Cause, condition, or mechanism?

EDITOR—Gardosi et al illustrate the inadequacy of current classification systems and emphasise the preponderance of fetal growth restriction, which, presumably, is not diagnosed before the death occurs.1 Although definition of relevant conditions at death may mute the debate about its cause, the distinction between conditions, causes, or mechanisms of death is still not clear in this paper. Clear definitions or guidelines are not provided. Asphyxia is a non-specific final common pathway of death, not a cause or condition. The authors intend to identify as many conditions as possible for a case.

This would be a powerful tool to stop debates about the cause where conditions overlap or where several entities coexist, such as fetal growth restriction, preeclampsia, placental insufficiency, and oligohydramnios. However, the paper describes one condition as primary (cause?) and one as secondary. Interestingly, in the primary group of fetal growth restriction only 53/1129 (4.7%) have placental insufficiency as a secondary condition. This unexpected low number illustrates the loss of insight into the pathway to death.

The issue of using a hierarchy is motivated to “reflect clinical relevance.” Although it seems preferable, a classification system for perinatal mortality cannot be strictly hierarchical because of the cognitive process of how doctors make a diagnosis.2 Any system restricted to stillbirths neglects the issue of iatrogenic preterm delivery with neonatal death in cases with the same relevant conditions. We welcome any suggestion for better classification of perinatal mortality, since this is essential for both patient care and prevention. The value of ReCoDe needs to be proved.