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  1. 1
    Peer Reviewed

    Trend and causes of maternal mortality in a tertiary care hospital in Jharkhand, India: a five years retrospective study.

    Kashyap V; Kumar M; Kumar A; Kanayamkandy J

    International Journal of Community Medicine and Public Health. 2016 Nov; 3(11):3030-3032.

    Background: Maternal mortality ratio (MMR) is an indicator of effectiveness of health care facilities for women of child bearing age. It strongly reflects the overall effectiveness of the health system functioning in a developing country. This study attempts to study the trends of maternal mortality and it’s association with different causes in RIMS, Ranchi, Jharkhand, India. The objectives were to study the trends of maternal death in RIMS, Ranchi during 2011-2015 and to study the causes of maternal mortality. Methods: It is a retrospective study design. Data for analysis of trends of maternal mortality were collected from Medical Record Department, RIMS, Ranchi during period 2011 to 2015. Total sample size for this period was 220. Statistical Analysis: Templates were generated in MS excel sheet and analysis was done using SPSS software. Results: Five year data analysis of 220 subjects showed that number of maternal death was more in rural (80.26%) and tribal (86.92%) population. More number of maternal deaths was of antenatal (77.12%) and primigravida (55.06%) cases. Haemorrhage (37%) was most common obstetric cause of maternal death followed by eclampsia (18.34%). Conclusions: Trend of maternal death is higher in tribal, rural population and among primigravida. Obstetric causes accounted for more than half of maternal death (71.5%).
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  2. 2
    Peer Reviewed

    Preventability of maternal near miss and mortality in Rwanda: A case series from the University Teaching Hospital of Kigali (CHUK).

    Benimana C; Small M; Rulisa S

    PloS One. 2018; 13(6):e0195711.

    OBJECTIVE: Assess the primary causes and preventability of maternal near misses (MNM) and mortalities (MM) at the largest tertiary referral hospital in Rwanda, Kigali University Teaching Hospital (CHUK). METHODS: We reviewed records for all women admitted to CHUK with pregnancy-related complications between January 1st, 2015 and December 31st, 2015. All maternal deaths and near misses, based on WHO near miss criteria were reviewed (Appendix A). A committee of physicians actively involved in the care of pregnant women in the obstetric-gynecology department reviewed all maternal near misses/ pregnancy-related deaths to determine the preventability of these outcomes. Preventability was assessed using the Three Delays Model.[1] Descriptive statistics were used to show qualitative and quantitative outcomes of the maternal near miss and mortality. RESULTS: We identified 121 maternal near miss (MNM) and maternal deaths. The most common causes of maternal near miss and maternal death were sepsis/severe systemic infection (33.9%), postpartum hemorrhage (28.1%), and complications from eclampsia (18.2%)/severe preeclampsia (5.8%)/. In our obstetric population, MNM and deaths occurred in 87.6% and 12.4% respectively. Facility level delays (diagnostic and therapeutic) through human error or mismanagement (provider issues) were the most common preventable factors accounting for 65.3% of preventable maternal near miss and 10.7% maternal deaths, respectively. Lack of supplies, blood, medicines, ICU space, and equipment (system issues) were responsible for 5.8% of preventable maternal near misses and 2.5% of preventable maternal deaths. Delays in seeking care contributed to 22.3% of cases and delays in arrival from home to care facilities resulted in 9.1% of near misses and mortalities. Cesarean delivery was the most common procedure associated with sepsis/death in our population. Previous cesarean delivery (24%) and obstructed/prolonged labor (13.2%) contributed to maternal near miss and mortalities. CONCLUSION: The most common preventable causes of MNM and deaths were medical errors, shortage of medical supplies, and lack of patient education/understanding of obstetric emergencies. Reduction in medical errors, improved supply/equipment availability and patient education in early recognition of pregnancy-related danger signs will reduce the majority of delays associated with MNM and mortality in our population.
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  3. 3
    Peer Reviewed

    Applying the international classification of diseases to perinatal mortality data, South Africa.

    Lavin T; Allanson ER; Nedkoff L; Preen DB; Pattinson RC

    Bulletin of the World Health Organization. 2018 Dec; 96(12):806-816.

    Objective To examine the feasibility of applying the International Classification of Diseases-perinatal mortality (ICD-PM) coding to an existing data set in the classification of perinatal deaths. Methods One author, a researcher with a non-clinical public health background, applied the ICD-PM coding system to South Africa’s national perinatal mortality audit system, the Perinatal Problem Identification Program. The database for this study included all perinatal deaths (n = 26 810), defined as either stillbirths (of birth weight > 1000 g and after 28 weeks of gestation) or early neonatal deaths (age 0-7 days), that occurred between 1 October 2013 and 31 December 2016. A clinical obstetrician verified the coding. Findings The South African classification system does not include the timing of death; however, under the ICD-PM system, deaths could be classified as antepartum (n = 15 619; 58.2%), intrapartum (n = 3725; 14.0%) or neonatal (n = 7466; 27.8%). Further, the South African classification system linked a maternal condition to only 40.3% (10 802/26 810) of all perinatal deaths; this proportion increased to 68.9% (18 467/26 810) under the ICD-PM system. Conclusion The main benefit of using the clinically relevant and user-friendly ICD-PM system was an enhanced understanding of the data, in terms of both timing of death and maternal conditions. We have also demonstrated that it is feasible to convert an existing perinatal mortality classification system to one which is globally comparable and can inform policy-makers internationally.
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  4. 4
    Peer Reviewed

    A community based study of neonatal mortality in Aligarh by using verbal autopsy.

