Randomised comparison of two household survey modules for measuring stillbirths and neonatal deaths in five countries: the Every Newborn-INDEPTH study

Abstract

Background An estimated 5·1 million stillbirths and neonatal deaths occur annually. Household surveys, most notably the Demographic and Health Survey (DHS), run in more than 90 countries and are the main data source from the highest burden regions, but data-quality concerns remain. We aimed to compare two questionnaires: a full birth history module with additional questions on pregnancy losses (FBH+; the current DHS standard) and a full pregnancy history module (FPH), which collects information on all livebirths, stillbirths, miscarriages, and neonatal deaths. Methods Women residing in five Health and Demographic Surveillance System sites within the INDEPTH Network (Bandim in Guinea-Bissau, Dabat in Ethiopia, IgangaMayuge in Uganda, Matlab in Bangladesh, and Kintampo inGhana) were randomly assigned (individually) to be interviewed using either FBH+ or FPH between July 28, 2017, and Aug 13, 2018. The primary outcomes were stillbirths and neonatal deaths in the 5 years before the survey interview (measured by stillbirth rate [SBR] and neonatal mortality rate [NMR]) and mean time taken to complete the maternity history section of the questionnaire. We also assessed between-site heterogeneity. This study is registered with the Research Registry, 4720.Findings 69 176 women were allocated to be interviewed by either FBH+ (n=34 805) or FPH (n=34 371). The mean time taken to complete FPH (10·5 min) was longer than for FBH+ (9·1 min; p<0·0001). Using FPH, the estimated SBR was 17·4 per 1000 total births, 21% (95% CI -10 to 62) higher than with FBH+ (15·2 per 1000 total births; p=0·20) in the 5 years preceding the survey interview. There was strong evidence of between-site heterogeneity (I²=80·9%; p<0·0001), with SBR higher for FPH than for FBH+ in four of five sites. The estimated NMR did not differ between modules (FPH 25·1 per 1000 livebirths vs FBH+ 25·4 per 1000 livebirths), with no evidence of betweensite heterogeneity (I²=0·7%; p=0·40).Interpretation FPH takes an average of 1·4 min longer to complete than does FBH+, but has the potential to increase reporting of stillbirths in high burden contexts. The between-site heterogeneity we found might reflect variations in interviewer training and survey implementation, emphasising the importance of interviewer skills, training, and consistent implementation in data quality.

Four decades of measuring stillbirths and neonatal deaths in Demographic and Health Surveys: historical review

“…For stillbirths, we applied a simple test comparing the SBR to NMR ratio by survey modules, but this is simplistic and any potential variation with the level of NMR and SBR in LMICs is as yet poorly understood [7,18]. SBR were lower than expected in almost all the surveys conducted by DHS phase, including both FBH and FPH, and this was consistent with findings from the EN-INDEPTH study [42].…”

“…The change followed findings from the EN-INDEPTH study, a randomised comparison of the DHS-VII model questionnaire's FBH plus additional questions on recent non-live births to the most recent FPH implemented in Nepal. Evidence from that study suggested that FPH improved reporting of stillbirths, but had no effect for neonatal deaths [42]. However, whilst the FPH approach resulted in higher SBR estimates overall, this finding varied across sites underlining that changes to the questionnaire tools may be necessary but not sufficient, with other factors such as survey training and implementation likely playing an important role.…”

“…The DHS programme is planning to use the CSPro computer-assisted interviewing system for all future surveys [38,41]. Data quality for stillbirths and neonatal mortality for DHS phases I-VII Data quality may vary by maternity history approach [42]. Changes to the model DHS questionnaire over time designed to improve stillbirth or neonatal death data quality include the changes in prompts to seek to reduce omission of live births who died from the FBH over phases III-V and including additional questions for non-live births in DHS-VII (Fig.…”

Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study

“…The study also investigated the performance of existing and/or modified survey questions regarding other pregnancy-related outcomes, and conducted qualitative research exploring barriers and enablers to reporting these outcomes (Additional file 2). Further details have been published in the protocol and main study paper [19,20]. The survey questions were administered face-to-face, and data were collected on tablets using the Survey Solutions system [21].…”

VAR2CSA-Mediated Host Defense Evasion of Plasmodium falciparum Infected Erythrocytes in Placental Malaria

“…In 2019, an estimated 11 million pregnant women were infected by Plasmodium in sub-Saharan Africa, where P. falciparum is the most prevalent parasite species, accounting for 99.7% of estimated malaria cases ( 1 ). P. falciparum infection contracted during pregnancy can lead to placental malaria (PM), a condition that could cause very serious clinical outcomes for both mother and child, including maternal anemia ( 2 , 3 ), hypertension ( 4 , 5 ), stillbirth ( 6 , 7 ) as well as low birth-weight infants, which affected over 800,000 children in 2019 ( 1 ).…”