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Understanding high rates of stillbirth and neonatal death in a disadvantaged, high-migrant district in France: a perinatal audit.

INTRODUCTION
The objective of this study is to investigate factors associated with risks of perinatal death in a disadvantaged, high-migrant French district with mortality rates above the national average.


MATERIAL AND METHODS
The study design is a perinatal audit in all 11 maternity units in the Seine-Saint-Denis district in 2014 (25037 births). The data come from medical chart abstraction, maternal interviews and peer-assessor confidential review of deaths. A representative sample of live births in the same district, from the 2010 French Perinatal Survey, was used for comparisons (N=429). The main outcome measures were stillbirth and neonatal death (0 to 27 days) at ≥ 22 weeks of gestation.


RESULTS
The audit included 218 women and 227 deaths (156 stillbirths, 71 neonatal deaths); 75 women were interviewed. In addition to primiparity and multiple pregnancy, overweight and obesity increased mortality risks (50% of cases, adjusted odds ratios (aOR): 1.7 [95% confidence interval (CI): 1.1-2.8] and 1.9 [95% CI: 1.1-3.2], respectively) as did presence of pre-existing medical/obstetric conditions (28.6% of cases, aOR: 3.2 [95% CI: 2.0-5.3]). Problems accessing or complying with care were noted in 25% of medical records and recounted in 50% of interviews. Assessors identified suboptimal factors in 73.2% of deaths and judged 33.9% to be possibly or probably preventable. Care not adapted to risk factors and poor healthcare coordination were frequent suboptimal factors. Possibly preventable deaths were higher (p<.05) for women with gestational diabetes or hypertension (44.6%) than without (29.0%).


CONCLUSIONS
Preventive actions to improve healthcare referral and coordination, especially for overweight and obese women and women with medical and obstetrical risk factors, could reduce perinatal mortality in disadvantaged areas.