Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan

Public health surveillance through community health workers: a scoping review of evidence from 25 low-income and middle-income countries

BACKGROUND

The last 3 years have witnessed global health challenges, ranging from the pandemics of COVID-19 and mpox (monkeypox) to the Ebola epidemic in Uganda. Public health surveillance is critical for preventing these outbreaks, yet surveillance systems in resource-constrained contexts struggle to provide timely disease reporting. Although community health workers (CHWs) support health systems in low-income and middle-income countries (LMICs), very little has been written about their role in supporting public health surveillance. This review identified the roles, impacts and challenges CHWs face in public health surveillance in 25 LMICs.

METHODS

We conducted a scoping review guided by Arksey and O'Malley's framework. We exported 1,156 peer-reviewed records from Embase, Global Health and PubMed databases. After multiple screenings, 29 articles were included in the final review.

RESULTS

CHWs significantly contribute to public health surveillance in LMICs including through contact tracing and patient visitation to control major infectious diseases such as HIV/AIDS, malaria, tuberculosis, Ebola, neglected tropical diseases and COVID-19. Their public health surveillance roles typically fall into four main categories including community engagement; data gathering; screening, testing and treating; and health education and promotion. The use of CHWs in public health surveillance in LMICs has been impactful and often involves incorporation of various technologies leading to improved epidemic control and disease reporting. Nonetheless, use of CHWs can come with four main challenges including lack of education and training, lack of financial and other resources, logistical and infrastructural challenges as well as community engagement challenges.

CONCLUSION

CHWs are important stakeholders in surveillance because they are closer to communities than other healthcare workers. Further integration and training of CHWs in public health surveillance would improve public health surveillance because CHWs can provide health data on 'hard-to-reach' populations. CHWs' work in public health surveillance would also be greatly enhanced by infrastructural investments.

Approaches to improve and adapt maternal mortality estimations in low- and middle-income countries: A scoping review

BACKGROUND

In the absence of robust vital registration systems, many low- and middle-income countries (LMICs) rely on national surveys or routine surveillance systems to estimate the maternal mortality ratio (MMR). Although the importance of MMR estimates in ending preventable maternal deaths is acknowledged, there is limited research on how different approaches are used and adapted, and how these adaptations function.

OBJECTIVES

To assess methods for estimating maternal mortality in LMICs and the rationale for these modifications.

SEARCH STRATEGY

A literature search with the terms "maternal death", "surveys" and "low- and middle-income countries" was performed in Medline, Embase, Web of Science, Scopus, CINAHL, APA PsycINFO, ERIC, and IBSS from January 2013 to March 17, 2023.

SELECTION CRITERIA

Studies were eligible if their main focus was to compare, adapt, or assess methods to estimate maternal mortality in LMICs.

DATA COLLECTION AND ANALYSIS

Titles and abstracts were screened using Rayyan. Relevant articles were independently reviewed by two reviewers against inclusion criteria. Data were extracted on mortality measurement methods, their context, and results.

MAIN RESULTS

Nineteen studies were included, focusing on data completeness, subnational estimates, and community involvement. Routinely generated MMR estimates are more complete when multiple data sources are triangulated, including data from public and private health facilities, the community, and local authorities (e.g. vital registration, police reports). For subnational estimates, existing (e.g. the sisterhood method and reproductive-age mortality surveys [RAMOS]) and adapted methods (e.g. RAMOS 4 + 2 and Pictorial Sisterhood Method) provided reliable confidence intervals. Community engagement in data collection increased community awareness of maternal deaths, provided local ownership, and was expected to reduce implementation costs. However, most studies did not include a cost-effectiveness analysis.

CONCLUSION

Household surveys with community involvement and RAMOS can be used to increase data validity, improve local awareness of maternal mortality estimates, and reduce costs in LMICs.

