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Kc A, Bergström A, Chaulagain D, Brunell O, Ewald U, Gurung A, Eriksson L, Litorp H, Wrammert J, Grönqvist E, Edin PA, Le Grange C, Lamichhane B, Shrestha P, Pokharel A, Pun A, Singh C, Målqvist M. Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial. BMJ Glob Health 2017; 2:e000497. [PMID: 29071130 PMCID: PMC5640082 DOI: 10.1136/bmjgh-2017-000497] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 09/15/2017] [Accepted: 09/18/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction Nepal Perinatal Quality Improvement Project (NePeriQIP) intends to scale up a quality improvement (QI) intervention for perinatal care according to WHO/National guidelines in hospitals of Nepal using the existing health system structures. The intervention builds on previous research on the implementation of Helping Babies Breathe-quality improvement cycle in a tertiary healthcare setting in Nepal. The objective of this study is to evaluate the effect of this scaled-up intervention on perinatal health outcomes. Methods/design Cluster-randomised controlled trial using a stepped wedged design with 3 months delay between wedges will be conducted in 12 public hospitals with a total annual delivery rate of 60 000. Each wedge will consist of 3 hospitals. Impact will be evaluated on intrapartum-related mortality (primary outcome), overall neonatal mortality and morbidity and health worker’s performance on neonatal care (secondary outcomes). A process evaluation and a cost-effectiveness analysis will be performed to understand the functionality of the intervention and to further guide health system investments will also be performed. Discussion In contexts where resources are limited, there is a need to find scalable and sustainable implementation strategies for improved care delivery. The proposed study will add to the scarce evidence base on how to scale up interventions within existing health systems. If successful, the NePeriQIP model can provide a replicable solution in similar settings where support and investment from the health system is poor, and national governments have made a global pledge to reduce perinatal mortality. Trial registration number ISRCTN30829654.
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Affiliation(s)
- Ashish Kc
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Health Section, UNICEF, UN House, Lalitpur, Nepal
| | - Anna Bergström
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Institute for Global Health, University College London, London, UK
| | - Dipak Chaulagain
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Lifeline Nepal, Kathmandu, Nepal
| | - Olivia Brunell
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Uwe Ewald
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | - Leif Eriksson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Helena Litorp
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Johan Wrammert
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Erik Grönqvist
- Health Economic Forum, Uppsala University, Uppsala, Sweden
| | - Per-Anders Edin
- Department of Economics, Uppsala University, Uppsala, Sweden
| | - Claire Le Grange
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | - Amrit Pokharel
- Department of Health Services, Ministry of Health, Nepal
| | - Asha Pun
- Health Section, UNICEF, UN House, Lalitpur, Nepal
| | | | - Mats Målqvist
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Rai SK, Kant S, Srivastava R, Gupta P, Misra P, Pandav CS, Singh AK. Causes of and contributors to infant mortality in a rural community of North India: evidence from verbal and social autopsy. BMJ Open 2017; 7:e012856. [PMID: 28801384 PMCID: PMC5577880 DOI: 10.1136/bmjopen-2016-012856] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To identify the medical causes of death and contribution of non-biological factors towards infant mortality by a retrospective analysis of routinely collected data using verbal and social autopsy tools. SETTING The study site was Health and Demographic Surveillance System (HDSS), Ballabgarh, North India PARTICIPANTS: All infant deaths during the years 2008-2012 were included for verbal autopsy and infant deaths from July 2012 to December 2012 were included for social autopsy. OUTCOME MEASURES Cause of death ascertained by a validated verbal autopsy tool and level of delay based on a three-delay model using the INDEPTH social autopsy tool were the main outcome measures. The level of delay was defined as follows: level 1, delay in identification of danger signs and decision making to seek care; level 2, delay in reaching a health facility from home; level 3, delay in getting healthcare at the health facility. RESULTS The infant mortality rate during the study period was 46.5/1000 live births. Neonatal deaths contributed to 54.3% of infant deaths and 39% occurred on the first day of life. Birth asphyxia (31.5%) followed by low birth weight (LBW)/prematurity (26.5%) were the most common causes of neonatal death, while infection (57.8%) was the most common cause of post-neonatal death. Care-seeking was delayed among 50% of neonatal deaths and 41.2% of post-neonatal deaths. Delay at level 1 was most common and occurred in 32.4% of neonatal deaths and 29.4% of post-neonatal deaths. Deaths due to LBW/prematurity were mostly followed by delay at level 1. CONCLUSION A high proportion of preventable infant mortality still exists in an area which is under continuous health and demographic surveillance. There is a need to enhance home-based preventive care to enable the mother to identify and respond to danger signs. Verbal autopsy and social autopsy could be routinely done to guide policy interventions aimed at reduction of infant mortality.
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Affiliation(s)
- Sanjay Kumar Rai
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
- INDEPTH Network, Accra, Ghana
| | - Shashi Kant
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
- INDEPTH Network, Accra, Ghana
| | | | - Priti Gupta
- Centre for Chronic Disease Control, Gurgaon, India
| | - Puneet Misra
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
- INDEPTH Network, Accra, Ghana
| | | | - Arvind Kumar Singh
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Koffi AK, Wounang RS, Nguefack F, Moluh S, Libite PR, Kalter HD. Sociodemographic, behavioral, and environmental factors of child mortality in Eastern Region of Cameroon: results from a social autopsy study. J Glob Health 2017; 7:010601. [PMID: 28400957 PMCID: PMC5344009 DOI: 10.7189/jogh.07.010601] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND While most child deaths are caused by highly preventable and treatable diseases such as pneumonia, diarrhea, and malaria, several sociodemographic, cultural and health system factors work against children surviving from these diseases. METHODS A retrospective verbal/social autopsy survey was conducted in 2012 to measure the biological causes and social determinants of under-five years old deaths from 2007 to 2010 in Doume, Nguelemendouka, and Abong-Mbang health districts in the Eastern Region of Cameroon. The present study sought to identify important sociodemographic and household characteristics of the 1-59 month old deaths, including the coverage of key preventive indicators of normal child care, and illness recognition and care-seeking for the children along the Pathway to Survival model. FINDINGS Of the 635 deceased children with a completed interview, just 26.8% and 11.2% lived in households with an improved source of drinking water and sanitation, respectively. Almost all of the households (96.1%) used firewood for cooking, and 79.2% (n = 187) of the 236 mothers who cooked inside their home usually had their children beside them when they cooked. When 614 of the children became fatally ill, the majority (83.7%) of caregivers sought or tried to seek formal health care, but with a median delay of 2 days from illness onset to the decision to seek formal care. As a result, many (n = 111) children were taken for care only after their illness progressed from mild or moderate to severe. The main barriers to accessing the formal health system were the expenses for transportation, health care and other related costs. CONCLUSIONS The most common social factors that contributed to the deaths of 1-59-month old children in the study setting included poor living conditions, prevailing customs that led to exposure to indoor smoke, and health-related behaviors such as delaying the decision to seek care. Increasing caregivers' ability to recognize the danger signs of childhood illnesses and to facilitate timely and appropriate health care-seeking, and improving standards of living such that parents or caregivers can overcome the economic obstacles, are measures that could make a difference in the survival of the ill children in the study area.
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Affiliation(s)
- Alain K Koffi
- Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, USA
| | | | | | | | | | - Henry D Kalter
- Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, USA
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Adewemimo A, Kalter HD, Perin J, Koffi AK, Quinley J, Black RE. Direct estimates of cause-specific mortality fractions and rates of under-five deaths in the northern and southern regions of Nigeria by verbal autopsy interview. PLoS One 2017; 12:e0178129. [PMID: 28562611 PMCID: PMC5451023 DOI: 10.1371/journal.pone.0178129] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/09/2017] [Indexed: 11/18/2022] Open
Abstract
Nigeria’s under-five mortality rate is the eighth highest in the world. Identifying the causes of under-five deaths is crucial to achieving Sustainable Development Goal 3 by 2030 and improving child survival. National and international bodies collaborated in this study to provide the first ever direct estimates of the causes of under-five mortality in Nigeria. Verbal autopsy interviews were conducted of a representative sample of 986 neonatal and 2,268 1–59 month old deaths from 2008 to 2013 identified by the 2013 Nigeria Demographic and Health Survey. Cause of death was assigned by physician coding and computerized expert algorithms arranged in a hierarchy. National and regional estimates of age distributions, mortality rates and cause proportions, and zonal- and age-specific mortality fractions and rates for leading causes of death were evaluated. More under-fives and 1–59 month olds in the South, respectively, died as neonates (N = 24.1%, S = 32.5%, p<0.001) and at younger ages (p<0.001) than in the North. The leading causes of neonatal and 1–59 month mortality, respectively, were sepsis, birth injury/asphyxia and neonatal pneumonia, and malaria, diarrhea and pneumonia. The preterm delivery (N = 1.2%, S = 3.7%, p = 0.042), pneumonia (N = 15.0%, S = 21.6%, p = 0.004) and malaria (N = 34.7%, S = 42.2%, p = 0.009) fractions were higher in the South, with pneumonia and malaria focused in the South East and South South; while the diarrhea fraction was elevated in the North (N = 24.8%, S = 13.2%, p<0.001). However, the diarrhea, pneumonia and malaria mortality rates were all higher in the North, respectively, by 222.9% (Z = -10.9, p = 0.000), 27.6% (Z = -2.3, p = 0.020) and 50.6% (Z = -5.7, p = 0.000), with the greatest excesses in older children. The findings support that there is an epidemiological transition ongoing in southern Nigeria, suggest the way forward to a similar transition in the North, and can help guide maternal, neonatal and child health programming and their regional and zonal foci within the country.
