A Low-Cost, Community Knowledge Approach to Estimate Maternal and Jaundice-Associated Mortality in Rural Bangladesh

Abstract

In the absence of a civil registration system, a house-to-house survey is often used to estimate causespecific mortality in low-and middle-income countries. However, house-to-house surveys are resource and time intensive. We applied a low-cost community knowledge approach to identify maternal deaths from any cause and jaundiceassociated deaths among persons aged ³ 14 years, and stillbirths and neonatal deaths in mothers with jaundice during pregnancy in five rural communities in Bangladesh. We estimated the method's sensitivity and cost savings compared with a house-to-house survey. In the five communities with a total of 125,570 population, we identified 13 maternal deaths, 60 deaths among persons aged ³ 14 years associated with jaundice, five neonatal deaths, and four stillbirths born to a mother with jaundice during pregnancy over the 3-year period before the survey using the community knowledge approach. The sensitivity of community knowledge method in identifying target deaths ranged from 80% for neonatal deaths to 100% for stillbirths and maternal deaths. The community knowledge approach required 36% of the staff time to undertake compared with the house-to-house survey. The community knowledge approach was less expensive but highly sensitive in identifying maternal and jaundice-associated mortality, as well as all-cause adult mortality in rural settings in Bangladesh. This method can be applied in rural settings of other low-and middle-income countries and, in conjunction with hospital-based hepatitis diagnoses, used to monitor the impact of programs to reduce the burden of cause-specific hepatitis mortality, a current World Health Organization priority.

Causes of mortality among female sex workers: Results of a multi-country study

“…In the CKA study from Bangladesh, deaths of women reported by community groups was compared with records of those deaths in local health facilities to determine the accuracy of those reports. 26 In contrast, our study was unable to compare reported deaths of FSW from the community with health facility documentation of the deaths as many FSW die outside of medical facilities. In our study, when the specific location of death was reported, only 280 deaths (13·3%) occurred at the hospital.…”

“…Although this study did not include an economic analysis of using the CKA or validate its use to identify all causes of death among FSW, the CKA is reported to be a less expensive and faster alternative to labor-intensive household surveys while also being highly sensitive. 26 In addition, other studies confirm that community informants can reliably report maternal deaths at a lower cost than other more labor intensive methods. 20 While there are other methods for identifying maternal deaths, including the Maternal Death Surveillance Finally, studies early in the COVID-19 pandemic reported an increase in maternal deaths related to compromised access to health services resulting from lockdowns, disruption of clinical care, and fear of being infected with the virus at health care facilities.…”

“…Although this study did not include an economic analysis of using the CKA or validate its use to identify all causes of death among FSW, the CKA is reported to be a less expensive and faster alternative to labor-intensive household surveys while also being highly sensitive. 26 In addition, other studies confirm that community informants can reliably report maternal deaths at a lower cost than other more labor intensive methods. 20 …”

“…These methods include MADE-IN/MADE-FOR, the Maternal Death Surveillance and Response (MDSR) system, civil registrations, household surveys, Reproductive Age Mortality Studies (RAMOS), the sisterhood methodology, informant method, and community knowledge approach. 20 , 21 , 22 , 23 , 24 , 25 , 26 Within resource-poor populations, identifying deaths among vulnerable groups such as FSW, refugees, and internally displaced persons, is arguably even more difficult than identifying maternal deaths in the general population.…”

“…The CKA was validated in a study that identified maternal, neonatal, and jaundice-associated deaths among women living in a community with an 80–100% sensitivity. 26 Recognized advantages of the CKA include its high sensitivity for identifying deaths and the relatively short time amount of time required to employ this death-counting method. While this methodology was not designed specifically for use among FSW communities nor designed to capture data on every death and every cause of death, we aimed to identify causes of mortality among FSW in the communities included in this study.…”