    Chauhan A; Shah MS; Khalique N; Eram U

    International Journal of Community Medicine and Public Health. 2018 Jun; 5(6):2491-2494.

    Background: Neonatal mortality rate is regarded as an important and sensitive indicator of the health status of a community. Children face the highest risk of dying in their first month of life. The present study was aimed to 1) determine the prevalence of neonatal mortality rate 2) identify socio-biological factors in relation to neonatal mortality.3) determine the causes of neonatal mortality. Methods: A community based cross sectional study was conducted in the field practice areas of Department of Community Medicine, AMU, Aligarh. All the live births and all neonatal deaths were taken for one year from June 2016 to May 2017. A standard Verbal autopsy questionnaire (WHO 2012) was used as a study tool. Results: The prevalence of neonatal mortality rate was 38.2/1000 live births. The early neonatal mortality rate was 28.3/1000 live births and late neonatal mortality rate was 9.9/1000 live births. The associated socio –biological factors were gender [OR-2.381, 95% CI-1.037-5.468], birth order [OR-4.090, 95% CI-1.119-14.946] and gestational age [OR-12.62, 95% CI-3.26-48.82]. The leading causes of deaths among newborns were preterm births (22.2%), birth asphyxia (22.2%), other causes (19%), ARI (14.3%), congenital anomalies (14.3%) and diarrhoea and neonatal sepsis accounted for (4.8%) each. Conclusions: The neonatal mortality rate assessed by verbal autopsy is higher than nationally reported. Most of the deaths were in early neonatal period. There is a need for programs encouraging the use of antenatal care, encouraging institutional deliveries and care of LBW neonates; as well as implementation of community-based newborn survival strategies.
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  5. 5
    Peer Reviewed

    Determinants of maternal deaths amongst mothers who suffered from post-partum haemorrhage: a community-based case control study.

    Khanna D; Singh JV; Agarwal M; Kumar V

    International Journal of Community Medicine and Public Health. 2018 Jul; 5(7):2814-2820.

    Background: The WHO estimates that, of the 529 000 maternal deaths occurring every year 136 000 take place in India amongst which postpartum haemorrhage (PPH) being the most (29.6%) commonly reported complication. However deaths from PPH can be prevented. The purpose of this study was to identify the risk factors contributing to maternal deaths amongst women who develop PPH. Methods: This was a community based paired case-control study done in rural areas of Lucknow, UP (India) done in a period of one year. Thirty-one maternal deaths due to PPH (cases) were matched and compared with two mothers who survived from PPH (controls). Data was analysed using SPSS version 17.0 and Open Epi version 2.3. The appropriate significance test was applied using MacNemar test for paired data. Risk factors obtained significant in bivariate analysis were subjected to conditional multiple logistic regressions for adjustment and controlling the effect of confounding variables. Results have been given in form of unadjusted Odds ratio (UOR) and adjusted Odds ratio (AOR). Results: It was seen that the mothers who had taken =4 antenatal visits during the index pregnancy had a protective effect against deaths due to PPH. Home delivery raised the odds of death by seven times. Conclusions: Deaths due to PPH can be reduced by ensuring institutional delivery, good antenatal care and better referral facilities, especially for mothers from weaker sections of society.
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  6. 6
    Peer Reviewed

    A rapid appraisal of causes of child death in community settings in district Bhopal.

    Gour D; Toppo M; Melwani V; Khan A; Dohare P; Dandotiya D

    International Journal of Community Medicine and Public Health. 2018 Oct; 5(10):4515-4521.

    Background: Child mortality is considered as a core indicator for child health and well-being. SRS (December 2016) has shown that maximum IMR is in Madhya Pradesh which is 50 per 1000 live births and U5MR is 77 per 1000 live birth (2011). The study was carried out with the objectives to list out and categorize medical as well as socio-economic factors associated with these deaths and to evaluate the current status of child deaths in terms of the provision of health services and gaps in planning and execution of these services. Methods: This cross sectional study was conducted on 42 deaths which occurred in Home settings in Bhopal District. A team visited the identified household and conducted in depth interview regarding the entire event related to antenatal care, place of delivery, intranatal and postnatal care, accessibility of the health services and quality of care rendered that contributed to poor child health that resulted in the death of the child. Results: Out of 42 child deaths covered, 23 took place in the neonatal period, of which 21 were home deaths. 47.61% were attended by trained birth attendant. Breastfeeding was started immediately in 94.11% neonates whereas 5.88% were breastfed second day or later. 19 deaths took place in the post neonatal period, of which 17 were home deaths. (68.75%) were breast fed immediately within one hour of birth. Conclusions: A majority of home based child deaths are occurring in families with high illiteracy rates and those belonging to BPL families.
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  7. 7

    Risk factors for maternal mortality among eclamptics in Hawassa University Referral Hospital, 2016.

    Solomon F; Kasay Z

    Ethiopian Journal of Reproductive Health. 2016 Feb; 8(1):8-18.