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Affiliation(s)
- Adeyinka Adewemimo
- Department of Planning, Research, and Statistics, Federal Ministry of Health, Abuja, Nigeria
| | - Henry D. Kalter
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- * E-mail:
| | - Jamie Perin
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Alain K. Koffi
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | - Robert E. Black
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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Beyond causes of death: The social determinants of mortality among children aged 1-59 months in Nigeria from 2009 to 2013. PLoS One 2017; 12:e0177025. [PMID: 28562610 PMCID: PMC5451019 DOI: 10.1371/journal.pone.0177025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/26/2017] [Indexed: 11/24/2022] Open
Abstract
Background Millions of children worldwide suffer and die from conditions for which effective interventions exist. While there is ample evidence regarding these diseases, there is a dearth of information on the social factors associated with child mortality. Methods The 2014 Verbal and Social Autopsy Study was conducted based on a nationally representative sample of 3,254 deaths that occurred in children under the age of five and were reported on the birth history component of the 2013 Nigerian Demographic and Health Survey. We conducted a descriptive analysis of the preventive and curative care sought and obtained for the 2,057 children aged 1–59 months who died in Nigeria and performed regional (North vs. South) comparisons. Results A total of 1,616 children died in the northern region, while 441 children died in the South. The majority (72.5%) of deceased children in the northern region were born to mothers who had no education, married at a young age, and lived in the poorest two quintiles of households. When caregivers first noticed that their child was ill, a median of 2 days passed before they sought or attempted to seek healthcare for their children. The proportion of children who reached and departed from their first formal healthcare provider alive was greater in the North (30.6%) than in the South (17.9%) (p<0.001). A total of 548 children were moderately or severely sick at discharge from the first healthcare provider, yet only 3.9%-18.1% were referred to a second healthcare provider. Cost, lack of transportation, and distance from healthcare facilities were the most commonly reported barriers to formal care-seeking behavior. Conclusions Maternal, household, and healthcare system factors contributed to child mortality in Nigeria. Information regarding modifiable social factors may be useful in planning intervention programs to promote child survival in Nigeria and other low-income countries in sub-Saharan Africa.
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Gouda HN, Flaxman AD, Brolan CE, Joshi R, Riley ID, AbouZahr C, Firth S, Rampatige R, Lopez AD. New challenges for verbal autopsy: Considering the ethical and social implications of verbal autopsy methods in routine health information systems. Soc Sci Med 2017; 184:65-74. [PMID: 28501755 DOI: 10.1016/j.socscimed.2017.05.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 04/27/2017] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
Abstract
Verbal autopsy (VA) methods are designed to collect cause-of-death information from populations where many deaths occur outside of health facilities and where death certification is weak or absent. A VA consists of an interview with a relative or carer of a recently deceased individual in order to gather information on the signs and symptoms the decedent presented with prior to death. These details are then used to determine and assign a likely cause-of-death. At a population level this information can be invaluable to help guide prioritisation and direct health policy and services. To date VAs have largely been restricted to research contexts but many countries are now venturing to incorporate VA methods into routine civil registration and vital statistics (CRVS) systems. Given the sensitive nature of death, however, there are a number of ethical, legal and social issues that should be considered when scaling-up VAs, particularly in the cross-cultural and socio-economically disadvantaged environments in which they are typically applied. Considering each step of the VA process this paper provides a narrative review of the social context of VA methods. Harnessing the experiences of applying and rolling out VAs as part of routine CRVS systems in a number of low and middle income countries, we identify potential issues that countries and implementing institutions need to consider when incorporating VAs into CRVS systems and point to areas that could benefit from further research and deliberation.
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Affiliation(s)
- Hebe N Gouda
- University of Queensland, School of Public Health, Australia; University of Queensland, Queensland Centre for Mental Health Research, Australia.
| | - Abraham D Flaxman
- University of Washington, Institute of Health Metrics and Evaluation, USA
| | - Claire E Brolan
- University of Melbourne, Melbourne School of Population and Global Health, Australia; University of Toronto, Dalla Lana School of Public Health, Canada
| | - Rohina Joshi
- University of Melbourne, Melbourne School of Population and Global Health, Australia; University of Sydney, The George Institute of Public Health, Australia
| | - Ian D Riley
- University of Queensland, School of Public Health, Australia; University of Melbourne, Melbourne School of Population and Global Health, Australia
| | | | - Sonja Firth
- University of Melbourne, Melbourne School of Population and Global Health, Australia
| | - Rasika Rampatige
- University of Melbourne, Melbourne School of Population and Global Health, Australia
| | - Alan D Lopez
- University of Melbourne, Melbourne School of Population and Global Health, Australia
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Koffi AK, Mleme T, Nsona H, Banda B, Amouzou A, Kalter HD. Social autopsy of neonatal mortality suggests needed improvements in maternal and neonatal interventions in Balaka and Salima districts of Malawi. J Glob Health 2017; 5:010416. [PMID: 27698997 PMCID: PMC5032326 DOI: 10.7189/jogh.05.010416] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background The Every Newborn Action Plan calls for reducing the neonatal mortality rates to fewer than 10 deaths per 1000 live births in all countries by 2035. The current study aims to increase our understanding of the social and modifiable factors that can be addressed or reinforced to improve and accelerate the decline in neonatal mortality in Malawi. Methods The data come from the 2013 Verbal and Social Autopsy (VASA) study that collected data in order to describe the biological causes and the social determinants of deaths of children under 5 years of age in Balaka and Salima districts of Malawi. This paper analyses the social autopsy data of the neonatal deaths and presents results of a review of the coverage of key interventions along the continuum of normal maternal and newborn care and the description of breakdowns in the care provided for neonatal illnesses within the Pathway to Survival framework. Results A total of 320 neonatal deaths were confirmed from the VASA survey. While one antenatal care (ANC) visit was high at 94%, the recommended four ANC visits was much lower at 41% and just 17% of the mothers had their urines tested during the pregnancy. 173 (54%) mothers of the deceased newborns had at least one labor/delivery complication that began at home. The caregivers of 65% (n = 75) of the 180 newborns that were born at home or born and left a health facility alive perceived them to be severely ill at the onset of their illness, yet only 44% (n = 80) attempted and 36% (n = 65)could reach the first health provider after an average of 91 minutes travel time. Distance, lack of transport and cost emerged as the most important constraints to formal care–seeking during delivery and during the newborn fatal illness. Conclusions This study suggests that maternal and neonatal health organizations and the local government of Malawi should increase the demand for key maternal and child health interventions, including the recommended 4 ANC visits, and ensure urine screening for all pregnant women. Early recognition and referrals of women with obstetric complications and interventions to promote maternal recognition of neonatal illnesses and care–seeking before the child becomes severely ill are also needed to improve newborn survival in Balaka and Salima districts of Malawi.
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Affiliation(s)
- Alain K Koffi
- Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD, USA
| | | | | | | | | | - Henry D Kalter
- Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD, USA
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Biswas A, Halim MA, Dalal K, Rahman F. Exploration of social factors associated to maternal deaths due to haemorrhage and convulsions: Analysis of 28 social autopsies in rural Bangladesh. BMC Health Serv Res 2016; 16:659. [PMID: 27846877 PMCID: PMC5111193 DOI: 10.1186/s12913-016-1912-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022] Open
Abstract
Background Social autopsy is an innovative approach to explore social barriers and factors associated to a death in the community. The process also sensitize the community people to avert future deaths. Social autopsy has been introduced in maternal deaths in Bangladesh first time in 2010. This study is to identify the social factors in the rural community associated to maternal deaths. It also looks at how the community responses in social autopsy intervention to prevent future maternal deaths. Methods The study was conducted in the Thakurgaon district of Bangladesh in 2010. We have purposively selected 28 social autopsy cases of which maternal deaths occurred due to either haemorrhage or due to convulsions. The autopsy was conducted by the Government health and family planning first line field supervisors in rural community. Family members and neighbours of the deceased participated in each autopsy and provided their comments and responses. Results A number of social factors including delivery conducted by the untrained birth attendant or family members, delays in understanding about maternal complications, delays in decision making to transfer the mother, lack of proper knowledge, education and traditional myth influences the maternal deaths. The community identified their own problems, shared within them and decide upon rectify themselves for future death prevention. Conclusions Social autopsy is a useful tools to identify social community within the community by discussing the factors that took place during a maternal death. The process supports villagers to think and change their behavioural patterns and commit towards preventing such deaths in the future.
