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Year : 2016  |  Volume : 60  |  Issue : 1  |  Page : 73-76  

Agreement between international classification of disease (ICD) and cause of death and associated conditions (CODAC) for the ascertainment of cause of stillbirth (SB) in the rural areas of north India

1 Assistant Professor, Department of Community Medicine, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
2 Assistant Professor, Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Himachal Pradesh, India
3 Professor and Head, Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Himachal Pradesh, India

Date of Web Publication23-Feb-2016

Correspondence Address:
Dinesh Kumar
Department of Community Medicine. Dr. Rajendra Prasad Government Medical College, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-557X.177348

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International Classification of Diseases-10 th version (ICD-10) has been used to ascertain the cause of death but its use for stillbirths (SBs) is limited. Cause of Death and Associated Conditions (CODAC) as a detailed system expected to provide the exact cause of SB, so a community-based study was planned to study the level of agreement between ICD-10 and CODAC for ascertaining the cause of SB. A verbal autopsy (VA) tool was used to collect the information and then the cause of each SB was assigned using ICD-10 and CODAC separately. Each tool was used for 87 SBs and found that prolonged singleton labor, maternal pregnancy induced hypertension (PIH), and central nervous system (CNS) related congenital malformations were considered the top three causes. There was a significant agreement between ICD-10 and CODAC but the latter offers a scope to delineate the causes more precisely due to its hierarchal nature.

Keywords: Cause of Death and Associated Conditions (CODAC), International Classification of Diseases-10 th version (ICD-10), stillbirth (SB)

How to cite this article:
Kaistha M, Kumar D, Bhardwaj A. Agreement between international classification of disease (ICD) and cause of death and associated conditions (CODAC) for the ascertainment of cause of stillbirth (SB) in the rural areas of north India. Indian J Public Health 2016;60:73-6

How to cite this URL:
Kaistha M, Kumar D, Bhardwaj A. Agreement between international classification of disease (ICD) and cause of death and associated conditions (CODAC) for the ascertainment of cause of stillbirth (SB) in the rural areas of north India. Indian J Public Health [serial online] 2016 [cited 2021 Sep 20];60:73-6. Available from:

Stillbirth (SB) was defined as "a dead baby born with weight more than 1000 grams, age more than 28 weeks and length more than 35 cms." [1] Globally, there are expected 26,46,800 (uncertainty range (UR) of 20,77,010-37,90,420) SBs, contributing more than half of the perinatal deaths. About 40.0% of the world SBs are shared by South Asia and 20.0% by India alone. [2] An uncertainty (wide UR) for SB assessment lies due to the lack of knowledge for its due importance, and nonreporting of SB in case of birth at home and by the private practitioners. Ascertainment of the cause of SB is vital to plan an intervention. Verbal autopsy (VA) is a validated tool to collect the information at the time of death/SB in case it occurred at home or hospital records are not - available. [1] International Classification of Diseases-10 th version (ICD-10) is a standard method of classification of death to assure comparability. Its use is limited for SB, as it identifies birth weight as a preferred criterion without specifying the duration of pregnancy, but it requires reporting for gestational age for comparison. [3] Suboptimal classification method tend to lose the information and causes a large fraction of "unknown" cause of death. Though in an evaluation, the CODAC method of classification suited best for ascertaining cause of death for SBs. [4] As ICD-10, CODAC enlists all causes of perinatal mortality, which are quite similar to the SB causes, and is a standard method for ascertaining all causes of death. With this, the present study planned with the objective to assess the level of agreement between ICD-10 and CODAC in ascertaining the cause of SBs in the rural blocks of Himachal Pradesh.

A cross-sectional study was planned in two rural blocks of Kangra district of Himachal Pradesh catering to a population of 2,48,000. Blocks were selected for convenience as they are part of the Community Based Teaching Program (CBTP) of the Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh. A prior ethical approval was obtained from Institutional Ethics Committee. The study was carried out in the year 2012, where all SBs reported in routine Health Management Information System (HMIS) for 2010, 2011, and 2012 were considered for the administration of the VA questionnaire. The VA tool was administered to family by the trained Multipurpose Health Worker (MPHW-F) after a mourning period of 21 days (applicable for 2012 SBs only). So, the data of SB for 3 years (2010, 2011, and 2012) were collected in the present study. The operational definition for SBs was "a mother between 18 years and 45 years of age who delivered dead fetus with gestational age more than 28 weeks showing no signs of life at birth." All VA forms were reviewed by the investigator for completeness and were validated by independent visit to 10.0% of families. All the VA forms were assessed independently by the two trained coders for ascertaining the cause of SB. Two different methods of coding - ICD-10 and CODAC - were used. In cases of dissimilar codes, a final code was assigned by third coder independently. ICD-10 deals with causes of perinatal mortality that are more in common with SB causes. Only one diagnoses upto three digits (one alpha and two numeric), as recommended by the World Health Organization (WHO), was used for arriving at the probable cause of death. The CODAC classification system has designed to retain information for the main cause of death as well as upto two associated conditions. It provides three different levels for cause of death. [4]

