Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries

doi:10.1111/1471-0528.17606

. 2024 Jan;131(2):163-174.

doi: 10.1111/1471-0528.17606. Epub 2023 Jul 19.

Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries

Ursula Gazeley^{1

2}, Georges Reniers², Julio E Romero-Prieto², Clara Calvert^{1

3}, Momodou Jasseh⁴, Kobus Herbst^{5

6}, Sammy Khagayi⁷, David Obor⁷, Daniel Kwaro⁷, Albert Dube⁸, Merga Dheresa⁹, Chodziwadziwa W Kabudula¹⁰, Kathleen Kahn^{10

11}, Mark Urassa¹², Amek Nyaguara¹³, Marleen Temmerman¹⁴, Laura A Magee^{15

16}, Peter von Dadelszen^{15

16}, Veronique Filippi¹

Affiliations

¹ Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
² Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
³ Usher Institute, University of Edinburgh, Edinburgh, UK.
⁴ Medical Research Council Unit The Gambia at LSHTM, Serekunda, The Gambia.
⁵ Africa Health Research Institute, Durban, South Africa.
⁶ DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Durban, South Africa.
⁷ Kenya Medical Research Institute - Centre for Global Health Research, Kisumu, Kenya.
⁸ Malawi Epidemiology and Intervention Research Institute, Karonga, Malawi.
⁹ School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
¹⁰ MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
¹¹ Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
¹² The Tazama Project, National Institute for Medical Research, Mwanza, Tanzania.
¹³ KEMRI-Wellcome Trust, Kilifi, Kenya.
¹⁴ Centre of Excellence in Women and Children's Health, Aga Khan University, Nairobi, Kenya.
¹⁵ Department of Women and Children's Health, School of Life Course and Population Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.
¹⁶ Institute of Women and Children's Health, King's College London, London, UK.

PMID: 37469195
PMCID: PMC10952650
DOI: 10.1111/1471-0528.17606

Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries

Ursula Gazeley et al. BJOG. 2024 Jan.

. 2024 Jan;131(2):163-174.

doi: 10.1111/1471-0528.17606. Epub 2023 Jul 19.

Authors

Affiliations

¹ Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
² Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.
³ Usher Institute, University of Edinburgh, Edinburgh, UK.
⁴ Medical Research Council Unit The Gambia at LSHTM, Serekunda, The Gambia.
⁵ Africa Health Research Institute, Durban, South Africa.
⁶ DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Durban, South Africa.
⁷ Kenya Medical Research Institute - Centre for Global Health Research, Kisumu, Kenya.
⁸ Malawi Epidemiology and Intervention Research Institute, Karonga, Malawi.
⁹ School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia.
¹⁰ MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
¹¹ Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
¹² The Tazama Project, National Institute for Medical Research, Mwanza, Tanzania.
¹³ KEMRI-Wellcome Trust, Kilifi, Kenya.
¹⁴ Centre of Excellence in Women and Children's Health, Aga Khan University, Nairobi, Kenya.
¹⁵ Department of Women and Children's Health, School of Life Course and Population Sciences, Faculty of Life Science and Medicine, King's College London, London, UK.
¹⁶ Institute of Women and Children's Health, King's College London, London, UK.

PMID: 37469195
PMCID: PMC10952650
DOI: 10.1111/1471-0528.17606

Abstract

Objective: To compare the causes of death for women who died during pregnancy and within the first 42 days postpartum with those of women who died between >42 days and within 1 year postpartum.

Design: Open population cohort (Health and Demographic Surveillance Systems).

Setting: Ten Health and Demographic Surveillance Systems (HDSS) in The Gambia, Kenya, Malawi, Tanzania, Ethiopia and South Africa.

Population: 2114 deaths which occurred within 1 year of the end of pregnancy where a verbal autopsy interview was conducted from 2000 to 2019.

Methods: InterVA5 and InSilicoVA verbal autopsy algorithms were used to attribute the most likely underlying cause of death, which were grouped according to adapted International Classification of Diseases-Maternal Mortality categories. Multinomial regression was used to compare differences in causes of deaths within 42 days versus 43-365 days postpartum adjusting for HDSS and time period (2000-2009 and 2010-2019).

Main outcome measures: Cause of death and the verbal autopsy Circumstances of Mortality Categories (COMCATs).

Results: Of 2114 deaths, 1212 deaths occurred within 42 days postpartum and 902 between 43 and 365 days postpartum. Compared with deaths within 42 days, deaths from HIV and TB, other infectious diseases, and non-communicable diseases constituted a significantly larger proportion of late pregnancy-related deaths beyond 42 days postpartum, and health system failures were important in the circumstances of those deaths. The contribution of HIV and TB to deaths beyond 42 days postpartum was greatest in Southern Africa. The causes of pregnancy-related mortality within and beyond 42 days postpartum did not change significantly between 2000-2009 and 2010-2019.