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Affiliation(s)
- Animesh Biswas
- Department of Public Health Science, School of Health Sciences, Örebro University, Örebro, Sweden. .,Reproductive and Child Health Unit, Centre for Injury Prevention and Research, Bangladesh (CIPRB), House B 162, Road 23, New DOHS, Mohakahlai, Dhaka, 1206, Bangladesh.
| | - M A Halim
- Reproductive and Child Health Unit, Centre for Injury Prevention and Research, Bangladesh (CIPRB), House B 162, Road 23, New DOHS, Mohakahlai, Dhaka, 1206, Bangladesh
| | - Koustuv Dalal
- Department of Public Health Science, School of Health Sciences, Örebro University, Örebro, Sweden
| | - Fazlur Rahman
- Reproductive and Child Health Unit, Centre for Injury Prevention and Research, Bangladesh (CIPRB), House B 162, Road 23, New DOHS, Mohakahlai, Dhaka, 1206, Bangladesh
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Biswas A, Rahman F, Eriksson C, Halim A, Dalal K. Social Autopsy of maternal, neonatal deaths and stillbirths in rural Bangladesh: qualitative exploration of its effect and community acceptance. BMJ Open 2016; 6:e010490. [PMID: 27554100 PMCID: PMC5013352 DOI: 10.1136/bmjopen-2015-010490] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Social Autopsy (SA) is an innovative strategy where a trained facilitator leads community groups through a structured, standardised analysis of the physical, environmental, cultural and social factors contributing to a serious, non-fatal health event or death. The discussion stimulated by the formal process of SA determines the causes and suggests preventative measures that are appropriate and achievable in the community. Here we explored individual experiences of SA, including acceptance and participant learning, and its effect on rural communities in Bangladesh. The present study had explored the experiences gained while undertaking SA of maternal and neonatal deaths and stillbirths in rural Bangladesh. DESIGN Qualitative assessment of documents, observations, focus group discussions, group discussions and in-depth interviews by content and thematic analyses. RESULTS Each community's maternal and neonatal death was a unique, sad story. SA undertaken by government field-level health workers were well accepted by rural communities. SA had the capability to explore the social reasons behind the medical cause of the death without apportioning blame to any individual or group. SA was a useful instrument to raise awareness and encourage community responses to errors within the society that contributed to the death. People participating in SA showed commitment to future preventative measures and devised their own solutions for the future prevention of maternal and neonatal deaths. CONCLUSIONS SA highlights societal errors and promotes discussion around maternal or newborn death. SA is an effective means to deliver important preventative messages and to sensitise the community to death issues. Importantly, the community itself is enabled to devise future strategies to avert future maternal and neonatal deaths in Bangladesh.
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Affiliation(s)
- Animesh Biswas
- Department of Public Health Science, School of Health and Medical Sciences, Örebro University, Örebro, Sweden Centre for Injury Prevention and Research, Dhaka, Bangladesh
| | - Fazlur Rahman
- Centre for Injury Prevention and Research, Dhaka, Bangladesh
| | - Charli Eriksson
- Department of Public Health Science, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Abdul Halim
- Centre for Injury Prevention and Research, Dhaka, Bangladesh
| | - Koustuv Dalal
- Department of Public Health Science, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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Koffi AK, Maina A, Yaroh AG, Habi O, Bensaïd K, Kalter HD. Social determinants of child mortality in Niger: Results from the 2012 National Verbal and Social Autopsy Study. J Glob Health 2016; 6:010603. [PMID: 26955473 PMCID: PMC4766790 DOI: 10.7189/jogh.06.010603] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Understanding the determinants of preventable deaths of children under the age of five is important for accelerated annual declines – even as countries achieve the UN’s Millennium Development Goals and the target date of 2015 has been reached. While research has documented the extent and nature of the overall rapid decline in child mortality in Niger, there is less clear evidence to provide insight into the contributors to such deaths. This issue is the central focus of this paper. Methods We analyzed a nationally representative cross–sectional sample of 620 child deaths from the 2012 Niger Verbal Autopsy/Social Autopsy (VASA) Survey. We conducted a descriptive analysis of the data on preventive and curative care, guided by the coverage of proven indicators along the continuum of well child care and illness recognition and care–seeking for child illnesses encompassed by the BASICS/CDC Pathway to Survival model. Results Six hundred twenty deaths of children (1–59 months of age) were confirmed from the VASA survey. The majority of these children lived in households with precarious socio–economic conditions. Among the 414 children whose fatal illnesses began at age 0–23 months, just 24.4% were appropriately fed. About 24% of children aged 12–59 months were fully immunized. Of 601 children tracked through the Pathway to Survival, 62.4% could reach the first health care provider after about 67 minutes travel time. Of the 306 children who left the first health care provider alive, 161 (52.6%) were not referred for further care nor received any home care recommendations, and just 19% were referred to a second provider. About 113 of the caregivers reported cost (35%), distance (35%) and lack of transport (30%) as constraints to care–seeking at a health facility. Conclusion Despite Niger’s recent major achievements in reducing child mortality, the following determinants are crucial to continue building on the gains the country has made: improved socio–economic state of the poor in the country, investment in women’s education, adoption of the a law to prevent marriage of young girls before 18 years of age, and implementation of health programs that encourage breastfeeding and complementary feeding, immunization, illness recognition, prompt and appropriate care–seeking, and improved referral rates.
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Affiliation(s)
- Alain K Koffi
- The Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Abdou Maina
- Institut National de la Statistique, Niamey, Niger
| | | | - Oumarou Habi
- Institut National de la Statistique, Niamey, Niger
| | - Khaled Bensaïd
- UNICEF/Niger country office, Niamey, Niger (retired staff)
| | - Henry D Kalter
- The Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Bensaïd K, Yaroh AG, Kalter HD, Koffi AK, Amouzou A, Maina A, Kazmi N. Verbal/Social Autopsy in Niger 2012-2013: A new tool for a better understanding of the neonatal and child mortality situation. J Glob Health 2016; 6:010602. [PMID: 26955472 PMCID: PMC4766792 DOI: 10.7189/jogh.06.010602] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Niger, one of the poorest countries in the world, recently used for the first time the integrated verbal and social autopsy (VASA) tool to assess the biological causes and social and health system determinants of neonatal and child deaths. These notes summarize the Nigerien experience in the use of this new tool, the steps taken for high level engagement of the Niger government and stakeholders for the wide dissemination of the study results and their use to support policy development and maternal, neonatal and child health programming in the country. The experience in Niger reflects lessons learned by other developing countries in strengthening the use of data for evidence–based decision making, and highlights the need for the global health community to provide continued support to country data initiatives, including the collection, analysis, interpretation and utilization of high quality data for the development of targeted, highly effective interventions. In Niger, this is supporting the country’s progress toward achieving Millennium Development Goal 4. A follow–up VASA study is being planned and the tool is being integrated into the National Health Management Information System. VASA studies have now been completed or are under way in additional sub–Saharan African countries, in each through the same collaborative process used in Niger to bring together health policy makers, program planners and development partners.
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Affiliation(s)
| | | | - Henry D Kalter
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alain K Koffi
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Abdou Maina
- Institute National des Statistics, Niamey, Niger
| | - Narjis Kazmi
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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D’Ambruoso L, Kahn K, Wagner RG, Twine R, Spies B, van der Merwe M, Gómez-Olivé FX, Tollman S, Byass P. Moving from medical to health systems classifications of deaths: extending verbal autopsy to collect information on the circumstances of mortality. Glob Health Res Policy 2016; 1:2. [PMID: 29202052 PMCID: PMC5675065 DOI: 10.1186/s41256-016-0002-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 05/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Verbal autopsy (VA) is a health surveillance technique used in low and middle-income countries to establish medical causes of death (CODs) for people who die outside hospitals and/or without registration. By virtue of the deaths it investigates, VA is also an opportunity to examine social exclusion from access to health systems. The aims were to develop a system to collect and interpret information on social and health systems determinants of deaths investigated in VA. METHODS A short set of questions on care pathways, circumstances and events at and around the time of death were developed and integrated into the WHO 2012 short form VA (SF-VA). Data were subsequently analysed from two census rounds in the Agincourt Health and Socio-Demographic Surveillance Site (HDSS), South Africa in 2012 and 2013 where the SF-VA had been applied. InterVA and descriptive analysis were used to calculate cause-specific mortality fractions (CSMFs), and to examine responses to the new indicators and whether and how they varied by medical CODs and age/sex sub-groups. RESULTS One thousand two hundred forty-nine deaths were recorded in the Agincourt HDSS censuses in 2012-13 of which 1,196 (96 %) had complete VA data. Infectious and non-communicable conditions accounted for the majority of deaths (47 % and 39 % respectively) with smaller proportions attributed to external, neonatal and maternal causes (5 %, 2 % and 1 % respectively). 5 % of deaths were of indeterminable cause. The new indicators revealed multiple problems with access to care at the time of death: 39 % of deaths did not call for help, 36 % found care unaffordable overall, and 33 % did not go to a facility. These problems were reported consistently across age and sex sub-groups. Acute conditions and younger age groups had fewer problems with overall costs but more with not calling for help or going to a facility. An illustrative health systems interpretation suggests extending and promoting existing provisions for transport and financial access in this setting. CONCLUSIONS Supplementing VA with questions on the circumstances of mortality provides complementary information to CSMFs relevant for health planning. Further contextualisation of the method and results are underway with health systems stakeholders to develop the interpretation sequence as part of a health policy and systems research approach.
