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Pathology Following Stillbirth: Differences by Insurance Status and Educational Attainment
Ellie Diamond1,2, Suzan L Carmichael3,4, Elliott K Main4
1Department of Epidemiology and Population Health, Stanford University School of Medicine, California, USA.
Paediatric and Perinatal Epidemiology
|May 15, 2026
Summary
Higher socioeconomic status is linked to increased use of stillbirth pathology, particularly fetal autopsy. This highlights a disparity in determining stillbirth causes, emphasizing the need for equitable access to diagnostic procedures.
Area of Science:
- Perinatal epidemiology
- Public health research
- Socioeconomic determinants of health
Background:
- Stillbirth affects approximately 1 in 175 US births annually, necessitating pathological examination for etiological determination.
- Socioeconomic factors like education and insurance status may influence the utilization of stillbirth pathology services.
- Understanding these disparities is crucial for improving perinatal care and stillbirth investigation.
Purpose of the Study:
- To investigate the association between socioeconomic factors and the utilization of fetal autopsy and placental histopathology after stillbirth.
- To identify potential socioeconomic disparities in accessing post-stillbirth diagnostic procedures.
Main Methods:
- Analysis of linked California stillbirth records (2007-2020) including fetal death certificates and maternal hospitalization data.
- Socioeconomic indicators assessed: maternal education level and insurance status.
- Modified Poisson regression models were used to calculate adjusted risk ratios (RRs) for autopsy and placental histopathology, controlling for covariates.
Main Results:
- Only 22% of 34,668 stillbirths underwent fetal autopsy, while 55% had placental histopathology.
- Private insurance was associated with higher likelihood of both fetal autopsy (aRR 1.19) and placental histopathology (aRR 1.13) compared to public insurance.
- Individuals with a graduate degree were more likely to have a fetal autopsy (aRR 1.48) than those with less than a high school degree; no significant difference was observed for placental histopathology by education level.
Conclusions:
- Higher socioeconomic advantage correlates with increased utilization of stillbirth pathology, especially fetal autopsy.
- Significant disparities exist in accessing post-stillbirth diagnostic evaluations based on socioeconomic status.
- Addressing these inequities is essential for the critical goal of determining stillbirth causes and improving perinatal outcomes.
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