A comparison of approaches to measuring maternal mortality in Bangladesh, Mozambique, and Bolivia

Background Many low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality. Objective The objective is to inform on potential options for measuring maternal mortality. Methods This paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia—national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS). Results For Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS’ MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998–2003. Conclusions Overall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches. Contribution Recommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system.

Seroprevalence of SARS-CoV-2 antibodies and retrospective mortality in a refugee camp, Dagahaley, Kenya

Background Camps of forcibly displaced populations are considered to be at risk of large COVID-19 outbreaks. Low screening rates and limited surveillance led us to conduct a study in Dagahaley camp, located in the Dadaab refugee complex in Kenya to estimate SARS-COV-2 seroprevalence and, mortality and to identify changes in access to care during the pandemic. Methods To estimate seroprevalence, a cross-sectional survey was conducted among a sample of individuals (n = 587) seeking care at the two main health centres and among all household members (n = 619) of community health workers and traditional birth attendants working in the camp. A rapid immunologic assay was used (BIOSYNEX® COVID‐19 BSS [IgG/IgM]) and adjusted for test performance and mismatch between the sampled population and that of the general camp population. To estimate mortality, all households (n = 12860) were exhaustively interviewed in the camp about deaths occurring from January 2019 through March 2021. Results In total 1206 participants were included in the seroprevalence study, 8% (95% CI: 6.6%-9.7%) had a positive serologic test. After adjusting for test performance and standardizing on age, a seroprevalence of 5.8% was estimated (95% CI: 1.6%-8.4%). The mortality rate for 10,000 persons per day was 0.05 (95% CI 0.05–0.06) prior to the pandemic and 0.07 (95% CI 0.06–0.08) during the pandemic, representing a significant 42% increase (p<0.001). Médecins Sans Frontières health centre consultations and hospital admissions decreased by 38% and 37% respectively. Conclusion The number of infected people was estimated 67 times higher than the number of reported cases. Participants aged 50 years or more were among the most affected. The mortality survey shows an increase in the mortality rate during the pandemic compared to before the pandemic. A decline in attendance at health facilities was observed and sustained despite the easing of restrictions.

Trends and outcomes in opioid related cardiac arrest in a contemporary US population from 2012–18

Background Opioid abuse is a significant problem and has been associated in patients presenting with cardiac arrest. We aimed to investigate and compare the contemporary trends of cardiac arrest in patients with and without opioid abuse. Methods All hospitalizations for primary diagnosis of Cardiac arrest between 2012 and 2018 identified in the Nationwide Readmissions Database were categorized into those with or without a secondary diagnosis of opioid disease. Cardiac arrest hospitalizations with opioid use using the year of admission, discharge quarter, age, sex, and elixhauser comorbidity index. Primary outcomes were inpatient mortality. Survey techniques were used to do comparative analyses using Stata 16.0. Results Of 1,410,475 cardiac arrest hospitalizations that met inclusion criteria, 43,090 (3.1%) had cardiac arrest with a secondary diagnosis of opioid use. In hospital mortality in cardiac arrest patients with and without opioid use was 56.7% vs 61.2%. Hospitalizations for cardiac arrest with opioid use were associated with higher prevalence of alcohol (16.9% vs. 7.1%; p&lt;0.05), depression (18.8% vs. 9%; p&lt;0.05), and smoking (37.0% vs. 21.8%; p&lt;0.05) as compared with cardiac arrest without opioid use. Hospitalizations for cardiac arrest with opioid use was seen less likely in patients with heart failure (21.2% vs. 40.6%; p&lt;0.05), diabetes mellitus (19.5% vs. 35.4%; p&lt;0.05), hypertension (43.4% vs. 64.9%; p&lt;0.05) and renal failure (14.3% vs. 30.2%; p&lt;0.05). Over the last 7 years, there has been a significant increasing trend in opioid associated cardiac arrest (p for trend &lt;0.05) see figure. Conclusions Opioid remains a significant cause of cardiac arrests in the contemporary US population with an increase in its incidence over last 7 years. Lifestyle choices is most attributing to this increasing trend. Opioid users that presented with cardiac arrest were twice as more likely to have depression. FUNDunding Acknowledgement Type of funding sources: None. Trends of opioid related cardiac arrest

Seroprevalence of SARS-CoV-2 antibodies and retrospective mortality in a refugee camp, Dagahaley, Kenya