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Affiliation(s)
- Lucia D’Ambruoso
- Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana
| | - Ryan G. Wagner
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Barry Spies
- Directorate for Maternal, Child, Women and Youth Health and Nutrition, Mpumalanga Department of Health, Nelspruit, Mpumalanga South Africa
| | - Maria van der Merwe
- Directorate for Maternal, Child, Women and Youth Health and Nutrition, Mpumalanga Department of Health, Nelspruit, Mpumalanga South Africa
| | - F. Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana
| | - Stephen Tollman
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH: An International Network for the Demographic Evaluation of Populations and Their Health, Accra, Ghana
| | - Peter Byass
- Institute of Applied Health Sciences, University of Aberdeen, Scotland, UK
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Kalter HD, Yaroh AG, Maina A, Koffi AK, Bensaïd K, Amouzou A, Black RE. Verbal/social autopsy study helps explain the lack of decrease in neonatal mortality in Niger, 2007-2010. J Glob Health 2016; 6:010604. [PMID: 26955474 PMCID: PMC4766793 DOI: 10.7189/jogh.06.010604] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This study was one of a set of verbal/social autopsy (VASA) investigations undertaken by the WHO/UNICEF-supported Child Health Epidemiology Reference Group to estimate the causes and determinants of neonatal and child deaths in high priority countries. The study objective was to help explain the lack of decrease in neonatal mortality in Niger from 2007 to 2010, a period during which child mortality was decreasing. METHODS VASA interviews were conducted of a random sample of 453 neonatal deaths identified by the 2010 Niger National Mortality Survey (NNMS). Causes of death were determined by expert algorithm analysis, and the prevalence of household, community and health system determinants were examined along the continuum of maternal and newborn care, the Pathway to Survival for newborn illnesses, and an extended pathway for maternal complications. The social autopsy findings were compared to available data for survivors from the same cohort collected by the NNMS and the 2012 Niger Demographic and Health Survey. FINDINGS Severe neonatal infection and birth asphyxia were the leading causes of early neonatal death in the community and facilities. Death in the community after delayed careseeking for severe infection predominated during the late neonatal period. The levels of nearly all demographic, antenatal and delivery care factors were in the direction of risk for the VASA study decedents. They more often resided rurally (P < 0.001) and their mothers were less educated (P = 0.03) and gave birth when younger (P = 0.03) than survivors' mothers. Their mothers also were less likely to receive quality antenatal care (P < 0.001), skilled attendance at birth (P = 0.03) or to deliver in an institution (P < 0.001). Nearly half suffered an obstetric complication, with more maternal infection (17.9% vs 0.2%), antepartum hemorrhage (12.5% vs 0.5%) and eclampsia/preeclampsia (9.5% vs 1.6%) than for all births in Niger. Their mothers also were unlikely to seek health care for their own complications (37% to 42%) as well as for the newborn's illness (30.6%). CONCLUSIONS Niger should scale up its recently implemented package of high-impact interventions to additional integrated health facilities and expand the package to provide antenatal care and management of labor and delivery, with support to reach a higher level facility when required. Community interventions are needed to improve illness recognition and careseeking for severe neonatal infection.
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Affiliation(s)
- Henry D Kalter
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Abdou Maina
- Institute National des Statistics, Niamey, Niger
| | - Alain K Koffi
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Khaled Bensaïd
- UNICEF, Niger country office, Niamey, Niger (retired staff)
| | | | - Robert E Black
- The Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Moyer CA, Aborigo RA, Kaselitz EB, Gupta ML, Oduro A, Williams J. PREventing Maternal And Neonatal Deaths (PREMAND): a study protocol for examining social and cultural factors contributing to infant and maternal deaths and near-misses in rural northern Ghana. Reprod Health 2016; 13:20. [PMID: 26957319 PMCID: PMC4784316 DOI: 10.1186/s12978-016-0142-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 02/25/2016] [Indexed: 11/30/2022] Open
Abstract
Plain English Summary The Preventing Maternal And Neonatal Deaths (PREMAND) project works to understand the social and cultural factors that may contribute to the deaths and near-misses (people who almost die but end up surviving) of mothers and babies in four districts in Northern Ghana. Examples of these factors include such thing as treating a sick baby at home with traditional medicine instead of going to a hospital or health center, or pregnant women needing permission from several people before they can go to a hospital to deliver. These social and cultural factors will be placed on a map to understand where patterns and clusters of deaths and near-misses are present in these four communities. The final phase of the project will include support and small grants for community members and local leaders to use these maps and this information to create their own solutions that address the specific needs of each community. Abstract Background While Ghana is a leader in some health indicators among West African nations, it still struggles with high maternal and neonatal morbidity and mortality rates, especially in the northern areas. The clinical causes of mortality and morbidity are relatively well understood in Ghana, but little is known about the impact of social and cultural factors on maternal and neonatal outcomes. Less still is understood about how such factors may vary by geographic location, and how such variability may inform locally-tailored solutions. Methods/Design Preventing Maternal And Neonatal Deaths (PREMAND) is a three-year, three-phase project that takes place in four districts in the Upper East, Upper West, and Northern Regions of Ghana. PREMAND will prospectively identify all maternal and neonatal deaths and ‘near-misses’, or those mothers and babies who survive a life threatening complication, in the project districts. Each event will be followed by either a social autopsy (in the case of deaths) or a sociocultural audit (in the case of near-misses). Geospatial technology will be used to visualize the variability in outcomes as well as the social, cultural, and clinical predictors of those outcomes. Data from PREMAND will be used to generate maps for local leaders, community members and Government of Ghana to identify priority areas for intervention. PREMAND is an effort of the Navrongo Health Research Centre and the University of Michigan Medical School. Discussion PREMAND uses an innovative, multifaceted approach to better understand and address neonatal and maternal morbidity and mortality in northern Ghana. It will provide unprecedented access to information on the social and cultural factors that contribute to deaths and near-misses in the project regions, and will allow such causal factors to be situated geographically. PREMAND will create the opportunity for local, regional, and national stakeholders to see how these events cluster, and place them relative to traditional healer compounds, health facilities, and other important geographic markers. Finally, PREMAND will enable local communities to generate their own solutions to maternal and neonatal morbidity and mortality, an effort that has great potential for long-term impact. Electronic supplementary material The online version of this article (doi:10.1186/s12978-016-0142-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cheryl A Moyer
- University of Michigan Medical School, 1111 Catherine St, Ann Arbor, MI, 48109, USA.
| | | | - Elizabeth B Kaselitz
- University of Michigan Medical School, 1111 Catherine St, Ann Arbor, MI, 48109, USA.
| | - Mira L Gupta
- University of Michigan Medical School, 1111 Catherine St, Ann Arbor, MI, 48109, USA.
| | - Abraham Oduro
- Navrongo Health Research Centre, PO Box 114, Navrongo, UE/R, Ghana.
| | - John Williams
- Navrongo Health Research Centre, PO Box 114, Navrongo, UE/R, Ghana.
