We have performed a full cross-validation of this clinical Femina data collection against the routinely collected data of the Medical Birth Registry of Norway to validate the estimates of reduced mortality in the total population. The original estimate of fewer deaths during the intervention with OR 0.7 remains virtually unchanged for the original data collection

A Grant

ACOG

AE Heazell

AG Olesen

Babill Stray-Pedersen

CV Smith

D Sinha

DJ Tuffnell

DP Eller

E Saastad

E Sadovsky

Eli Saastad

F Sergent

FC Christensen

Frøen

G Cito

J Frederik Frøen

J Gardosi

J Westgate

JA DiPietro

JF Frøen

JF Pearson

JP Neilson

Julie Victoria Holm Tveit

K Sjostrom

L Mangesi

L Valentin

LM Gomez

M Coppens

M Dubiel

MA Manders

MD Velazquez

N Pattison

National Institute for Clinical Excellence

NJ Sebire

Per E Børdahl

R Berbey

Ruth Fretts

S Neldam

Sosial-og Helsedirektoratet

TR Moore

V Flenady

Vicki Flenady

English

PubMed

Springer - Publisher Connector

CORRECTION Open Access
Correction: Reduction of late stillbirth with the
introduction of fetal movement information and
guidelines - a clinical quality improvement
Julie Victoria Holm Tveit1,2, Eli Saastad2,3, Babill Stray-Pedersen1, Per E Børdahl4,5, Vicki Flenady6, Ruth Fretts7,
J Frederik Frøen2*
Abstract
We have performed a full cross-validation of this clinical Femina data collection against the routinely collected data
of the Medical Birth Registry of Norway to validate the estimates of reduced mortality in the total population. The
original estimate of fewer deaths during the intervention with OR 0.7 remains virtually unchanged for the original
data collection.
The validation procedures revealed inaccuracies in data from the Medical Birth Registry of Norway for a partial
comparison with mortality outside the study area, and we here correct this comparison. We present new, corrected
and cross-validated data. Despite comparability issues, the most robust and cross-validated estimates confirm
similar estimates of reduced mortality during the quality improvement intervention.
Introduction: Comparison with registry data
This article is based on the clinical Femina data collec-
tion - independent of the Medical Birth Registry of Nor-
way (MBRN). However, a partial comparison with the
population outside the cohort was included, using
MBRN data [1].
In accordance with the study protocol of 2005, we
aimed to compare our Femina data with MBRN data for
the full cohort for an independent validation of stillbirth
rates in the total population. The complete data set for
Norway for 2007, needed for this final comparison, was
released by the MBRN on December 13, 2009. Upon
receipt of these complete data we found discrepancies
with the data our project had previously received from
the MBRN and published [1]. The MBRN performed an
inquiry into the two data deliveries, and on February,
17, 2010, the MBRN issued a public report which con-
firmed that the previous data delivery to our project was
inaccurate.
We deeply regret this, and wish to correct the original
article accordingly and provide new and validated data.
Correction
From the section Data collection, the following sentence
describes the data found to be inaccurate, and should be
discarded: “In addition to the registrations by our study
protocol, the numbers of births and stillbirths from our
population were obtained from the Medical Birth Regis-
try in Norway to assess overall trends in stillbirth, for
the most updated period available: April 2005 to December
2006.”
From the third paragraph of the Results section, the
following sentence is based on the inaccurate data, and
should be discarded: “Independent data from the Medi-
cal Birth Registry in Norway, confirmed that the still-
birth rate in our total cohort of births was comparable
to the rest of Norway in the baseline observation (OR
1.06; 95% CI 0.70-1.65, p = 0.73), and significantly lower
during the intervention period (OR 0.64; 95% CI 0.47-
0.87, p = 0.005).”
Limitations in comparisons of Femina data and
MBRN data
There was a dual capture of deaths in the Femina study.
Primarily, deaths were registered retrospectively by clini-
cal study site coordinators (midwife or obstetrician)
reporting births, deaths and causes of death monthly
* Correspondence: frederik.froen@fhi.no
2Norwegian Institute of Public Health, Division of Epidemiology, Oslo,
Norway
Full list of author information is available at the end of the article
Tveit et al. BMC Pregnancy and Childbirth 2010, 10:49
http://www.biomedcentral.com/1471-2393/10/49
© 2010 Tveit et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
from the clinical logs and hospital records. All hospitals
provided monthly reports. In addition, women present-
ing with a complaint of decreased fetal movements were
captured prospectively, prior to the registration of out-
come [1].
Notification of all births to the MBRN is compulsory
in Norway. However, missed or erroneous key variables
leading to missing capture of cases may occur in any
registry.
Femina and MBRN data differ in some aspects. 1)
Femina did not register cases born after ≥ 28 weeks if
death occurred prior to 28 weeks. Time of intrauterine
death is not reported to the MBRN. 2) In Femina the
clinicians reported the best estimate of gestational age
(combining clinical assessment, last menstrual period,
ultrasound screening and autopsies). The MBRN is
based on the LMP and ultrasound alone. 3) Femina
included immediate neonatal deaths in the delivery
room, which would by definition not be captured as a
stillbirth in the MBRN.
In their report of February 17, 2010, the MBRN find
that gestational age alone is insufficient to track third
trimester stillbirths due to missing data on gestation.
For comparisons with the Femina data they therefore
report cases of ≥ 28 weeks of gestation and a birth
weight ≥ 1000 grams, or one of these criterions if the
other is missing (Cat. 28). The MBRN also reports that
the completeness of stillbirth reports increase with
gestation; this is also our experience. With the existing
limitations for comparisons at the limits around 28
weeks and 1000 grams, the MBRN suggest to report
cases of ≥ 32 weeks and 1500 grams (Cat. 32) to mini-
mize bias in comparisons. We agree that this improves
comparability, and probably represent the most robust
data for comparing the point estimates (odds ratios),
despite having less statistical power due to smaller
groups and thus wider confidence intervals.
New data from the MBRN and cross-validation
with Femina data
We found some discrepancies between the MBRN and
Femina in the number of deaths registered. Prior to
intervention, the MBRN registered 47 deaths in Cat. 28,
while Femina registered significantly more cases, alto-
gether 56. During the intervention, both registered 92.
Due to the concerns this raised, the Norwegian Institute
of Public Health (NIPH), owners of both the Femina
and MBRN data, combined Femina and MBRN registra-
tions on day and hospital of birth, birth weight and
gestational age to compare case by case. The probability
of identical details for all four variables in separate cases
is negligible in our setting - e.g. two deaths on the same
day in the same delivery unit only occurred once in our
two-year study, and their gestation and weight differed.
Cases on which both registries agreed were deemed to
be validated by each other.
In total, there were 33 unique Cat. 28 cases only
found in one of the datasets. The hospitals in question
were requested to re-confirm these cases to the NIPH.
Two duplicates in the Femina material were found by
this procedure: The dual prospective and retrospective
capture of stillbirths in Femina, described above, lead to
two stillbirths being reported twice from different hospi-
