Two reviewers (AS and NH) independently reviewed the information available and used the ICD-PM three-step to first assign the timing of death as antepartum, intrapartum or postpartum. Subsequently, the cause of death was assigned to one of the six, seven or eleven groups of ICD-PM perinatal cause of death under the antepartum, intrapartum and neonatal groups, respectively [5]. The main ICD-PM perinatal cause of death was then linked to ICD-10 codes of broad and specific causes of death. The third step in the process was to identify the main maternal condition or disease affecting the fetus or infant. Five main maternal groups exist and each group has subgroups to specify the maternal condition. The main perinatal and/or maternal condition was defined as the condition that started the chain of events leading to the death.1 The definitions in S1 Table were used to standardise the classification. An obstetrician (MJR) helped resolve any disagreement between the two reviewers.

The WHO recommended interactive based Excel system (S1 Fig), ICD-PM documentation provided by WHO, and ICD-10 were used to extract and classify the perinatal deaths [5]. The excel system contains the minimum set of indicators for perinatal deaths, timing and ICD-PM and ICD-10 codes of causes of death. To assist the classification, we added extra columns in the excel system for the following information: mother’s age, fresh/macerated stillbirth, foetal heart rate on admission (pre- or intrahospital death), cervical dilatation on admission, whether the partograph was available and used, the mother’s haemoglobin (Hb) on admission and the Apgar score after one and five minutes. As the appearance of maceration is not an accurate method of determining timing of stillbirth, various indicators were triangulated in order to classify the timing of stillbirth as antenatal or intrapartum: the presence/absence of foetal heart rate or foetal heart activity on admission and/or during the course of labour, and the physical appearance at birth (i.e. fresh or macerated).

When the timing remained unclear, an attempt was still made to determine the cause of death and the presence of maternal complications. As almost half of the women in Tanzania are anaemic and the prevalence is highest in Zanzibar [12], we classified only severe anaemia (Hb <7.0 g/dl) as a maternal condition of ICD-PM group M4: maternal medical and surgical conditions (maternal circulatory and respiratory diseases) [13].

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