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of public health epidemiology in Ontario

Perinatal Mortality and Stillbirth Rates Core Indicator

  • Perinatal mortality: the total number of deaths of a fetus or infant between the end of the 20th week gestation and the end of the 6th day of life in a calendar year per 1,000 total births (live births and stillbirths) in the same calendar year.
  • Crude stillbirth rate: the total number of stillbirths per 1,000 total births.
  • Stillbirth rate ≥ 500 g: the total number of stillbirths ≥500 g per 1,000 total births. 
Report an IssueAppendices

Related OPHS Topics

Reproductive Outcomes
 

Method of Calculation

 
Perinatal Mortality Rate
Total number of stillbirths and deaths in infants 6 days of age or younger
1000
Total number of births (live births & stillbirths)
1000
 
Crude Stillbirth Rate
Total number of stillbirths
1000
Total number of births (live births & stillbirths)
1000
 
Stillbirth Rate ≥ 500 g
Total number of stillbirths ≥ 500 g
1000
Total number of births ≥ 500 g (live births & stillbirths)
1000

Recommended Subset Analyses

Age of Mother
Gestational Age
Birth Weight
Sex
  • There are no recommended groupings, consider category grouping based on the analysis question.
Geographic Areas of Patient Residence
  • Ontario
  • Public health unit
  • Municipality 
  • Smaller areas of geography based on aggregated postal code
Specific Cause of Death
  • Analyse by ICD code depending on the analysis question.


Data Sources

Numerator
Denominator 
Vital Statistics Stillbirth DataVital Statistics Mortality Data

Original Source:

Vital Statistics, Office of Registrar General (ORG), Service Ontario

Distributed by:

Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH Ontario (IntelliHEALTH)

Suggested Citation:

Ontario Stillbirth Data [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].

Ontario Mortality Data [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].
Vital Statistics Live Birth DataVital Statistics Stillbirth Data

Original Source:

Vital Statistics, Office of Registrar General (ORG), Service Ontario

Distributed by:

Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH Ontario (IntelliHEALTH)

Suggested Citation:

Ontario Live Birth Data [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].

Ontario Stillbirth Data [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].
Alternative Data Source Alternative Data Source 
Hospitalization Data

Original Source:

Discharge Abstract Database (DAD), Canadian Institute for Health Information (CIHI)

Distributed by:

Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH Ontario (IntelliHEALTH)

Suggested Citation:

Inpatient Discharges [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].
BORN Information System

Original Source:

Better Outcomes Registry Network (BORN) Ontario

Distributed by:

Better Outcomes Registry Network (BORN) Ontario

Suggested Citation:

BORN Information System [years], Date Extracted: [date].
Data Elements in the BORN Information System (BIS) Public Health Data Cube

Dimension

Categories

Data Dictionary Definition

Pregnancy Outcome
  • Live birth
  • Stillbirth at >=20 weeks or >=500 gms
  • Stillbirth at >=20 weeks or >=500 gms \ Spontaneous - occurred during antepartum period
  • Stillbirth at >=20 weeks or >=500 gms \ Spontaneous - occurred during intrapartum period
  • Missing data

Stillbirth at >=20 weeks or >=500 gms
Newborn DOB Calendar
  • 2013 - Present

Newborn calendar year of birth
For further detail, please see the BORN Data Dictionary.  

  
  
 

Analysis Checklist  

General Checklist
  • Analyze mortality and live birth data by infant residence, not place of death. Analyze stillbirth data by mother's residence.
  • Note that three data sources are listed for use: 1) Vital statistics, 2) Hospitalization, 3) BORN. The choice of data source will depend upon data quality within a health unit as well as data access and the specific analysis questions. Possible alternatives are provided in case the vital statistics are too far out of date.  
      • Please follow the Analysis Checklist for the selected data source(s).  If using IntelliHealth, the Vital Statistics: Stillbirth page includes the relevant Analysis Checklist.  
  • When using hospitalization, please note that early neonatal deaths are well captured but later neonatal deaths will not be so well captured.
  • There are some cautions when using BORN for this indicator.  For instance, the definition of stillbirths in BORN can vary according to reporting source.  The definition of neonatal deaths in the BORN data dictionary is <28 days, which is different from APHEO definition of <7 days. This difference may also affect reporting of stillbirths and perinatal deaths because perinatal deaths include stillbirths and early neonatal deaths.