    INTRODUCTION: Globally eclampsia is an important cause of morbidity and mortality during pregnancy, child birth and puerperium. Early intervention and provision of critical care for those at risk of significant morbidity and mortality is important. OBJECTIVE: To identify important risk factors for maternal mortality among eclamptic women managed in Hawassa University Referral Hospital. METHODOLOGY: A five years retrospective case - control analysis of risk factors for maternal mortality among eclamptic women was done. Cases were those mothers who died and the controls were those who survived. Data was collected from patient charts and variables were assessed among cases and controls to identify risk factors for mortality. Odds ratio with 95% confidence interval and P- values were computed. RESULTS: The majority of eclamptics were below 26 years of age, 95 (65 %); primigravida, 76 (52 %) and from out of Hawassa, 95 (65 %). Five or more convulsions before admission (OR = 3.90, 95%CI, 1.64 -9.37), creatinine level above 0.9 mg/dl (0R = 7.73, 95%CI, 2.84 -21.63) and platelet count less than 100,000/mm3 (OR = 11.20, 95%CI, 3.70 -36.32) were significantly associated with the risk of mortality at admission. The case fatality rate of eclampsia was 24% and the most important causes of deaths were respiratory failure and acute renal failure. CONCLUSION: Closer follow up should be considered for those eclamptics with 5 or more convulsions before admission; and elevated creatinine level and thrombocytopenia at admission. The quality of care provided in the intensive care unit should be improved.
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  8. 8
    Peer Reviewed

    Implementation project of the non-pneumatic anti-shock garment and m-communication to enhance maternal health care in rural Tanzania.

    Mbaruku G; Therrien MS; Tillya R; Mbuyita S; Mtema Z; Kinyonge I; Godfrey R; Temu S; Miller S

    Reproductive Health. 2018 Oct 19; 15(1):177.

    BACKGROUND: Obstetric hemorrhage (OH) remains one of the leading causes of maternal mortality, particularly in rural Africa. Tanzania has a high maternal mortality ratio, and approximately 80% of the population accesses health care lower level facilities, unable to provide Comprehensive Emergency Obstetric Care (CEmOC). The non-pneumatic anti-shock garment (NASG) has been demonstrated to reduce mortality as it buys time for women in shock to be transported to or to overcome delays at referral facilities. METHODS: This report describes one component of an ongoing maternal health improvement project, Empower, implemented in 280 facilities in four regions in rural Tanzania. The NASG along with a Closed User Group (CUG) mobile phone network were implemented within the overall EmOC project. Simulation trainings, repeated trainings, and close hands-on supportive supervision via site visits and via the CUG network were the training/learning methods. Data collection was conducted via the CUG network, with a limited data collection form, which also included free text options for project improvement. One-to-one interviews were also conducted. Outcome Indicators included appropriate use of NASG for women with hypovolemic shock We also compared baseline case fatality rates (CFR) from OH with endline CFRs. Data were analyzed using cohort study Risk Ratio (RR). Qualitative data analysis was conducted by content analysis. RESULTS: Of the 1713 women with OH, 419 (24.5%) met project hypovolemic shock criteria, the NASG was applied to 70.8% (n = 297), indicating high acceptability and utilization. CFR at baseline (1.70) compared to CFR at endline (0.76) showed a temporal association of a 67% reduced risk for women during the project period (RR: 0.33, 95% CI = .19, .60). Qualitative feedback was used to make course corrections during the project to enhance training and implementation. CONCLUSIONS: This implementation project with 280 facilities and over 1000 providers supported via CUG demonstrated that NASG can have high uptake and appropriate use for hypovolemic shock secondary to OH. With the proper implementation strategies, NASG utilization can be high and should be associated with decreased mortality among mothers at risk of death from obstetric hemorrhage.
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  9. 9

    A 3 years review of maternal death and associated factors at Ayder Comprehensive Specialized Hospital, Northern Ethiopia.

    Teka H; Zelelow YB

    Ethiopian Journal of Reproductive Health. 2018 Jul; 10(3):38-45.

    BACKGROUND: Maternal mortality ratio in Ethiopia is one of the highest in the world. Despite measures to alleviate it and showing a promising declining trend, it still remains one of the highest at 412 maternal deaths per 100,000 live births. To our knowledge there is no accessible published study on maternal mortality at Ayder Comprehensive Specialized Hospital (ACSH). OBJECTIVE: The aim of this study is to systematically analyze causes of maternal deaths and contributing factors at (ACSH). METHODS: This was a descriptive, retrospective chart review of institutional maternal deaths using a 3-years record from July 1, 2014 -June 30, 2017 at ACSH. RESULTS There were 52 maternal deaths from July 1, 2014 -June 30, 2017 at ACSH. The main causes of these deaths were related to obstetric hemorrhage (n=11, 21.2 %), hypertensive disorders of pregnancy (n=10, 19.2%) and sepsis (n=7, 13.5%). About 86.5% (n=45) of the mothers were referral cases of whom 24 (53.33%) of them travelled more than 100 kilometers to reach ACSH. The furthest referral site was 498 kilometers from ACSH. Most common reasons for referral include for admission to intensive care unit, for further workup and management, for blood transfusion and for high risk admission. Most of the maternal deaths occurred in the postpartum period. CONCLUSION: There is an urgent need for expansion of intensive care unit (ICU) and availing blood transfusion services in all the general and regional hospitals with close monitoring of mothers in the postpartum period. The referral system needs coordination from the lower level to the teritirary care centers.
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  10. 10
    Peer Reviewed

    Contribution of social factors to maternal deaths in urban India: Use of care pathway and delay models.

    Kaur M; Gupta M; Pandara Purayil V; Rana M; Chakrapani V

    PloS One. 2018; 13(10):e0203209.

