A prospective study of maternal, fetal and neonatal deaths in low- and middle-income countries

Bulletin of the World Health Organization, Volume 92, No. 8, Year 2014

Interprétation

Objective: To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths. Methods: A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum. Findings: Between 2010 and 2012, 214 070 of 220 235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100 000 live births, ranging from 69 per 100 000 in Argentina to 316 per 100 000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97-11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26-5.67) and 7-day (RR: 3.94; 95% CI: 2.74-5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54-9.77). Conclusion: Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality. Between 2010 to 2012, as part of a prospective, maternal newborn health study of all pregnancies, we documented maternal, fetal and neonatal deaths that occurred up to six weeks postpartum. The study was done in 106 communities at six sites in five low-income countries (Chimaltenango, Guatemala; Nagpur District and Karnataka District, India; Western Provence, Kenya; Thatta District, Pakistan; and Lusaka, Zambia) and at one site in a middle-income country (Corrientes, Argentina).9 These seven sites were selected by the Eunice Kennedy Shriver National Institute of Child Health and Human Development in the United States of America (USA), which supports the Global Network for Women’s and Children’s Health Research, to represent rural or semi-urban geographical areas served by government health services. Each site included between six and 24 distinct communities. In general, each community represented the catchment area of a primary health-care centre and, in each, 300 to 500 births took place annually. Beginning in 2009, the study investigators at each site initiated an ongoing, prospective maternal and newborn health registry of pregnant women for each community. The objective was to enrol pregnant women by 20 weeks’ gestation and to obtain data on pregnancy outcomes for all deliveries that took place in the community. Each community employed a registry administrator who identified and tracked pregnancies and their outcomes in coordination with community elders, birth attendants and other health-care workers. All pregnant women resident in study communities were eligible for inclusion. Women were enrolled during pregnancy and data on pregnancy outcomes were collected by the trained registry administrators – usually nurses or health workers – who were supervised by study site investigators. At each site, efforts were made to verify that all pregnant women residing in the study communities were included in the registry and that data on all outcomes had been obtained. The study coordinators, who were generally nurses or physicians, monitored enrolment and follow-up to ensure that the data collected were consistent, complete and of a high quality. For hospital births, registry administrators reviewed hospital birth records routinely to identify deliveries to women from the study communities. In addition, culturally appropriate strategies were used at each site to ensure that all outcomes were reported. For example, elders or chiefs in one village used mobile phones to send text messages when women enrolled in the study gave birth. Such strategies increased the likelihood that we were able to identify all pregnancies and maternal and fetal outcomes. Demographic and medical data were obtained for each woman by either the registry administrator or the study coordinator. All deaths that occurred during pregnancy or in the six weeks postpartum were reported using World Health Organization (WHO) classifications.31 The cause of each maternal death was assigned by the registry administrator on the basis of clinical and other information provided by the birth attendant and the woman’s family. All death reports were reviewed by the supervising physician at the study site. For deaths for which a definite cause could not be established, we undertook a secondary investigation to identify contributing factors, such as haemorrhage, pre-eclampsia, eclampsia or obstructed labour, and classified the cause accordingly. Details of this procedure have been described elsewhere.9 Study data were entered onto Microsoft Access computer files (Microsoft, Redmond, USA) at each study site and data were edited before transmission to the central data centre at RTI International in the United States, where additional data edits were performed and the data were analysed using SAS version 9.2 (SAS Institute, Cary, USA). The study findings were reported using descriptive statistics and risk ratios were calculated for maternal, fetal and neonatal outcomes. Generalized estimation equations were used to adjust for the characteristics of each site and for clustering. The study was approved by university review boards at each local site, by partner universities in the United States and by RTI International and was registered as trial {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01073475″,”term_id”:”NCT01073475″}}NCT01073475 at the ClinicalTrials.gov registry (United States National Library of Medicine, Bethesda, USA). All women provided informed consent before enrolment.

Résumé de l’IA

Study Justification:

– The study aimed to quantify maternal, fetal, and neonatal mortality in low- and middle-income countries.
– The objective was to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths.
– The study was conducted to provide data on the causes of these deaths and to highlight preventable causes.

Study Highlights:

– Between 2010 and 2012, 214,070 out of 220,235 enrolled women (97.2%) completed follow-up.
– The maternal mortality ratio was 168 per 100,000 live births, with variations across countries.
– Most maternal deaths occurred around the time of delivery and were attributed to preventable causes such as hemorrhage, pre-eclampsia or eclampsia, and sepsis.
– Stillbirths were more common in women who died than in those alive six weeks postpartum, indicating a higher risk of perinatal and neonatal death.
– Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.

Recommendations:

– Enhance access to quality obstetric and neonatal care in low- and middle-income countries.
– Strengthen healthcare systems to address preventable causes of maternal, fetal, and neonatal deaths.
– Improve training and resources for healthcare providers to manage complications during delivery.
– Implement strategies to reduce the risk of hemorrhage, pre-eclampsia or eclampsia, and sepsis.
– Increase awareness and education among pregnant women and their families about the importance of prenatal care and skilled birth attendance.