A Data-Driven Paradigm for a Resilient and Sustainable Integrated Health Information Systems for Health Care Applications

Introduction

Many transformations and uncertainties, such as the fourth industrial revolution and pandemics, have propelled healthcare acceptance and deployment of health information systems (HIS). External and internal determinants aligning with the global course influence their deployments. At the epic is digitalization, which generates endless data that has permeated healthcare. The continuous proliferation of complex and dynamic healthcare data is the digitalization frontier in healthcare that necessitates attention.

Objective

This study explores the existing body of information on HIS for healthcare through the data lens to present a data-driven paradigm for healthcare augmentation paramount to attaining a sustainable and resilient HIS.

Method

Preferred Reporting Items for Systematic Reviews and Meta-Analyses: PRISMA-compliant in-depth literature review was conducted systematically to synthesize and analyze the literature content to ascertain the value disposition of HIS data in healthcare delivery.

Results

This study details the aspects of a data-driven paradigm for robust and sustainable HIS for health care applications. Data source, data action and decisions, data sciences techniques, serialization of data sciences techniques in the HIS, and data insight implementation and application are data-driven features expounded. These are essential data-driven paradigm building blocks that need iteration to succeed.

Discussions

Existing literature considers insurgent data in healthcare challenging, disruptive, and potentially revolutionary. This view echoes the current healthcare quandary of good and bad data availability. Thus, data-driven insights are essential for building a resilient and sustainable HIS. People, technology, and tasks dominated prior HIS frameworks, with few data-centric facets. Improving healthcare and the HIS requires identifying and integrating crucial data elements.

Conclusion

The paper presented a data-driven paradigm for a resilient and sustainable HIS. The findings show that data-driven track and components are essential to improve healthcare using data analytics insights. It provides an integrated footing for data analytics to support and effectively assist health care delivery.

Incompleteness and misclassification of maternal death recording: a systematic review and meta-analysis

OBJECTIVE

To quantify the extent of incompleteness and misclassification of maternal and pregnancy related deaths, and to identify general and context-specific factors associated with incompleteness and/or misclassification of maternal death data.

METHODS

We conducted a systematic review of incompleteness and/or misclassification of maternal and pregnancy-related deaths. We conducted a narrative synthesis to identify methods used to capture and classify maternal deaths, as well as general and context specific factors affecting the completeness and misclassification of maternal death recording. We conducted a meta-analysis of proportions to obtain estimates of incompleteness and misclassification of maternal death recording, overall and disaggregated by income and surveillance system types.

FINDINGS

Of 2872 title-abstracts identified, 29 were eligible for inclusions in the qualitative synthesis, and 20 in the meta-analysis. Included studies relied principally on record linkage and review for identifying deaths, and on review of medical records and verbal autopsies to correctly classify cause of death. Deaths to women towards the extremes of the reproductive age range, those not classified by a medical examiner or a coroner, and those from minority ethnic groups in their setting were more likely misclassified or unrecorded. In the meta-analysis, we found maternal death recording to be incomplete by 34% (95% CI: 28-48), with 60% sensitivity (95% CI: 31-81.). Overall, we found maternal mortality was under-estimated by 39% (95% CI: 30-48) due to incompleteness and/or misclassification. Reporting of deaths away from the intrapartum, due to indirect causes or occurring at home were less complete than their counterparts. There was substantial between and within group variability across most results.

CONCLUSION

Maternal deaths were under-estimated in almost all contexts, but the extent varied across settings. Countries should aim towards establishing Civil Registration and Vital Statistics systems where they are not instituted. Efforts to improve the completeness and accuracy of maternal cause of death recording, such as Confidential Enquiries into Maternal Deaths, are needed even where CRVS is considered to be well-functioning.