tals. The two duplicate reports did not mention that the
stillbirth had occurred in another hospital, and slight
differences in the details reported made them go
unrecognized.
A cross-validated dataset may be the most robust esti-
mate available, compensating for underreporting to both
datasets by including all deaths registered in any of the
two. Validation identified 46 deaths prior to vs. 78 dur-
ing intervention in Cat. 32, and 55 deaths vs. 102 in
Cat. 28.
Overall, for stillbirths ≥ 28 weeks/1000 grams, 10%
were not found in the MBRN, and 7% were not found
in Femina. For the MBRN, this does not exclude the
possibility that they had been reported in some form,
but neither gestation nor birth weight identified them as
deaths in any of these categories.
Analyses of the cross-validated data, Femina data
and MBRN data
Removing the two duplicates from the Femina data pro-
vides an essentially identical estimate of the original sig-
nificant association with lower mortality in the total
population with OR 0.7 (table 1). In the subset Cat. 32
the estimates of OR 0.7 is found to be identical in both
the Femina data, the MBRN data, as well as in the
cross-validated data combining Femina and MBRN, and
the widened confidence interval a natural consequence
of the smaller subset from the total material. In the
cross-validated data the mortality rates are 2.4/1000
prior to vs. 1.7/1000 during intervention.
In the subset Cat. 28 we find support for the expecta-
tions, discussed above, that the clearest differences in
data collection and reporting, are found in the lowest
gestational ages. With Cat. 32 estimates being identical
in all three datasets, the one fifth of deaths occurring
between 28 and 32 weeks account for the discrepancies.
During the intervention, reporting of these early deaths
to Femina remained unchanged (increased by 9%, 7 vs.
18 cases among 19035 vs. 44967 births) while reporting
to the MBRN increased by 80% (4 vs. 17 cases). As a
result, the MBRN finds an estimate of OR 0.8 where
Femina finds OR 0.7 in Cat. 28.
For analyses of mortality rates outside our study area,
only MBRN data is available. In Cat. 32 these indicate
more deaths in the Femina area than in the rest of
Tveit et al. BMC Pregnancy and Childbirth 2010, 10:49
http://www.biomedcentral.com/1471-2393/10/49
Page 2 of 4
Norway prior to intervention with OR 1.2, while this is
reversed during intervention to OR 0.7 (table 1). As
noted above, the intervention in the Femina area was
associated with OR 0.7 while in the rest of Norway
there was an increased number of deaths with OR 1.1 in
this period. In Cat. 28, again, the estimate in the MBRN
is OR 0.8 rather than 0.7.
Conclusion: Support of original estimates, but
more studies needed
The validation of MBRN and Femina data show that
neither had optimal robustness - 10% and 7% of deaths
were not identified, respectively. Thorough validation
using independent data collections was needed to iden-
tify two duplicates. Yet, the reproduction of identical
estimates of OR 0.7 among deaths in Cat. 32 in Femina
data, MBRN data and cross-validated data, lend signifi-
cant support to the validity of the study’s original data
collection and results. The discrepancy produced by
including deaths between 28 and 32 weeks questions
whether there was truly more deaths in this group dur-
ing the intervention (as the MBRN data may suggest),
or whether the rate was unaffected and discrepancy is
due to data collection/comparability issues (as the com-
parison of Femina and MBRN data may suggest). In an
intervention increasing stillbirth awareness among
health professionals, an increased proportion of early
gestation deaths being reported to the MBRN is not sur-
prising. In a prolonged quality improvement project like
ours, “registration fatigue” would not be surprising
either.
In taking all possible comparisons into account, we
find odds ratios of 0.69, 0.71, 0.72, 0.72, 0.74, 0.74, 0.79,
0.82 and 0.83, mostly at borderline significance levels. It
therefore seems prudent to estimate an association
between the intervention and mortality in the range of
OR 0.7 - 0.8. The precise effect of optimal information
to pregnant women about decreased fetal movements,
and the optimal management of complaints for
decreased fetal movements, remains to be identified in
randomized controlled trials.
We have reviewed the commentaries in light of our
findings. The MBRN data were not directly questioned
by Dr. Salvesen, however, he did compare with the
MBRN and found reasons for concern over numbers
that apparently demonstrated the opposite of the actual
results of the study [2]. Dr. Salvesen should be com-
mended for his interest in the study and for acting on
such concerns. The published data indicated that a com-
parison based solely on gestational age in the MBRN
was valid and helpful, which is regrettable.
Acknowledgements
We thank the MBRN and its staff, and the participating hospitals, for their
collaboration and openness in identifying the inaccuracies and correcting
the data.
Author details
1Division of Obstetrics and Gynecology, and Centre for Perinatal Research,
Rikshospitalet University Hospital, University of Oslo, Medical Faculty, Norway.
2Norwegian Institute of Public Health, Division of Epidemiology, Oslo,
Norway. 3Akershus University College, and University of Oslo, Medical faculty,
Norway. 4Department of Obstetrics and Gynecology, Haukeland University
Hospital, Bergen, Norway. 5Institute for Clinical Medicine, Section for
Table 1 Odds ratios (OR) and 95% confidence intervals (CI) for all comparisons of mortality associated with the
intervention period, both within the Femina cohort (actual study), outside the study area (trends unrelated to study),
and between the study area and the rest of Norway, stratified by the data sources available for the comparison
Comparison Femina area: Intervention
period vs. pre-intervention
period
Rest of Norway: Intervention
period vs. pre-intervention
period
Femina area vs. rest of
Norway prior to intervention
period
Femina area vs. rest of
Norway during intervention
period
Group & data source OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Original comparison
Femina data 0.69 0.50 - 0.96 - - - - - -
MBRN data - - - - - - - -
Cross-validated data - - - - - - - -
≥ 32 weeks or 1500 g
Femina data 0.74 0.50 - 1.08 - - - - - -
MBRN data 0.71 0.48 - 1.05 1.11 0.71 - 1.73 1.16 0.71 - 1.88 0.74 0.53 - 1.04
Cross-validated data 0.72 0.50 - 1.03 - - - - - -
≥ 28 weeks or 1000 g
Femina data 0.72 0.52 - 1.01 - - - - - -
MBRN data 0.83 0.58 - 1.18 1.07 0.72 - 1.59 1.05 0.68 - 1.63 0.82 0.61 - 1.10
Cross-validated data 0.79 0.57 - 1.09 - - - - - -
Tveit et al. BMC Pregnancy and Childbirth 2010, 10:49
http://www.biomedcentral.com/1471-2393/10/49
Page 3 of 4
Gynaecology and Obstetrics, University of Bergen. 6Department of Obstetrics
and Gynecology, University of Queensland, Mater Mothers’ Hospital, South
Brisbane, Australia. 7Brigham and Women’s Hospital, Division of Maternal-
Fetal Medicine, Harvard Medical School, Boston, MA.
Received: 1 September 2010 Accepted: 2 September 2010
Published: 2 September 2010
References
1. Tveit Victoria Holm Julie, Saastad Eli, Stray-Pedersen Babill, Børdahl EPer,
Flenady Vicki, Fretts CRuth, Frøen J Frederik: Reduction of late stillbirth
with the introduction of fetal movement information and guidelines - a
clinical quality improvement. BMC Pregnancy and Childbirth 2009, 9:32.
2. [http://www.biomedcentral.com/1471-2393/9/32/comments#368667].
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with the introduction of fetal movement information and guidelines - a
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Erratum to: Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement

We have performed a full cross-validation of this clinical Femina data collection against the routinely collected data of the Medical Birth Registry of Norway to validate the estimates of reduced mortality in the total population. The original estimate of fewer deaths during the intervention with OR 0.7 remains virtually unchanged for the original data collection. The validation procedures revealed inaccuracies in data from the Medical Birth Registry of Norway for a partial comparison with mortality outside the study area, and we here correct this comparison. We present new, corrected and cross-validated data. Despite comparability issues, the most robust and cross-validated estimates confirm similar estimates of reduced mortality during the quality improvement intervention

Tveit, Julie Victoria Holm

Saastad, Eli

Stray-Pedersen, Babill

Bordahl, Per E.

Flenady, Vicki

Fretts, Ruth

Froen, J. Frederik

University of Queensland eSpace

Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement (vol 9, pg 32, 2009)

We have performed a full cross-validation of this clinical Femina data collection against the routinely collected data of the Medical Birth Registry of Norway to validate the estimates of reduced mortality in the total population. The original estimate of fewer deaths during the intervention with OR 0.7 remains virtually unchanged for the original data collection. The validation procedures revealed inaccuracies in data from the Medical Birth Registry of Norway for a partial comparison with mortality outside the study area, and we here correct this comparison. We present new, corrected and cross-validated data. Despite comparability issues, the most robust and cross-validated estimates confirm similar estimates of reduced mortality during the quality improvement intervention. The online version of the original article can be found at 10.1186/1471-2393-9-3