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Jithesh V, Ravindran TS. Social and health system factors contributing to maternal deaths in a less developed district of Kerala, India. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.jrhm.2015.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Koffi AK, Libite PR, Moluh S, Wounang R, Kalter HD. Social autopsy study identifies determinants of neonatal mortality in Doume, Nguelemendouka and Abong-Mbang health districts, Eastern Region of Cameroon. J Glob Health 2015; 5:010413. [PMID: 26171142 PMCID: PMC4459092 DOI: 10.7189/jogh.05.010413] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Reducing preventable medical causes of neonatal death for faster progress toward the MGD4 will require Cameroon to adequately address the social factors contributing to these deaths. The objective of this paper is to explore the social, behavioral and health systems determinants of newborn death in Doume, Nguelemendouka and Abong–Mbang health districts, in Eastern Region of Cameroon, from 2007–2010. Methods Data come from the 2012 Verbal/Social Autopsy (VASA) study, which aimed to determine the biological causes and social, behavioral and health systems determinants of under–five deaths in Doume, Nguelemendouka and Abong–Mbang health districts in Eastern Region of Cameroon. The analysis of the data was guided by the review of the coverage of key interventions along the continuum of normal maternal and newborn care and by the description of breakdowns in the care provided for severe neonatal illnesses within the Pathway to Survival conceptual framework. Results One hundred sixty–four newborn deaths were confirmed from the VASA survey. The majority of the deceased newborns were living in households with poor socio–economic conditions. Most (60–80%) neonates were born to mothers who had one or more pregnancy or labor and delivery complications. Only 23% of the deceased newborns benefited from hygienic cord care after birth. Half received appropriate thermal care and only 6% were breastfed within one hour after birth. Sixty percent of the deaths occurred during the first day of life. Fifty–five percent of the babies were born at home. More than half of the deaths (57%) occurred at home. Of the 64 neonates born at a health facility, about 63% died in the health facility without leaving. Careseeking was delayed for several neonates who became sick after the first week of life and whose illnesses were less serious at the onset until they became more severely ill. Cost, including for transport, health care and other expenses, emerged as main barriers to formal care–seeking both for the mothers and their newborns. Conclusions This study presents an opportunity to strengthen maternal and newborn health by increasing the coverage of essential and low cost interventions that could have saved the lives of many newborns in eastern Cameroon.
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Affiliation(s)
- Alain K Koffi
- Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD, USA
| | | | | | | | - Henry D Kalter
- Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD, USA
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Kalter HD, Roubanatou AM, Koffi A, Black RE. Direct estimates of national neonatal and child cause-specific mortality proportions in Niger by expert algorithm and physician-coded analysis of verbal autopsy interviews. J Glob Health 2015; 5:010415. [PMID: 25969734 PMCID: PMC4416334 DOI: 10.7189/jogh.05.010415] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This study was one of a set of verbal autopsy investigations undertaken by the WHO/UNCEF-supported Child Health Epidemiology Reference Group (CHERG) to derive direct estimates of the causes of neonatal and child deaths in high priority countries of sub-Saharan Africa. The objective of the study was to determine the cause distributions of neonatal (0-27 days) and child (1-59 months) mortality in Niger. METHODS Verbal autopsy interviews were conducted of random samples of 453 neonatal deaths and 620 child deaths from 2007 to 2010 identified by the 2011 Niger National Mortality Survey. The cause of each death was assigned using two methods: computerized expert algorithms arranged in a hierarchy and physician completion of a death certificate for each child. The findings of the two methods were compared to each other, and plausibility checks were conducted to assess which is the preferred method. Comparison of some direct measures from this study with CHERG modeled cause of death estimates are discussed. FINDINGS The cause distributions of neonatal deaths as determined by expert algorithms and the physician were similar, with the same top three causes by both methods and all but two other causes within one rank of each other. Although child causes of death differed more, the reasons often could be discerned by analyzing algorithmic criteria alongside the physician's application of required minimal diagnostic criteria. Including all algorithmic (primary and co-morbid) and physician (direct, underlying and contributing) diagnoses in the comparison minimized the differences, with kappa coefficients greater than 0.40 for five of 11 neonatal diagnoses and nine of 13 child diagnoses. By algorithmic diagnosis, early onset neonatal infection was significantly associated (χ(2) = 13.2, P < 0.001) with maternal infection, and the geographic distribution of child meningitis deaths closely corresponded with that for meningitis surveillance cases and deaths. CONCLUSIONS Verbal autopsy conducted in the context of a national mortality survey can provide useful estimates of the cause distributions of neonatal and child deaths. While the current study found reasonable agreement between the expert algorithm and physician analyses, it also demonstrated greater plausibility for two algorithmic diagnoses and validation work is needed to ascertain the findings. Direct, large-scale measurement of causes of death complement, can strengthen, and in some settings may be preferred over modeled estimates.
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Affiliation(s)
- Henry D Kalter
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Alain Koffi
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert E Black
- The Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Bayley O, Chapota H, Kainja E, Phiri T, Gondwe C, King C, Nambiar B, Mwansambo C, Kazembe P, Costello A, Rosato M, Colbourn T. Community-linked maternal death review (CLMDR) to measure and prevent maternal mortality: a pilot study in rural Malawi. BMJ Open 2015; 5:e007753. [PMID: 25897028 PMCID: PMC4410129 DOI: 10.1136/bmjopen-2015-007753] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In Malawi, maternal mortality remains high. Existing maternal death reviews fail to adequately review most deaths, or capture those that occur outside the health system. We assessed the value of community involvement to improve capture and response to community maternal deaths. METHODS We designed and piloted a community-linked maternal death review (CLMDR) process in Mchinji District, Malawi, which partnered community and health facility stakeholders to identify and review maternal deaths and generate actions to prevent future deaths. The CLMDR process involved five stages: community verbal autopsy, community and facility review meetings, a public meeting and bimonthly reviews involving both community and facility representatives. RESULTS The CLMDR process was found to be comparable to a previous research-driven surveillance system at identifying deaths in Mchinji District (population 456,500 in 2008). 52 maternal deaths were identified between July 2011 and June 2012, 27 (52%) of which would not have been identified without community involvement. Based on district estimates of population (500,000) and crude birth rate (35 births per 1000 population), the maternal mortality ratio was around 300 maternal deaths per 100,000 live births. Of the 41 cases that started the CLMDR process, 28 (68%) completed all five stages. We found the CLMDR process to increase the quantity of information available and to involve a wider range of stakeholders in maternal death review (MDR). The process resulted in high rates of completion of community-planned actions (82%), and district hospital (67%) and health centre (65%) actions to prevent maternal deaths. CONCLUSIONS CLMDR is an important addition to the established forms of MDR. It shows potential as a maternal death surveillance system, and may be applicable to similar contexts with high maternal mortality.
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Affiliation(s)
- Olivia Bayley
- University College London Institute for Global Health, London, UK
| | | | | | | | - Chelmsford Gondwe
- Department of Safe Motherhood, Mchinji District Health Management Team, Mchinji, Malawi
| | - Carina King
- University College London Institute for Global Health, London, UK
| | - Bejoy Nambiar
- University College London Institute for Global Health, London, UK
| | - Charles Mwansambo
- Government of Malawi Ministry of Health, Lilongwe, Malawi Parent and Child Health Initiative (PACHI), Lilongwe, Malawi
| | - Peter Kazembe
- Parent and Child Health Initiative (PACHI), Lilongwe, Malawi Baylor College of Medicine Children's Foundation, Lilongwe, Malawi
| | - Anthony Costello
- University College London Institute for Global Health, London, UK
| | | | - Tim Colbourn
- University College London Institute for Global Health, London, UK
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Jat TR, Deo PR, Goicolea I, Hurtig AK, San Sebastian M. Socio-cultural and service delivery dimensions of maternal mortality in rural central India: a qualitative exploration using a human rights lens. Glob Health Action 2015; 8:24976. [PMID: 25840595 PMCID: PMC4385127 DOI: 10.3402/gha.v8.24976] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 03/04/2015] [Accepted: 03/10/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite the avoidable nature of maternal mortality, unacceptably high numbers of maternal deaths occur in developing countries. Considering its preventability, maternal mortality is being increasingly recognised as a human rights issue. Integration of a human rights perspective in maternal health programmes could contribute positively in eliminating avertable maternal deaths. This study was conducted to explore socio-cultural and service delivery-related dimensions of maternal deaths in rural central India using a human rights lens. DESIGN Social autopsies were conducted for 22 maternal deaths during 2011 in Khargone district in central India. The data were analysed using thematic analysis. The factors associated with maternal deaths were classified by using the 'three delays' framework and were examined by using a human rights lens. RESULTS All 22 women tried to access medical assistance, but various factors delayed their access to appropriate care. The underestimation of the severity of complications by family members, gender inequity, and perceptions of low-quality delivery services delayed decisions to seek care. Transportation problems and care seeking at multiple facilities delayed reaching appropriate health facilities. Negligence by health staff and unavailability of blood and emergency obstetric care services delayed receiving adequate care after reaching a health facility. CONCLUSIONS The study highlighted various socio-cultural and service delivery-related factors which are violating women's human rights and resulting in maternal deaths in rural central India. This study highlights that, despite the health system's conscious effort to improve maternal health, normative elements of a human rights approach to maternal health (i.e. availability, accessibility, acceptability, and quality of maternal health services) were not upheld. The data and analysis suggest that the deceased women and their relatives were unable to claim their entitlements and that the duty bearers were not successful in meeting their obligations. Based on the findings of our study, we conclude that to prevent maternal deaths, further concentrated efforts are required for better community education, women's empowerment, and health systems strengthening to provide appropriate and timely services, including emergency obstetric care, with good quality.