Community engagement in maternal and perinatal death surveillance and response (MPDSR): Realist review protocol

Background: While there has been a decline in maternal and perinatal mortality, deaths remain high in sub-Saharan Africa and Asia. With the sustainable development goals (SDGs) targets to reduce maternal and perinatal mortality, more needs to be done to accelerate progress and improve survival. Maternal and perinatal death surveillance and response (MPDSR) is a strategy to identify the clinical and social circumstances that contribute to maternal and perinatal deaths. Through MPDSR, an active surveillance and response cycle is established by bringing together different stakeholders to review and address these social and clinical factors. Community engagement in MPDSR provides a strong basis for collective action to address social factors and quality of care issues that contribute to maternal and perinatal deaths. Studies have shown that community members can support identification and reporting of maternal and/or perinatal deaths. Skilled care at birth has been increasing globally, but there are still gaps in quality of care. Through MPDSR, community members can collaborate with health workers to improve quality of care. But we do not know how community engagement in MPDSR works in practice; for whom it works and what aspects work (or do not work) and why. This realist review answers the question: which strategies of community engagement in MPDSR produce which outcomes in which contexts? Methods : For this realist review, we will identify published and grey literature by searching relevant databases for articles. We will include papers published from 2004 in all languages and from all countries. We have set up an advisory group drawn from academia, international organizations, and practitioners of both MPDSR and community engagement to guide the process. Conclusion: This protocol and the subsequent realist review will use theoretical approaches from the community engagement literature to generate theory on community engagement in MPDSR. Prospero registration number:  CRD42022345216.

Health system readiness to manage maternal death data and avail evidence for decision-making through the Maternal Death Surveillance System in Ethiopia, 2020

BACKGROUND

Maternal mortality remains a major health problem in Ethiopia. To generate contextual evidence on the burden and distribution of existing causes and contributing factors for programmatic and individual-level decision-making, the Maternal Death Surveillance and Response System was introduced in 2013. This assessment describes the Ethiopian health system's readiness to avail evidence for decision-making through the MDSR system.

METHOD

A cross-sectional study designed using the WHO framework for evaluating surveillance systems was used. By employing a multistage sampling, 631 health facilities and 539 health posts were included. ODK collect data entry software was used to collect data from September 2019 to April 2020. Findings are presented in text descriptions, graphs, maps, and tables.

FINDINGS

Four hundred (77.1%) health facilities (332 (74.6%) health centers and 68 (91.9%) hospitals) and 264 (71.5%) health posts reported implementing the MDSR system. Of the implementing health facilities, 349 (87.3%) had a death review committee, and only 42 (12.4%) were functional. About 89.4% of health centers and 79.4% of hospitals had sub-optimal maternal death identification and notification readiness. Only 23 (6.96%) and 18 (26.47%) MDSR-implementing health centers and hospitals had optimal readiness to investigate and review maternal deaths, respectively. Moreover, only 39 (14.0%) health posts had locally translated case definitions and 28 (10.6%) had verbal autopsy format to investigate maternal deaths. Six (1.5%) facility officers and 24 (9.1%) health extension workers were engaged in data analysis and evidence generation at least once during 2019/20. Regional variation is observed in system implementation.

CONCLUSIONS AND RECOMMENDATIONS

Sub-optimal MDSR system implementation is recorded. Revitalizing the system by addressing all system components is critical. Having a national-level roadmap for MDSR system implementation and mobilizing all available resources and stakeholders to facilitate this is vital. Establishing a system for routine data quality monitoring and assurance by integrating with the existing PHEM structure, having a system for routine capacity building, advocacy, and monitoring and evaluating the availability and functionality of MDSR committees at health facilities are all critical. Digitalization, designing a system to fit emerging regions' health service delivery, and availing required resources for the system is key.

Maternal Mortality in a Rural District of Pakistan and Contributing Factors

INTRODUCTION

Pakistan is among the ten countries that account for 60% of global maternal mortality. Lack of accurate data on maternal mortality and a complex interrelation of access and quality of healthcare services, healthcare delivery system, and socio-economic and demographic factors contribute significantly to inadequate progress in reducing maternal mortality.