Tveit, Julie VH

Børdahl, Per E

Frøen, J Frederik

NORA - Norwegian Open Research Archives

CORRECTION Open AccessCorrection: Reduction of late stillbirth with theintroduction of fetal movement information andguidelines - a clinical quality improvementJulie Victoria Holm Tveit1,2, Eli Saastad2,3, Babill Stray-Pedersen1, Per E Børdahl4,5, Vicki Flenady6, Ruth Fretts7,J Frederik Frøen2*AbstractWe have performed a full cross-validation of this clinical Femina data collection against the routinely collected dataof the Medical Birth Registry of Norway to validate the estimates of reduced mortality in the total population. Theoriginal estimate of fewer deaths during the intervention with OR 0.7 remains virtually unchanged for the originaldata collection.The validation procedures revealed inaccuracies in data from the Medical Birth Registry of Norway for a partialcomparison with mortality outside the study area, and we here correct this comparison. We present new, correctedand cross-validated data. Despite comparability issues, the most robust and cross-validated estimates confirmsimilar estimates of reduced mortality during the quality improvement intervention.Introduction: Comparison with registry dataThis article is based on the clinical Femina data collec-tion - independent of the Medical Birth Registry of Nor-way (MBRN). However, a partial comparison with thepopulation outside the cohort was included, usingMBRN data [1].In accordance with the study protocol of 2005, weaimed to compare our Femina data with MBRN data forthe full cohort for an independent validation of stillbirthrates in the total population. The complete data set forNorway for 2007, needed for this final comparison, wasreleased by the MBRN on December 13, 2009. Uponreceipt of these complete data we found discrepancieswith the data our project had previously received fromthe MBRN and published [1]. The MBRN performed aninquiry into the two data deliveries, and on February,17, 2010, the MBRN issued a public report which con-firmed that the previous data delivery to our project wasinaccurate.We deeply regret this, and wish to correct the originalarticle accordingly and provide new and validated data.CorrectionFrom the section Data collection, the following sentencedescribes the data found to be inaccurate, and should bediscarded: “In addition to the registrations by our studyprotocol, the numbers of births and stillbirths from ourpopulation were obtained from the Medical Birth Regis-try in Norway to assess overall trends in stillbirth, forthe most updated period available: April 2005 to December2006.”From the third paragraph of the Results section, thefollowing sentence is based on the inaccurate data, andshould be discarded: “Independent data from the Medi-cal Birth Registry in Norway, confirmed that the still-birth rate in our total cohort of births was comparableto the rest of Norway in the baseline observation (OR1.06; 95% CI 0.70-1.65, p = 0.73), and significantly lowerduring the intervention period (OR 0.64; 95% CI 0.47-0.87, p = 0.005).”Limitations in comparisons of Femina data andMBRN dataThere was a dual capture of deaths in the Femina study.Primarily, deaths were registered retrospectively by clini-cal study site coordinators (midwife or obstetrician)reporting births, deaths and causes of death monthly* Correspondence: frederik.froen@fhi.no2Norwegian Institute of Public Health, Division of Epidemiology, Oslo,NorwayFull list of author information is available at the end of the articleTveit et al. BMC Pregnancy and Childbirth 2010, 10:49http://www.biomedcentral.com/1471-2393/10/49© 2010 Tveit et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.from the clinical logs and hospital records. All hospitalsprovided monthly reports. In addition, women present-ing with a complaint of decreased fetal movements werecaptured prospectively, prior to the registration of out-come [1].Notification of all births to the MBRN is compulsoryin Norway. However, missed or erroneous key variablesleading to missing capture of cases may occur in anyregistry.Femina and MBRN data differ in some aspects. 1)Femina did not register cases born after ≥ 28 weeks ifdeath occurred prior to 28 weeks. Time of intrauterinedeath is not reported to the MBRN. 2) In Femina theclinicians reported the best estimate of gestational age(combining clinical assessment, last menstrual period,ultrasound screening and autopsies). The MBRN isbased on the LMP and ultrasound alone. 3) Feminaincluded immediate neonatal deaths in the deliveryroom, which would by definition not be captured as astillbirth in the MBRN.In their report of February 17, 2010, the MBRN findthat gestational age alone is insufficient to track thirdtrimester stillbirths due to missing data on gestation.For comparisons with the Femina data they thereforereport cases of ≥ 28 weeks of gestation and a birthweight ≥ 1000 grams, or one of these criterions if theother is missing (Cat. 28). The MBRN also reports thatthe completeness of stillbirth reports increase withgestation; this is also our experience. With the existinglimitations for comparisons at the limits around 28weeks and 1000 grams, the MBRN suggest to reportcases of ≥ 32 weeks and 1500 grams (Cat. 32) to mini-mize bias in comparisons. We agree that this improvescomparability, and probably represent the most robustdata for comparing the point estimates (odds ratios),despite having less statistical power due to smallergroups and thus wider confidence intervals.New data from the MBRN and cross-validationwith Femina dataWe found some discrepancies between the MBRN andFemina in the number of deaths registered. Prior tointervention, the MBRN registered 47 deaths in Cat. 28,while Femina registered significantly more cases, alto-gether 56. During the intervention, both registered 92.Due to the concerns this raised, the Norwegian Instituteof Public Health (NIPH), owners of both the Feminaand MBRN data, combined Femina and MBRN registra-tions on day and hospital of birth, birth weight andgestational age to compare case by case. The probabilityof identical details for all four variables in separate casesis negligible in our setting - e.g. two deaths on the sameday in the same delivery unit only occurred once in ourtwo-year study, and their gestation and weight differed.Cases on which both registries agreed were deemed tobe validated by each other.In total, there were 33 unique Cat. 28 cases onlyfound in one of the datasets. The hospitals in questionwere requested to re-confirm these cases to the NIPH.Two duplicates in the Femina material were found bythis procedure: The dual prospective and retrospectivecapture of stillbirths in Femina, described above, lead totwo stillbirths being reported twice from different hospi-tals. The two duplicate reports did not mention that thestillbirth had occurred in another hospital, and slightdifferences in the details reported made them gounrecognized.A cross-validated dataset may be the most robust esti-mate available, compensating for underreporting to bothdatasets by including all deaths registered in any of thetwo. Validation identified 46 deaths prior to vs. 78 dur-ing intervention in Cat. 32, and 55 deaths vs. 102 inCat. 