Key Role Players:

– Government health services
– Community elders
– Birth attendants
– Health-care workers
– Registry administrators
– Study investigators
– Study coordinators
– Supervising physicians

Cost Items for Planning Recommendations:

– Training programs for healthcare providers
– Equipment and supplies for obstetric and neonatal care
– Infrastructure improvements in healthcare facilities
– Awareness campaigns and educational materials
– Monitoring and evaluation systems for tracking progress
– Research and data analysis support

Force de la preuve

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a prospective study that included a large number of participants from multiple low- and middle-income countries. The study followed pregnant women until six weeks postpartum and collected data on maternal, fetal, and neonatal deaths. The findings provide specific numbers and ratios for maternal mortality and causes of death. The conclusion suggests actionable steps to improve obstetric and neonatal care. To improve the evidence, the abstract could include more details about the study design, such as the specific methods used to collect data and the criteria for enrollment. Additionally, providing information on the statistical analysis methods used would enhance the transparency and reliability of the findings.

Abstrait

Between 2010 to 2012, as part of a prospective, maternal newborn health study of all pregnancies, we documented maternal, fetal and neonatal deaths that occurred up to six weeks postpartum. The study was done in 106 communities at six sites in five low-income countries (Chimaltenango, Guatemala; Nagpur District and Karnataka District, India; Western Provence, Kenya; Thatta District, Pakistan; and Lusaka, Zambia) and at one site in a middle-income country (Corrientes, Argentina).9 These seven sites were selected by the Eunice Kennedy Shriver National Institute of Child Health and Human Development in the United States of America (USA), which supports the Global Network for Women’s and Children’s Health Research, to represent rural or semi-urban geographical areas served by government health services. Each site included between six and 24 distinct communities. In general, each community represented the catchment area of a primary health-care centre and, in each, 300 to 500 births took place annually. Beginning in 2009, the study investigators at each site initiated an ongoing, prospective maternal and newborn health registry of pregnant women for each community. The objective was to enrol pregnant women by 20 weeks’ gestation and to obtain data on pregnancy outcomes for all deliveries that took place in the community. Each community employed a registry administrator who identified and tracked pregnancies and their outcomes in coordination with community elders, birth attendants and other health-care workers. All pregnant women resident in study communities were eligible for inclusion. Women were enrolled during pregnancy and data on pregnancy outcomes were collected by the trained registry administrators – usually nurses or health workers – who were supervised by study site investigators. At each site, efforts were made to verify that all pregnant women residing in the study communities were included in the registry and that data on all outcomes had been obtained. The study coordinators, who were generally nurses or physicians, monitored enrolment and follow-up to ensure that the data collected were consistent, complete and of a high quality. For hospital births, registry administrators reviewed hospital birth records routinely to identify deliveries to women from the study communities. In addition, culturally appropriate strategies were used at each site to ensure that all outcomes were reported. For example, elders or chiefs in one village used mobile phones to send text messages when women enrolled in the study gave birth. Such strategies increased the likelihood that we were able to identify all pregnancies and maternal and fetal outcomes. Demographic and medical data were obtained for each woman by either the registry administrator or the study coordinator. All deaths that occurred during pregnancy or in the six weeks postpartum were reported using World Health Organization (WHO) classifications.31 The cause of each maternal death was assigned by the registry administrator on the basis of clinical and other information provided by the birth attendant and the woman’s family. All death reports were reviewed by the supervising physician at the study site. For deaths for which a definite cause could not be established, we undertook a secondary investigation to identify contributing factors, such as haemorrhage, pre-eclampsia, eclampsia or obstructed labour, and classified the cause accordingly. Details of this procedure have been described elsewhere.9 Study data were entered onto Microsoft Access computer files (Microsoft, Redmond, USA) at each study site and data were edited before transmission to the central data centre at RTI International in the United States, where additional data edits were performed and the data were analysed using SAS version 9.2 (SAS Institute, Cary, USA). The study findings were reported using descriptive statistics and risk ratios were calculated for maternal, fetal and neonatal outcomes. Generalized estimation equations were used to adjust for the characteristics of each site and for clustering. The study was approved by university review boards at each local site, by partner universities in the United States and by RTI International and was registered as trial {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01073475″,”term_id”:”NCT01073475″}}NCT01073475 at the ClinicalTrials.gov registry (United States National Library of Medicine, Bethesda, USA). All women provided informed consent before enrolment.

Matériaux

N/A

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile phone-based reporting system: Implementing a mobile phone-based reporting system, similar to the one used in one of the study communities, can help improve communication and ensure that all pregnancies and maternal and fetal outcomes are reported accurately and in a timely manner.