For 3 years, mothers of 87 SBs out of a reported sum of 89 could be contacted and interviewed (two migrated). In the study area, a total of 1,105 births in 2010, 937 births in 2011, and 655 births in 2012 were observed. The stillbirth rate (SBR) was observed with an increasing trend of 13.6, 35.2, and 59.5/1,000 total births (tbs) for the years 2010, 2011, and 2012, respectively. When assessed for gender of SB, the rate was observed to be significantly more for females than for males during the 3 years (data not shown). Majority of the respondent mothers were in the age group of 21-30 years with the mean age of 26.9 ± 3.7 years and almost half (47.2%) of them were educated upto high school. It was found that 66.7% of mothers did not report any significant antenatal risk factor. Whereas, 8.0% observed with anemia, 6.9% with high blood pressure, 2.3% with diabetes, and 4.6% had reported other health problems such as typhoid and malaria.

CODAC based assessment found that intrapartum period associated cause was responsible for 48.3% (42/87) of SBs, whereas, maternal (10/87) and congenital malformations (10/87) together were responsible for 24.0% of SBs. Prolonged singleton labor was found to be responsible for 47.6% (20/42) SBs occurred during the intrapartum period. Pregnancy induced hypertension (PIH) was observed as a common maternal health associated condition in 70.0% (7/10) and central nervous system (CNS) malformation in 40.0% (4/10) of SBs with congenital disorders. The increasing trend for SBR was observed for factors related with intrapartum period (3.6 to 27.5/1,000 tbs), maternal health related conditions (0.9 to 7.6/1,000 tbs) and congenital malformations (0.9 to 6.1/1,000 tbs). Of all specific causes, SBR in the prolonged labor category (singleton) was commonly responsible for the SBs in 2011 and 2012 (5.3 and 19.8/1,000 tbs) [Table 1]. As CODAC, the ICD-10 classification also showed majority [58.7% (51/87)] of SBs were associated with complications occurred during labor and delivery (intrapartum period). Congenital malformation was responsible for 8.0% (7/87) and factors associated with placenta/cord/membranes were responsible for 9.1% (8/87) of SBs. However, 25.3% (22/87) and 23.0% (20/87) of SBs remained unclassified as per the CODAC and ICD-10 classification method, respectively [Table 1] and [Table 2].
Table 1: CODAC method of classification for reported stillbirth from 2010 to 2012 in the rural area of Himachal Pradesh, India

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Table 2: ICD-10 method of classifi cation for reported stillbirth from 2010 to 2012 in the rural area of Himachal Pradesh, India

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Comparison of the CODAC and ICD-10 for broad classification of SBs, such as intrapartum, maternal, congenital, placental, medical termination, and unknown areas, was done. The agreement level was observed to be "almost perfect" (kappa: 0.90) and was statistically significant (p: 0.00). Concordance was observed for the factors associated with intrapartum period and maternal conditions. Difference was observed for congenital conditions (CODAC: 3.7/1,000 tbs; ICD-10: 2.6/1,000 tbs), placental related conditions (CODAC: 0.7/1,000 tbs; ICD-10: 3.0/1,000 tbs) and for unknown conditions (CODAC: 8.2/1,000 tbs; ICD-10: 7.4/1,000 tbs) (data not shown). As compared, both methods of classification, an observed agreement was observed among 93.1% (81/87) SBs for the abovementioned broad classification of causes.

