Rising Perinatal Mortality in Greece, 2014-2024: Are Changes in Stillbirth Registration Practices the Only Explanation?

BACKGROUND: Perinatal mortality appears to have increased recently in Greece; however, it is unclear whether this increase can be solely attributed to the 2018 change in the defined gestational age threshold for stillbirth registration. OBJECTIVES: To examine temporal trends in perinatal mortality rates in Greece during the period 2014-2024 and evaluate the potential impact of changes in stillbirth registration practices. METHODS: Nationwide data from the Hellenic Statistical Authority (2014-2024; Ν = 926,154 total births) were analysed to estimate trends in perinatal mortality. Changes in stillbirth recording after 2018, following the adoption of a 22-week gestational viability threshold, were taken into account. Poisson Regression, Interrupted Time Series (ITS) and Joinpoint Regression analyses were used. RESULTS: Perinatal mortality was 5.6 in 2014 versus 8.2 in 2024 per 1000 total births. Poisson regression showed an overall increase in perinatal mortality rates (4.4% annually, 95% confidence interval [CI] 3.5 to 5.3), driven by rising stillbirth rates (6.8% annually, 95% CI 5.5 to 8.1), while early neonatal mortality rates declined (-2.0% annually; 95% CI -3.0 to -1.1). Stillbirth rates at < 26 weeks' gestation increased sharply (36.1% annually, 95% CI 24.9 to 47.4), whereas a smaller increase was observed at ≥ 26 weeks (1.7% annually, 95% CI 0.4 to 2.9). ITS analysis showed a level increase in 2019 and an increasing post-2019 trend in stillbirth rates at < 26 weeks, whereas no corresponding level or post-2019 trend changes were detected at ≥ 26 weeks. Joinpoint regression also identified 2019 as a breakpoint for stillbirths at < 26 weeks. CONCLUSIONS: The rise in perinatal mortality in Greece over the past decade has been driven by increased stillbirth rates, largely attributable to changes in stillbirth recording practices at gestational ages < 26 weeks. The modest upward trend in stillbirths at ≥ 26 weeks' gestation warrants further investigation and ongoing monitoring.