Population-based rates, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa: a multi-country prospective cohort study

Abstract

SummaryBackgroundModelled mortality estimates have been useful for health programmes in low-income and middle-income countries. However, these estimates are often based on sparse and low-quality data. We aimed to generate high quality data about the burden, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa.MethodsIn this prospective cohort study done in 11 community-based research sites in south Asia and sub-Saharan Africa, between July, 2012, and February, 2016, we conducted population-based surveillance of women of reproductive age (15–49 years) to identify pregnancies, which were followed up to birth and 42 days post partum. We used standard operating procedures, data collection instruments, training, and standardisation to harmonise study implementation across sites. Verbal autopsies were done for deaths of all women of reproductive age, neonatal deaths, and stillbirths. Physicians used standardised methods for cause of death assignment. Site-specific rates and proportions were pooled at the regional level using a meta-analysis approach.FindingsWe identified 278 186 pregnancies and 263 563 births across the study sites, with outcomes ascertained for 269 630 (96·9%) pregnancies, including 8761 (3·2%) that ended in miscarriage or abortion. Maternal mortality ratios in sub-Saharan Africa (351 per 100 000 livebirths, 95% CI 168–732) were similar to those in south Asia (336 per 100 000 livebirths, 247–458), with far greater variability within sites in sub-Saharan Africa. Stillbirth and neonatal mortality rates were approximately two times higher in sites in south Asia than in sub-Saharan Africa (stillbirths: 35·1 per 1000 births, 95% CI 28·5–43·1 vs 17·1 per 1000 births, 12·5–25·8; neonatal mortality: 43·0 per 1000 livebirths, 39·0–47·3 vs 20·1 per 1000 livebirths, 14·6–27·6). 40–45% of pregnancy-related deaths, stillbirths, and neonatal deaths occurred during labour, delivery, and the 24 h postpartum period in both regions. Obstetric haemorrhage, non-obstetric complications, hypertensive disorders of pregnancy, and pregnancy-related infections accounted for more than three-quarters of maternal deaths and stillbirths. The most common causes of neonatal deaths were perinatal asphyxia (40%, 95% CI 39–42, in south Asia; 34%, 32–36, in sub-Saharan Africa) and severe neonatal infections (35%, 34–36, in south Asia; 37%, 34–39 in sub-Saharan Africa), followed by complications of preterm birth (19%, 18–20, in south Asia; 24%, 22–26 in sub-Saharan Africa).InterpretationThese results will contribute to improved global estimates of rates, timing, and causes of maternal and newborn deaths and stillbirths. Our findings imply that programmes in sub-Saharan Africa and south Asia need to further intensify their efforts to reduce mortality rates, which continue to be high. The focus on improving the quality of maternal intrapartum care and immediate newborn care must be further enhanced. Efforts to address perinatal asphyxia and newborn infections, as well as preterm birth...

Are perceived barriers to accessing health care associated with inadequate antenatal care visits among women of reproductive age in Rwanda?

“…Maternal and neonatal mortality remain a global health concern despite different interventions that have been implemented to address this issue [1]. Sub-Saharan Africa (SSA) is by far among the regions with the highest ratios of maternal mortality with 351 per 100 000 live births and high neonatal mortality rates with 20 per 1000 live births [2]. Several studies have shown that 15% of maternal and newborn deaths in SSA are attributed to pregnancy complications that are a result of inadequate pregnancy follow-up [2][3][4].…”

Peripartum interventions resulting in reduced perinatal mortality rates, and birth asphyxia rates, over 18 years in a tertiary centre in South India: a retrospective study

“…[1][2][3] Poor quality of care contributes to morbidity and mortality, and therefore attention has shifted to the quality of care. In low-and middle-income countries (LMIC), the challenge has been the need for balancing coverage with quality.…”

“…[1][2][3] Poor quality of care contributes to morbidity and mortality, and therefore attention has shifted to the quality of care. 2 A significant contributor to the neonatal mortality rate was birth asphyxia, with only prematurity occurring more frequently. 6 The disease burden is high, particularly in LMIC.…”

“…Reductions in maternal and neonatal mortality remain slow. [1][2][3] Poor quality of care contributes to morbidity and mortality, and therefore attention has shifted to the quality of care. 4,5 The effect of improving quality of care during labour and delivery, will reflect in health indicators such as perinatal mortality and birth asphyxia rates.…”

“…1 In a study conducted in South Asia and Sub-Saharan Africa, 40-45% of pregnancy-related deaths, stillbirths, and neonatal deaths occurred during labour, delivery, and the 24-hour postpartum period in both regions. 2 A significant contributor to the neonatal mortality rate was birth asphyxia, with only prematurity occurring more frequently. 3,4 It is clear that a multifactorial approach rather than any one single intervention is the key to improving quality of care provided, as so many factors are involved in making the peripartum period a safe one.…”