Indicator Comments

General Comments
  • Perinatal mortality reflects quality of obstetric and pediatric care, as well as the effectiveness of public health initiatives (3).
  • Perinatal mortality is associated with age of mother, marital status, poverty, birth weight, and length of gestation (4). Disparities in the risk of perinatal death across subpopulations have been reported previously in Canada (including aboriginal populations) (5).
  • The definition of stillbirth can vary over place and time. In Canada, a stillbirth is defined as ≥20 weeks gestation or ≥500 g. However this has not been consistent in all provinces over time. Other jurisdictions may have a different definition of stillbirth by length of gestation (≥20, 22, or 28 weeks), or weight (≥400 g, 500 g, or 1,000 g), or both. Therefore provincial or international comparisons of stillbirth and perinatal mortality rates should be made with caution.
  • The definition of a stillbirth is consistent across Ontario. The APHEO Core Indicator assumes that stillbirths recorded in Vital Statistics, hospitalization data, or the BORN Information System are true stillbirths, regardless of whether birth weight is recorded.
  • Determining the true cause of death is not always clear resulting in somewhat subjective primary cause of death being listed on death certificate. The reported cause of death may also be influenced by the social or legal conditions surrounding the death and by the level of medical investigation (3). ICD code groupings provided in the Canadian Perinatal Health Report, appendix A.2, may be useful if examining cause-specific fetal mortality (5, p197).
  • The number of stillbirths may be under-reported. Data quality concerns for 1991 and 1992 stillbirth information indicate that it should not be used. Please refer to Vital Statistics Live Births and Vital Statistics Stillbirths resources for details.
  • World Health Organization (WHO) "Stillbirths" definition can be found under "Maternal, newborn, child and adolescent health". WHO defines stillbirth as a baby born with no signs of life at or after 28 weeks’ gestation. This is available at: https://www.who.int/maternal_child_adolescent/epidemiology/stillbirth/en/
  • The WHO definition can also be found in the 2015 Global Reference List of 100 Core Health Indicators: "For purposes of international comparison, stillbirths are defined as third trimester fetal deaths (≥ 1000 g or ≥ 28 weeks)”. https://www.who.int/healthinfo/indicators/2015/en/
  • For International Comparisons the WHO’s recommendations are used - Fetal Mortality (Stillbirth) Rate: 1) number of fetal deaths with a birth weight ≥500 g, and if birth weight is missing, those with a gestational age ≥22 weeks, per 1000 total births; and 2) number of fetal deaths among births with a birth weight ≥1000 g, or if birth weight is missing, those with a gestational age ≥28 weeks, per 1000 total births.

Vital Statistics Live Birth Data
  • There has been an increase in the number of stillbirths which have P964, (Termination of pregnancy affecting fetus and newborn), as the cause of death in Ontario over time. (Please refer Vital Statistics Stillbirths documents for details). It is unknown whether this increase is the result of a true increase in the occurrence of such events or due to increased registration of these stillbirth events. Overall, the number of stillbirths in Ontario has been increasing; however, stillbirth numbers are stable if those with P964 cause of death are removed. Health units may want to calculate overall rates as well as rates with P964-coded stillbirths removed to determine their impact.
  • Mortality rate is higher among live births <500g (6). Excluding stillbirths and live births <500g from stillbirth and perinatal mortality rates may reduce fluctuations in estimates and facilitate comparisons across jurisdictions. Please refer to Reproductive Health Documentation Report for recommendations on excluding stillbirths and live births < 500 g from reproductive health indicators.
  • Given the small number of stillbirths/perinatal and infant deaths, stillbirth rate, perinatal and infant mortality rates may fluctuate from year to year. It may be beneficial to group years when reporting stillbirth, perinatal mortality, infant mortality rates, or to calculate a three-year moving average (Refer to Document: Methods for Calculating Moving Averages).
  • Refer to the Reproductive Health Documentation Report for a summary of data quality concerns identified for stillbirth data. 
  • Registration fees initiated in some CSDs in 1996 may have reduced the number of infants registered, especially for low income and/or adolescent parents (7); however, it is worth noting that registration fees have since been discontinued in Ontario. For more details, including information about temporal changes in municipal fees for birth registration, please refer to the Timeline of Changes in Live Birth Registration in Ontario document.
  • The number of births registered in some Census Subdivisions (CSDs) changed dramatically starting in 1991 when the Office of the Registrar General moved from Toronto to Thunder Bay (8). Aggregation may be necessary for reliability.


BORN Information System
  • Note: While BORN data is often the most up to date, users should take caution when using it as an alternative source for this indicator, as there have been issues identified with BORN stillbirth data (see the PHO BORN report (1) ).  BORN has made improvements in data quality over time, and undertook a comparison of BORN data to CIHI-DAD data in 2019, with a discussion around stillbirth capture in that publication (2). Ideally, when more recent years of data are available from the Vital Statistics Stillbirth data, a comparison between all three different sources will be done.

Components of Fetal-Infant Mortality






References

Glossary

Gestational age - calculated as the interval between the date of delivery of the fetus or newborn and the first day of the mother's last normal menstrual period.

Live birth - the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of the pregnancy, which, after such separation, breathes or shows any other evidence of life (such as a heartbeat, umbilical cord pulsation, or definite movement of voluntary muscles), whether the umbilical cord has been cut or the placenta is attached. A live birth is not necessarily a viable birth.

Miscarriage - pregnancies that end by spontaneous abortion before 20 weeks of gestation or a birth weight of 500 grams.

Perinatal mortality - death during the period between 20 weeks of gestation and the 7th day of life (0 - 6 days of age).

Neonatal mortality - death of a live born infant before the 28th day of life (0 - 27 days of age).

Early neonatal mortality - death of a live born infant before the 7th day of life (0 - 6 days of age).

Late neonatal mortality - death of a live born infant during the period between the 7th and 28th day of life (7 - 27 days of age).

Postneonatal mortality - death of a live born infant between the 28th and 364th day of life.

Infant mortality - death of a live born infant before the 365th day of life.

Stillbirth - death prior to the complete expulsion or extraction from its mother of a product of conception. The death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles. Only fetal deaths where the product of conception has a birth weight of 500 grams or more or the duration of pregnancy is 20 weeks or longer are registered in Canada.

Stillbirth rate - the number of stillbirths per total births. Also called the fetal mortality rate.

Cited References
  1. Public Health Ontario. BORN Information System: A Data Quality Assessment for Public Health monitoring. Technical Report, March 2016; Available at: https://www.publichealthontario.ca/-/media/documents/born-data-quality-assessment.pdf?la=en. Accessed 2019-06-11.
  2. Miao Q, Fell DB, Dunn S, Sprague AE. Agreement assessment of key maternal and newborn data elements between birth registry and clinical administrative hospital databases in Ontario, Canada. Arch. Gynecol. Obstet. 2019;300(1):135-143. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31111244. Accessed prior to October 1, 2019.
  3. World Health Organization. Neonatal and Perinatal Mortality: Country, Regional and Global Estimates. 2006. Available at: http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf Accessed prior to February 22, 2013. 
  4. Spong CY, Iams J, Goldenberg R, Hauck FR, Willinger M. Disparities in perinatal medicine: preterm birth, stillbirth and infant mortality. Obstet Gynecol. 2011;117(4):948-55.
  5. Public Health Agency of Canada. Perinatal Health Indicators for Canada 2017. Available at: http://publications.gc.ca/collections/collection_2018/aspc-phac/HP7-1-2017-eng.pdf. Accessed prior to June 21, 2019.
  6. Joseph KS, Kramer MS. Recent trends in Canadian infant mortality rates: the effect of changes in registration of live newborns weighing less than 500g. Can Med Assoc J 1996; 155:1047-52.
  7. Bienefeld M, Woodward GL, Ardal S. Underreporting of live births in Ontario: 1991-1997. Central East Health Information Partnership, February 2001.
  8. Woodward GL, Ardal S. Data Quality Report: Effect of Residence Code Errors on Fertility Rates. Central East Health Information Partnership, July 2000.
  9. Statistics Canada. Data quality, concepts and methodology: definitions.  Available at:  https://www.statcan.gc.ca/eng/statistical-programs/document/3231_D5_T9_V1. Date modified: 2017-11-24. Accessed August 28, 2019. 
  10. Statistics Canada. Fetal deaths (20 weeks or more of gestation) and late fetal deaths (28 weeks or more of gestation). Available at:  https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310042701. Date modified: 2019-08-28. Accessed August 28, 2019.


Acknowledgements

Lead Authors

Adam Stevens, Brant County Health Unit

Natalie Greenidge, Public Health Ontario

Carol Paul, Ontario Ministry of Health and Long Term Care

Enayetur Raheem, Windsor Essex County Health Unit

Nancy Ramuscak, Peel Public Health

Reviewers

Sarah Ahmed, Toronto Public Health

Reproductive Health Subgroup

Revision History

 This Core Indicator Product webpage is maintained by the Reproductive Health Subgroup.  
Date Review Type Author Changes PDF
August 13, 2012 - January 16, 2013 Formal Review Reproductive Health Sub-Group
  • Replaced Mandatory Health Programs section with updated Ontario Public Health Standards outcomes.
  • All sections updated in alignment with the Guide to Creating or Editing Core Indicator pages.
  • Updated the indicator definition. Added Stillbirth rate ≥500 g to the Specific Indicators and removed Perinatal Mortality Ratio.
  • Three data sources cited with analysis check-list for each.
  • Updated Corresponding Indicators from Other Sources, Method of Calculation, Indicator Comments, Cited References.
February 22, 2013  Ad Hoc  Reproductive Health Sub-Group
  • Method of calculation for "Stillbirth Rate ³ 500 g": changed the denominator to "total number of births ³ 500 g" from "total number of births".
December 3, 2019 
Formal Review, and
Website Update
Reproductive Health Subgroup,
with Caitlyn Paget, on behalf of the CIWG 
    Full update of indicator document including:
  • Indicator definitions and analysis checklist accordingly.  

    • Migrated to new website structure and format, including:
  • Reorganized content to provide high-level information at a glance, and move in-depth analytic information into dedicated sections for users to access when needed.  
  • Renamed "Basic Categories" section to "Recommended Subset Analysis Categories"; "Definitions" renamed to "Glossary".  
  • Replaced both "Cross-References to Other Indicators" and "OPHS" sections with "Related OPHS Topics" to crosslink with relevant Core Indicators webpages including OPHS program standard(s) and associated indicator(s).
  • Added descriptive sub-headings to the Analysis Checklist and Indicator Comments sections.
  • Removed "Corresponding Health Indicator(s) from Statistics Canada and CIHI" and "from Other Sources" sections, moving WHO definitions into the Indicator Comments.  
  • Updated Revision History table, and added PDF copy of previous version for reference.

 

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