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Affiliation(s)
- Tej Ram Jat
- United Nations Population Fund, Bhopal, India
- Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Swedish Research School for Global Health, Umeå University, Umeå, Sweden; ;
| | | | - Isabel Goicolea
- Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Umeå Centre for Gender Studies, Umeå University, Umeå, Sweden
| | - Anna-Karin Hurtig
- Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Swedish Research School for Global Health, Umeå University, Umeå, Sweden
| | - Miguel San Sebastian
- Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Arauz MJ, Ridde V, Hernández LM, Charris Y, Carabali M, Villar LÁ. Developing a social autopsy tool for dengue mortality: a pilot study. PLoS One 2015; 10:e0117455. [PMID: 25658485 PMCID: PMC4320105 DOI: 10.1371/journal.pone.0117455] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 12/23/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Dengue fever is a public health problem in the tropical and sub-tropical world. Dengue cases have grown dramatically in recent years as well as dengue mortality. Colombia has experienced periodic dengue outbreaks with numerous dengue related-deaths, where the Santander department has been particularly affected. Although social determinants of health (SDH) shape health outcomes, including mortality, it is not yet understood how these affect dengue mortality. The aim of this pilot study was to develop and pre-test a social autopsy (SA) tool for dengue mortality. METHODS AND FINDINGS The tool was developed and pre-tested in three steps. First, dengue fatal cases and 'near misses' (those who recovered from dengue complications) definitions were elaborated. Second, a conceptual framework on determinants of dengue mortality was developed to guide the construction of the tool. Lastly, the tool was designed and pre-tested among three relatives of fatal cases and six near misses in 2013 in the metropolitan zone of Bucaramanga. The tool turned out to be practical in the context of dengue mortality in Colombia after some modifications. The tool aims to study the social, individual, and health systems determinants of dengue mortality. The tool is focused on studying the socioeconomic position and the intermediary SDH rather than the socioeconomic and political context. CONCLUSIONS The SA tool is based on the scientific literature, a validated conceptual framework, researchers' and health professionals' expertise, and a pilot study. It is the first time that a SA tool has been created for the dengue mortality context. Our work furthers the study on SDH and how these are applied to neglected tropical diseases, like dengue. This tool could be integrated in surveillance systems to provide complementary information on the modifiable and avoidable death-related factors and therefore, be able to formulate interventions for dengue mortality reduction.
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Affiliation(s)
- María José Arauz
- School of Public Health (ESPUM), University of Montreal / University of Montreal Hospital Research Center (CRCHUM), Montreal, Canada
| | - Valéry Ridde
- School of Public Health (ESPUM), University of Montreal / University of Montreal Hospital Research Center (CRCHUM), Montreal, Canada
| | - Libia Milena Hernández
- Centro de Atención y Diagnóstico de Enfermedades Infecciosas (CDI-APRESIA), Bucaramanga, Colombia
| | - Yaneth Charris
- Centro de Atención y Diagnóstico de Enfermedades Infecciosas (CDI-APRESIA), Bucaramanga, Colombia
| | - Mabel Carabali
- Dengue Vaccines Initiative / International Vaccines Institute, Seoul, Republic of Korea
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Moshabela M, Sene M, Nanne I, Tankoano Y, Schaefer J, Niang O, Sachs SE. Early detection of maternal deaths in Senegal through household-based death notification integrating verbal and social autopsy: a community-level case study. BMC Health Serv Res 2015; 15:16. [PMID: 25609079 PMCID: PMC4323233 DOI: 10.1186/s12913-014-0664-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 12/16/2014] [Indexed: 11/10/2022] Open
Abstract
Background Reliable detection of maternal deaths is an essential prerequisite for successful diagnosis of barriers to care and formulation of relevant targeted interventions. In a community-level case study, the use of household-level surveillance in Senegal unveiled an apparent increase in maternal deaths, which triggered a rapid-cycle collaborative response to implement a multipronged set of quick-win and sustained interventions intended to improve quality care. Methods Part of a multi-country effort, the Millennium Villages Project is implementing a routine community-level information system in Senegal, able to detect maternal deaths in real-time and uncover clinical and social factors contributing to mortality. Within this geographically demarcated area of approximately 32 000 inhabitants, with a well-structured health system with patient referral services, deaths were registered and notified by community health workers, followed by timely verbal and social autopsies. Using the Pathway to Survival conceptual framework, case analysis and mortality reviews were conducted for evaluation and quality improvement purposes. Results The estimated maternal mortality rates rose from 67/100000 births in 2009 (1 death), to 202/100000 births in 2010 (3 deaths) and 392/100000 births (5 deaths) in 2011. Although absolute numbers of maternal deaths remained too small for robust statistical analysis, following verbal autopsy analyses in 2011, it became evident that an unexpectedly high proportion of maternal deaths were occurring at the referral hospital, mostly post-Caesarian section. Inadequate case management of post-partum haemorrhage at the referral hospital was the most frequently identified probable cause of death. A joint task team systematically identified several layers of inefficiencies, with a potential negative impact on a larger catchment area than the study community. Conclusions In this study, routine community-based surveillance identified inefficiencies at a tertiary level of care. Community-level surveillance systems that include pregnancy, birth and death tracking through household visits by community health workers , combined with verbal and social autopsy can identify barriers within the continuum of maternal care. Use of mHealth data collection tools sensitive enough to detect small changes in community-level mortality trends in real-time, can facilitate rapid-cycle quality improvement interventions, particularly when associated with social accountability structures of mortality reviews.
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Affiliation(s)
- Mosa Moshabela
- Department of Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Science Drive, Howard College, Fourth Floor, George Campbell Building, Durban, 4001, South Africa.
| | - Massamba Sene
- Millennium Promise, Columbia University, Dakar, Senegal.
| | - Ingrid Nanne
- Millennium Development Goal Centre, Columbia University, Dakar, Senegal.
| | - Yombo Tankoano
- Earth Institute, Columbia University, New York City, USA.
| | - Jennifer Schaefer
- School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Australia.
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Cause of death among infants in rural western China: a community-based study using verbal autopsy. J Pediatr 2014; 165:577-84. [PMID: 24929335 DOI: 10.1016/j.jpeds.2014.04.047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 03/24/2014] [Accepted: 04/28/2014] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To determine the causes of death among infants in high-mortality areas of western China with the use of globally recognized methods. STUDY DESIGN A survey of all infant deaths identified over 1 year in 4 counties in Yunnan and Xinjiang in which combined verbal autopsy was combined with a physician's diagnosis of the cause to calculate the local infant mortality rate. RESULTS Among 470 completed investigations, a cause of death was assigned to 423 cases (90%). Overall, pneumonia (34.5%), preterm birth complications (16.5%), diarrhea (10.4%), birth asphyxia (10.3%), and congenital abnormalities (8.5%) were the main causes, with 56.6% of deaths occurring in the neonatal period. Deaths were attributable predominantly to prematurity or birth asphyxia in the early neonatal period, whereas infection accounted for more than 60% and 80% of deaths in the late and postneonatal periods, respectively. Calculated infant mortality was 21.9 in 1000 live births. CONCLUSIONS The pattern of infant mortality observed in the surveyed counties differs markedly from that reported previously at the national level, with a high proportion the result of causes that may be preventable with globally recommended interventions. Financial and political support is needed to promote improved cause of death surveillance and newborn and infant health care in China's western region.
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73
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Njuki R, Kimani J, Obare F, Warren C. Using verbal and social autopsies to explore health-seeking behaviour among HIV-positive women in Kenya: a retrospective study. BMC Womens Health 2014; 14:77. [PMID: 24968717 PMCID: PMC4082620 DOI: 10.1186/1472-6874-14-77] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is limited understanding of the factors that influence decisions to seek HIV care and treatment services in community settings. The aim of this study was to explore the socio-cultural and health system factors affecting health-seeking behaviour among deceased women in Kenya who were living with HIV at the time of death. METHODS Out of a total of 796 deaths for which a caregiver was available to provide information, retrospective data were drawn from verbal and social autopsies administered to caregivers of 218 women who had died of AIDS-related illnesses aged 15 to 49 years. Information was collected on essential elements of the care-seeking process from the onset of severe illness episodes and analysed using qualitative and quantitative techniques. RESULTS Results from the quantitative data showed that poor women were less likely to access formal health services (OR = 0.2; p < 0.001) compared to non-poor women. The qualitative data showed that socioeconomic status, poor knowledge and understanding of AIDS-related illness, distance to facility and transportation costs, medical pluralism, stigma, low HIV risk perception, lack of family support and health care system barriers contributed to delays/constraints in seeking care. CONCLUSIONS The findings highlight important issues that have implications for addressing challenges faced by women living with HIV, including non-adherence to treatment regimen and late diagnosis of HIV. Provision of transportation subsidies as part of the national social safety-net strategy can help in addressing financial constraints associated with transportation costs among poor women living with HIV.
