AOGS ORIGINAL RESEARCH ARTICLE Why babies die in unplanned out-of-institution births: an enquiry into perinatal deaths in Norway 1999–2013 BJ € ORN GUNNARSSON 1,2 , SIGURD FASTING 2,3 , EIRIK SKOGVOLL 2,3 , ALEXANDER K. SM  ARASON 4,5 & KJELL  A. SALVESEN 6,7 1 Department of Research, Norwegian Air Ambulance Foundation, Drøbak, 2 Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, 3 Department of Anesthesia and Intensive Care Medicine, St. Olav’s University Hospital, Trondheim, Norway, 4 Institute of Health Science Research, University of Akureyri, Akureyri, 5 Department of Obstetrics and Gynecology, Akureyri Hospital, Akureyri, Iceland, 6 Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, Trondheim, and 7 Depart- ment of Obstetrics and Gynecology, St. Olav’s University Hospital, Trondheim, Norway Key words Out-of-institution births, causes of death and associated conditions, perinatal mortality, Norwegian Institute of Public Health, Medical Birth Registry of Norway Correspondence Bj€ orn Gunnarsson, Institutt for sirkulasjon og bildediagnostikk – Akutten og Hjerte-lunge- senteret, St. Olavs Hospital, Prinsesse Kristinas gt. 3, Trondheim 7006, Norway. E-mail: bjorn.gunnarsson@ norskluftambulanse.no Conflict of interest The authors have had no relationships with any company that might have an interest in the submitted work in the previous 3 years and no financial interests that may be relevant to the submitted work. Please cite this article as: Gunnarsson B, Fasting S, Skogvoll E, Sm arason AK, Salvesen K  A. Why babies die in unplanned out-of- institution births: an enquiry into perinatal deaths in Norway 1999–2013. Acta Obstet Gynecol Scand 2017; 96:326–333. Received: 22 June 2016 Accepted: 19 November 2016 DOI: 10.1111/aogs.13067 Abstract Introduction. The aims were to describe causes of death associated with unplanned out-of-institution births, and to study whether they could be prevented. Material and methods. Retrospective population-based observational study based on data from the Medical Birth Registry of Norway and medical records. Between 1 January 1999 and 31 December 2013, 69 perinatal deaths among 6027 unplanned out-of-institution births, whether unplanned at home, during transportation, or unspecified, were selected for enquiry. Hospital records were investigated and cases classified according to Causes of Death and Associated Conditions. Results. 63 cases were reviewed. There were 25 (40%) antepartum deaths, 10 (16%) intrapartum deaths, and 24 neonatal (38%) deaths. Four cases were in the unknown death category (6%). Both gestational age and birthweight followed a bimodal distribution with modes at 24 and 38 weeks and 750 and 3400 g, respectively. The most common main cause of death was infection (n = 14, 22%), neonatal (n = 14, 22%, nine due to extreme prematurity) and placental (n = 12, 19%, seven placental abruptions). There were 86 associated conditions, most commonly perinatal (n = 32), placental (n = 15) and maternal (n = 14). Further classification revealed that the largest subgroup was associated perinatal conditions/sub-optimal care, involving 25 cases (40%), most commonly due to sub-optimal maternal use of available care (n = 14, 22%). Conclusions. Infections, neonatal, and placental causes accounted for almost two-thirds of perinatal mortality associated with unplanned out-of-institution births in Norway. Sub-optimal maternal use of available care was found in more than one-fifth of cases. Abbreviations: AC, associated condition; CODAC, causes of death and associated conditions; OOI birth, out-of-institution birth. Introduction Norway has a total area of 385 000 km 2 and a population of just over 5 million. It is one of the most sparsely pop- ulated countries in Europe. The travel times from home to hospital in rural areas can be hours, and the travel may include ferries or obstacles such as winter-closed mountain passes. Seven of 1000 births in Norway are unplanned out-of-institution (OOI) births. These are associated with increased perinatal mortality compared with hospital births (1), though the causes have not been ª 2016 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG)., 96 (2017) 326–333 326 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.