A meta-analysis of socio-demographic factors for perinatal mortality in developing countries: a subgroup analysis of the national surveys and small scale studies

Risk Factors for Neonatal Mortality in Rural Iganga District, Eastern Uganda: A Case Control Study

Background

Reducing Neonatal Mortality (NM) is vital in decreasing mortality in children below 5 years. Uganda has reported a significant reduction in under 5 and infant mortality over the past decade while NM has stagnated at 27 deaths per 1,000 live births. The NMR of 34 deaths per 1,000 live births in Eastern Uganda is higher than the national rate.

Objective

To determine risk factors for neonatal mortality in rural Iganga district, Eastern Uganda.

Methods

A matched case-control study was conducted between February and July 2019 in Nakigo and Nakalama sub-counties of Iganga district. Cases (n=91) were neonates that died and the controls (n=182) were live neonates at 1 month. Data on maternal, social demographic and neonatal variables were collected from mothers of neonates at household level. Descriptive analysis was performed to determine the profile of study participants. Data was presented as mean (and standard deviation) for continuous variables, and frequencies with percentages for categorical variables. A conditional logistic regression was performed to calculate Odds Ratios and to establish factors that were independently associated with risk of neonatal Mortality.

Results

Giving birth to 5 or more children (AOR=2.88, 95% CI =1.25-6.63), attending less than 4 antenatal care visits (AOR= 2.27, 95% CI= 1.14-5.54), and giving birth to twins (AOR= 6.30, 95% CI=1.24-32.0) were the risk factors for neonatal mortality while delivering from health facilities was protective (AOR= 0.26, 95% CI= 0.12-0.56).

Conclusion

The risk factors for NM are: - giving birth to 5 or more children, attendance of less than 4 antenatal care visits and giving birth to twins. To reduce the risk of NM, the study re-emphasises the need to put more focus on neonatal care during pregnancy and child birth. The study findings can be utilised to determine priorities for reducing the risk of NM in rural settings.

Induced abortions among Chinese adolescent girls

BACKGROUND

Induced abortion among adolescent girls is a global public health issue and a serious challenge in China, but still remains under-examined. We aimed to examine the overall trend and characteristics of induced abortions among Chinese adolescent girls and to investigate the factors associated with induced abortion.

STUDY DESIGN

Based on the 2017 China Fertility Survey, this study examined the trend and characteristics of induced abortions among adolescent girls with statistical analysis and multiple indicators of descriptive statistics from period and cohort perspectives, including induced abortion proportion and rate, age-specific cumulative proportion, and age-specific cumulative number of induced abortions in adolescent girls.

RESULTS

Between 1996 and 2016, the proportion and rate of adolescent induced abortions first increased and then decreased, and the mean age at the time of induced abortions among adolescent girls declined. The cumulative proportion of women who had experienced induced abortion at the age of 15-19 in a cohort is less than 2.5% but shows an upward trend. Over 70% of all adolescent induced abortions are premarital. The proportion of women with unintended pregnancy experiences increased and is higher among rural, less educated, and ethnic minority women. Similarly, the prevalence of induced abortion is higher among adolescent girls who live in rural areas, are less educated, and come from ethnic minorities. The cumulative number of induced abortions and premarital abortions increased with later cohorts.

CONCLUSIONS

This study shows an upward trend in adolescent-induced abortion and a decline in the age at the time of the induced abortion. Women in later birth cohort have a higher proportion of having experienced adolescent induced abortion. Adolescent girls who live in rural areas, who are less educated, or who are from ethnic minorities, are more likely to undergo induced abortions at the age of 15-19. More appropriate educational efforts and interventions are urgently needed to reduce the incidence of adolescent induced abortions.