MATERIAL AND METHODS

A population-based prospective cohort study was conducted in a rural district of Pakistan using data obtained from an enhanced surveillance system. A total of 7572 pregnancies and their outcomes were recorded by 273 Lady Health Workers and 73 Community Health Workers over 2016-2017. Logistic regression was used to calculate the unadjusted and adjusted odds ratios (OR) for maternal mortality for each risk factor. Population Attributable Fraction (PAF) was derived from the ORs and risk factor prevalence.

RESULTS

The study recorded 18 maternal deaths. The maternal mortality rate was estimated at 238/100,000 pregnancies (95% CI 141-376), and the maternal mortality ratio was 247/100,000 live births (95% CI 147-391). Half of the maternal deaths (9) were from obstetric hemorrhage, and 28% (5) from puerperal sepsis. Postpartum hemorrhage was associated with a 17-fold higher risk of maternal mortality (PAF = 40%) and puerperal sepsis with a 12-fold higher mortality risk (PAF = 29%) compared to women without these conditions. Women delivered by unskilled birth attendants had a three-fold (PAF = 21%), and women having prolonged labour had a fourfold risk of maternal mortality compared to those with these conditions. Women with leg swelling (47%) and pre-eclampsia (26%) are at seven times the risk of maternal mortality compared to those without these conditions. Mortality in women delivered by unskilled birth attendants was three times higher than with skilled attendants.

CONCLUSION

The study, among a few large-scale prospective cohort studies conducted at the community level in a rural district of Pakistan, provides a better understanding of the risk factors determining maternal mortality in Pakistan. Poverty emerged as a significant risk factor for maternal mortality in the study area and contributes to the underutilization of health facilities and skilled birth attendants. Incorporating poverty reduction strategies across all sectors, including health, is urgently required to address higher maternal mortality in Pakistan. A paradigm shift is required in Maternal and Child health related programs and interventions to include poverty estimation and measuring mortality through linking mortality surveillance with the Civil Registration and Vital Statistics system. Accelerated efforts to expand the coverage and completeness of mortality data with risk factors to address inequalities in access and utilization of health services.

Availability of priority maternal and newborn health indicators: Cross-sectional analysis of pregnancy, childbirth and postnatal care registers from 21 countries

Data from national health information systems are essential for routinely tracking progress, programmatic decision-making and to improve quality of services. Understanding the data elements captured in patient registers which are building blocks of national HMIS indicators, enables us to standardize data collection and measurement of key indicators for tracking progress towards achieving maternal and newborn health goals. This analysis was done through a review of antenatal care (ANC), childbirth and postnatal care (PNC) registers from 21 countries across five geographic regions. Between July and October 2020, country-based maternal and newborn experts, implementing agencies, program managers, and ministry of health personnel were asked to share the registers in use. Both paper-based and electronic registers were obtained. Twenty ANC registers, eighteen childbirth and thirteen PNC were available and analyzed. Both longitudinal and cross-sectional ANC and PNC registers were obtained, while the childbirth registers included in the analysis were all cross-sectional. Fifty-five percent (11/20) ANC registers and 54% (7/13) PNC registers were longitudinal. In four countries, the registers were electronic, while the rest were paper-based (17 countries). Sub-analysis of registers from four countries (Ghana, Kenya, Nigeria, and Zambia) where the 2017/2018 and 2019/2020 registers were available showed that the latest versions included 21/27 (78%) of data elements that are critical in the computation of key maternal and newborn care indicators. This analysis highlights some areas in where there are data gaps in data on pregnancy and childbirth. Program managers and health workers should use data gathered routinely to monitor the performance of their national health system and to guide the continuous improvement of health care services for women and newborns. The findings can help to inform the standardization of pregnancy and childbirth registers, and provide information for other countries seeking to introduce indicators in their health systems.

Maternal, infant, and perinatal mortality statistics and trends in Korea between 2018 and 2020

PURPOSE

This study aimed to identify maternal, infant, and perinatal mortality using the nationalpopulation data of South Korea between 2018 and 2020, and to analyze mortality rates according tocharacteristics such as age, date of death, and cause of death in each group. This study updates themost recent study using 2009 to 2017 data.