28.Overall, for stillbirths ≥ 28 weeks/1000 grams, 10%were not found in the MBRN, and 7% were not foundin Femina. For the MBRN, this does not exclude thepossibility that they had been reported in some form,but neither gestation nor birth weight identified them asdeaths in any of these categories.Analyses of the cross-validated data, Femina dataand MBRN dataRemoving the two duplicates from the Femina data pro-vides an essentially identical estimate of the original sig-nificant association with lower mortality in the totalpopulation with OR 0.7 (table 1). In the subset Cat. 32the estimates of OR 0.7 is found to be identical in boththe Femina data, the MBRN data, as well as in thecross-validated data combining Femina and MBRN, andthe widened confidence interval a natural consequenceof the smaller subset from the total material. In thecross-validated data the mortality rates are 2.4/1000prior to vs. 1.7/1000 during intervention.In the subset Cat. 28 we find support for the expecta-tions, discussed above, that the clearest differences indata collection and reporting, are found in the lowestgestational ages. With Cat. 32 estimates being identicalin all three datasets, the one fifth of deaths occurringbetween 28 and 32 weeks account for the discrepancies.During the intervention, reporting of these early deathsto Femina remained unchanged (increased by 9%, 7 vs.18 cases among 19035 vs. 44967 births) while reportingto the MBRN increased by 80% (4 vs. 17 cases). As aresult, the MBRN finds an estimate of OR 0.8 whereFemina finds OR 0.7 in Cat. 28.For analyses of mortality rates outside our study area,only MBRN data is available. In Cat. 32 these indicatemore deaths in the Femina area than in the rest ofTveit et al. BMC Pregnancy and Childbirth 2010, 10:49http://www.biomedcentral.com/1471-2393/10/49Page 2 of 4Norway prior to intervention with OR 1.2, while this isreversed during intervention to OR 0.7 (table 1). Asnoted above, the intervention in the Femina area wasassociated with OR 0.7 while in the rest of Norwaythere was an increased number of deaths with OR 1.1 inthis period. In Cat. 28, again, the estimate in the MBRNis OR 0.8 rather than 0.7.Conclusion: Support of original estimates, butmore studies neededThe validation of MBRN and Femina data show thatneither had optimal robustness - 10% and 7% of deathswere not identified, respectively. Thorough validationusing independent data collections was needed to iden-tify two duplicates. Yet, the reproduction of identicalestimates of OR 0.7 among deaths in Cat. 32 in Feminadata, MBRN data and cross-validated data, lend signifi-cant support to the validity of the study’s original datacollection and results. The discrepancy produced byincluding deaths between 28 and 32 weeks questionswhether there was truly more deaths in this group dur-ing the intervention (as the MBRN data may suggest),or whether the rate was unaffected and discrepancy isdue to data collection/comparability issues (as the com-parison of Femina and MBRN data may suggest). In anintervention increasing stillbirth awareness amonghealth professionals, an increased proportion of earlygestation deaths being reported to the MBRN is not sur-prising. In a prolonged quality improvement project likeours, “registration fatigue” would not be surprisingeither.In taking all possible comparisons into account, wefind odds ratios of 0.69, 0.71, 0.72, 0.72, 0.74, 0.74, 0.79,0.82 and 0.83, mostly at borderline significance levels. Ittherefore seems prudent to estimate an associationbetween the intervention and mortality in the range ofOR 0.7 - 0.8. The precise effect of optimal informationto pregnant women about decreased fetal movements,and the optimal management of complaints fordecreased fetal movements, remains to be identified inrandomized controlled trials.We have reviewed the commentaries in light of ourfindings. The MBRN data were not directly questionedby Dr. Salvesen, however, he did compare with theMBRN and found reasons for concern over numbersthat apparently demonstrated the opposite of the actualresults of the study [2]. Dr. Salvesen should be com-mended for his interest in the study and for acting onsuch concerns. The published data indicated that a com-parison based solely on gestational age in the MBRNwas valid and helpful, which is regrettable.AcknowledgementsWe thank the MBRN and its staff, and the participating hospitals, for theircollaboration and openness in identifying the inaccuracies and correctingthe data.Author details1Division of Obstetrics and Gynecology, and Centre for Perinatal Research,Rikshospitalet University Hospital, University of Oslo, Medical Faculty, Norway.2Norwegian Institute of Public Health, Division of Epidemiology, Oslo,Norway. 3Akershus University College, and University of Oslo, Medical faculty,Norway. 4Department of Obstetrics and Gynecology, Haukeland UniversityHospital, Bergen, Norway. 5Institute for Clinical Medicine, Section forTable 1 Odds ratios (OR) and 95% confidence intervals (CI) for all comparisons of mortality associated with theintervention period, both within the Femina cohort (actual study), outside the study area (trends unrelated to study),and between the study area and the rest of Norway, stratified by the data sources available for the comparisonComparison Femina area: Interventionperiod vs. pre-interventionperiodRest of Norway: Interventionperiod vs. pre-interventionperiodFemina area vs. rest ofNorway prior to interventionperiodFemina area vs. rest ofNorway during interventionperiodGroup & data source OR 95% CI OR 95% CI OR 95% CI OR 95% CIOriginal comparisonFemina data 0.69 0.50 - 0.96 - - - - - -MBRN data - - - - - - - -Cross-validated data - - - - - - - -≥ 32 weeks or 1500 gFemina data 0.74 0.50 - 1.08 - - - - - -MBRN data 0.71 0.48 - 1.05 1.11 0.71 - 1.73 1.16 0.71 - 1.88 0.74 0.53 - 1.04Cross-validated data 0.72 0.50 - 1.03 - - - - - -≥ 28 weeks or 1000 gFemina data 0.72 0.52 - 1.01 - - - - - -MBRN data 0.83 0.58 - 1.18 1.07 0.72 - 1.59 1.05 0.68 - 1.63 0.82 0.61 - 1.10Cross-validated data 0.79 0.57 - 1.09 - - - - - -Tveit et al. BMC Pregnancy and Childbirth 2010, 10:49http://www.biomedcentral.com/1471-2393/10/49Page 3 of 4Gynaecology and Obstetrics, University of Bergen. 6Department of Obstetricsand Gynecology, University of Queensland, Mater Mothers’ Hospital, SouthBrisbane, Australia. 7Brigham and Women’s Hospital, Division of Maternal-Fetal Medicine, Harvard Medical School, Boston, MA.Received: 1 September 2010 Accepted: 2 September 2010Published: 2 September 2010References1. Tveit Victoria Holm Julie, Saastad Eli, Stray-Pedersen Babill, Børdahl EPer,Flenady Vicki, Fretts CRuth, Frøen J Frederik: Reduction of late stillbirthwith the introduction of fetal movement information and guidelines - aclinical quality improvement. BMC Pregnancy and Childbirth 2009, 9:32.2. [http://www.biomedcentral.com/1471-2393/9/32/comments#368667].Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/10/49/prepubdoi:10.1186/1471-2393-10-49Cite this article as: Tveit et al.: Correction: Reduction of late stillbirthwith the introduction of fetal movement information and guidelines - aclinical quality improvement. BMC Pregnancy and Childbirth 2010 10:49.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitTveit et al. BMC Pregnancy and Childbirth 2010, 10:49http://www.biomedcentral.com/1471-2393/10/49Page 4 of 4

