THE PERINATAL-MORTALITY RATE AS AN INDICATOR OF QUALITY OF CARE IN INTERNATIONAL COMPARISONS

The perinatal mortality rate is used as an indicator of the quality of antenatal and perinatal care, yet uncritical application of this indi cator in international comparisons can be misleading. The perinatal mo rtality rate depends on a number of factors and important determinants that need to be assessed separately before reaching conclusions about quality-of-care issues. This article provides a conceptual model of t he construction of the perinatal mortality rate. It illustrates the re lationship between quality of antenatal and perinatal care and risk fa ctors for perinatal mortality and how these lead to the perinatal mort ality rate. It also indicates how differences in registration procedur es and practices influence the final mortality figures published by in dividual countries. For international comparison, the first step is to apply common definitions. The rate can vary by 50% depending on the d efinition used. Also, sources of registration bias need to be examined , because they differ considerably by country. Underregistration is kn own to be as high as 20% of perinatal deaths. The next step is to corr ect perinatal mortality figures according to differences in known risk factors. The perinatal mortality rate then can serve as a reasonable indicator for the quality of antenatal and perinatal care. In western countries, perinatal mortality could be seduced by as much as 25% with improved standards of care. Policies and practices in individual coun tries concerning ethical issues related to termination of pregnancy an d care of newborn infants with (very) poor prognosis need to be taken into account as well. They are not related to quality of care, but do have a relatively large impact on the perinatal mortality rate.