METHODS

Analyses of maternal, infant, and perinatal mortality were done with data identifiedthrough the supplementary investigation system for cases of death from the Census of PopulationDynamics data provided by Statistics Korea from 2018 to 2020.

RESULTS

Between 2018 and 2020, a total of 99 maternal deaths, 2,427 infant deaths, and 2,408 perinatal deaths were identified from 901,835 live births. The maternal mortality ratio was 11.3 deathsper 100,000 live births in 2018; it decreased to 9.9 in 2019 but increased again to 11.8 in 2020. Thematernal mortality ratio increased steeply in women over the age of 40 years. An increasing trend inthe maternal mortality ratio was found for complications related to the puerperium and hypertensive disorders. Both infant and perinatal mortality continued to decrease, from 2.8 deaths per 1,000live births in 2018 to 2.5 in 2020 and from 2.8 in 2018 to 2.5 in 2020, respectively.

CONCLUSION

Overall, the maternal, infant, and perinatal mortality statistics showed improvements.However, more attention should be paid to women over 40 years of age and specific causes of maternal deaths, which should be taken into account in Korea's maternal and child health policies.

Estimating stillbirth and neonatal mortality rate among Rohingya refugees in Bangladesh, September 2017 to December 2018: a prospective surveillance

INTRODUCTION

There is limited literature on neonatal mortality in humanitarian emergencies. We estimated neonatal mortality and stillbirth rates; determined whether an association exists between proximity to a secondary health facility and neonatal mortality or stillbirth; and tested the correlation between the number of health facilities in a camp and neonatal mortality or stillbirth rates in Rohingya refugee camps in Bangladesh.

METHODS

We conducted a prospective community-based mortality surveillance in 29 out of 34 Rohingya refugee camps between September 2017 and December 2018, covering approximately 811 543 Rohingya refugees with 19 477 estimated live births. We linked mortality surveillance data with publicly available information on camp population, number of functional health facilities and camp and health facility geospatial coordinates. Using descriptive statistics and spatial analyses, we estimated the mortality rate and tested for correlations.

RESULTS

Overall, the estimated neonatal mortality rate was 27.0 (95% CI: 22.3 to 31.8) per 1000 live births, and the stillbirth rate was 15.2 (95% CI: 10.8 to 19.6) per 1000 total births. The majority of neonatal deaths (76.3%, n=405/531) and stillbirths (72.1%, n=202/280) occurred at home or in the community. A positive correlation existed between the camp population size and number of health facilities inside the camp (Spearman's rho=0.56, p value<0.01). No statistically significant correlation existed between the camp neonatal mortality rate or stillbirth rate and number of health facilities inside the camp. Camps that were located closer to a secondary health facility as compared with a labour room/sexual and reproductive health unit had a lower neonatal mortality rate (p value<0.01).

CONCLUSIONS

The results provide insight into the neonatal mortality and stillbirth rates in Rohingya refugees camps in Bangladesh during 2017-2018. Prospective community-based mortality surveillance may be a feasible method to evaluate the effectiveness of humanitarian responses in improving neonatal survival and preventing stillbirths.

An audit of foeticide, neonaticide and infanticide: A retrospective study in the Department of Forensic Medicine, King Edward Medical University, Lahore

The deliberate killing of a foetus in the womb, or a child from the first 24 h of birth to one month of age, or within the first year of life, is called foeticide, neonaticide and infanticide, respectively. Socioeconomic stress, mental illness, gender selection, shame or fear of punishment of adultery or illegitimacy, grudge and jealousy with parents and negligent delivery by dai are major causative factors in such cases. This is a retrospective, descriptive, observational study, and the sample pool consisted of 35 cases. Foeticide cases were 42.9% of the total and the same percentage of cases were neonaticides, while 14.3% of cases were of infanticide. The male-to-female ratio was 1.26:1 and the major cause of death was head injury. The study shows a prevalence of foeticide and neonaticide as compared to infanticide. It also displays the prevalence of males in overall cases and a higher number of unknown cases in our setting.