Correction: Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement

Background
                Women experiencing decreased fetal movements (DFM) are at increased risk of adverse outcomes, including stillbirth. Fourteen delivery units in Norway registered all cases of DFM in a population-based quality assessment. We found that information to women and management of DFM varied significantly between hospitals. We intended to examine two cohorts of women with DFM before and during two consensus-based interventions aiming to improve care through: 1) written information to women about fetal activity and DFM, including an invitation to monitor fetal movements, 2) guidelines for management of DFM for health-care professionals.
              
              
                Methods
                All singleton third trimester pregnancies presenting with a perception of DFM were registered, and outcomes collected independently at all 14 hospitals. The quality assessment period included April 2005 through October 2005, and the two interventions were implemented from November 2005 through March 2007. The baseline versus intervention cohorts included: 19,407 versus 46,143 births and 1215 versus 3038 women with DFM, respectively.
              
              
                Results
                Reports of DFM did not increase during the intervention. The stillbirth rate among women with DFM fell during the intervention: 4.2% vs. 2.4%, (OR 0.51 95% CI 0.32–0.81), and 3.0/1000 versus 2.0/1000 in the overall study population (OR 0.67 95% CI 0.48–0.93). There was no increase in the rates of preterm births, fetal growth restriction, transfers to neonatal care or severe neonatal depression among women with DFM during the intervention. The use of ultrasound in management increased, while additional follow up visits and admissions for induction were reduced.
              
              
                Conclusion
                Improved management of DFM and uniform information to women is associated with fewer stillbirths

Holm Tveit, Julie V

Frøen, J F

Reduction of late stillbirth with the introduction of fetal movement information and guidelines – a clinical quality improvement

Background: Women experiencing decreased fetal movements (DFM) are at increased risk of adverse outcomes, including stillbirth. Fourteen delivery units in Norway registered all cases of
DFM in a population-based quality assessment. We found that information to women and management of DFM varied significantly between hospitals. We intended to examine two cohorts of women with DFM before and during two consensus-based interventions aiming to improve care through: 1) written information to women about fetal activity and DFM, including an invitation to
monitor fetal movements, 2) guidelines for management of DFM for health-care professionals. Methods: All singleton third trimester pregnancies presenting with a perception of DFM were registered, and outcomes collected independently at all 14 hospitals. The quality assessment period
included April 2005 through October 2005, and the two interventions were implemented from November 2005 through March 2007. The baseline versus intervention cohorts included: 19,407
versus 46,143 births and 1215 versus 3038 women with DFM, respectively. Results: Reports of DFM did not increase during the intervention. The stillbirth rate among
women with DFM fell during the intervention: 4.2% vs. 2.4%, (OR 0.51 95% CI 0.32–0.81), and 3.0/ 1000 versus 2.0/1000 in the overall study population (OR 0.67 95% CI 0.48–0.93). There was no
increase in the rates of preterm births, fetal growth restriction, transfers to neonatal care or severe neonatal depression among women with DFM during the intervention. The use of ultrasound in management increased, while additional follow up visits and admissions for induction were reduced.
Conclusion: Improved management of DFM and uniform information to women is associated with fewer stillbirth

ODA Open Digital Archive (Oslomet)

Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement

We have performed a full cross-validation of this clinical Femina data collection against the routinely collected data of the Medical Birth Registry of Norway to validate the estimates of reduced mortality in the total population. The original estimate of fewer deaths during the intervention with OR 0.7 remains virtually unchanged for the original data collection. The validation procedures revealed inaccuracies in data from the Medical Birth Registry of Norway for a partial comparison with mortality outside the study area, and we here correct this comparison. We present new, corrected and cross-validated data. Despite comparability issues, the most robust and cross-validated estimates confirm similar estimates of reduced mortality during the quality improvement intervention.Version of Recor

