Causes and circumstances of maternal death: a secondary analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials cohort

Abstract

Background Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. MethodsThe CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12-49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193-268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0•56 [95% CI 0•43-0•66]) or InterVA-5 (κ=0•44 [0•30-0•57]), and InterVA-4 and InterVA-5 (κ=0•72 [0•60-0•84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0•48 [0•38-0•58])...

Sustainability in Transformation of Maternal Mortality by Interaction Based Approach in Dairi, Indonesia

“… 23 , 24 It was found that the risk of increased maternal mortality for women aged 35 and up was concentrated in a few causes of death, and much of this excess mortality can be avoided. 25 , 26 In connection with the results of this study, the promotional efforts can be carried out in addition to forming good behavior attitudes. Therefore it is also very important to pay attention to the knowledge factor of pregnant women by carrying out health promotion strategies by empowering health cadres, so that the intentions of the pregnant women can be strengthened by adding more knowledge regarding mother's pregnancy care.…”

Dying to make a care policy: Community perception of causes of deaths using standardized verbal autopsy method: Saudi type 2 diabetes mellitus register data

“…Our results found that the odd ratio of the agreement for age groups (60-69, 70-79, and >=80 years) increases if the deceased aged 60-69 and 70-79 years compared to deaths aged 34-59 years, and the likelihood tends to decrease if the deceased was >=80 years compared to the reference (aOR: 1. 34 To evaluate the community perceptions of causes of death, CSMFs obtained from the VA using the InterVA-5 model were utilized to assess FRCoD, along with the CSMF absolute differences and their 95% confidence intervals. Table 2 shows that infectious diseases, stroke, and circulatory-related deaths were found to be underestimated as probable causes of death reported by families in relation to the VA reference standard.…”

“…The 2016 WHO VA instrument has been updated to contain all the input variables needed by all three software, making their use more consistent and standardized. [28, 34, 35]. In recent years, a series of InterVA models have been created to interpret VA data using Bayesian probabilistic modeling [36].…”

A novel regulated network mediated by downregulation HIF1A-AS2 lncRNA impairs placental angiogenesis by promoting ANGPTL4 expression in preeclampsia

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