    This paper uses care pathway and delay models to better understand the possible social reasons for maternal deaths in a city with good public and private health infrastructure. The findings can inform programmes to reduce maternal mortality. During 2007-15, 136 maternal deaths were reported in Chandigarh, India. Using World Health Organisation's verbal autopsy questionnaire, interviews were conducted with primary caregivers of 68 (50%) of the 136 deceased women, as majority of the families had returned to their native places. We used process-tracing techniques to construct the care pathways and identify delays, and explored open-ended responses using thematic analysis. The mean age of the deceased women was 27 years, 51% resided in slums, 32% were primigravida, 25% had their deliveries assisted by traditional birth attendants, and 23% had Caesarean section. Eight percent died at home, and 54% died in tertiary level facilities. Post-partum haemorrhage (26.5%), and complications of puerperium (25%) and labour/delivery (14.7%) were the reported medical causes. Male child preference and norms for home delivery were identified as the distal socio-cultural causes. Individual and family level factors included: shame on multiple pregnancies; fear of discrimination from providers; past successful deliveries at home leading to overconfidence and not seeking institutional care; and lack of awareness about family planning, antenatal care, and danger signs of pregnancy. Healthcare system factors were: non-availability of senior doctors at the time of consultation in the emergency that delayed initiation of immediate treatment, and lack of availability of life-saving equipment due to patient load. Empirical evidence was found on social causes of maternal deaths, which could have been prevented by appropriate actions at individual, family, societal, institutional and policy levels. This study identified potential preventable causes of primarily social origin, which could help in taking actionable steps at several levels to further reduce maternal deaths in India.
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  11. 11
    Peer Reviewed

    Child mortality: the challenge for India and the world.

    El Arifeen S; Masanja H; Rahman AE

    Lancet. 2017 Oct 28; 390(10106):1932-1933.

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  12. 12
    Peer Reviewed

    Epidemiological profile of maternal mortality.

    Martins ACS; Silva LS

    Revista Brasileira De Enfermagem. 2018; 71(suppl 1):677-683.

    OBJECTIVE: To know the epidemiological profile of maternal mortality in Juiz de Fora, a city in the state of Minas Gerais. Data collection was carried out from April to December 2016. METHOD: Summary of a confidential investigation of maternal mortality on deaths occurred from January 1st, 2005 to December 31, 2015. RESULTS: Eighty-five deaths of women residing in Juiz de Fora were identified and analyzed. The age group was between 20 and 36 years. The women carried out prenatal care (74.1%) with less than six visits (34.0%). Cesarean section was conducted in 38.8% of the childbirths and the obstetric treatment was considered appropriate (32.9%). The first cause of maternal death was hypovolemic shock 12 (14.10%), followed by uterine hypotony 6 (7.0%). CONCLUSION: Cesarean section rates are high and prenatal adherence is lower than that expected, which could justify the number of deaths in the period studied.
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  13. 13
    Peer Reviewed

    Identifying HIV care continuum gaps with verbal autopsy.

    Bogoch II; Gomes M; Fuente-Soro L; Varo R; Naniche D; Sacoor C; Gonzalez R; Nagelkerke N; Bassat Q; Jha P

    Lancet. HIV. 2018 Feb; 5(2):e65-e67.

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  14. 14
    Peer Reviewed

    Root-Cause Analysis of Persistently High Maternal Mortality in a Rural District of Indonesia: Role of Clinical Care Quality and Health Services Organizational Factors.

    Mahmood MA; Mufidah I; Scroggs S; Siddiqui AR; Raheel H; Wibdarminto K; Dirgantoro B; Vercruyssen J; Wahabi HA

    BioMed Research International. 2018; 2018:3673265.

    Background: Despite significant reduction in maternal mortality, there are still many regions in the world that suffer from high mortality. District Kutai Kartanegara, Indonesia, is one such region where consistently high maternal mortality was observed despite high rate of delivery by skilled birth attendants. Method: Thirty maternal deaths were reviewed using verbal autopsy interviews, terminal event reporting, medical records' review, and Death Audit Committee reports, using a comprehensive root-cause analysis framework including Risk Identification, Signal Services, Emergency Obstetrics Care Evaluation, Quality, and 3 Delays. Findings: The root causes were found in poor quality of care, which caused hospital to be unprepared to manage deteriorating patients. In hospital, poor implementation of standard operating procedures was rooted in inadequate skills, lack of forward planning, ineffective communication, and unavailability of essential services. In primary care, root causes included inadequate risk management, referrals to facilities where needed services are not available, and lack of coordination between primary healthcare and hospitals. Conclusion: There is an urgent need for a shift in focus to quality of care through knowledge, skills, and support for consistent application of protocols, making essential services available, effective risk assessment and management, and facilitating timely referrals to facilities that are adequately equipped.
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  15. 15

    A comparison of early neonatal deaths among preterm infants with term neonatal deaths at the University Teaching Hospital, Lusaka, Zambia.

    Kamfwa P; Ahmed Y; Vwalika B

    Medical Journal of Zambia. 2017; 44(4):250-254.