Vaginal discharge during pregnancy and associated adverse maternal and perinatal outcomes

Objectives:

To observe the effects of vaginal discharge during pregnancy on maternal and fetal outcomes.

Methods:

This observational study was undertaken form June 2018 to 31 May 2019 period in the Department of Obstetrics and Gynaecology at Liaquat University of Medical and Health Sciences hospital Jamshoro Unit IV. Data were collected from a convenience sample of 85 pregnant women. All the pregnant women with vaginal discharge were included in the study, while the women with bleeding and other medical disorders during pregnancy were excluded. Data was analyzed.

Results:

Women’s mean age as 27.4 (±4.7) years and most were 28-35 weeks pregnant (n=29, 34%) and primigravida (n=35, 41%). Seventy six women (89%) presented with vaginal discharge while nine women (11%) reported no vaginal discharge. Of those with vaginal discharge,53 women (69.7%) had vaginal infections: bacterial vaginosis (n=21, 39.6%), vaginal candidiasis (n=17, 32.1%) and vaginal trichomoniasis (n=15, 28.3%). Pathological vaginal discharge (PVD) was associated with vaginal irritation (n=30, p<0.0001), vaginal pain (n=50, p<0.0001), fever (n=12, p=0.015), uterine contractions (n=31, p<0.0001), premature membrane rupture (n=29, p<0.0001), abortion (n=13, p=0.009), pre-term delivery (n=24, p<0.0001) and post-partum endometritis (n=19, p=0.0006). PVD was associated with neonatal outcomes i.e. low birth weight (n=24, p<0.0001), low Apgar score at birth (n=22, p=0.0001), neonatal respiratory distress syndrome (n=21, p=0.0002), neonatal intensive care hospitalisation (n=20, p=0.002) and early neonatal death (n=16, p=0.003).

Conclusion:

Pathological vaginal discharge (PVD) during pregnancy is more frequent and is associated with adverse maternal and perinatal outcomes.

Hepatitis E virus genotyping in Pakistan: a regional study to explore the implications for pregnant females

Aim: Hepatitis E virus (HEV) has different genotypes 1–4, which is generally associated with mild to severe complications among immunocompromised patients and pregnant women. Materials & methods: Immunoglobulin M (IgM) HEV-positive samples were collected from the diagnostic center. HEV infection was further confirmed by RT-based PCR and genotyping was done to affirm the prevailing genotype. Results: This study identified 28 patients from Islamabad who were confirmed to have immunoglobulins type M against HEV showing acute infection, of which 17 were pregnant and 11 were non-pregnant women. All pregnant women were in their third trimester of pregnancy. Conclusion: Genotype-1 is commonly associated with pregnant females presenting with HEV infections in Islamabad. There is a need to further identify both the sources & route of infections.

An analysis of the impact of newborn survival policies in Pakistan using a policy triangle framework

Introduction

Pakistan has made slow progress towards reducing the newborn mortality burden; as a result, it has the highest burden of newborn mortality worldwide. This article presents an analysis of the current policies, plans, and strategies aimed at reducing the burden of newborn death in Pakistan for the purpose of identifying current policy gaps and contextual barriers towards proposing policy solutions for improved newborn health.

Methods

We begin with a content analysis of federal-level policies that address newborn mortality within the context of health system decentralization over the last 20 years. This is then followed by a case study analysis of policy and programme responses in a predominantly rural province of Pakistan, again within the context of broader health system decentralization. Finally, we review successful policies in comparable countries to identify feasible and effective policy choices that hold promise for implementation in Pakistan, considering the policy constraints we have identified.