Prediction of successful aging using ensemble machine learning algorithms

BACKGROUND

Aging is a chief risk factor for most chronic illnesses and infirmities. The growth in the aged population increases medical costs, thus imposing a heavy financial burden on families and communities. Successful aging (SA) is a positive and qualitative view of aging. From a biomedical perspective, SA is defined as the absence of diseases or disability disorders. This is distinct from normal aging, which is associated with age-related deterioration in physical and cognitive functions. From a social perspective, SA highlights life satisfaction and individual well-being, usually attained through socialization. It is an abstract and multidimensional concept surrounded by imprecision about its definition and measurement. Our study attempted to find the most effective features of SA as defined by Rowe and Kahn's theory. The determined features were used as input parameters of six machine learning (ML) algorithms to create and validate predictive models for SA.

METHODS

In this retrospective study, the raw data set was first pre-processed; then, based on the data of a sample of 983, five basic ML techniques including artificial neural network, decision tree, support vector machine, Naïve Bayes, and k-nearest neighbors (K-NN) with one ensemble method (that gathers 30 K-NN algorithms as weak learners) were trained. Finally, the prediction result was yielded using the majority vote method based on the output of the generated base models.

RESULTS

The experimental results revealed that the predictive system has been more successful in predicting SA with a 93% precision, 92.40% specificity, 87.80% sensitivity, 90.31% F-measure, 89.62% accuracy, and a ROC of 96.10%, using a five-fold cross-validation procedure.

CONCLUSIONS

Our results showed that ML techniques potentially have satisfactory performance in supporting the SA-related decisions of social and health policymakers. The KNN-based ensemble algorithm is superior to the other ML models in classifying people into SA and non-SA classes.

Prediction of stillbirth: an umbrella review of evaluation of prognostic variables

BACKGROUND

Stillbirth accounts for over 2 million deaths a year worldwide and rates remains stubbornly high. Multivariable prediction models may be key to individualised monitoring, intervention or early birth in pregnancy to prevent stillbirth.

OBJECTIVES

To collate and evaluate systematic reviews of factors associated with stillbirth in order to identify variables relevant to prediction model development.

SEARCH STRATEGY

MEDLINE, Embase, DARE and Cochrane Library databases and reference lists were searched up to November 2019.

SELECTION CRITERIA

We included systematic reviews of association of individual variables with stillbirth without language restriction.

DATA COLLECTION AND ANALYSIS

Abstract screening and data extraction were conducted in duplicate. Methodological quality was assessed using AMSTAR and QUIPS criteria. The evidence supporting association with each variable was graded.

RESULTS

The search identified 1198 citations. Sixty-nine systematic reviews reporting 64 variables were included. The most frequently reported were maternal age (n = 5), body mass index (n = 6) and maternal diabetes (n = 5). Uterine artery Doppler appeared to have the best performance of any single test for stillbirth. The strongest evidence of association was for nulliparity and pre-existing hypertension.

CONCLUSION

We have identified variables relevant to the development of prediction models for stillbirth. Age, parity and prior adverse pregnancy outcomes had a more convincing association than the best performing tests, which were PAPP-A, PlGF and UtAD. The evidence was limited by high heterogeneity and lack of data on intervention bias.

TWEETABLE ABSTRACT

Review shows key predictors for use in developing models predicting stillbirth include age, prior pregnancy outcome and PAPP-A, PLGF and Uterine artery Doppler.

Utilization of maternal healthcare services in women experiencing spousal violence in Pakistan: A comparative analysis of 2012-13 and 2017-18 Pakistan Demographic Health Surveys

BACKGROUND

Pakistan and other developing countries need to address disparities in maternal health care and factors associated with it. This justifies tracking the progress on two important indicators 'spousal violence' and 'maternal health care utilization' to improve maternal health and achieve Sustainable Development Goals (SDGs) for these nations.

OBJECTIVE

The objective of this study is to compare the data from the latest two Demographic Health Surveys of Pakistan to identify trends in prevalence of various forms of spousal violence and maternal healthcare utilization and to determine the predictive role of spousal violence in poor maternal health.