    Background: Prematurity is a common complication that contributes significantly to high neonatal mortality. In spite of many efforts by the government and other partners, non-significant decline has been achieved in the recent past. Globally, 15 million babies are born preterm (<37 weeks gestation) each year, and more than 1 million of those do not survive their first month of life. Preterm birth accounts for 75% of all perinatal mortality in some series thus identifying the determinants of preterm deaths is very crucial for policy improvement. This study was aimed at establishing factors associated with preterm deaths at UTH compared to those of term neonatal deaths. Methods: A case-control study was conducted among 208 neonates that were early neonatal deaths i.e. within 7 days in neonatal intensive care unit (NICU) at UTH in 2015. Antenatal and intrapartum details (parity, multiple pregnancy, birth weight, antenatal steroid exposure, antibiotic exposure, and the indication of admission to NICU) were obtained from 104 neonates that were preterm (between 24- 36 completed weeks gestation) and had died and of a further 104 term neonates (>37 weeks gestation) that died around the same time. The data was collected by int e rvi ewe r- admini s t e r ed s t ruc tur ed questionnaire and analyzed by SPSS v21. Bivariate analysis was used to identify variables for multivariate logistic regression model to identify obstetric determinants amongst deaths in neonates that were preterm compared to those born at term. Results: There were few differences between the two groups. The sex of the neonate significantly influenced the odds of dying. We confirmed that male neonates had a 57.1% higher risk than females (42.9%) of dying during the early neonatal period. More term neonates that died were male (P=0.0031) and had a very poor Apgar score (1-3) (P=0.0048). Both the indications for admission to NICU and cause of death were different in the two groups with preterms (P<0.0001) and terms P=0.0309. On multivariate regression analysis, poor Apgar score was associated with six-fold odds of RDS. More preterm neonates had died despite receiving steroids. None of the other factors reached statistical significance (adjOR 6.0, 95% CI 3.03-11.92, p<0.0001). Poor Apgar score was also the only factor associated with sepsis, though it was a neonate with a good Apgar score that had higher odds of dying due to sepsis. Primiparity was associated with a 2.6-fold odds (95% CI 1.03 to 6.68, p=0.04) of hypoxic ischaemic encephalopathy. On logistic regression, a preterm neonate dying only had a higher odds of being a LBW (<2500g) than any other factor [adjusted OR 132.72 (95% CI 39.49 to 387.66) P<00001]. Considering the main causes of death, hypoxic ischemic encephalopathy in preterm neonates was only associated with poor Apgar score (i.e. <7) [adjusted OR 2.03 (95% CI 1.12 to 3.67) P = 0.02]. Sepsis in term neonates OR 0.2 (95% CI 0.15 to 0.54) P<00001]. Respiratory distress syndrome in preterm neonates dying was only associated with poor Apgar score [adjusted OR 6.01 (3.03 to 11.92) P<00001]. Conclusions: Hypoxic ischemic encephalopathy as a cause of early neonatal death is commoner in term neonates but also common in preterm. Sepsis is commoner in preterm neonates as a cause of early neonatal death. Comparing different causes of death, poor Apgar score featured in all cases calling for improved resuscitation.
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  16. 16
    Peer Reviewed

    Assigning cause of maternal death: a comparison of findings by a facility-based review team, an expert panel using the new ICD-MM cause classification and a computer-based program (InterVA-4).

    Mgawadere F; Unkels R; van den Broek N

    BJOG. 2016 Sep; 123(10):1647-53.

    OBJECTIVE: To compare methodology used to assign cause of and factors contributing to maternal death. DESIGN: Reproductive Age Mortality Study. SETTING: Malawi. POPULATION: Maternal deaths among women of reproductive age. METHODS: We compared cause of death as assigned by a facility-based maternal death review team, an expert panel using the International Classification of Disease, 10th revision (ICD-10) cause classification for deaths during pregnancy, childbirth and the puerperium (ICD-MM) and a computer-based probabilistic program (InterVA-4). MAIN OUTCOME MEASURES: Number and cause of maternal deaths. RESULTS: The majority of maternal deaths occurred at a health facility (94/151; 62.3%). The estimated maternal mortality ratio was 363 per 100 000 live births (95% CI 307-425). There was poor agreement between cause of death assigned by a facility-based maternal death review team and an expert panel (kappa = 0.37, 86 maternal deaths). The review team considered 36% of maternal deaths to be indirect and caused by non-obstetric complications (ICD-MM Group 7) whereas the expert panel considered only 17.4% to be indirect maternal deaths with 33.7% due to obstetric haemorrhage (ICD-MM Group 3). The review team incorrectly assigned a contributing condition rather than cause of death in up to 15.1% of cases. Agreement between the expert panel and InterVA-4 regarding cause of death was good (kappa = 0.66, 151 maternal deaths). However, contributing conditions are not identified by InterVA-4. CONCLUSIONS: Training in the use of ICD-MM is needed for healthcare providers conducting maternal death reviews to be able to correctly assign underlying cause of death and contributing factors. Such information can help to identify what improvements in quality of care are needed. TWEETABLE ABSTRACT: For maternal deaths assigning cause of death is best done by an expert panel and helps to identify where quality of care needs to be improved. (c) 2016 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.
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  17. 17

    A study of infant deaths in tribal area of Andhra Pradesh, India.

    Garikipati U; Babu GR; Pant H; Murthy GV

    Global Journal of Medicine and Public Health. 2013; 2(4):5 p.

    Objectives: This study aimed to determine the prevalence of neonatal deaths and its underlying correlates in tribal area of Andhra Pradesh, India Methods: We conducted a two phase cross-sectional study (N=230). Semi-structured questionnaire schedules (in the vernacular-Telugu) were used in the initial qualitative phase, to obtain specific information from mothers who delivered in a one year period prior to the study. Information from the analysed qualitative data was used to construct a questionnaire-schedule for the 2nd phase which used quantitative survey techniques. Results: It was observed that Infant Mortality ratio (IMR) in Vizianagaram district was 239 per 1000 live births in the tribal areas under study. This was ten times higher than that reported by the district (22/1000) and 4-5 times higher than SRS data of 2011 for AP. It was observed that 28% of infants died within first day, 68% within first week (including the first day) and 81% within first month. Conclusions: The high IMR observed in the within first month of life in tribal areas, interventions to tackle them should be prioritized in this ‘golden period’. The health workers should be re-trained to identify and manage the early warning signs of neonatal complications.
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  18. 18
    Peer Reviewed

    A Prospective Study of Causes of Illness and Death in Preterm Infants in Ethiopia: The SIP Study Protocol.

