Strengths and limitations
The high acceptance rate for participation in this survey provides a representative overview on obstetrical practice in Austria. Of note, we received a response of all university departments, representing the major delivery units for stillborn babies in Austria. Furthermore, the majority of returned questionnaires were fully completed, thus limiting the number of missing data. The absence of a formal local guideline does not rule out any other form of routine practice performed after IUFD at an institution, which is intrinsically shared by team members and verbally established. The strength of the questionnaire was to capture these practices and provide an overview on clinical care. The combination of institutional data from questionnaires with epidemiological data from the Austrian Birth Registry allowed us to interpret the results with greater detail by adjusting for the numbers of live and stillbirths per institution.
Our study is not devoid of limitations inherent to the failure to control for recall bias of responders and thus data accuracy from returned questionnaires. As over half of the responding institutions showed both a lack of a local guideline and their support for implementation of a national stillbirth care bundle, at the same time, we cannot rule out a certain degree of selection bias. Also, small hospitals with low numbers of stillbirths might not have participated in this survey for the shortage of valid data they might have considered for this analysis. Finally, our survey covered secondary and tertiary degree hospitals in Austria only, and the collected data might not be fully translatable into other countries due to different local facilities and medico-legal practice after perinatal death. These limitations clearly indicate that our findings need to be confirmed by a larger European study to enhance the robustness of these questionnaire results.