Changes in State-Level Definitions of Fetal Death and the Reporting of Fetal Death and Periviable Live Births in the United States, 1996 to 2021: A Panel Study

The World Health Organization’s 2030 Sustainable Development Goals include reducing the risk of fetal death. Even in high-income countries such as the United States (US), fetal deaths remain under-counted, with reporting showing variable quality across place and time. In the US, a uniform national definition of fetal death does not exist. Scant work characterizes whether, and to what extent, definitional changes in fetal death in US states over time affect fetal death reporting as well as counting of live births among similarly very frail (i.e., periviable born <26 weeks) infants. We aimed to (i.) identify state-level changes in fetal death reporting guidelines or definitions for all 50 US states from 1995 to 2020 and (ii.) examine whether counts of fetal deaths, periviable births, and neonatal deaths among periviable births shifted in the years following such changes. We retrieved data for all 50 US states from 1996 to 2021 for this descriptive analysis (n=642,551 fetal deaths, n= 420,000 periviable births, n= 195,663 neonatal deaths among periviable births). We reviewed the fetal death user guides for state changes in reporting guidelines and conducted an internet search to find other state changes in the definition of fetal death. Next, we modeled fixed-effects linear regressions to examine associations between changes in fetal death reporting guidelines and our three outcomes. Over the test period, 12 states changed their definition of fetal death. Regression results show increases in the counts of fetal deaths, periviable births, and neonatal deaths among periviable births following changes in reporting guidelines. These increases followed any change in reporting guidelines—whether perceived as a more inclusive or more restrictive change. Results hold across a range of alternative specifications. Our findings cohere with the notion that any state-level change in fetal death definitions corresponds with broader efforts to improve data collection and reporting protocols among not only fetal deaths but also periviable births. The fact that we observe such associations should encourage strategies to control for such “data breaks” for scientists and officials concerned with fetal death and/or periviable birth.