title: Impact of stillbirths on international comparisons of preterm birth rates: a secondary analysis of the WHO multi-country survey of Maternal and Newborn Health.
abstract: OBJECTIVE
  To evaluate the extent to which stillbirths affect international comparisons of preterm birth rates in low- and middle-income countries.
  
  
  METHODS
  Secondary analysis of a multi-country cross-sectional study.
  
  
  METHODS
  29 countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.
  
  
  METHODS
  258 215 singleton deliveries in 286 hospitals.
  
  
  METHODS
  We describe how inclusion or exclusion of stillbirth affect rates of preterm births in 29 countries.
  
  
  METHODS
  Preterm delivery.
  
  
  RESULTS
  In all countries, preterm birth rates were substantially lower when based on live births only, than when based on total births. However, the increase in preterm birth rates with inclusion of stillbirths was substantially higher in low Human Development Index (HDI) countries [median 18.2%, interquartile range (17.2-34.6%)] compared with medium (4.3%, 3.0-6.7%), and high-HDI countries (4.8%, 4.4-5.5%).
  
  
  CONCLUSIONS
  Inclusion of stillbirths leads to higher estimates of preterm birth rate in all countries, with a disproportionately large effect in low-HDI countries. Preterm birth rates based on live births alone do not accurately reflect international disparities in perinatal health; thus improved registration and reporting of stillbirths are necessary.
  
  
  CONCLUSIONS
  Inclusion of stillbirths increases preterm birth rates estimates, especially in low-HDI countries.
authors.affiliation: Department of Social Medicine, National Center for Child Health and Research, Tokyo, Japan.
authors.forename: N
authors.initials: N
authors.lastname: Morisaki
authors.affiliation: Department of Global Health Nursing, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
authors.forename: T
authors.initials: T
authors.lastname: Ganchimeg
authors.affiliation: UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
authors.forename: J P
authors.initials: JP
authors.lastname: Vogel
authors.affiliation: Perinatal and Pediatric Epidemiology Research Team, Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.
authors.forename: J
authors.initials: J
authors.lastname: Zeitlin
authors.affiliation: Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil.
authors.forename: J G
authors.initials: JG
authors.lastname: Cecatti
authors.affiliation: Department of Social Medicine, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil.
authors.forename: J P
authors.initials: JP
authors.lastname: Souza
authors.affiliation: Department of Pediatrics, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil.
authors.forename: C
authors.initials: C
authors.lastname: Pileggi Castro
authors.affiliation: Evidence Based Healthcare Post-graduate Program, Sao Paulo Federal University, Sao Paulo, Brazil.
authors.forename: M R
authors.initials: MR
authors.lastname: Torloni
authors.affiliation: Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan.
authors.forename: E
authors.initials: E
authors.lastname: Ota
authors.affiliation: Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan.
authors.forename: R
authors.initials: R
authors.lastname: Mori
authors.affiliation: Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, New York, NY, USA.
authors.forename: S M
authors.initials: SM
authors.lastname: Dolan
authors.affiliation: Departments of Paediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Tough
authors.affiliation: Department of Obstetrics & Gynecology, Fortis Memorial Research Institute, Gurgaon, India.
authors.forename: S
authors.initials: S
authors.lastname: Mittal
authors.affiliation: Department of Gynaecology, Obstetrics and Perinatology Central Hospital, Social Security Institute, Asuncion, Paraguay.
authors.forename: V
authors.initials: V
authors.lastname: Bataglia
authors.affiliation: National Center for Communicable Diseases, Ulaanbaatar, Mongolia.
authors.forename: B
authors.initials: B
authors.lastname: Yadamsuren
authors.affiliation: Departments of Pediatrics and of Epidemiology, Biostatistics and Occupational Health, McGill University Faculty of Medicine, Montreal, QC, Canada.
authors.forename: M S
authors.initials: MS
authors.lastname: Kramer
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D014943:Global Health / Q000706:statistics & numerical data*; D006306:Health Surveys; D006801:Humans; D011247:Pregnancy; D047928:Premature Birth / Q000453:epidemiology*; D050497:Stillbirth / Q000453:epidemiology*; D014944:World Health Organization
keywords: Global health; low income country; perinatal health; preterm birth; stillbirth