METHODS

We conducted a retrospective analysis of nationally representative data from the 2012-13 and 2017-18 PDHS. The data used in this analysis is from the domestic violence module and core women's questionnaire. Spousal violence and sociodemographic background were predictor variables. Terminated pregnancy, number of pregnancy losses, number of antenatal visits for last birth and institutional delivery for last birth were taken as indicators of maternal health. Logistic regression analysis was conducted to test for association between maternal health indicators and various forms of spousal violence after controlling for sociodemographic variables.

RESULTS

Almost one quarter of women experienced physical and emotional violence as revealed by both surveys. Binary analysis revealed that all forms of spousal violence significantly associate with maternal health variables in both surveys. The comparison of results on logistic regression analysis showed that odd ratios were relatively higher for 2012-13 as compared to 2017-18 PDHS. Logistic regression analysis from 2017-18 data showed that experience of less severe physical violence (OR = 1.26; 95% CI, 1.08-1.47), severe physical violence (OR = 1.41; 95% CI, 1.09-1.83), sexual violence (OR = 1.39; 95% CI, 1.02-1.89), physical violence during pregnancy (OR = 1.37; 95% CI, 1.07-1.76) augment the risk of terminated pregnancy. Emotional violence decreases the likelihood for institutional delivery (OR = 0.64; 95% CI, 0.45-0.93) and above than four antenatal visits (OR = 0.54; 95% CI, 0.37-0.79).

CONCLUSIONS

Strategies to prevent spousal violence should be at the core of maternal health programs because health sector provides a platform to challenge social norms and promote attitudes that disapprove spousal violence which are essential for promoting gender equality, women empowerment (SDG 3) and improve maternal health (SDG 5).

Maternal, prenatal and traditional practice factors associated with perinatal mortality in Yemen

BACKGROUND

Perinatal mortality remains a major international problem responsible for nearly six million stillbirths and neonatal deaths.

OBJECTIVES

To estimate the perinatal mortality rate in Sana'a, Yemen and to identify risk factors for perinatal deaths.

METHODS

A community-based prospective cohort study was carried out between 2015 and 2016. Nine-hundred and eighty pregnant women were identified and followed up to 7 days following birth. A multi-stage cluster sampling was used to select participants from community households', residing in the five districts of the Sana'a City, Yemen.

RESULTS

Total of 952 pregnant women were tracked up to 7 days after giving birth. The perinatal mortality rate, the stillbirth rate and the early neonatal mortality rate, were 89.3 per 1000, 46.2 per 1000 and 45.2 per 1000, respectively. In multivariable analysis older age (35+ years) of mothers at birth (Relative Risk=2.83), teenage mothers' age at first pregnancy (<18 years) (Relative Risk=1.57), primipara mothers (Relative Risk=1.90), multi-nuclear family (Relative Risk=1.74), mud house (Relative Risk=2.02), mothers who underwent female genital mutilation (Relative Risk=2.92) and mothers who chewed khat (Relative Risk=1.60) were factors associated with increased risk of perinatal death, whereas a positive mother's tetanus vaccination status (Relative Risk=0.49) were significant protective factors against perinatal deaths.

CONCLUSION

Rates of perinatal mortality were higher in Sana'a City compared to perinatal mortality at the national level estimated by World Health Organization. It is imperative there be sustainable interventions in order to improve the country's maternal and newborn health.

Pregnancy-related morbidity and risk factors for fatal foetal outcomes in the Taabo health and demographic surveillance system, Côte d'Ivoire

Background

Reliable, population-based data on pregnancy-related morbidity and mortality, and risk factors for fatal foetal outcomes are scarce for low- and middle-income countries. Yet, such data are essential for understanding and improving maternal and neonatal health and wellbeing.