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 Correction: Reduction of Late Stillbirth with the Introduction ofFetal Movement Information and Guidelines - A Clinical QualityImprovement  (Article begins on next page)The Harvard community has made this article openly available.Please share how this access benefits you. Your story matters.Citation Tveit, Julie Victoria Holm, Eli Saastad, Babill Stray-Pedersen,Per E Børdahl, Vicki Flenady, Ruth Fretts, and J Frederik Frøen.2010. Correction: Reduction of late stillbirth with theintroduction of fetal movement information and guidelines - aclinical quality improvement. BMC Pregnancy and Childbirth10: 49.Published Version doi://10.1186/1471-2393-10-49Accessed February 19, 2015 8:15:41 AM ESTCitable Link http://nrs.harvard.edu/urn-3:HUL.InstRepos:4772941Terms of Use This article was downloaded from Harvard University's DASHrepository, and is made available under the terms and conditionsapplicable to Other Posted Material, as set forth athttp://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAACORRECTION Open AccessCorrection: Reduction of late stillbirth with theintroduction of fetal movement information andguidelines - a clinical quality improvementJulie Victoria Holm Tveit1,2, Eli Saastad2,3, Babill Stray-Pedersen1, Per E Børdahl4,5, Vicki Flenady6, Ruth Fretts7,J Frederik Frøen2*AbstractWe have performed a full cross-validation of this clinical Femina data collection against the routinely collected dataof the Medical Birth Registry of Norway to validate the estimates of reduced mortality in the total population. Theoriginal estimate of fewer deaths during the intervention with OR 0.7 remains virtually unchanged for the originaldata collection.The validation procedures revealed inaccuracies in data from the Medical Birth Registry of Norway for a partialcomparison with mortality outside the study area, and we here correct this comparison. We present new, correctedand cross-validated data. Despite comparability issues, the most robust and cross-validated estimates confirmsimilar estimates of reduced mortality during the quality improvement intervention.Introduction: Comparison with registry dataThis article is based on the clinical Femina data collec-tion - independent of the Medical Birth Registry of Nor-way (MBRN). However, a partial comparison with thepopulation outside the cohort was included, usingMBRN data [1].In accordance with the study protocol of 2005, weaimed to compare our Femina data with MBRN data forthe full cohort for an independent validation of stillbirthrates in the total population. The complete data set forNorway for 2007, needed for this final comparison, wasreleased by the MBRN on December 13, 2009. Uponreceipt of these complete data we found discrepancieswith the data our project had previously received fromthe MBRN and published [1]. The MBRN performed aninquiry into the two data deliveries, and on February,17, 2010, the MBRN issued a public report which con-firmed that the previous data delivery to our project wasinaccurate.We deeply regret this, and wish to correct the originalarticle accordingly and provide new and validated data.CorrectionFrom the section Data collection, the following sentencedescribes the data found to be inaccurate, and should bediscarded: “In addition to the registrations by our studyprotocol, the numbers of births and stillbirths from ourpopulation were obtained from the Medical Birth Regis-try in Norway to assess overall trends in stillbirth, forthe most updated period available: April 2005 to December2006.”From the third paragraph of the Results section, thefollowing sentence is based on the inaccurate data, andshould be discarded: “Independent data from the Medi-cal Birth Registry in Norway, confirmed that the still-birth rate in our total cohort of births was comparableto the rest of Norway in the baseline observation (OR1.06; 95% CI 0.70-1.65, p = 0.73), and significantly lowerduring the intervention period (OR 0.64; 95% CI 0.47-0.87, p = 0.005).”Limitations in comparisons of Femina data andMBRN dataThere was a dual capture of deaths in the Femina study.Primarily, deaths were registered retrospectively by clini-cal study site coordinators (midwife or obstetrician)reporting births, deaths and causes of death monthly* Correspondence: frederik.froen@fhi.no2Norwegian Institute of Public Health, Division of Epidemiology, Oslo,NorwayFull list of author information is available at the end of the articleTveit et al. BMC Pregnancy and Childbirth 2010, 10:49http://www.biomedcentral.com/1471-2393/10/49© 2010 Tveit et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.from the clinical logs and hospital records. All hospitalsprovided monthly reports. In addition, women present-ing with a complaint of decreased fetal movements werecaptured prospectively, prior to the registration of out-come [1].Notification of all births to the MBRN is compulsoryin Norway. However, missed or erroneous key variablesleading to missing capture of cases may occur in anyregistry.F e m i n aa n dM B R Nd a t ad i f f e ri ns o m ea s p e c t s .1 )Femina did not register cases born after ≥ 28 weeks ifdeath occurred prior to 28 weeks. Time of intrauterinedeath is not reported to the MBRN. 2) In Femina theclinicians reported the best estimate of gestational age(combining clinical assessment, last menstrual period,ultrasound screening and autopsies). The MBRN isbased on the LMP and ultrasound alone. 3) Feminaincluded immediate neonatal deaths in the deliveryroom, which would by definition not be captured as astillbirth in the MBRN.In their report of February 17, 2010, the MBRN findthat gestational age alone is insufficient to track thirdtrimester stillbirths due to missing data on gestation.F o rc o m p a r i s o n sw i t ht h eF e m i n ad a t at h e yt h e r e f o r ereport cases of ≥ 28 weeks of gestation and a birthweight ≥ 1000 grams, or one of these criterions if theother is missing (Cat. 28). The MBRN also reports thatthe completeness of stillbirth reports increase withgestation; this is also our experience. With the existinglimitations for comparisons at the limits around 28weeks and 1000 grams, the MBRN suggest to reportcases of ≥ 32 weeks and 1500 grams (Cat. 32) to mini-mize bias in comparisons. We agree that this improvescomparability, and probably represent the most robustdata for comparing the point estimates (odds ratios),despite having less statistical power due to smallergroups and thus wider confidence intervals.New data from the MBRN and cross-validationwith Femina dataWe found some discrepancies between the MBRN andFemina in the number of deaths registered. Prior tointervention, the MBRN registered 47 deaths in Cat. 28,while Femina registered significantly more cases, alto-gether 56. During the intervention, both registered 92.Due to the concerns this raised, the Norwegian Instituteof Public Health (NIPH), owners of both the Feminaand MBRN data, combined Femina and MBRN registra-tions on day and hospital of birth, birth weight andgestational age to compare case by case. The probabilityof identical details for all four variables in separate casesis negligible in our setting - e.g. two deaths on the sameday in the same delivery unit only occurred once in ourtwo-year study, and their gestation and weight differed.Cases on which both registries agreed were deemed tobe validated by each other.In total, there were 33 unique Cat. 28 cases onlyfound in one of the datasets. The hospitals in questionwere requested to re-confirm these cases to the NIPH.Two duplicates in the Femina material were found bythis procedure: The dual prospective and retrospectivecapture of stillbirths in Femina, described above, lead totwo stillbirths being reported twice from different hospi-tals. The two duplicate reports did not mention that thestillbirth had occurred in another hospital, and slightdifferences in the details reported made them gounrecognized.A cross-validated dataset may be the most robust esti-mate available, compensating for underreporting to bothdatasets by including all deaths registered in any of thetwo. Validation identified 46 deaths prior to vs. 78 dur-ing intervention in Cat. 32, and 55 deaths vs. 102 inCat. 