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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.
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