Methods

Within the 4-monthly surveillance rounds of the Taabo health and demographic surveillance system (HDSS) in south-central Côte d’Ivoire, all women of reproductive age identified to be pregnant between 2011 and 2014 were followed-up. A questionnaire pertaining to antenatal care, pregnancy-related morbidities, delivery circumstances, and birth outcome was administered to eligible women. Along with sociodemographic information retrieved from the Taabo HDSS repository, these data were subjected to penalized maximum likelihood logistic regression analysis, to determine risk factors for fatal foetal outcomes.

Results

A total of 2976 pregnancies were monitored of which 118 (4.0%) resulted in a fatal outcome. Risk factors identified by multivariable logistic regression analysis included sociodemographic factors of the expectant mother, such as residency in a rural area (adjusted odds ratio (aOR) = 2.87; 95% confidence interval (CI) 1.31–6.29) and poorest wealth tertile (aOR = 1.79; 95% CI 1.02–3.14), a history of miscarriage (aOR = 23.19; 95% CI 14.71–36.55), non-receipt of preventive treatment such as iron/folic acid supplementation (aOR = 3.15; 95% CI 1.71–5.80), only two doses of tetanus vaccination (aOR = 2.59; 95% CI 1.56–4.30), malaria during pregnancy (aOR = 1.94; 95% CI 1.21–3.11), preterm birth (aOR = 4.45; 95% CI 2.82–7.01), and delivery by caesarean section (aOR = 13.03; 95% CI 4.24–40.08) or by instrumental delivery (aOR = 5.05; 95% CI 1.50–16.96). Women who paid for delivery were at a significantly lower odds of a fatal foetal outcome (aOR = 0.39; 95% CI 0.25–0.74).

Conclusions

We identified risk factors for fatal foetal outcomes in a mainly rural HDSS site of Côte d’Ivoire. Our findings call for public health action to improve access to, and use of, quality services of ante- and perinatal care.

Survival of low birthweight neonates in Uganda: analysis of progress between 1995 and 2011

Background

Although low birthweight (LBW) babies represent only 15.5% of global births, it is the leading underlying cause of deaths among newborns in countries where neonatal mortality rates are high. In Uganda, like many other sub-Saharan African countries, the progress of reducing neonatal mortality has been slow and the contribution of low birthweight to neonatal deaths over time is unclear. The aim of this study is to investigate the association between low birthweight and neonatal mortality and to determine the trends of neonatal deaths attributable to low birthweight in Uganda between 1995 and 2011.

Methods

Cross-sectional survey datasets from Uganda Demographic and Health Surveys between 1995 and 2011 were analyzed using binary logistic regression with 95% confidence interval (CI) and Kaplan-Meier survival analysis to examine associations and trends of neonatal mortalities with respect to LBW. A total of 5973 singleton last-born live births with measured birthweights were included in the study.

Results

The odds of mortality among low birthweight neonates relative to normal birthweight babies were; in 1995, 6.2 (95% CI 2.3 −17.0), in 2000–2001, 5.3 (95% CI 1.7 −16.1), in 2006, 4.3 (95% CI 1.3 − 14.2) and in 2011, 3.8 (95% CI 1.3 − 11.2). The proportion of neonatal deaths attributable to LBW in the entire population declined by more than half, from 33.6% in 1995 to 15.3% in 2011. Neonatal mortality among LBW newborns also declined from 83.8% to 73.7% during the same period.

Conclusion

Low birthweight contributes to a substantial proportion of neonatal deaths in Uganda. Although significant progress has been made to reduce newborn deaths, about three-quarters of all LBW neonates died in the neonatal period by 2011. This implies that the health system has been inadequate in its efforts to save LBW babies. A holistic strategy of community level interventions such as improved nutrition for pregnant mothers, prevention of teenage pregnancies, use of mosquito nets during pregnancy, antenatal care for all, adequate skilled care during birth to prevent birth asphyxia among LBW babies, and enhanced quality of postnatal care among others could effectively reduce the mortality numbers.