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Affiliation(s)
- Rebecca Njuki
- Center for Population Health Research Management, Magharibi Place, 2nd Floor, Room 2, P.O. Box 19607–00202, Nairobi, Kenya
| | - James Kimani
- Population Council, General Accident Insurance House, Ralph Bunche Road, P.O. Box 17643–00500, Nairobi, Kenya
| | - Francis Obare
- Population Council, General Accident Insurance House, Ralph Bunche Road, P.O. Box 17643–00500, Nairobi, Kenya
| | - Charlotte Warren
- Population Council, General Accident Insurance House, Ralph Bunche Road, P.O. Box 17643–00500, Nairobi, Kenya
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Upadhyay RP, Krishnan A, Rai SK, Chinnakali P, Odukoya O. Need to focus beyond the medical causes: a systematic review of the social factors affecting neonatal deaths. Paediatr Perinat Epidemiol 2014; 28:127-37. [PMID: 24354747 DOI: 10.1111/ppe.12098] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Reducing the global total of 3.3 million neonatal deaths is crucial to meeting the fourth Millennium Development Goal. Until recently, attention has been on the medical causes of the neonatal deaths, while the social factors contextualising these deaths have largely remained unaddressed. The current review aimed to quantify the role of these factors in neonatal deaths. METHODS A systematic search was performed through PubMed, Google scholar, Cochrane library, Medline, IndMed, Embase, World Health Organization and Biomed central databases. Studies published from 1995 to 2011 were included. Random effects meta-analysis was performed to derive at an estimate of the burden of delays, as defined by the 'three delays model' by Thadeus and Maine. RESULTS A total of 17 studies were reviewed. The majority of them (n = 10) were from the African continent. Level 3 delay, i.e. delay in receiving appropriate treatment upon reaching a health facility (38.7%, 95% CI, 21.7%-57.3%) and delay in deciding to seek care for the illness (Level 1 delay) (28%, 95% CI, 16%-43%) were the major contributors to neonatal deaths. Level 2 delay, i.e. delay in reaching a health facility (18.3%, 95% CI, 2.6-43.8%) contributed least to the neonatal deaths. CONCLUSION Creating awareness among caregivers regarding early recognition and treatment seeking for neonatal illness along with improving the quality of neonatal care provided at the health facilities is essential to reduce neonatal mortality.
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Affiliation(s)
- Ravi Prakash Upadhyay
- Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Houston KT, Surkan PJ, Katz J, West KP, LeClerq SC, Christian P, Wu L, Dali SM, Khatry SK. Deaths due to injury, including violence among married Nepali women of childbearing age: a qualitative analysis of verbal autopsy narratives. Inj Prev 2014; 21:e93-8. [DOI: 10.1136/injuryprev-2013-040871] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
10 years ago, The Lancet published a Series about child survival. In this Review, we examine progress in the past decade in child survival, with a focus on epidemiology, interventions and intervention coverage, strategies of health programmes, equity, evidence, accountability, and global leadership. Knowledge of child health epidemiology has greatly increased, and although more and better interventions are available, they still do not reach large numbers of mothers and children. Child survival should remain at the heart of global goals in the post-2015 era. Many countries are now making good progress and need the time and support required to finish the task. The global health community should show its steadfast commitment to child survival by amassing knowledge and experience as a basis for ever more effective programmes. Leadership and accountability for child survival should be strengthened and shared among the UN system; governments in high-income, middle-income, and low-income countries; and non-governmental organisations.
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Affiliation(s)
- Jennifer Bryce
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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Engmann C, Adongo P, Aborigo RA, Gupta M, Logonia G, Affah G, Waiswa P, Hodgson A, Moyer CA. Infant illness spanning the antenatal to early neonatal continuum in rural northern Ghana: local perceptions, beliefs and practices. J Perinatol 2013; 33:476-81. [PMID: 23348868 DOI: 10.1038/jp.2012.151] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To explore community understanding of perinatal illness in northern Ghana. STUDY DESIGN A cross-sectional descriptive study design. RESULT 253 community members participated in in-depth interviews and focus group discussions, including women with newborn infants, grandmothers and health care providers. Four overarching themes emerged: (1) Local understanding of illness affects treatment practices. Respondents recognized danger signs of illness spanning antenatal to early neonatal periods. Understanding of causation often had a distinctly local flavor, and thus treatment sometimes differed from mainstream recommendations; (2) Mothers are frequently blamed for their infant's illness; (3) Healthcare decisions regarding infant care are often influenced by community members aside from the infant's mother and (4) Confidence in healthcare providers is issue-specific, and many households use a blended approach to meet their health needs. CONCLUSION Despite widespread recognition of danger signs and reported intentions to treat ill infants through the formal health care system, traditional approaches to perinatal illness remain common. Interventions need to be aligned with community perceptions if they are to succeed.
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Affiliation(s)
- C Engmann
- Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina Schools of Medicine and Public Health, Chapel Hill, NC 27599-7596, USA.
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Storeng KT, Drabo S, Filippi V. Too poor to live? A case study of vulnerability and maternal mortality in Burkina Faso. Glob Health Promot 2013; 20:33-8. [DOI: 10.1177/1757975912462420] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This paper examines the concept of vulnerability in the context of maternal morbidity and mortality in Burkina Faso, an impoverished country in West Africa. Drawing on a longitudinal cohort study into the consequences of life-threatening or ‘near miss’ obstetric complications, we provide an in-depth case study of one woman’s experience of such morbidity and its aftermath. We follow Kalizeta’s trajectory from her near miss and the stillbirth of her child to her death from pregnancy-related hypertension after a subsequent delivery less than two years later, in order to examine the impact of severe and persistent illness and catastrophic health expenditure on her health and on her family’s everyday life. Kalizeta’s case illustrates how vulnerability in health emerges and is maintained or exacerbated over time. Even where social arrangements are supportive, structural impediments, including unaffordable and inadequate healthcare, can severely limit individual resilience to mitigate the negative social and economic consequences of ill health.
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Affiliation(s)
- Katerini T. Storeng
- Centre for Development and the Environment, University of Oslo, Oslo, Norway
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Seydou Drabo
- Centre for Development and the Environment, University of Oslo, Oslo, Norway
| | - Véronique Filippi
- London School of Hygiene & Tropical Medicine, London, United Kingdom
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Iyer A, Sen G, Sreevathsa A. DecipheringRashomon: An approach to verbal autopsies of maternal deaths. Glob Public Health 2013; 8:389-404. [DOI: 10.1080/17441692.2013.772219] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Gerdts C, Vohra D, Ahern J. Measuring unsafe abortion-related mortality: a systematic review of the existing methods. PLoS One 2013; 8:e53346. [PMID: 23341939 PMCID: PMC3544771 DOI: 10.1371/journal.pone.0053346] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 11/27/2012] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists. STUDY DESIGN To be included in this study, articles had to meet the following criteria: (1) published between September 1(st), 2000-December 1(st), 2011; (2) utilized data from a country where abortion is "considered unsafe"; (3) specified and enumerated causes of maternal death including "abortion"; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal. RESULTS 7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated "Very Good" found the highest estimates of abortion related mortality (median 16%, range 1-27.4%). Studies rated "Very Poor" found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3-9.4%). CONCLUSIONS Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.
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Affiliation(s)
- Caitlin Gerdts
- Advancing New Standards in Reproductive Health, University of California San Francisco, San Francisco, CA, USA.
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82
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Alvesson HM, Lindelow M, Khanthaphat B, Laflamme L. Shaping healthcare-seeking processes during fatal illness in resource-poor settings. A study in Lao PDR. BMC Health Serv Res 2012; 12:477. [PMID: 23259434 PMCID: PMC3543714 DOI: 10.1186/1472-6963-12-477] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 12/18/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are profound social meanings attached to bearing children that affect the experience of losing a child, which is akin to the loss of a mother in the household. The objective of this study is to comprehend the broader processes that shape household healthcare-seeking during fatal illness episodes or reproductive health emergencies in resource-poor communities. METHODS The study was conducted in six purposively selected poor, rural communities in Lao PDR, located in two districts that represent communities with different access to health facilities and contain diverse ethnic groups. Households having experienced fatal cases were first identified in focus group discussions with community members, which lead to the identification of 26 deaths in eleven households through caregiver and spouse interviews. The interviews used an open-ended anthropological approach and followed a three-delay framework. Interpretive description was used in the data analysis. RESULTS The healthcare-seeking behavior reported by caregivers revealed a broad range of providers, reflecting the mix of public, private, informal and traditional health services in Lao PDR. Most caregivers had experienced multiple constraints in healthcare-seeking prior to death. Decisions regarding care-seeking were characterized as social rather than individual actions. They were constrained by medical costs, low expectations of recovery and worries about normative expectations from healthcare workers on how patients and caregivers should behave at health facilities to qualify for treatment. Caregivers raised the difficulties in determining the severity of the state of the child/mother. Delays in reaching care related to lack of physical access and to risks associated with taking a sick family member out of the local community. Delays in receiving care were affected by the perceived low quality of care provided at the health facilities. CONCLUSIONS Care-seeking is influenced by family- and community-based relations, which are integrated parts of people's everyday life. The medical and normative responses from health providers affect the behavior of care-seekers. An anthropological approach to capture the experience of caregivers in relation to deciding, seeking and reaching care reveals the complexity and socio-cultural context surrounding maternal and child mortality and has implications for how future mortality data should be developed and interpreted.
