Antenatal care ultrasound did not improve a composite outcome that included maternal, fetal, and neonatal mortality.

An algorithmic system for determining maternal cause of death in low-resource settings is described.

Objective Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions.Design We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered.Setting and population Pregnancies in SSA in 2012.Methods For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates.Main outcome measures Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions.Results Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/ eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth.Conclusions Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries.Keywords Mortality, stillbirth, sub-Saharan Africa.Tweetable abstract Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery.Please cite this paper as: Goldenberg RL, Griffin JB, Kamath-Rayne BD, Harrison M, Rouse DJ, Moran K, Hepler B, Jobe AH, McClure EM. Clinical interventions to reduce stillbirths in sub-Saharan Africa: a mathematical model to estimate the potential reduction of stillbirths associated with specific obstetric conditions. BJOG 2018;125:119-129.

Summary Objective To determine the comparability between cause of death by a single physician coder and a two-physician panel, using verbal autopsy. Methods The study was conducted between May 2007 and June 2008. Within a week of a perinatal death in 38 rural remote communities in Guatemala, the Democratic Republic of Congo, Zambia and Pakistan, VA questionnaires were completed. Two independent physicians, unaware of the others decisions, assigned an underlying cause of death, in accordance with the causes listed in the chapter headings of the International classification diseases and related health problems, 10th revision (ICD-10). Cohen's kappa statistic was used to assess level of agreement between physician coders. Results There were 9461 births during the study period; 252 deaths met study enrollment criteria and underwent verbal autopsy. Physicians assigned the same COD for 75% of stillbirths (K=0.69; 95% confidence interval: 0.61–0.78) and 82% early neonatal deaths (K=0.75; 95% confidence interval: 0.65–0.84). The patterns and proportion of stillbirths and early neonatal deaths determined by the physician coders were very similar compared to causes individually assigned by each physician. Similarly, rank order of the top 5 causes of stillbirth and early neonatal death were identical for each physician. Conclusion This study raises important questions about the utility of a system of multiple coders that is currently widely accepted, and speculates that a single physician coder may be an effective and economical alternative to VA programs that use traditional two-physician panels to assign COD.

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