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Introduction: Neonatal deaths have decreased steadily in Sweden since the 1960s, but the stillbirth rate has been stable at around 4 per 1000 births, for the last 40 years. Risk factors of stillbirth are well studied; however, the cause of death is unclear in many cases. The purpose of this study was to examine causes of death in stillbirth using a classification system. In addition, we aimed to assess substandard care factors and identify areas for quality improvement.

Materials and Methods: We performed a retrospective clinical audit of all stillbirths delivered between January 2006 and December 2019. We performed a detailed investigation of medical records and classified the causes of death according to ‘The Stockholm classification of stillbirth’. Unclear cases were discussed in a multidisciplinary local audit group. Substandard care factors were identified and classified as probable, possible, or unlikely, with respect to the cause of death.

Results: In total, there were 64 cases of stillbirth. It was possible to determine a cause of death in 91% (95% confidence interval [CI]: 81.02–95.63) of the cases. The leading cause of death was intrauterine growth restriction (IUGR)/placental insufficiency (45%) (95% CI: 33.73–57.43), followed by infection (13%) (95% CI: 6.47–22.8) and placental abruption (9%) (95% CI: 4.37–18.98). Factors of substandard care were identified in 49% (95% CI: 37.06–61.4) of the cases, but in only 10% the substandard care factor had a probable association with the cause of death.

Conclusion: Introducing a local audit group and using a validated classification system made it possible to find a cause of death in about 90% of the cases of stillbirth. Since IUGR/placental insufficiency is the leading cause of death, it is important to improve current strategies to identify pregnancies at risk for IUGR, antenatally. Our results suggest that there is a possibility to improve the quality of care in many areas, particularly regarding symphysis-fundus measurements.