Description | Specific Indicators | Ontario Public Health Standards | Corresponding Health Indicator(s) from Statistics Canada and CIHI | Corresponding Indicator(s) from Other Sources | Data Sources | ICD Codes | Analysis Check List | Method of Calculation |  Basic Categories | Indicator Comments | Definitions |  Cross-References to Other Indicators | Cited References | Changes Made | Acknowledgements

Description

• 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. 

• Perinatal mortality rate
• Crude stillbirth rate
• Stillbirth rate ≥ 500 g

• Board of Health Outcome (Reproductive Health): The board of health is aware of and uses epidemiology to influence the development of healthy public policy and its programs and services for the promotion of reproductive health. 
• Board of Health Outcome (Foundational Standard): The public, community partners, and health care providers are aware of relevant and current population health information Assessment and/or Surveillance Requirements Related to this Indicator.

Assessment and Surveillance Requirements Related to this Indicator (Reproductive Health)

• The board of health shall conduct epidemiological analysis of surveillance data... in the area of reproductive health outcomes.

http://www.ontario.ca/publichealthstandards

• Stillbirth Rate: Total fetal deaths occurring at gestational age of 28 weeks or more per 1000 total births.
• Perinatal Mortality Rate: Total stillbirths and infant deaths occurring in the first 7 completed days (i.e. 0 - 6 days after birth) per 1000 total births. Under "Health Status, Deaths".

Note that Statistics Canada includes stillbirths ≥28 weeks gestation in their Perinatal Mortality Rate, not ≥20 weeks gestation as per the APHEO Core Indicator definition.

http://www.statcan.gc.ca/pub/84f0210x/2008000/technote-notetech1-eng.htm

http://www.statcan.gc.ca/pub/82-221-x/2012002/tblstructure/1hs/1de/de1pmx-eng.htm

• World Health Organization (WHO) "Stillbirth Rate" definition can be found under "World Health Statistics" - "Mortality and burden of disease" - "Child Mortality": fetus ≥1000 grams or more or ≥28 weeks completed gestation http://apps.who.int/ghodata/
• WHO rates are adjusted estimates produced for the United Nations by the Inter-agency Group for Mortality Estimation (IGME) and are not necessarily the same as official national statistics. For detailed indicator definition, see the latest World Health Statistics Indicators Compendium: http://www.who.int/gho/indicator_registry/en/index.html 
• Canadian Perinatal Surveillance System (1):
• Crude Fetal Mortality (Stillbirth) Rate: number of fetal deaths (≥500g or ≥20 weeks gestation) per 1,000 total births.
• Fetal Mortality (Stillbirth) Rate ≥500 g: number of fetal deaths with a birth weight ≥500 g, and if birth weight unknown, with a gestational age ≥22 weeks, per 1000 total births.

Canadian Perinatal Health Report, 2008 

Note that 3 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. For information related to the data sources, refer to the Data Source resources and the Reproductive Health Core Indicators Documentation Report.

Vital Statistics Stillbirth Data
Original source: Vital Statistics, Ontario Office of Registrar General (ORG)
Distributed by: Ontario Ministry of Health and Long-Term Care (MOHLTC): IntelliHEALTH ONTARIO (IntelliHEALTH)
Suggested citation (see Data Citation Notes): Ontario Mortality Data [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].

Numerator & Denominator: 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 (see Data Citation Notes): Inpatient Discharges [years], Ontario Ministry of Health and Long-Term Care, IntelliHEALTH ONTARIO, Date Extracted: [date].

Numerator & Denominator: BORN Information System
Original source: Better Outcomes Registry Network (BORN) Ontario
Distributed by: Better Outcomes Registry Network (BORN) Ontario
Suggested citation (see Data Citation Notes): BORN Information System [years], Date Extracted: [date].