    Muhe LM; McClure EM; Mekasha A; Worku B; Worku A; Dimtse A; Gebreyesus G; Tigabu Z; Abayneh M; Workneh N; Eshetu B; Girma A; Asefa M; Portales R; Arayaselassie M; Gebrehiwot Y; Bekele T; Bezabih M; Metaferia G; Gashaw M; Abebe B; Geleta A; Shehibo A; Hailu Y; Berta H; Alemu A; Desta T; Hailu R; Patterson J; Nigussie AK; Goldenberg RL

    Reproductive Health. 2018 Jun 27; 15(1):116.

    BACKGROUND: With nearly 15 million annual preterm births globally, preterm birth is the most common cause of neonatal death. Forty to 60 % of neonatal deaths are directly or indirectly associated with preterm mortality. As countries aim to meet the Sustainable Development Goals to reduce neonatal mortality, significant reductions in preterm mortality are needed. This study aims to identify the common causes of preterm illness and their contribution to preterm mortality in low-resource settings. This article will describe the methods used to undertake the study. METHODS: This is a prospective, multi-centre, descriptive clinical study. Socio-demographic, obstetric, and maternal factors, and clinical and laboratory findings will be documented. The major causes of preterm mortality will be identified using clinical, laboratory, imaging, and autopsy methods and use the national Ethiopian guidelines on management of preterm infants including required investigations to reach final diagnoses. The study will document the clinical and management protocols followed in these settings. The approach consists of clinical examinations and monitoring, laboratory investigations, and determination of primary and contributory causes of mortality through both clinical means and by post-mortem examinations. An independent panel of experts will validate the primary and contributory causes of mortality. To obtain the estimated sample size of 5000 preterm births, the study will be undertaken in five hospitals in three regions of Ethiopia, which are geographically distributed across the country. All preterm infants who are either born or transferred to these hospitals will be eligible for the study. Three methods (last menstrual period, physical examination using the New Ballard Score, and ultrasound) will be used to determine gestational age. All clinical procedures will be conducted per hospital protocol and informed consent will be taken from parents or caretakers prior to their participation in the study as well as for autopsy if the infant dies. DISCUSSION: This study will determine the major causes of death and illness among hospitalized preterm infants in a low-resource setting. The result will inform policy makers and implementers of areas that can be prioritized in order to contribute to a significant reduction in neonatal mortality.
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  19. 19

    Abortion in the Structure of Causes of Maternal Mortality. Aborto na estrutura das causas da mortalidade materna.

    Volkov VG; Granatovich NN; Survillo EV; Pichugina LV; Achilgova ZS

    Revista Brasileira de Ginecologia e Obstetricia. 2018 Jun; 40(6):309-312.

    OBJECTIVE: To study the structure of maternal mortality caused by abortion in the Tula region. METHODS: The medical records of deceased pregnant women, childbirth, and postpartum from January 01, 2001, to December 31, 2015, were analyzed. RESULTS: Overall, 204,095 abortion cases were recorded in the Tula region for over 15 years. The frequency of abortion was reduced 4-fold, with 18,200 in 2001 to 4,538 in 2015. The rate of abortions per 1,000 women (age 15-44 years) for 15 years decreased by 40.5%, that is, from 46.53 (2001) to 18.84 (2015), and that of abortions per 100 live births and stillbirths was 29.5%, that is, from 161.7 (2001) to 41.5 (2015). Five women died from abortion complications that began outside of the hospital, which accounted for 0.01% of the total number. In the structure of causes of maternal mortality for 15 years, abortion represented 14.3% of the cases. Lethality mainly occurred in the period from 2001 to 2005 (4 cases). Among the maternal deaths, many women died in rural areas after pregnancy termination at 18 to 20 weeks of gestation (n = 4). In addition, three women died from sepsis and two from bleeding. CONCLUSION: The introduction of modern, effective technologies of family planning has reduced maternal mortality due to abortion. Thieme Revinter Publicacoes Ltda Rio de Janeiro, Brazil.
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  20. 20

    A review on child and maternal health status of Bangladesh.

    Mahmudur Rahman AH

    CHRISMED Journal of Health and Research. 2018 Jan-Mar; 5(1):1-7.

    Child and maternal nutritional and health status is a very much concerning issue of Bangladesh. To summarize the specific conditions of Bangladeshi child and maternal health and related issues. This is a descriptive review and overall analysis and description of the literature was done regarding child and maternal health of the general population living in Bangladesh. The evidence reflected that infant, child, and maternal mortality in Bangladesh have declined gradually at least over the past years. It is found that infant mortality 2 times, child mortality 6 times, and under five mortality rates 3 times declined comparatively than the last two decades but it is noted that maternal assassination circumstance has not declined. Knowledge on child and maternal health carries an important role in education. Health knowledge index significantly improve child and maternal health although differentially. It is obvious that poverty is one of the root causes that have led to a high child and maternal mortalities and morbidities faced by the people of Bangladesh. The requirement for socio economic relief for those living in rural Bangladesh remains one of the core issues. Recently, Bangladesh is successfully declining the total number of childhood and nutrition related mortalities despites various complexities, but maternal health status is not improving at the same pace. Nongovernment and government funded organizations and policymakers should come forward for running some effective programs to conquer the situation completely in Bangladesh.
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  21. 21
    Peer Reviewed

    Infant mortality trend in the city of Rio Branco, AC, 1999 to 2015.