Determinants of early neonatal mortality in Afghanistan: an analysis of the Demographic and Health Survey 2015

Background

Neonatal mortality is declining slowly compared to under-five mortality in many developing countries including Afghanistan. About three-fourths of these deaths occur in the early neonatal period (i.e., the first week of life). Although a number of studies investigated determinants of early neonatal mortality in other countries, there is a lack of evidence regarding this in Afghanistan. This study investigated determinants of early neonatal mortality in Afghanistan.

Methods

Data from the Afghanistan Demographic and Health Survey 2015 (AfDHS 2015) were analyzed. After reporting the weighted frequency distributions of selected factors, a multilevel logistic regression model revealed adjusted associations of factors with early neonatal mortality.

Results

A total of 19,801 weighted live-births were included in our analysis; 266 (1.4%) of the newborns died in this period. Multivariable analysis found that multiple gestations (adjusted odds ratio (AOR): 9.3; 95% confidence interval (CI): 5.7–15.0), larger (AOR: 2.9; 95% CI: 2.2–3.8) and smaller (AOR: 1.8; 95% CI: 1.2–2.6) than average birth size, maternal age ≤ 18 years (AOR: 1.8; 95% CI: 1.1–3.2) and ≥ 35 years (AOR: 1.7; 95% CI: 1.3–2.3), and birth interval of < 2 years (AOR: 2.6; 95% CI: 1.4–4.9) had higher odds of early neonatal mortality. On the other hand, antenatal care by a skilled provider (AOR: 0.7; 95% CI: 0.5–0.9), facility delivery (AOR: 0.7; 955 CI: 0.5–0.9), paternal higher education level (AOR: 0.7; 95% CI: 0.5–1.0), living in north-western (AOR: 0.3; 95% CI: 0.1–0.6), central-western regions (AOR: 0.5; 95% CI: 0.3–0.9) and in a community with higher maternal education level (AOR: 0.4; 95% CI: 0.2–0.9) had negative association.

Conclusions

Several individual, maternal and community level factors influence early neonatal deaths in Afghanistan; significance of the elements of multiple levels indicates that neonatal survival programs should follow a multifaceted approach to incorporate these associated factors. Programs should focus on birth interval prolongation with the promotion of family planning services, utilization of antenatal care and institutional delivery services along with management of preterm and sick infants to prevent this large number of deaths in this period.

Skilled delivery service utilization and its association with the establishment of Women's Health Development Army in Yeky district, South West Ethiopia: a multilevel analysis

Background

Because of the unacceptably high maternal and perinatal morbidity and mortality, the government of Ethiopia has established health extension program with a community-based network involving health extension workers (HEWs) and a community level women organization which is known as “Women’s Health Development Army” (WHDA). Currently, the HEWs and WHDA network is the approach preferred by the government to register pregnant women and encourage them to link in the healthcare system. However, its association with skilled delivery service utilization is not well known.

Methods

A community-based cross-sectional study was conducted from January to February 2015. Within 380 clusters of WHDA, a total of 748 reproductive-age women who gave birth in 1 year preceding the study, were included using multistage sampling technique. The data were entered into EPI info version 7 statistical software and exported to STATA version 11 for analysis. Multilevel analysis technique was applied to check for an association of selected variables with a utilization of skilled delivery service.

Results

About 45% of women have received skilled delivery care. A significant heterogeneity was observed between “Women’s Health Development Teams (clusters)” for skilled delivery care service utilization which explains about 62% of the total variation. Individual-level predictors including urban residence [AOR (95% CI) 35.10 (4.62, 266.52)], previous exposure of complications [AOR (95% CI) 3.81 (1.60, 9.08)], at least four ANC visits [AOR (95% CI) 7.44 (1.48, 37.42)] and preference of skilled personnel [AOR (95% CI) 8.11 (2.61, 25.15)] were significantly associated with skilled delivery service use. Among cluster level variables, the distance of clusters within 2 km radius from the nearest health facility was significantly associated [AOR (95% CI) 6.03 (1.92, 18.93)] with skilled delivery service utilization.

