title: An evaluation of classification systems for stillbirth.
abstract: BACKGROUND
  Audit and classification of stillbirths is an essential part of clinical practice and a crucial step towards stillbirth prevention. Due to the limitations of the ICD system and lack of an international approach to an acceptable solution, numerous disparate classification systems have emerged. We assessed the performance of six contemporary systems to inform the development of an internationally accepted approach.
  
  
  METHODS
  We evaluated the following systems: Amended Aberdeen, Extended Wigglesworth; PSANZ-PDC, ReCoDe, Tulip and CODAC. Nine teams from 7 countries applied the classification systems to cohorts of stillbirths from their regions using 857 stillbirth cases. The main outcome measures were: the ability to retain the important information about the death using the InfoKeep rating; the ease of use according to the Ease rating (both measures used a five-point scale with a score <2 considered unsatisfactory); inter-observer agreement and the proportion of unexplained stillbirths. A randomly selected subset of 100 stillbirths was used to assess inter-observer agreement.
  
  
  RESULTS
  InfoKeep scores were significantly different across the classifications (p < or = 0.01) due to low scores for Wigglesworth and Aberdeen. CODAC received the highest mean (SD) score of 3.40 (0.73) followed by PSANZ-PDC, ReCoDe and Tulip [2.77 (1.00), 2.36 (1.21), 1.92 (1.24) respectively]. Wigglesworth and Aberdeen resulted in a high proportion of unexplained stillbirths and CODAC and Tulip the lowest. While Ease scores were different (p < or = 0.01), all systems received satisfactory scores; CODAC received the highest score. Aberdeen and Wigglesworth showed poor agreement with kappas of 0.35 and 0.25 respectively. Tulip performed best with a kappa of 0.74. The remainder had good to fair agreement.
  
  
  CONCLUSIONS
  The Extended Wigglesworth and Amended Aberdeen systems cannot be recommended for classification of stillbirths. Overall, CODAC performed best with PSANZ-PDC and ReCoDe performing well. Tulip was shown to have the best agreement and a low proportion of unexplained stillbirths. The virtues of these systems need to be considered in the development of an international solution to classification of stillbirths. Further studies are required on the performance of classification systems in the context of developing countries. Suboptimal agreement highlights the importance of instituting measures to ensure consistency for any classification system.
authors.affiliation: Mater Mothers' Research Centre, Mater Health Services, Brisbane, Australia. Vicki.flenady@mater.org.au
authors.forename: Vicki
authors.initials: V
authors.lastname: Flenady
authors.forename: J Frederik
authors.initials: JF
authors.lastname: Frøen
authors.forename: Halit
authors.initials: H
authors.lastname: Pinar
authors.forename: Rozbeh
authors.initials: R
authors.lastname: Torabi
authors.forename: Eli
authors.initials: E
authors.lastname: Saastad
authors.forename: Grace
authors.initials: G
authors.lastname: Guyon
authors.forename: Laurie
authors.initials: L
authors.lastname: Russell
authors.forename: Adrian
authors.initials: A
authors.lastname: Charles
authors.forename: Catherine
authors.initials: C
authors.lastname: Harrison
authors.forename: Lawrence
authors.initials: L
authors.lastname: Chauke
authors.forename: Robert
authors.initials: R
authors.lastname: Pattinson
authors.forename: Rachel
authors.initials: R
authors.lastname: Koshy
authors.forename: Safiah
authors.initials: S
authors.lastname: Bahrin
authors.forename: Glenn
authors.initials: G
authors.lastname: Gardener
authors.forename: Katie
authors.initials: K
authors.lastname: Day
authors.forename: Karin
authors.initials: K
authors.lastname: Petersson
authors.forename: Adrienne
authors.initials: A
authors.lastname: Gordon
authors.forename: Kristen
authors.initials: K
authors.lastname: Gilshenan
mesh_terms: D002423:Cause of Death; D002965:Classification / Q000379:methods*; D006801:Humans; D007391:International Cooperation; D015588:Observer Variation; D012042:Registries / Q000145:classification; D050497:Stillbirth