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Affiliation(s)
- Helle M Alvesson
- Department of Public Health Sciences, Division of Global Health, Karolinska Institutet, Nobels väg 9, Stockholm, 171 77, Sweden
| | - Magnus Lindelow
- Human Development Department, The World Bank, Brazil SCN, Quadra 2, Lote A. Ed. Corporate Center, 7th andar, Brasilia, DF, 70712-900, Brazil
| | - Bouasavanh Khanthaphat
- Indochina Research Laos Ltd, IRL Building, 282/17 Phontong-Savath, PO Box 1887, Vientiane Capital, Chanthabouly District, Laos
| | - Lucie Laflamme
- Department of Public Health Sciences, Division of Global Health, Karolinska Institutet, Nobels väg 9, Stockholm, 171 77, Sweden
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Pacagnella RC, Cecatti JG, Osis MJ, Souza JP. The role of delays in severe maternal morbidity and mortality: expanding the conceptual framework. REPRODUCTIVE HEALTH MATTERS 2012; 20:155-63. [PMID: 22789093 DOI: 10.1016/s0968-8080(12)39601-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Maternal mortality has gained importance in research and policy since the mid-1980s. Thaddeus and Maine recognized early on that timely and adequate treatment for obstetric complications were a major factor in reducing maternal deaths. Their work offered a new approach to examining maternal mortality, using a three-phase framework to understand the gaps in access to adequate management of obstetric emergencies: phase I--delay in deciding to seek care by the woman and/or her family; phase II--delay in reaching an adequate health care facility; and phase III--delay in receiving adequate care at that facility. Recently, efforts have been made to strengthen health systems' ability to identify complications that lead to maternal deaths more rapidly. This article shows that the combination of the "three delays" framework with the maternal "near-miss" approach, and using a range of information-gathering methods, may offer an additional means of recognizing a critical event around childbirth. This approach can be a powerful tool for policymakers and health managers to guarantee the principles of human rights within the context of maternal health care, by highlighting the weaknesses of systems and obstetric services.
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84
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Waiswa P, Kalter HD, Jakob R, Black RE. Increased use of social autopsy is needed to improve maternal, neonatal and child health programmes in low-income countries. Bull World Health Organ 2012; 90:403-403A. [PMID: 22690025 DOI: 10.2471/blt.12.105718] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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D'Ambruoso L. Relating the construction and maintenance of maternal ill-health in rural Indonesia. Glob Health Action 2012; 5:GHA-5-17989. [PMID: 22872791 PMCID: PMC3413021 DOI: 10.3402/gha.v5i0.17989] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 06/12/2012] [Accepted: 06/26/2012] [Indexed: 11/28/2022] Open
Abstract
Estimates suggest that over 350,000 deaths and more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. Death and disability occur predominately among disadvantaged women in resource-poor settings and are largely preventable with adequate delivery care. This paper presents the substantive findings and policy implications from a programme of PhD research, of which the overarching objective was to assess quality of, and access to, care in obstetric emergencies. Three critical incident audits were conducted in two rural districts on Java, Indonesia: a confidential enquiry, a verbal autopsy survey, and a community-based review. The studies examined cases of maternal mortality and severe morbidity from the perspectives of local service users and health providers. A range of inter-related determining factors was identified. When unexpected delivery complications occurred, women and families were often uninformed, unprepared, found care unavailable, unaffordable, and many relied on traditional providers. Midwives in villages made important contributions by stabilising women and facilitating referrals but were often scarce in remote areas and lacked sufficient clinical competencies and payment incentives to treat the poor. Emergency transport was often unavailable and private transport was unreliable and incurred costs. In facilities, there was a reluctance to admit poorer women and those accepted were often admitted to ill-equipped, under-staffed wards. As a result, referrals between hospitals were also common. Otherwise, social health insurance, designed to reduce financial barriers, was particularly problematic, constraining quality and access within and outside facilities. Health workers and service users provided rich and explicit assessments of care and outcomes. These were used to develop a conceptual model in which quality and access are conceived of as social processes, observable through experience and reflective of the broader relationships between individuals and health systems. According to this model, differential quality and access can become both socially legitimate (imposed by structural arrangements) and socially legitimised (reciprocally maintained through the actions of individuals). This interpretation suggests that in a context of commodified care provision, adverse obstetric outcomes will occur and recur for disadvantaged women. Health system reform should focus on the unintended effects of market-based service provision to exclude those without the ability to pay for delivery care directly.
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Affiliation(s)
- Lucia D'Ambruoso
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden.
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Affiliation(s)
- Zulfiqar A Bhutta
- Division of Women and Child Health, The Aga Khan University, Karachi 74800, Pakistan.
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Storeng KT, Drabo S, Ganaba R, Sundby J, Calvert C, Filippi V. Mortality after near-miss obstetric complications in Burkina Faso: medical, social and health-care factors. Bull World Health Organ 2012; 90:418-425B. [PMID: 22690031 PMCID: PMC3370364 DOI: 10.2471/blt.11.094011] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 11/18/2011] [Accepted: 01/23/2012] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To investigate mortality in women in Burkina Faso in the 4 years following a life-threatening near-miss obstetric complication and to identify the medical, social and health-care-related causes of death. METHODS In total, 1014 women were recruited after hospital discharge and followed for up to 4 years: 337 had near-miss complications and 677 had uncomplicated pregnancies. Significant differences in mortality between the groups were assessed using Fisher's exact test. The medical causes of death were identified from medical records and verbal autopsy data; social and health-care-related factors associated with death were identified from interviews with the deceased women's relatives. FINDINGS In the 4 years, 15 (5.3%) women died in the near-miss group and 5 (0.9%) died after uncomplicated pregnancies (P < 0.001). More than half the deaths after a near miss, but none after an uncomplicated delivery, were pregnancy-related. Indirect factors contributed to many of these deaths, particularly human immunodeficiency virus infection. Relatives' accounts suggested that the high cost and poor quality of health care, a lack of follow-up care and an unmet need for contraception contributed to the excess mortality in the near-miss group. CONCLUSION Women in Burkina Faso who initially survived a near-miss obstetric complication had an increased risk of all-cause and pregnancy-related death in the ensuing 4 years. The likelihood of survival over the longer term could be increased by offering a continuum of care that addresses the indirect and social causes of death and supplements the emergency intrapartum obstetric care provided by current safe motherhood programmes.
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Affiliation(s)
- Katerini T Storeng
- Centre for Development and the Environment, University of Oslo, PB 1116 Blindern, Oslo 0317, Norway.
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Kaneko S, K'opiyo J, Kiche I, Wanyua S, Goto K, Tanaka J, Changoma M, Ndemwa M, Komazawa O, Karama M, Moji K, Shimada M. Health and Demographic Surveillance System in the Western and coastal areas of Kenya: an infrastructure for epidemiologic studies in Africa. J Epidemiol 2012; 22:276-85. [PMID: 22374366 PMCID: PMC3798630 DOI: 10.2188/jea.je20110078] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The Health and Demographic Surveillance System (HDSS) is a longitudinal data collection process that systematically and continuously monitors population dynamics for a specified population in a geographically defined area that lacks an effective system for registering demographic information and vital events. Methods HDSS programs have been run in 2 regions in Kenya: in Mbita district in Nyanza province and Kwale district in Coast Province. The 2 areas have different disease burdens and cultures. Vital events were obtained by using personal digital assistants and global positioning system devices. Additional health-related surveys have been conducted bimonthly using various PDA-assisted survey software. Results The Mbita HDSS covers 55 929 individuals, and the Kwale HDSS covers 42 585 individuals. In the Mbita HDSS, the life expectancy was 61.0 years for females and 57.5 years for males. Under-5 mortality was 91.5 per 1000 live births, and infant mortality was 47.0 per 1000 live births. The total fertility rate was 3.7 per woman. Data from the Kwale HDSS were not available because it has been running for less than 1 year at the time of this report. Conclusions Our HDSS programs are based on a computer-assisted survey system that provides a rapid and flexible data collection platform in areas that lack an effective basic resident registration system. Although the HDSS areas are not representative of the entire country, they provide a base for several epidemiologic and social study programs, and for practical community support programs that seek to improve the health of the people in these areas.
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Affiliation(s)
- Satoshi Kaneko
- Department of EcoEpidemiology, Institute of Tropical Medicine, Nagasaki University, Japan.
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Community-driven impact of a newborn-focused behavioral intervention on maternal health in Shivgarh, India. Int J Gynaecol Obstet 2012; 117:48-55. [DOI: 10.1016/j.ijgo.2011.10.031] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 10/27/2011] [Accepted: 12/13/2011] [Indexed: 11/19/2022]
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