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

The Alliance for Maternal and Newborn Health Improvement (AMANHI) mortality study group

Research output: Contribution to journalArticle

Abstract

Background: Modelled 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. Methods: In 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. Findings: We 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). Interpretation: These 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 critical to achieving survival goals in the Sustainable Development Goals era. Funding: Bill & Melinda Gates Foundation.

Original languageEnglish (US)
JournalThe Lancet Global Health
DOIs
StateAccepted/In press - Jan 1 2018

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Maternal Death
Stillbirth
Africa South of the Sahara
Cause of Death
Cohort Studies
Prospective Studies
Population
Pregnancy
Parturition
Asphyxia
Premature Birth
Infant Mortality
Newborn Infant
Mortality
Infection
Population Surveillance
Perinatal Death
Maternal Mortality
Conservation of Natural Resources
Spontaneous Abortion

ASJC Scopus subject areas

  • Medicine(all)

Cite this

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. / The Alliance for Maternal and Newborn Health Improvement (AMANHI) mortality study group.

In: The Lancet Global Health, 01.01.2018.

Research output: Contribution to journalArticle

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title = "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 = "Background: Modelled 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. Methods: In 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. Findings: We 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). Interpretation: These 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 critical to achieving survival goals in the Sustainable Development Goals era. Funding: Bill & Melinda Gates Foundation.",
author = "{The Alliance for Maternal and Newborn Health Improvement (AMANHI) mortality study group} and Imran Ahmed and Ali, {Said Mohammed} and Seeba Amenga-Etego and Shabina Ariff and Rajiv Bahl and Abdullah Baqui and Nazma Begum and Nita Bhandari and Kiran Bhatia and Bhutta, {Zulfiqar A.} and Godfrey Biemba and Saikat Deb and Usha Dhingra and Brinda Dube and Arup Dutta and Karen Edmond and Fabian Esamai and Wafaie Fawzi and Ghosh, {Amit Kumar} and Peter Gisore and Caroline Grogan and Hamer, {Davidson H.} and Julie Herlihy and Lisa Hurt and Muhammad Ilyas and Fyezah Jehan and Michel Kalonji and Jasmine Kaur and Rasheda Khanam and Betty Kirkwood and Aarti Kumar and Alok Kumar and Vishwajeet Kumar and Alexander Manu and Irene Marete and Honorati Masanja and Sarmila Mazumder and Usma Mehmood and Shambhavi Mishra and Mitra, {Dipak K.} and Erick Mlay and Mohan, {Sanjana Brahmawar} and Moin, {Mamun Ibne} and Karim Muhammad and Alfa Muhihi and Samuel Newton and Serge Ngaima and Andre Nguwo and Imran Nisar and Maureen O'Leary",
year = "2018",
month = "1",
day = "1",
doi = "10.1016/S2214-109X(18)30385-1",
language = "English (US)",
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TY - JOUR

T1 - Population-based rates, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa

T2 - a multi-country prospective cohort study

AU - The Alliance for Maternal and Newborn Health Improvement (AMANHI) mortality study group

AU - Ahmed, Imran

AU - Ali, Said Mohammed

AU - Amenga-Etego, Seeba

AU - Ariff, Shabina

AU - Bahl, Rajiv

AU - Baqui, Abdullah

AU - Begum, Nazma

AU - Bhandari, Nita

AU - Bhatia, Kiran

AU - Bhutta, Zulfiqar A.

AU - Biemba, Godfrey

AU - Deb, Saikat

AU - Dhingra, Usha

AU - Dube, Brinda

AU - Dutta, Arup

AU - Edmond, Karen

AU - Esamai, Fabian

AU - Fawzi, Wafaie

AU - Ghosh, Amit Kumar

AU - Gisore, Peter

AU - Grogan, Caroline

AU - Hamer, Davidson H.

AU - Herlihy, Julie

AU - Hurt, Lisa

AU - Ilyas, Muhammad

AU - Jehan, Fyezah

AU - Kalonji, Michel

AU - Kaur, Jasmine

AU - Khanam, Rasheda

AU - Kirkwood, Betty

AU - Kumar, Aarti

AU - Kumar, Alok

AU - Kumar, Vishwajeet

AU - Manu, Alexander

AU - Marete, Irene

AU - Masanja, Honorati

AU - Mazumder, Sarmila

AU - Mehmood, Usma

AU - Mishra, Shambhavi

AU - Mitra, Dipak K.

AU - Mlay, Erick

AU - Mohan, Sanjana Brahmawar

AU - Moin, Mamun Ibne

AU - Muhammad, Karim

AU - Muhihi, Alfa

AU - Newton, Samuel

AU - Ngaima, Serge

AU - Nguwo, Andre

AU - Nisar, Imran

AU - O'Leary, Maureen

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Background: Modelled 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. Methods: In 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. Findings: We 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). Interpretation: These 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 critical to achieving survival goals in the Sustainable Development Goals era. Funding: Bill & Melinda Gates Foundation.

AB - Background: Modelled 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. Methods: In 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. Findings: We 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). Interpretation: These 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 critical to achieving survival goals in the Sustainable Development Goals era. Funding: Bill & Melinda Gates Foundation.

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UR - http://www.scopus.com/inward/citedby.url?scp=85055117376&partnerID=8YFLogxK

U2 - 10.1016/S2214-109X(18)30385-1

DO - 10.1016/S2214-109X(18)30385-1

M3 - Article

C2 - 30361107

JO - The Lancet Global Health

JF - The Lancet Global Health

SN - 2214-109X

ER -