Pathology Following Stillbirth: Differences by Insurance Status and Educational Attainment

One in 175 births in the United States is a stillbirth-approximately 21,000 births annually. Pathology (fetal autopsy and placental histopathology) is recommended to help determine the aetiology of a stillbirth. However, socioeconomic factors, such as education level and insurance status, may influence whether stillbirth pathology is pursued.

We evaluated associations between socioeconomic factors and the use of pathology following stillbirth.

We analysed linked fetal death certificates and maternal hospitalisation discharge records from stillbirths occurring in California from 2007 to 2020. Socioeconomic indicators included maternal education level and insurance status. Study outcomes were fetal autopsy and placental histopathology, categorised as none or yes (completed or planned), as reported on the fetal death certificate. We used modified Poisson regression models with robust standard errors to estimate risk ratios (RRs) with 95% confidence intervals (CIs), adjusting for prespecified covariates: Birth year, maternal age, and racial and ethnic group.

Among 34,668 stillbirths, 22% (n = 7557) had an autopsy, and 55% (n = 19,000) had placental histopathology. Compared with public insurance, those with private insurance were more likely to have a fetal autopsy (adjusted RR 1.19, 95% confidence interval [CI] 1.12, 1.26) and placental histopathology (adjusted RR 1.13, 95% CI 1.09, 1.17). Compared with having less than a high school degree, those with a graduate degree were more likely to have a fetal autopsy (adjusted RR 1.48, 95% CI 1.32, 1.64); however, placental histopathology utilisation did not differ by education level after adjustment for covariates.

In this population-based study, we found that higher socioeconomic advantage is associated with higher use of pathology following stillbirth, particularly the use of fetal autopsy. Determining causes of stillbirth remains an important perinatal priority, and these results identify an important disparity to address.