Results

The major health policies aimed at reduction of newborn mortality, following Pakistan’s endorsement of global newborn survival goals and targets, lacked time-bound targets. We found confusion around roles and responsibilities of institutions in the implementation process and accountability for the outcomes, which was exacerbated by an incomplete decentralization of healthcare policy-making and health service delivery, particularly for women around birth, and newborns. Such wide gaps in the areas of target-setting, implementation mechanism, and evaluation could be because the policy-making largely ignored international commitments and lessons of successful policy-making in comparable regional counties.

Conclusions

Inclusion of clear goals and targets in newborn survival policies and plans, completion of the decentralization process of maternal and child healthcare service delivery, and policy-making and implementation by translating complex evidence and using regional but locally applicable case studies will be essential to any effective policy-making on newborn survival in Pakistan.

What is meant by validity in maternal and newborn health measurement? A conceptual framework for understanding indicator validation

BACKGROUND

Rigorous monitoring supports progress in achieving maternal and newborn mortality and morbidity reductions. Recent work to strengthen measurement for maternal and newborn health highlights the existence of a large number of indicators being used for this purpose. The definitions and data sources used to produce indicator estimates vary and challenges exist with completeness, accuracy, transparency, and timeliness of data. The objective of this study is to create a conceptual overview of how indicator validity is defined and understood by those who develop and use maternal and newborn health indicators.

METHODS

A conceptual framework of validity was developed using mixed methods. We were guided by principles for conceptual frameworks and by a review of the literature and key maternal and newborn health indicator guidance documents. We also conducted qualitative semi-structured interviews with 32 key informants chosen through purposive sampling.

RESULTS

We categorised indicator validity into three main types: criterion, convergent, and construct. Criterion or diagnostic validity, comparing a measure with a gold standard, has predominantly been used to assess indicators of care coverage and content. Studies assessing convergent validity quantify the extent to which two or more indicator measurement approaches, none of which is a gold-standard, relate. Key informants considered construct validity, or the accuracy of the operationalisation of a concept or phenomenon, a critical part of the overall assessment of indicator validity.

CONCLUSION

Given concerns about the large number of maternal and newborn health indicators currently in use, a more consistent understanding of validity can help guide prioritization of key indicators and inform development of new indicators. All three types of validity are relevant for evaluating the performance of maternal and newborn health indicators. We highlight the need to establish a common language and understanding of indicator validity among the various global and local stakeholders working within maternal and newborn health.

Maternal and perinatal death surveillance and response in Ethiopia: Achievements, challenges and prospects

Background

Maternal and Perinatal Death Surveillance and Response (MPDSR) was a pilot program introduced in Tigray, Ethiopia to monitor maternal and perinatal death. However; its implementation and operation is not evaluated yet. Therefore, this study aimed to assess the implementation and operational status and determinants of MPDSR using a programmatic data and stakeholders involved in the program.

Methods

Institutional based cross-sectional study was applied in public health facilities (75 health posts, 50 health centers and 16 hospitals) using both qualitative and quantitative methods. Data were entered in to Epi-info and then transferred to SPSS version 21 for analysis. All variables with a p-value of ≤ 0.25 in the bivariate analysis were included in to multivariable logistic regression model to identify the independent predictors. For the qualitative part, manual thematic content analysis was done following data familiarization (reading and re-reading of the transcripts).

Results

In this study, only 34 (45.3%) of health posts were practicing early identification and notification of maternal/perinatal death. Furthermore, only 36 (54.5%) and 35(53%) of health facilities were practiced good quality of death review and took proper action respectively following maternal/perinatal deaths. Availability of three to four number of Health Extension Workers (HEWs) (Adjusted Odds Ratio (AOR) = 6.09, 95%CI (Confidence Interval): 1.51–24.49), availability of timely Public Health Emergency Management (PHEM) reports (AOR = 4.39, 95%CI: 1.08–17.80) and participation of steering committee’s in death response (AOR = 9.19, 95%CI: 1.31–64.34) were the predictors of early identification and notification of maternal and perinatal death among health posts. Availability of trained nurse (AOR = 3.75, 95%CI: 1.08–12.99) and health facility’s head work experience (AOR = 3.70, 95%CI: 1.04–13.22) were also the predictors of quality of death review among health facilities. Furthermore; availability of at least one cluster review meeting (AOR = 4.87, 95%CI: 1.30–18.26) and uninterrupted pregnant mothers registration (AOR = 6.85, 95%CI: 1.22–38.54) were associated with proper response implementation to maternal and perinatal death. Qualitative findings highlighted that perinatal death report was so neglected. Community participation and intersectoral collaboration were among the facilitators for MPDSR implementation while limited human work force capacity and lack of maternity waiting homes were identified as some of the challenges for proper response implementation.