• Maternal complications of pregnancy: (ICD-9: E761); (ICD-10-CA: P01)
• Complications of placenta/cord/membranes: (ICD-9: E762); (ICD-10-CA: P02)
• Intrauterine hypoxia and birth asphyxia: (ICD-9: E768); (ICD-10-CA: P20; P21)
• Unspecified: (ICD-9: 779.9); (ICD-10-CA: P95; P96.9)
• Congenital anomalies: (ICD-9: 740-759); (ICD-10-CA: Q00-Q99)

• All causes
• All accidental deaths: (ICD-9: E800-E999); (ICD-10-CA: V01-Z99)
• Homicide/infanticide: (ICD-9: E960-E969); (ICD-10-CA: X85-Y09)
• Shaken Baby Syndrome: (ICD-9: 850-854 with E967); (ICD-10-CA: S06 with Y07)
• Child battery and maltreatment or criminal neglect: (ICD-9: E967 & E968.4); (ICD-10-CA: Y06-Y07)
• Falls: (ICD-9: E880-E888); (ICD-10-CA: W00-W19)
• RDS: Respiratory Distress Syndrome (ICD-9: 769.0-769.9); (ICD-10-CA: P22)
• SIDS: Sudden Infant Death Syndrome (ICD-9: 798.0); (ICD-10-CA: R95)
• Congenital anomalies: (ICD-9: 740-759); (ICD-10-CA: Q00-Q99)
• Low birth weight (not short gestation): (ICD-9: 764); (ICD-10-CA: P05)
• Low birth weight with short gestation: (ICD-9: 765); (ICD-10-CA: P07)
• Intrauterine hypoxia and birth asphyxia: (ICD-9: 768); (ICD-10-CA: P20 & P21)
• Other conditions of the perinatal period: (ICD-9: 760-764, 766, & 770-779); (ICD-10-CA: P00-P04, P08, & P23-P96)
• Pneumonia and influenza (ICD-9: 480-487); (ICD-10-CA: J10-J18)
• Certain gastrointestinal diseases (ICD-9: 008-009, 535, & 555-558); (ICD-10-CA: A00-A09, K29, K50-K52, K55-K63)

• The IntelliHEALTH licensing agreement does not require suppression of small cells, but caution should be used when reporting at a level that could identify individuals, (e.g. reporting at the postal code level by age and sex). Please note that privacy policies may vary by organization. Prior to releasing data, ensure adherence to the privacy policy of your organization.
• Aggregation (e.g. combining years, age groups, categories) should also be considered when small numbers result in unstable rates.
• Analyze mortality data by infant residence, not place of death. Analyze stillbirth data by mother's residence.
• For detailed information about live birth and stillbirth data provided in by the Ontario Registrar General, refer to Vital Statistics Live Births and Vital Statistics Stillbirths resources.
• HELPS Data: Historically, PHUs obtained data for live births, stillbirths, therapeutic abortions, congenital anomalies, and deaths from the Ministry of Health through HELPS (the HEalthPlanning System). Although these data are no longer commonly used, some PHUs may still be accessing these data files. Information about the data can be found in the HELPS Data Source resource.

• Use Deaths data source from the Vital Statistics folder in IntelliHEALTH, select #ON Deaths measure (number of deaths for Ontario residents who died in Ontario). Note: deaths for Ontario residents who died outside the province are not captured in Vital Statistics.
• Select appropriate geography from Deceased Information folder (public health unit or LHIN). Include other items, depending on your requirements (ICD10 Chapter, Lead Cause Group, age group, sex, etc.).
• In mortality data set, External Cause of Injury Codes (ICD10 V-Y; ICD9 E-Codes), and not Injury & Poisoning Codes (ICD20S-T codes; ICDD9 800 - 999 codes) are used in assigning primary cause of death. ICD-9 Chapter Primary Cause of death is available from C1986 to C1999, excludes Chap. 17 - Nature of Injury codes (never underlying cause) - includes Chap. 19 - External Causes.

• Use Birth Summary data source under Vital Statistics information map.
• Select a measure under Measures data item.  "# Births" gives the number of births (live births & stillbirths) to Ontario mothers who gave birth in ON excluding ON mothers who gave birth outside ON and "# LB" gives the number of live births.
• When selecting Maternal PHU, exclude births to "out-of-province" mothers.
• "Birth Type" under Birth Information may be used to select whether the birth is singleton, twin, or other.

• Use Stillbirth data source under Vital Statistics information map
• Under "Measures" data item, select "#SB(ON Res)" to obtain the number of stillbirths to mothers who resided in ON and gave birth in ON which excludes ON mothers who gave birth outside ON.