    Ramalho AA; Andrade AM; Martins FA; Koifman RJ

    Revista De Saude Publica. 2018 Apr 9; 52:33.

    OBJECTIVE: Analyze the trend of infant mortality in Rio Branco, state of Acre, from 1999 to 2015. METHODS: An ecological observational study of a time series, in which data from deaths from the Information System on Mortality and Births of the Information System on Live Births were used. The annual percentage change was estimated using the Joinpoint software. RESULTS: The infant mortality rate decreased from 26.99 in 1999 to 14.50 in 2015 per 1,000 live births, with an annual percentage change of -4.37 (95%CI -5.4- -3.4). When stratified by age components, the neonatal period presented an annual percentage change of -4.73 (95%CI -5.7- -3.7), and the post-neonatal period was -3.7 (95%CI -5.4- -2.0). Avoidability, avoidable causes and poorly defined causes showed a downward trend throughout the period and causes not clearly preventable showed an upward trend until 2008. The group of causes that contributed most to the infant deaths during the period studied was perinatal diseases, followed by malformations, infectious and parasitic diseases, and respiratory diseases. CONCLUSIONS: Despite the decreasing trend in infant mortality rates in the capital compared to developed countries, it is relatively high.
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  22. 22
    Peer Reviewed

    Azithromycin to Reduce Childhood Mortality in Sub-Saharan Africa.

    Keenan JD; Bailey RL; West SK; Arzika AM; Hart J; Weaver J; Kalua K; Mrango Z; Ray KJ; Cook C; Lebas E; O'Brien KS; Emerson PM; Porco TC; Lietman TM

    New England Journal of Medicine. 2018 Apr 26; 378(17):1583-1592.

    BACKGROUND: We hypothesized that mass distribution of a broad-spectrum antibiotic agent to preschool children would reduce mortality in areas of sub-Saharan Africa that are currently far from meeting the Sustainable Development Goals of the United Nations. METHODS: In this cluster-randomized trial, we assigned communities in Malawi, Niger, and Tanzania to four twice-yearly mass distributions of either oral azithromycin (approximately 20 mg per kilogram of body weight) or placebo. Children 1 to 59 months of age were identified in twice-yearly censuses and were offered participation in the trial. Vital status was determined at subsequent censuses. The primary outcome was aggregate all-cause mortality; country-specific rates were assessed in prespecified subgroup analyses. RESULTS: A total of 1533 communities underwent randomization, 190,238 children were identified in the census at baseline, and 323,302 person-years were monitored. The mean (+/-SD) azithromycin and placebo coverage over the four twice-yearly distributions was 90.4+/-10.4%. The overall annual mortality rate was 14.6 deaths per 1000 person-years in communities that received azithromycin (9.1 in Malawi, 22.5 in Niger, and 5.4 in Tanzania) and 16.5 deaths per 1000 person-years in communities that received placebo (9.6 in Malawi, 27.5 in Niger, and 5.5 in Tanzania). Mortality was 13.5% lower overall (95% confidence interval [CI], 6.7 to 19.8) in communities that received azithromycin than in communities that received placebo (P<0.001); the rate was 5.7% lower in Malawi (95% CI, -9.7 to 18.9), 18.1% lower in Niger (95% CI, 10.0 to 25.5), and 3.4% lower in Tanzania (95% CI, -21.2 to 23.0). Children in the age group of 1 to 5 months had the greatest effect from azithromycin (24.9% lower mortality than that with placebo; 95% CI, 10.6 to 37.0). Serious adverse events occurring within a week after administration of the trial drug or placebo were uncommon, and the rate did not differ significantly between the groups. Evaluation of selection for antibiotic resistance is ongoing. CONCLUSIONS: Among postneonatal, preschool children in sub-Saharan Africa, childhood mortality was lower in communities randomly assigned to mass distribution of azithromycin than in those assigned to placebo, with the largest effect seen in Niger. Any implementation of a policy of mass distribution would need to strongly consider the potential effect of such a strategy on antibiotic resistance. (Funded by the Bill and Melinda Gates Foundation; MORDOR number, NCT02047981 .).
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  23. 23
    Peer Reviewed

    Feasibility and acceptability of conducting hiv vaccine trials in adolescents in South Africa: Going beyond willingness to participate towards implementation.

    Wallace M; Middelkoop K; Smith P; Pike C; Bennie T; Chandia J; Churchyard G; Gray G; Latka MH; Mathebula M; Nchabeleng M; Roux S; Slack C; Strode A; Bekker LG

    South African Medical Journal. 2018; 108(4):291-298.

