an incorrect cause of death, certificates issued where the baby was known to have died before week 24 of the pregnancy (which is considered a miscarriage, not a stillbirth), and certificates issued for babies who showed signs of life at birth (a neonatal death, not stillbirth). All other errors, including incorrect sex and birthweight, were considered minor.

The researchers found that:

  • most (82%) certificates contained an error; more than half (56%) errors were major
  • incorrect or unexplained causes of death were the most common major error; many (43%) certificates had an unexplained cause of death, despite most (78%) of these ‘unexplained deaths’ having an identifiable cause after case review
  • many causes of death were underreported, especially fetal growth restriction, which caused 1 in 4 deaths, plus conditions related to the placenta.

Neither the seniority nor profession of the person who issued the certificate influenced the accuracy of certificates. Certificates from hospitals that had been previously audited in 2015 were less likely to contain major errors, as were certificates issued to women who had experienced a previous stillbirth.  

Why is this important?

This was the largest study to date of the accuracy of medical certificates of stillbirth. The national results were similar to the 2015 study in North West England. The researchers say the number of errors is unacceptably high and they call for a national, independent review of the process of medical certification of stillbirth.

Not knowing the cause of the baby’s death can add to families’ distress. It can also put mothers and future pregnancies at risk. Recording the cause of death alerts clinicians to potential problems in subsequent pregnancies, and allows them to make appropriate plans for pregnancy care.

On a wider scale, inaccurate certificates make it difficult to determine what steps need to be taken to improve care in maternity services, locally and nationally.

There were fewer errors in certificates when women had experienced a previous stillbirth. It may be that healthcare professionals paid closer attention to the available information when certifying cause of stillbirths among this group.  

What’s next?

In hospitals that had previously been audited, certificates were more accurate. Local initiatives had been put in place: sharing guidelines and carrying out regular reviews of certificates, for example. The researchers recommend that these initiatives are implemented nationally. A review of every stillbirth, involving midwifery and medical team members, and other professionals as required, could improve the quality of medical certificates of stillbirth, they say.

Fetal growth restriction, which may be a potentially preventable death, was underreported. For lessons to be learned, the researchers recommend that the birthweight centile of the baby and their growth trajectory before birth should be assessed for every stillbirth.

With simple guidance, junior doctors could assign a likely cause of death for most stillborn babies in this study. Basic training for midwifery and medical clinicians of all experience levels, could improve the accuracy of certificates, they say.

The researchers suggest that an electronic reporting system could allow initial certificates to be issued quickly for the purposes of funeral services. These initial certificates could be updated with more information following a specialist team review and investigation results. However, this would require a major change to current UK legislation and practice. Bereaved parents could be told in a follow-up appointment about any changes to the certificate and any implications for the mother’s health or future pregnancies.

The researchers reviewed a relatively small number of stillbirths (1270) and information was often missing. This could mean there were actually more errors than these findings suggest. However, the reported number is still unacceptably high, the researchers say.

You may be interested to read

This NIHR Alert is based on: Rimmer MP, and others. Worth the paper it’s written on? A cross-sectional study of Medical Certificate of Stillbirth accuracy in the UK. International Journal of Epidemiology 2022

Video summary of the study created by UKARCOG NESTT.

A plain language summary of the paper has been created by Tommy’s.

The Stillbirth and Neonatal Death Society (SANDS) charity provides information and support regarding pregnancy loss and stillbirth.  

A similar study conducted in the US examining the accuracy of stillbirth certificates: Brooks EG, and others. Principles and pitfalls: a guide to death certification. Clinical Medical & Research 2015;13:74–82.

Funding: Authors of the study were supported by the NIHR Academic Clinical Lectureship and the NIHR Clinician Scientist Fellowship.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

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