Conclusions: Cause of death data from the extended postpartum period are critical to inform prevention. The dominance of HIV and TB, other infectious and non-communicable diseases to (late) pregnancy-related mortality highlights the need for better integration of non-obstetric care with ante-, intra- and postpartum care in high-burden settings.

Keywords: causes of death; maternal health; pregnancy-related mortality; verbal autopsy.

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Conflict of interest statement

None declared.

Figures

**FIGURE 1**
Panel A: Causes of pregnancy‐related deaths up to 1 year postpartum by timing and age;Panel B: Causes of pregnancy‐related deaths up to 1 year postpartum by timing and ICD‐MM category. There were no deaths attributed to ICD‐MM category 6. Unanticipated complications of management, so this category is not shown.

**FIGURE 2**
Cause of pregnancy‐related deaths up to 1 year postpartum from 2000–2009 and 2010–2019, InterVA5. *Note*: There were no deaths attributed to ICD‐MM category 6. There were unanticipated complications of management, so this category is not shown.

**FIGURE 3**
Cause of pregnancy‐related deaths up to 1 year postpartum by timing and HDSS, InterVA5. *Note*: There were no deaths attributed to ICD‐MM category 6. There were unanticipated complications of management, so this category is not shown.

**FIGURE 4**
Circumstances of Mortality (COMCATs) by adapted ICD‐MM category, InterVA5. *Note*: There were no deaths attributed to ICD‐MM category 6. There were unanticipated complications of management, so this category is not shown.

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References

1. Sliwa K, Anthony J. Late maternal deaths: a neglected responsibility. Lancet. 2016;387(10033):2072–2073. - PubMed
1. Adomako J, Asare GQ, Ofosu A, Iott BE, Anthony T, Momoh AS, et al. Community‐based surveillance of maternal deaths in rural Ghana. Bull World Health Organ. 2016;94(2):86–91. - PMC - PubMed
1. Hoj L, Stensballe J, Aaby P. Maternal mortality in Guinea‐Bissau: the use of verbal autopsy in a multi‐ethnic population. Int J Epidemiol. 1999;28(1):70–76. - PubMed
1. Ziraba AK, Madise N, Mills S, Kyobutungi C, Ezeh A. Maternal mortality in the informal settlements of Nairobi city: what do we know? Reprod Health. 2009;6(1):6. - PMC - PubMed
1. Etard JF, Kodio B, Traoré S. Assessment of maternal mortality and late maternal mortality among a cohort of pregnant women in Bamako, Mali. BJOG. 1999;106(1):60–65. - PubMed

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[1] Sliwa K, Anthony J. Late maternal deaths: a neglected responsibility. Lancet. 2016;387(10033):2072–2073. - PubMed

[2] Sliwa K, Anthony J. Late maternal deaths: a neglected responsibility. Lancet. 2016;387(10033):2072–2073. - PubMed

[3] Adomako J, Asare GQ, Ofosu A, Iott BE, Anthony T, Momoh AS, et al. Community‐based surveillance of maternal deaths in rural Ghana. Bull World Health Organ. 2016;94(2):86–91. - PMC - PubMed

[4] Adomako J, Asare GQ, Ofosu A, Iott BE, Anthony T, Momoh AS, et al. Community‐based surveillance of maternal deaths in rural Ghana. Bull World Health Organ. 2016;94(2):86–91. - PMC - PubMed

[5] Hoj L, Stensballe J, Aaby P. Maternal mortality in Guinea‐Bissau: the use of verbal autopsy in a multi‐ethnic population. Int J Epidemiol. 1999;28(1):70–76. - PubMed

[6] Hoj L, Stensballe J, Aaby P. Maternal mortality in Guinea‐Bissau: the use of verbal autopsy in a multi‐ethnic population. Int J Epidemiol. 1999;28(1):70–76. - PubMed

[7] Ziraba AK, Madise N, Mills S, Kyobutungi C, Ezeh A. Maternal mortality in the informal settlements of Nairobi city: what do we know? Reprod Health. 2009;6(1):6. - PMC - PubMed

[8] Ziraba AK, Madise N, Mills S, Kyobutungi C, Ezeh A. Maternal mortality in the informal settlements of Nairobi city: what do we know? Reprod Health. 2009;6(1):6. - PMC - PubMed

[9] Etard JF, Kodio B, Traoré S. Assessment of maternal mortality and late maternal mortality among a cohort of pregnant women in Bamako, Mali. BJOG. 1999;106(1):60–65. - PubMed

[10] Etard JF, Kodio B, Traoré S. Assessment of maternal mortality and late maternal mortality among a cohort of pregnant women in Bamako, Mali. BJOG. 1999;106(1):60–65. - PubMed

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Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries

Affiliations

Pregnancy-related mortality up to 1 year postpartum in sub-Saharan Africa: an analysis of verbal autopsy data from six countries

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

Similar articles

Cited by

References

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical