REPORT OF COMMITTEE ON MATERNAL AND PERINATAL HEALTH
CM-MPH Report 5-A-06
Subject: Need for Perinatal Autopsies Following Stillbirth
Presented by: Janet Realini, MD, MPH, Chair
Referred to: Reference Committee on Public Health
Stillbirth is a common occurrence. In 2003, there were nearly as many cases - about 26,000 a year - as there were deaths of babies in the entire first year of life. One major study found that stillbirths are five times more common than sudden infant death syndrome.
However, the medical community knows little about intrauterine death, its causes, its frequency, and parental needs following such an experience. This is due to limits of the medical and scientific information about stillbirths and to the lack of access to information that does exist.
While the cause for about half of all stillbirths is unknown, some causes are detectable through a perinatal autopsy performed by a perinatal pathologist: (1) 15 to 20 percent of stillborn children have a major malformation, (2) 8 percent of stillbirths have a chromosomal abnormality, and (3) 20 percent have dysmorphic or skeletal abnormalities.
The value of routinely conducting a perinatal autopsy after stillbirth is well-documented in the peer-reviewed literature, where it has been shown that a conclusive autopsy can change or significantly add to the clinical diagnosis 25 percent of the time. In addition to adding to the scientific body of knowledge about stillbirth, a perinatal autopsy leads to improved patient care through (1) emotional closure for the family, (2) proper counseling for future pregnancies, (3) improved management approach for future pregnancies, and (4) detection of chronic disease states of the mother (e.g., thrombophilias) and prevention of maternal morbidity/mortality.
The American College of Obstetricians and Gynecologists (ACOG) and the College of American Pathologists (CAP) encourage the use of autopsies for all perinatal deaths. But there are hurdles. Many families cannot pay for the procedure, which typically costs about $1,000 to $1,500 in routine cases. And in Texas, no established mechanism exists for connecting perinatal pathologists with the need for their services or to share information learned from autopsies.
The Committee on Maternal and Perinatal Health believes TMA should study a way to ensure availability, insurance coverage - including Medicaid coverage, and coordination of perinatal autopsies in Texas.
Models and resources are available. For example, CAP already has developed protocols for proper investigational procedures performed by a perinatal pathologist. The Wisconsin Stillbirth Service Program at the University of Wisconsin-Madison, a research program dedicated to stillbirth since 1983, provides families and health professionals of Wisconsin comprehensive services for the evaluation of stillborn infants. In 2003, the National Institute of Child Health and Human Development established the Stillbirth Collaborative Research Network to study the epidemiology and etiology of stillbirth; the network includes The University of Texas Medical Branch at Galveston and The University of Texas at San Antonio .
The National Fetal and Infant Mortality Review (NFIMR) Program is a collaborative effort between the U.S. Maternal and Child Health Bureau and the ACOG that addresses FIMR issues. In 2005, TMA supported Texas SB 1183, which would have created FIMR review teams in Texas to identify trends in mortality of fetuses and infants through the study of medical and other records. This bill, which the March of Dimes also supported, passed the Senate and its House committee (the clock ran out before it could progress). Fetal autopsies should be an integral part of this study.
Recommendation : That the Texas Medical Association study a system for Texas that would coordinate the provision and reporting of results of fetal autopsies following stillbirth, performed by perinatal pathologists with coverage through health insurance or government payer.
TMA House of Delegates: TexMed 2006