Our results indicate that the Georgia Birth Registry has a rate of completeness of 93.9 % in its first year compared with the numbers officially reported to Georgia’s Civil Registry. The first results from the Georgia Birth Registry show that the perinatal mortality rate in Georgia in 2016 was 14.8/1000, which is slightly higher than the officially reported rate of 13.8/1000 (3). The probable explanation for the discrepancy in numbers is that the Georgia Birth Registry records the number of infants born in Georgia annually, except home deliveries (-0.5 %), while Georgia’s Civil Registry records the number of newborn citizens.
This situation may occur in countries that do not have a well-functioning birth registry. Infants may be legally registered as citizens even if they are not born in Georgia, as long as one of the parents is a Georgian citizen (7). Parents may choose to do so because there are advantages to being Georgian, for example that Georgians may visit the Schengen area without a visa, a convenience not shared by any of the surrounding countries. Consequently, the true perinatal mortality rate is probably somewhere between 13.8/1000 and 14.8/1000, but closer to the latter.
The Caesarean section rate in Georgia is 43.5 %, which is 2 to 3 times higher than in the Nordic countries, where Caesarean section rates vary between 15 and 21 % (8). Although WHO no longer recommends a specific Caesarean section rate, proportions above 10 % are not associated with a reduction in maternal and perinatal mortality (9). The high Caesarean section rate is a governmental challenge because a caesarean delivery is more expensive than a vaginal birth, but it is also a burden for the women, since having one Caesarean section predisposes for Caesarean section in later deliveries (8).
The mean gestational age in Georgia is 271 days, 4 days shorter than in for example Norway (10). Newborns are much more likely to be delivered by Caesarean section in Georgia (where the mean gestational age in the Caesarean section group was only 269 days) than in Norway where the Caesarean section rate was 16.1 % in 2016 (11). If everything else was equal between the two countries, these differences could indicate that there is an association between high Caesarean section rates and lower gestational age. Unfortunately, our cross sectional design and the fact that we did not have access to reliable data on the clinical indication for performing Caesarean section in Georgia, restrict our possibility to do so. However, our results highlight that the causes and consequences of the high Caesarean section rate in Georgia need future attention.
The quality of the Georgia Birth Registry data is acceptable and in agreement with well-established international findings: i) the proportion of male newborns is slightly higher than the proportion of females (12); ii) higher birth weight among male compared to female newborns (13) and iii) 7 % of newborns had a birth weight <2500 g (14). The employees at the registry office perform continuous quality control of data in the Georgia Birth Registry. Additionally, there are several hundred built-in quality assurance measures e.g. ranges of acceptable values.
The Georgia Birth Registry has only been operational for one year, and system weaknesses are expected. Hospitals have reported some lack of motivation among staff to enter information into the Georgia Birth Registry as this is considered additional work without benefits to themselves or their patients. Therefore, there are substantial amounts of missing values for some optional variables, such as parity and number of fetuses. The birth weight variable also displayed inconsistencies with a disproportionate number of birth weights rounded off to the nearest hundred grams. Ideally the Wilcox and Russel method (or an adapted version) (15) should have been applied in order to double-check probable birth weight outliers routinely. Several major upgrades were implemented in the Georgia Birth Registry during May and June 2017. The same will apply to the Wilcox and Russel method as soon as sufficient data material is available.
During the development period, we discovered the importance of establishing national ownership of the final product. In addition, the Georgia Birth Registry has been dependent on a national and institutional initiative that has created enthusiasm and dedication among local and national health authorities that use the registry for statistics and quality improvement purposes. These are all prerequisites for the sustainability of a system such as the Georgia Birth Registry, a finding which finds strong support in The Lancet series “Civil registration and vital statistics” from 2015 (16).