Background: Camps of forcibly displaced populations are considered to be at risk of large COVID-19 outbreaks. Low screening rates and limited surveillance led us to conduct a study in Dagahaley camp, located in the Dadaab refugee complex in Kenya to estimate SARS-COV-2 seroprevalence and, mortality and to identify changes in access to care during the pandemic. Methods: To estimate seroprevalence, we conducted a cross-sectional survey among a sample of individuals (n=587) seeking care at the two main health centres and among all household members (n=619) of community health workers and traditional birth attendants working in the camp. We used a rapid immunologic assay (BIOSYNEX COVID-19 BSS [IgG/IgM]) and adjusted for test performance and mismatch between the sampled population and that of the general camp population. To estimate mortality, we exhaustively interviewed all households (n=12860) in the camp about deaths occurring from January 2019 through March 2021. Results: We included 1206 participants in the seroprevalence study. In total, 8% (95% CI: 6.6%-9.7%) had a positive serologic test. After adjusting for test performance and standardizing on age, we estimated a seroprevalence of 5.8% (95% CI: 1.6%-8.4%). The mortality rate for 10,000 persons per day was 0.05 (95% CI 0.05-0.06) prior to the pandemic and 0.07 (95% CI 0.06-0.08) during the pandemic, representing a significant 42% increase (p<0.001). MSF health centre consultations and hospital admissions decreased by 38% and 37% respectively. Conclusion: We estimated that the number of infected people was 67 times higher than the number of reported cases. Participants aged 50 years or more where among the most affected. The mortality survey shows an increase in the mortality rate during the pandemic compared to before the pandemic. A decline in attendance at health facilities was observed and sustained despite the easing of restrictions.

Mortality beyond emergency threshold in a silent crisis– results from a population-based mortality survey in Ouaka prefecture, Central African Republic, 2020

Background The Central African Republic (CAR) suffers a protracted conflict and has the second lowest human development index in the world. Available mortality estimates vary and differ in methodology. We undertook a retrospective mortality study in the Ouaka prefecture to obtain reliable mortality data. Methods We conducted a population-based two-stage cluster survey from 9 March to 9 April, 2020 in Ouaka prefecture. We aimed to include 64 clusters of 12 households for a required sample size of 3636 persons. We assigned clusters to communes proportional to population size and then used systematic random sampling to identify cluster starting points from a dataset of buildings in each commune. In addition to the mortality survey questions, we included an open question on challenges faced by the household. Results We completed 50 clusters with 591 participating households including 4000 household members on the interview day. The median household size was 7 (interquartile range (IQR): 4—9). The median age was 12 (IQR: 5—27). The birth rate was 59.0/1000 population (95% confidence interval (95%-CI): 51.7—67.4). The crude and under-five mortality rates (CMR & U5MR) were 1.33 (95%-CI: 1.09—1.61) and 1.87 (95%-CI: 1.37–2.54) deaths/10,000 persons/day, respectively. The most common specified causes of death were malaria/fever (16.0%; 95%-CI: 11.0–22.7), violence (13.2%; 95%-CI: 6.3–25.5), diarrhoea/vomiting (10.6%; 95%-CI: 6.2–17.5), and respiratory infections (8.4%; 95%-CI: 4.6–14.8). The maternal mortality ratio (MMR) was 2525/100,000 live births (95%-CI: 825—5794). Challenges reported by households included health problems and access to healthcare, high number of deaths, lack of potable water, insufficient means of subsistence, food insecurity and violence. Conclusions The CMR, U5MR and MMR exceed previous estimates, and the CMR exceeds the humanitarian emergency threshold. Violence is a major threat to life, and to physical and mental wellbeing. Other causes of death speak to poor living conditions and poor access to healthcare and preventive measures, corroborated by the challenges reported by households. Many areas of CAR face similar challenges to Ouaka. If these results were generalisable across CAR, the country would suffer one of the highest mortality rates in the world, a reminder that the longstanding “silent crisis” continues.

Post-Partum Hemorrhage is Still Killing Mothers in Bangladesh: An Observation from the 2016 Bangladesh Maternal Mortality Survey (BMMS)

The main cause of maternal death in Bangladesh is postpartum hemorrhage (PPH). PPH accounts for 31%of maternal deaths. Proven interventions to prevent maternal mortality are active management of third stage of labour (AMTSL) and the availability of comprehensive emergency obstetric care (CEmOC). Both of these interventions mandate the administration of oxytocin. In Bangladesh there are nonfunctioning institutionalized guidelines from the Director General of Health Services on the storage of oxytocin, which may impact the potency of oxytocin used during labour. To reduce preventable PPH morbidity and mortality, Bangladesh needs to evaluate the potency of current stores of oxytocin used in both in public and private facilities, develop and enforce protocols to ensure the potency of oxytocin, and promote universal access to quality AMSTL and CEmOC services.

Progress towards the Ending Preventable Maternal Mortality (EPMM) target for Bangladesh: The role of female education

Educational attainment among women is a well-recognized predictor for maternal mortality. Data from nationally representative surveys and the United Nations are used in the analysis for estimating maternal mortality due to improved education status up to 2030. Analysis of data from 2001 and 2010 Bangladesh Maternal Mortality Survey shows that MMR varies considerably by education level. The study shows that during 2011–2030, 15% maternal deaths will be averted due to fertility change (i.e. fewer births) and 24% of the maternal deaths can be averted only by improving the female education levels. However, in order to achieve the Ending Preventable Maternal Mortality (EPMM) target of 59 maternal deaths per 100,000 live births by 2030 for Bangladesh, a further 64% reduction will be required. Factors outside the health sector, like female education, will continue to have an impact maternal mortality in Bangladesh. However, reaching the EPMM target for Bangladesh by 2030 will also require significant investments in maternal health programs, in particular those to increase access to and quality of services.