28.Overall, for stillbirths ≥ 28 weeks/1000 grams, 10%were not found in the MBRN, and 7% were not foundin Femina. For the MBRN, this does not exclude thepossibility that they had been reported in some form,but neither gestation nor birth weight identified them asdeaths in any of these categories.Analyses of the cross-validated data, Femina dataand MBRN dataRemoving the two duplicates from the Femina data pro-vides an essentially identical estimate of the original sig-nificant association with lower mortality in the totalpopulation with OR 0.7 (table 1). In the subset Cat. 32the estimates of OR 0.7 is found to be identical in boththe Femina data, the MBRN data, as well as in thecross-validated data combining Femina and MBRN, andthe widened confidence interval a natural consequenceof the smaller subset from the total material. In thecross-validated data the mortality rates are 2.4/1000prior to vs. 1.7/1000 during intervention.In the subset Cat. 28 we find support for the expecta-tions, discussed above, that the clearest differences indata collection and reporting, are found in the lowestgestational ages. With Cat. 32 estimates being identicalin all three datasets, the one fifth of deaths occurringbetween 28 and 32 weeks account for the discrepancies.During the intervention, reporting of these early deathsto Femina remained unchanged (increased by 9%, 7 vs.18 cases among 19035 vs. 44967 births) while reportingto the MBRN increased by 80% (4 vs. 17 cases). As aresult, the MBRN finds an estimate of OR 0.8 whereFemina finds OR 0.7 in Cat. 28.For analyses of mortality rates outside our study area,only MBRN data is available. In Cat. 32 these indicatem o r ed e a t h si nt h eF e m i n aa r e at h a ni nt h er e s to fTveit et al. BMC Pregnancy and Childbirth 2010, 10:49http://www.biomedcentral.com/1471-2393/10/49Page 2 of 4Norway prior to intervention with OR 1.2, while this isreversed during intervention to OR 0.7 (table 1). Asnoted above, the intervention in the Femina area wasassociated with OR 0.7 while in the rest of Norwaythere was an increased number of deaths with OR 1.1 inthis period. In Cat. 28, again, the estimate in the MBRNis OR 0.8 rather than 0.7.Conclusion: Support of original estimates, butmore studies neededThe validation of MBRN and Femina data show thatneither had optimal robustness - 10% and 7% of deathswere not identified, respectively. Thorough validationusing independent data collections was needed to iden-tify two duplicates. Yet, the reproduction of identicalestimates of OR 0.7 among deaths in Cat. 32 in Feminadata, MBRN data and cross-validated data, lend signifi-cant support to the validity of the study’so r i g i n a ld a t acollection and results. The discrepancy produced byincluding deaths between 28 and 32 weeks questionswhether there was truly more deaths in this group dur-ing the intervention (as the MBRN data may suggest),or whether the rate was unaffected and discrepancy isdue to data collection/comparability issues (as the com-parison of Femina and MBRN data may suggest). In anintervention increasing stillbirth awareness amonghealth professionals, an increased proportion of earlygestation deaths being reported to the MBRN is not sur-prising. In a prolonged quality improvement project likeours, “registration fatigue” would not be surprisingeither.In taking all possible comparisons into account, wefind odds ratios of 0.69, 0.71, 0.72, 0.72, 0.74, 0.74, 0.79,0.82 and 0.83, mostly at borderline significance levels. Ittherefore seems prudent to estimate an associationbetween the intervention and mortality in the range ofOR 0.7 - 0.8. The precise effect of optimal informationto pregnant women about decreased fetal movements,and the optimal management of complaints fordecreased fetal movements, remains to be identified inrandomized controlled trials.We have reviewed the commentaries in light of ourfindings. The MBRN data were not directly questionedby Dr. Salvesen, however, he did compare with theMBRN and found reasons for concern over numbersthat apparently demonstrated the opposite of the actualresults of the study [2]. Dr. Salvesen should be com-mended for his interest in the study and for acting onsuch concerns. The published data indicated that a com-parison based solely on gestational age in the MBRNwas valid and helpful, which is regrettable.AcknowledgementsWe thank the MBRN and its staff, and the participating hospitals, for theircollaboration and openness in identifying the inaccuracies and correctingthe data.Author details1Division of Obstetrics and Gynecology, and Centre for Perinatal Research,Rikshospitalet University Hospital, University of Oslo, Medical Faculty, Norway.2Norwegian Institute of Public Health, Division of Epidemiology, Oslo,Norway.3Akershus University College, and University of Oslo, Medical faculty,Norway.4Department of Obstetrics and Gynecology, Haukeland UniversityHospital, Bergen, Norway.5Institute for Clinical Medicine, Section forTable 1 Odds ratios (OR) and 95% confidence intervals (CI) for all comparisons of mortality associated with theintervention period, both within the Femina cohort (actual study), outside the study area (trends unrelated to study),and between the study area and the rest of Norway, stratified by the data sources available for the comparisonComparison Femina area: Interventionperiod vs. pre-interventionperiodRest of Norway: Interventionperiod vs. pre-interventionperiodFemina area vs. rest ofNorway prior to interventionperiodFemina area vs. rest ofNorway during interventionperiodGroup & data source OR 95% CI OR 95% CI OR 95% CI OR 95% CIOriginal comparisonFemina data 0.69 0.50 - 0.96 - - - - - -MBRN data - - - - - - - -Cross-validated data - - - - - - - -≥ 32 weeks or 1500 gFemina data 0.74 0.50 - 1.08 - - - - - -MBRN data 0.71 0.48 - 1.05 1.11 0.71 - 1.73 1.16 0.71 - 1.88 0.74 0.53 - 1.04Cross-validated data 0.72 0.50 - 1.03 - - - - - -≥ 28 weeks or 1000 gFemina data 0.72 0.52 - 1.01 - - - - - -MBRN data 0.83 0.58 - 1.18 1.07 0.72 - 1.59 1.05 0.68 - 1.63 0.82 0.61 - 1.10Cross-validated data 0.79 0.57 - 1.09 - - - - - -Tveit et al. BMC Pregnancy and Childbirth 2010, 10:49http://www.biomedcentral.com/1471-2393/10/49Page 3 of 4Gynaecology and Obstetrics, University of Bergen.6Department of Obstetricsand Gynecology, University of Queensland, Mater Mothers’ Hospital, SouthBrisbane, Australia.7Brigham and Women’s Hospital, Division of Maternal-Fetal Medicine, Harvard Medical School, Boston, MA.Received: 1 September 2010 Accepted: 2 September 2010Published: 2 September 2010References1. Tveit Victoria Holm Julie, Saastad Eli, Stray-Pedersen Babill, Børdahl EPer,Flenady Vicki, Fretts CRuth, Frøen J Frederik: Reduction of late stillbirthwith the introduction of fetal movement information and guidelines - aclinical quality improvement. BMC Pregnancy and Childbirth 2009, 9:32.2. [http://www.biomedcentral.com/1471-2393/9/32/comments#368667].Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/10/49/prepubdoi:10.1186/1471-2393-10-49Cite this article as: Tveit et al.: Correction: Reduction of late stillbirthwith the introduction of fetal movement information and guidelines - aclinical quality improvement. BMC Pregnancy and Childbirth 2010 10:49.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitTveit et al. BMC Pregnancy and Childbirth 2010, 10:49http://www.biomedcentral.com/1471-2393/10/49Page 4 of 4

BMC Pregnancy and Childbirth

Correction: Reduction of Late Stillbirth with the Introduction of Fetal Movement Information and Guidelines - A Clinical Quality Improvement

Abstract
          We have performed a full cross-validation of this clinical Femina data collection against the routinely collected data of the Medical Birth Registry of Norway to validate the estimates of reduced mortality in the total population. The original estimate of fewer deaths during the intervention with OR 0.7 remains virtually unchanged for the original data collection.
          The validation procedures revealed inaccuracies in data from the Medical Birth Registry of Norway for a partial comparison with mortality outside the study area, and we here correct this comparison. We present new, corrected and cross-validated data. Despite comparability issues, the most robust and cross-validated estimates confirm similar estimates of reduced mortality during the quality improvement intervention.</jats:p

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Børdahl EPer, Flenady Vicki, Fretts CRuth, Frøen J Frederik: Reduction of late stillbirth with the introduction of fetal movement information and guidelines - a clinical quality improvement. BMC Pregnancy and Childbirth

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Reduction of late stillbirth with the introduction of fetal movement information and guidelines – a clinical quality improvement

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