Conclusions

In this study, significant variation among clusters of WHDA was observed. Both individual and cluster level variables were identified to predict skilled delivery service utilization. Encouraging women to have frequent ANC visits (− 4 and above), enhancing awareness creation towards the delivery care attendance, constructing more health facilities and roads in hard to reach areas and establishing telemedicine services are recommended.

A meta-analysis of selected maternal and fetal factors for perinatal mortality

BACKGROUND

In several developing countries, achieving Millennium Development Goal 4 is still off track. Multiple maternal and fetal risk factors were inconsistently attributed to the high perinatal mortality in developing countries. However, there was no meta-analysis that assessed the pooled effect of these factors on perinatal mortality. The purpose of this meta-analysis was to identify maternal and fetal factors predicting perinatal mortality.

METHODS

In this meta-analysis, we included 23 studies that assessed perinatal mortality in relation to antenatal care, parity, mode of delivery, gestational age, birth weight and sex of the fetus. A computer based search of articles was conducted mainly in the databases of PUBMED, MEDLINE, HINARI, AJOL, Google Scholar and Cochrane Library. The overall odds ratios (OR) were determined by the random-effect model. Heterogeneity testing and sensitivity analysis were also conducted.

RESULTS

The pooled analysis showed a strong association of perinatal mortality with lack of antenatal care (OR=3.2), prematurity (OR=7.9), low birth weight (OR=9.6), and marginal association with primigravidity (OR=1.5) and male sex (OR=1.2). The regression analysis also showed down-going trend lines of stillbirth and neonatal mortality rates in relation to the proportion of antenatal care. The metaanalysis showed that there was no association between mode of delivery and perinatal mortality.

CONCLUSION

The present meta-analysis indicated a significant reduction in perinatal mortality among women who attended antenatal care, gave birth to term and normal birth weight baby. However, the association of perinatal mortality with parity, mode of delivery and fetal sex needs further investigation.

Reasons for persistently high maternal and perinatal mortalities in Ethiopia: Part II-Socio-economic and cultural factors

BACKGROUND

The major causes of maternal and perinatal deaths are mostly pregnancy related. However, there are several predisposing factors for the increased risk of pregnancy related complications and deaths in developing countries. The objective of this review was to grossly estimate the effect of selected socioeconomic and cultural factors on maternal mortality, stillbirths and neonatal mortality in Ethiopia.

METHODS

A comprehensive literature review was conducted focusing on the effect of total fertility rate (TFR), modern contraceptive use, harmful traditional practice, adult literacy rate and level of income on maternal and perinatal mortalities. For the majority of the data, regression analysis and Pearson correlation coefficient were used as a proxy indicator for the association of variables with maternal, fetal and neonatal mortality.

RESULTS

Although there were variations in the methods for estimation, the TFR of women in Ethiopia declined from 5.9 to 4.8 in the last fifteen years, which was in the middle as compared with that of other African countries. The preference of injectable contraceptive method has increased by 7-fold, but the unmet contraceptive need was among the highest in Africa. About 50% reduction in female genital cutting (FGC) was reported although some women's attitude was positive towards the practice of FGC. The regression analysis demonstrated increased risk of stillbirths, neonatal and maternal mortality with increased TFR. The increased adult literacy rate was associated with increased antenatal care and skilled person attended delivery. Low adult literacy was also found to have a negative association with stillbirths and neonatal and maternal mortality. A similar trend was also observed with income.

CONCLUSION

Maternal mortality ratio, stillbirth rate and neonatal mortality rate had inverse relations with income and adult education. In Ethiopia, the high total fertility rate, low utilization of contraceptive methods, low adult literacy rate, low income and prevalent harmful traditional practices have probably contributed to the high maternal mortality ratio, stillbirth and neonatal mortality rates.