    Background. HIV/AIDS remains a leading cause of death in adolescents (aged 15 - 25 years), and in sub-Saharan Africa HIV-related deaths continue to rise in this age group despite a decline in both adult and paediatric populations. This is attributable in part to high adolescent infection rates and supports the urgent need for more efficacious prevention strategies. In particular, an even partially effective HIV vaccine, given prior to sexual debut, is predicted to significantly curb adolescent infection rates. While adolescents have indicated willingness to participate in HIV vaccine trials, there are concerns around safety, uptake, adherence, and ethical and logistic issues. Objectives. To initiate a national, multisite project with the aim of identifying obstacles to conducting adolescent HIV vaccine trials in South Africa (SA). Method. A simulated HIV vaccine trial was conducted in adolescents aged 12 - 17 years across five SA research sites, using the already licensed Merck human papillomavirus vaccine Gardasil as a proxy for an HIV vaccine. Adolescents were recruited at community venues and, following a vaccine discussion group, invited to participate in the trial. Consent for trial enrolment was obtained from a parent or legal guardian, and participants aged 16 - 17 years were eligible only if sexually active. Typical vaccine trial procedures were applied during the five study visits, including the administration of vaccination injections at study visits 2, 3 and 4. Results. The median age of participants was 14 years (interquartile range 13 - 15), with 81% between the ages of 12 and 15 years at enrolment. Overall, 98% of screened participants opted to receive the vaccine, 588 participants enrolled, and 524 (89%) attended the final visit. Conclusions. This trial showed that adolescents can be recruited, enrolled and retained in clinical prevention trials with parental support. While promising, these results were tempered by the coupling of sexual-risk eligibility criteria and the requirement for parental/guardian consent, which was probably a barrier to the enrolment of high-risk older adolescents. Further debate around appropriate consent approaches for such adolescents in HIV prevention studies is required. © 2018, South African Medical Association. All rights reserved.
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  24. 24
    Peer Reviewed

    Socioeconomic differences in mortality in the antiretroviral therapy era in Agincourt, rural South Africa, 2001-13: a population surveillance analysis.

    Kabudula CW; Houle B; Collinson MA; Kahn K; Gomez-Olive FX; Tollman S; Clark SJ

    Lancet. Global Health. 2017 Sep; 5(9):e924-e935.

    BACKGROUND: Understanding the effects of socioeconomic disparities in health outcomes is important to implement specific preventive actions. We assessed socioeconomic disparities in mortality indicators in a rural South African population over the period 2001-13. METHODS: We used data from 21 villages of the Agincourt Health and socio-Demographic Surveillance System (HDSS). We calculated the probabilities of death from birth to age 5 years and from age 15 to 60 years, life expectancy at birth, and cause-specific and age-specific mortality by sex (not in children <5 years), time period, and socioeconomic status (household wealth) quintile for HIV/AIDS and tuberculosis, other communicable diseases (excluding HIV/AIDS and tuberculosis) and maternal, perinatal, and nutritional causes, non-communicable diseases, and injury. We also quantified differences with relative risk ratios and relative and slope indices of inequality. FINDINGS: Between 2001 and 2013, 10 414 deaths were registered over 1 058 538 person-years of follow-up, meaning the overall crude mortality was 9.8 deaths per 1000 person-years. We found significant socioecomonic status gradients for mortality and life expectancy at birth, with outcomes improving with increasing socioeconomic status. An inverse relation was seen for HIV/AIDS and tuberculosis mortality and socioeconomic status that persisted from 2001 to 2013. Deaths from non-communicable diseases increased over time in both sexes, and injury was an important cause of death in men and boys. Neither of these causes of death, however, showed consistent significant associations with household socioeconomic status. INTERPRETATION: The poorest people in the population continue to bear a high burden of HIV/AIDS and tuberculosis mortality, despite free antiretroviral therapy being made available from public health facilities. Associations between socioeconomic status and increasing burden of mortality from non-communicable diseases is likely to become prominent. Integrated strategies are needed to improve access to and uptake of HIV testing, care, and treatment, and management of non-communicable diseases in the poorest populations. FUNDING: Wellcome Trust, South African Medical Research Council, and University of the Witwatersrand, South Africa. Copyright (c) 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.
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  25. 25
    Peer Reviewed

    Factors associated with maternal mortality in Malawi: application of the three delays model.

    Mgawadere F; Unkels R; Kazembe A; van den Broek N

    BMC Pregnancy and Childbirth. 2017 Jul 12; 17(1):219.

    BACKGROUND: The three delays model proposes that maternal mortality is associated with delays in: 1) deciding to seek care; 2) reaching the healthcare facility; and 3) receiving care. Previously, the majority of women who died were reported to have experienced type 1 and 2 delays. With increased coverage of healthcare services, we sought to explore the relative contribution of each type of delay. METHOD: 151 maternal deaths were identified during a 12-month reproductive age mortality survey (RAMOS) conducted in Malawi; verbal autopsy and facility-based medical record reviews were conducted to obtain details about the circumstances surrounding each death. Using the three delays framework, data were analysed for women who had; 1) died at a healthcare facility, 2) died at home but had previously accessed care and 3) died at home and had not accessed care. RESULTS: 62.2% (94/151) of maternal deaths occurred in a healthcare facility and a further 21.2% (32/151) of mothers died at home after they had accessed care at a healthcare facility. More than half of all women who died at a healthcare facility (52.1%) had experienced more than one type of delay. Type 3 delays were the most significant delay for women who died at a healthcare facility or women who died at home after they had accessed care, and was identified in 96.8% of cases. Type 2 delays were experienced by 59.6% and type 1 delays by 39.7% of all women. Long waiting hours before receiving treatment at a healthcare facility, multiple delays at the time of admission, shortage of drugs, non-availability and incompetence of skilled staff were some of the major causes of type 3 delays. Distance to a healthcare facility was the main problem resulting in type 2 delays. CONCLUSION: The majority of women do try to reach health services when an emergency occurs, but type 3 delays present a major problem. Improving quality of care at healthcare facility level will help reduce maternal mortality.
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