Characteristics and clinician perspectives associated with fetal autopsy completion and counseling

Fetal death certificate data reflect low fetal autopsy rates despite evidence-based recommendations that autopsy be performed in nearly all stillbirths. Data are lacking regarding clinical characteristics associated with fetal autopsy counseling and completion as well as clinician perspectives.

To identify (1) patient factors and (2) clinician beliefs and opinions associated with clinician counseling and performance of fetal autopsy STUDY DESIGN: A retrospective cohort study was performed including fetal deaths at 16w0d and greater across 20 hospitals in a geographically diverse healthcare system. Deliveries between 2014 and 2019 were included to minimize the potential effect of the COVID-19 pandemic on results. Pregnancies that ended due to elective or indicated termination were excluded. The primary analysis included stillbirths at 20w0d and greater with an exploratory analysis of fetal deaths between 16w0d and 19w6d. Demographic, medical, and obstetric data were obtained by medical record abstraction. Performance of counseling regarding fetal autopsy was determined by documentation of fetal autopsy as an evaluation option in the medical record. Rate of fetal autopsy, clinician counseling regarding fetal autopsy, and additional components of the stillbirth evaluation are reported overall; patient characteristics are then compared by these categories, with between-group differences tested with chi-square. Obstetric clinicians from the same medical system as the retrospective cohort were surveyed over a 10-week period in 2023 to assess beliefs, perceptions, and considerations regarding the use of fetal autopsy in stillbirth evaluation. Clinician responses were summarized descriptively and compared by clinician-reported perception of autopsy utility, and clinician-reported autopsy counseling completion, with differences tested using chi-square.

Overall, 1209 stillbirths were recorded during the study period, with 840 meeting criteria for analysis. A total of 558 (66%) were included in the primary analysis with a mean gestational age of 29.4 weeks. Fetal autopsy was performed following 126 (22.6%) of stillbirths, and autopsy was offered to 368 (65.9%) patients experiencing stillbirth. Higher maternal level of care was associated with fetal autopsy performance and clinician counseling for fetal autopsy (P=.024 and P=.008, respectively). No other patient characteristics were significantly associated with fetal autopsy performance or counseling. Among 383 invited clinicians, 131 (34.2%) responded to the survey; the majority were OB/GYN physicians (61.5%) followed by CNMs (23.0%). Most clinicians reported counseling >75% their patients on fetal autopsy (79.2%), but 54.6% also felt that it was helpful <25% of the time.

Despite being a valuable tool in identifying causes of stillbirth, fetal autopsy was completed in a minority of patients. Efforts are needed to improve clinician education on fetal autopsy, as this may increase counseling regarding the benefits of autopsy, performance of autopsy, and lead to better understanding of causes of stillbirth. Additional research into barriers and facilitators as well as the motivations of patients who pursue or decline fetal autopsy will enable designing more effective counseling on options for stillbirth evaluation.