2. Community-based registry administrators: Training and employing registry administrators in each community, who can identify and track pregnancies and their outcomes, can help ensure that all pregnant women in the study communities are included in the registry and that data on all outcomes are obtained.

3. Culturally appropriate strategies: Using culturally appropriate strategies, such as involving community elders or chiefs in reporting births through mobile phones, can increase the likelihood of identifying all pregnancies and maternal and fetal outcomes, especially in remote or underserved areas.

4. Secondary investigation for deaths with unknown causes: Undertaking a secondary investigation for deaths with unknown causes, as mentioned in the study, can help identify contributing factors and classify the cause accordingly. This can provide valuable insights into preventable causes of maternal, fetal, and neonatal deaths.

5. Central data center for analysis: Establishing a central data center, like the one used at RTI International, can ensure that data from multiple sites are collected, edited, and analyzed in a standardized and efficient manner. This can help identify trends, patterns, and risk factors associated with maternal, fetal, and neonatal outcomes.

It’s important to note that these are just potential recommendations based on the information provided. The implementation and effectiveness of these innovations would require further research and evaluation.

AI Innovations Description

The recommendation to improve access to maternal health based on the study is to focus on improving obstetric and neonatal care around the time of birth. This is because the study found that most maternal, fetal, and neonatal deaths occurred at or around delivery and were attributed to preventable causes.

By enhancing the quality and availability of obstetric and neonatal care services, such as skilled birth attendance, emergency obstetric care, and postnatal care, the risk of mortality can be significantly reduced. This can be achieved through various strategies, including:

1. Strengthening healthcare infrastructure: Investing in healthcare facilities, equipment, and supplies to ensure that they are adequately equipped to handle obstetric and neonatal emergencies.

2. Training healthcare providers: Providing comprehensive training to healthcare professionals, including midwives, nurses, and doctors, to enhance their skills in managing complications during childbirth and providing appropriate care to newborns.

3. Increasing access to prenatal care: Ensuring that pregnant women have access to regular prenatal check-ups, screenings, and counseling to detect and manage any potential risks or complications early on.

4. Promoting community awareness and education: Conducting community-based awareness campaigns to educate pregnant women and their families about the importance of seeking timely and appropriate healthcare services during pregnancy, childbirth, and the postnatal period.

5. Strengthening referral systems: Establishing effective referral systems between primary healthcare centers, hospitals, and specialized care facilities to ensure that pregnant women and newborns in need of specialized care can access it in a timely manner.

6. Addressing socio-economic barriers: Identifying and addressing socio-economic barriers, such as poverty, lack of transportation, and cultural beliefs, that hinder access to maternal healthcare services.

By implementing these recommendations, it is possible to improve access to maternal health and reduce maternal, fetal, and neonatal mortality rates in low- and middle-income countries.

AI Innovations Methodology

To improve access to maternal health, here are some potential recommendations:

1. Telemedicine: Implementing telemedicine programs can provide remote access to healthcare professionals for prenatal care, consultations, and monitoring. This can be especially beneficial for women in rural or underserved areas who may have limited access to healthcare facilities.

2. Mobile health (mHealth) applications: Developing mobile applications that provide information and resources on maternal health can empower women to take control of their own health. These apps can provide educational materials, appointment reminders, and access to healthcare providers.

3. Community health workers: Training and deploying community health workers can help bridge the gap between healthcare facilities and communities. These workers can provide education, support, and referrals for pregnant women, ensuring they receive the care they need.

4. Transportation services: Lack of transportation can be a significant barrier to accessing maternal healthcare, especially in remote areas. Implementing transportation services, such as ambulances or community-based transportation programs, can help women reach healthcare facilities in a timely manner.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population that will benefit from the recommendations, such as pregnant women in low-income communities.

2. Collect baseline data: Gather data on the current access to maternal health services, including the number of women receiving prenatal care, the distance to healthcare facilities, and any existing barriers.

3. Implement the recommendations: Introduce the recommended innovations, such as telemedicine programs, mHealth applications, community health workers, and transportation services.

4. Monitor and evaluate: Track the implementation of the recommendations and collect data on the utilization of the new services. This can include the number of women using telemedicine, the number of app downloads, the number of community health worker visits, and the utilization of transportation services.

5. Analyze the impact: Compare the baseline data with the post-implementation data to assess the impact of the recommendations. This can include measuring changes in the number of women receiving prenatal care, the reduction in travel time to healthcare facilities, and improvements in maternal health outcomes.

6. Adjust and refine: Based on the findings, make any necessary adjustments or refinements to the recommendations to further improve access to maternal health.

By following this methodology, researchers and policymakers can gain insights into the effectiveness of these recommendations in improving access to maternal health and make informed decisions on scaling up successful interventions.

Auteur

Dima Health

Statistics:

Citations: 127

Identifiers:

DOI: 10.2471/BLT.13.127464

ISSN: 00429686

Research Areas:

Community Interventions, Health System and Policy, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Kenya, Multi-Countries, Zambia

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female

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