• Under the Inpatient Discharge Main Table data source from the ‘05 Inpatient Discharges' folder, use the "Hospital Births-newborns, stillborns" predefined report. This report can be modified, renamed and saved under your own folder.
• The report provides hospital birth counts (Admit Entry Type = N for Newborn or S for Stillbirth) for Ontario and by PHU, including only Ontario residents (Patient Province equal to ON).
• The calendar year for date of admission is used (Admit CYear) rather than date of discharge since the date of admission will be the same as the birthdate.
• Even though counts are grouped by calendar year of admission, it is the actual number of discharges that is counted.
• Select the appropriate calendar years, PHU, and "Newborn - Born Alive in Reporting Institution" and/or "Stillborn Infant born in Reporting Institution.
• Birth weight is not available in hospitalization data for stillbirths; as a result only the crude stillbirth rate can be calculated and not the stillbirth rate ≥500 g. Counts of stillbirths are available as of the 2003 calendar year.

• Public Health Units access BORN data through public health reports and data cubes.
• Refer to the BORN Information System Data Source for more information about the data.

• Geographic areas of patient residence:
  • Vital Statistics, Hospitalization data: Ontario, public health unit, municipality, and smaller areas of geography based on aggregated postal code
  • BORN data: Ontario, public health unit
• Age of mother, gestational age, birth weight, sex
• Specific cause of death

• Perinatal mortality reflects quality of obstetric and pediatric care, as well as the effectiveness of public health initiatives (2).
• Perinatal mortality is associated with age of mother, marital status, poverty, birth weight, and length of gestation (3). Disparities in the risk of perinatal death across subpopulations have been reported previously in Canada (including aboriginal populations) (4).
• 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 actual stillbirths, regardless of whether birth weight is recorded. The WHO recommends that all fetuses and infants weigh at least 500g, whether alive or dead, be included in international statistics, and when the weight is unavailable, that a gestational age of ≥22 weeks be used. This is because the legal requirement for registration of fetal deaths and live births vary across jurisdictions. This is the practice of the Canadian Perinatal Surveillance System. This is not the case in Ontario. 
• 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 (2). ICD code groupings provided in the Canadian Perinatal Health Report, appendix A.2, may be useful if examining cause-specific fetal mortality (1, 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.
• 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 (5). Aggregation may be necessary for reliability.
• 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. 
• 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 (6); 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.
• Mortality rate is higher among live births < 500g (7). Excluding stillbirths and live births <500 g 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 rate, perinatal mortality, infant mortality and/or calculate a three-year moving average (Refer to Document: Methods for Calculating Moving Averages).

• 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 7^th day of life (0 - 6 days of age).
• Neonatal mortality - death of a live born infant before the 28^th day of life (0 - 27 days of age).
• Early neonatal mortality - death of a live born infant before the 7^th day of life (0 - 6 days of age).
• Late neonatal mortality - death of a live born infant during the period between the 7^th and 28^th day of life (7 - 27 days of age).
• Postneonatal mortality - death of a live born infant between the 28^th and 364^th day of life.
• Infant mortality - death of a live born infant before the 365^th 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.

 Components of Fetal-Infant Mortality

• All-cause mortality (Section 3: Mortality, Morbidity and Health-Related Quality of Life)
• Potential Years of Life Lost [75] (Section 3: Mortality, Morbidity and Health-Related Quality of Life)
• Child and adolescent mortality (Section 6C: Child and Adolescent Health)
• Neonatal and Infant Mortality (Section 6B: Reproductive Health)

1. Public Health Agency of Canada. Canadian Perinatal Health Report. 2008 Edition. Ottawa, 2008
2. World Health Organization. Neonatal and Perinatal Mortality: Country, Regional and Global Estimates. 2006. Available from: http://whqlibdoc.who.int/publications/2006/9241563206_eng.pdf
3. 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.
4. Zhong-Cheng L, Senecal S, Simonet F, Guimond E, Penney C, Wilkins R. Birth outcomes in the Inuit-inhabited areas of Canada. CMAJ. 2010;182(3):235-42.
5. Woodward GL, Ardal S. Data Quality Report: Effect of Residence Code Errors on Fertility Rates. Central East Health Information Partnership, July 2000.
6. Bienefeld M, Woodward GL, Ardal S. Underreporting of live births in Ontario: 1991-1997. Central East Health Information Partnership, February 2001.
7. 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.