Correct ascertainment for SB cause depends on the availability of hospital records during pregnancy. In their unavailability, VA is a valid tool to collect chronologic information. [1] Information precision improves the accuracy of classification methods to clearly delineate the cause of SB and it ranges from a self-developed algorithm to standard methods of classification. The current study used the ICD-10 and CODAC as independent standard methods of classification and observed that about a quarter of SB causes (ICD-10: 25.3%; CODAC: 23.0%) remained unknown due to the lack of information by the respondents. As for unknown cause, the concordance was observed also for causes associated with intrapartum period (CODAC: 15.6%; ICD-10: 15.2%) and maternal health related conditions (CODAC: 3.8%; ICD-10: 3.7%). The discordance was observed for congenital malformations and placenta related causes. However, CODAC was able to further delineate prolonged singleton labor as a leading specific cause. Though unspecific, ICD-10 also hinted that 47.1% stillbirths were attributed for complications arising during labor and 11.5% due to maternal health related conditions.

Adoption of algorithm determines the identification of specific cause, as a self-developed algorithm in rural Zambia (2008-2009) observed infection (26.0%), birth asphyxia (18.0%), and obstetric complication (12.0%) as common causes for SBs. [5] A Conesus based algorithm in Nepal found that the obstetric related complication was a common cause (67.0%). [6] Wigglesworth classification methods in Thailand attributed asphyxia in 55.5%, antepartum hemorrhage in 33.3%, congenital malformation in 12.5%, and cord complication in 11.1% of SBs. [7] Intrapartum asphyxia observed as common cause more than half (53.6%) of SBs based on computer based algorithms in rural Bangladesh. [8] Independent classification system observed obstetric complications as a common reason for SBs in Mumbai, India. [9]

   Conclusion Top

It is to be concluded that both the methods in the present study showed statistical significant agreement for broad causes of SBs, but CODAC improved identification of cause as it was able to spell out clearly prolonged singleton labor, PIH, and CNS malformations as the proximal causes of SBs. Relative to ICD-10, its detailed nature helped to effectively manage the information and in turn improved the precision for assigning the SB cause. Therefore, CODAC can be recommended to delineate the specific cause for SB in operationally feasible and resource limited settings.


We acknowledge the support from Dr. Arun Kumar Aggarwal, Professor, School of Public Health, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, for providing validated WHO VA tool. We also acknowledge the general and material support received from Dr. Pardeep Bansal, Associate Professor, Department of Community Medicine. We also acknowledge Dr. RP Government Medical College, Himachal Pradesh, India.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Aggarwal AK, Jain V, Kumar R. Validity of verbal autopsy for ascertaining the causes of stillbirth. Bull World Health Organ 2011;89:31-40.  Back to cited text no. 1
Lawn JE, Blencowe H, Pattinson R, Cousens S, Kumar R, Ibiebele I, et al.; Lancet's Stillbirths Series Steering Committee. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011:23;377:1448-63.  Back to cited text no. 2
World Health Organization. International Statistical Classification of Diseases and Related Health Problems. Geneva: World Health Organization; 1993. p. 613-727.   Back to cited text no. 3
Flenady V, Frøen JF, Pinar H, Torabi R, Saastad E, Guyon G, et al. An evaluation of classification systems of stillbirth. BMC Pregnancy Childbirth 2009;9:24.  Back to cited text no. 4
Turnbull E, Lembalemba MK, Guffey MB, Bolton-Moore C, Mubiana-Mbewe M, Chintu N, et al. Causes of stillbirth, neonatal death and early childhood death in rural Zambia by verbal autopsy assessments. Trop Med Int Health 2011;16:894-901.  Back to cited text no. 5
Manandhar SR, Ojha A, Manandhar DS, Shrestha B, Shrestha D, Saville N, et al. Causes of stillbirths and neonatal deaths in Dhanusha district, Nepal: A verbal autopsy study. Kathmandu Univ Med J (KUMJ) 2010;8:62-72.  Back to cited text no. 6
Mo-suwan L, Isaranurug S, Chanvitan P, Techasena W, Sutra S, Supakunpinyo C, et al. Perinatal death pattern in the four districts of Thailand: Findings from the Prospective Cohort Study of Thai Children (PCTC). J Med Assoc Thai 2009;92:660-6.  Back to cited text no. 7
Baqui AH, Choi Y, Williams EK, Arifeen SE, Mannan I, Darmstadt GL, et al. Levels, timing, and etiology of stillbirths in Sylhet district of Bangladesh. BMC Pregnancy Childbirth 2011;11:25.  Back to cited text no. 8
Bapat U, Alcock G, More NS, Das S, Joshi W, Osrin D. Stillbirths and newborn deaths in slum settlements in Mumbai, India: A prospective verbal autopsy study. BMC Pregnancy Childbirth 2012;12:39.  Back to cited text no. 9


  [Table 1], [Table 2]

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