Conclusion

This study showed that the magnitude of: early death identification and notification, review and response implementation were low. Strengthening active surveillance with active community participation alongside with strengthening capacity building and recruitment of additional HEWs with special focus to improve the quality of health service could enhance the implementation of MPDSR in the region.

Health care professionals' knowledge and awareness of the ICD-10 coding system for assigning the cause of perinatal deaths in Jordanian hospitals

Objectives

There is a lack of studying vital registration and disease classification systems in low- and middle-income countries. This study aimed to assess health care professionals’ (HCPs’) level of awareness, knowledge, use, and perceived barriers of the International Classification of Diseases, 10th version (ICD-10) as well as their perceptions of the electronic neonatal death registration system.

Participants and methods

A mixed method approach including descriptive cross-sectional quantitative and focus groups with HCPs (physicians, nurses, and midwives) was used to collect data from four major selected hospitals in Jordan. A total of 16 focus groups were conducted. Also, a survey, which included three case studies about the ability of nurses and physicians to identify cause of death, was completed using structured face-to-face interviews.

Results

Overall, there was congruency between both the quantitative results and the qualitative findings. The majority of nurses and physicians in the four hospitals were not familiar with the ICD-10 coding system and hence reported minimal use of the coding system. Additionally, the majority of HCPs were not aware whether or not their departments used the ICD-10 to record perinatal mortality. These HCPs identified that lack of knowledge, time, staff and support, and an effective and comprehensive electronic system that allows physicians to accurately choose the exact cause of death were their main barriers to the use of the ICD-10 coding system.

Conclusion

Our findings emphasize the importance of developing an effective and comprehensive electronic system which allows HCPs to accurately report and register all perinatal deaths. This system needs to account for the direct and indirect causes of death and for contributing factors such as maternal conditions at the time of perinatal death. Training HCPs on how to use the system is vital for the success and accuracy of the data registration process.

Completeness of a Maternal and Perinatal Mortality Enhanced Surveillance System in Pakistan: Evidence from Capture-Recapture Methods

Objectives An enhanced surveillance system that integrated health information systems and extended surveillance to previously uncovered areas to capture all births, perinatal and maternal deaths in a rural district of Pakistan was established in 2015, and this study uses capture-recapture methodology to assess completeness. Methods Births and deaths collected by the survey were matched with the data captured by the enhanced surveillance system. Capture-recapture methodology was used to estimate the total number of births and deaths, measure the degree of underestimation, and adjust mortality rates. Results Of all births, 99% were captured by the enhanced surveillance system. Ninety percent of neonatal deaths and 86% of early neonatal deaths were recorded. The recorded neonatal mortality rate was 40 per 1000 live births (95% CI 35-44), and after adjustment for under-enumeration was 42 per 1000 live births (95% CI 37-46). Recorded rates underestimated neonatal mortality by 5% and perinatal mortality by 7%. Five stillbirths were recorded by the survey and all were matched to recorded stillbirths. The one maternal death recorded by the survey was matched with the maternal death captured by the enhanced surveillance system. The maternal mortality ratio prior to adjustment for under-enumeration was 247 per 100,000 live births (95% CI 147-391), whereas after adjustment it was 246 per 100,000 live births (95% CI 146-389). Conclusion Application of capture-recapture methods to the enhanced surveillance system indicated a high completeness of birth and death recording by the surveillance system.