Lancet Glob Health. 2018 Dec;6(12):e1297-e1308. doi: 10.1016/S2214-109X(18)30385-1. Epub 2018 Oct 22.
Modelled mortality estimates have been useful for health programmes in low-income and middle-income countries. However, these estimates are often based on sparse and low-quality data. We aimed to generate high quality data about the burden, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa.
In this prospective cohort study done in 11 community-based research sites in south Asia and sub-Saharan Africa, between July, 2012, and February, 2016, we conducted population-based surveillance of women of reproductive age (15-49 years) to identify pregnancies, which were followed up to birth and 42 days post partum. We used standard operating procedures, data collection instruments, training, and standardisation to harmonise study implementation across sites. Verbal autopsies were done for deaths of all women of reproductive age, neonatal deaths, and stillbirths. Physicians used standardised methods for cause of death assignment. Site-specific rates and proportions were pooled at the regional level using a meta-analysis approach.
We identified 278 186 pregnancies and 263 563 births across the study sites, with outcomes ascertained for 269 630 (96·9%) pregnancies, including 8761 (3·2%) that ended in miscarriage or abortion. Maternal mortality ratios in sub-Saharan Africa (351 per 100 000 livebirths, 95% CI 168-732) were similar to those in south Asia (336 per 100 000 livebirths, 247-458), with far greater variability within sites in sub-Saharan Africa. Stillbirth and neonatal mortality rates were approximately two times higher in sites in south Asia than in sub-Saharan Africa (stillbirths: 35·1 per 1000 births, 95% CI 28·5-43·1 vs 17·1 per 1000 births, 12·5-25·8; neonatal mortality: 43·0 per 1000 livebirths, 39·0-47·3 vs 20·1 per 1000 livebirths, 14·6-27·6). 40-45% of pregnancy-related deaths, stillbirths, and neonatal deaths occurred during labour, delivery, and the 24 h postpartum period in both regions. Obstetric haemorrhage, non-obstetric complications, hypertensive disorders of pregnancy, and pregnancy-related infections accounted for more than three-quarters of maternal deaths and stillbirths. The most common causes of neonatal deaths were perinatal asphyxia (40%, 95% CI 39-42, in south Asia; 34%, 32-36, in sub-Saharan Africa) and severe neonatal infections (35%, 34-36, in south Asia; 37%, 34-39 in sub-Saharan Africa), followed by complications of preterm birth (19%, 18-20, in south Asia; 24%, 22-26 in sub-Saharan Africa).
These results will contribute to improved global estimates of rates, timing, and causes of maternal and newborn deaths and stillbirths. Our findings imply that programmes in sub-Saharan Africa and south Asia need to further intensify their efforts to reduce mortality rates, which continue to be high. The focus on improving the quality of maternal intrapartum care and immediate newborn care must be further enhanced. Efforts to address perinatal asphyxia and newborn infections, as well as preterm birth, are critical to achieving survival goals in the Sustainable Development Goals era.
Bill & Melinda Gates Foundation.
模型化的死亡率估计数已被用于低收入和中等收入国家的卫生规划。然而，这些估计数通常基于稀疏和低质量的数据。我们的目的是在南亚和撒哈拉以南非洲获取关于孕产妇死亡、死产和新生儿死亡的负担、时间和原因的高质量数据。
在这项在南亚和撒哈拉以南非洲的 11 个社区研究点进行的前瞻性队列研究中，我们于 2012 年 7 月至 2016 年 2 月期间开展了一项针对育龄妇女（15-49 岁）的人群监测，以识别妊娠，并对妊娠进行随访，直至分娩和产后 42 天。我们使用标准操作程序、数据收集工具、培训和标准化，以协调各研究点的实施。对所有育龄妇女死亡、新生儿死亡和死产进行了死因推断性尸检。医生使用标准化方法进行死因分配。采用荟萃分析方法在区域水平上汇总了各研究点的特定比率和比例。
在研究点共发现了 278186 例妊娠和 263563 例分娩，对 269630 例（96.9%）妊娠结局进行了确定，包括 8761 例（3.2%）流产或堕胎。撒哈拉以南非洲的孕产妇死亡率（每 100000 例活产 351 例，95%CI 168-732）与南亚相似（每 100000 例活产 336 例，247-458），但撒哈拉以南非洲的各研究点之间差异更大。与撒哈拉以南非洲相比，南亚的死产和新生儿死亡率大约高出两倍（死产：每 1000 例分娩 35.1 例，95%CI 28.5-43.1 比每 1000 例分娩 17.1 例，12.5-25.8；新生儿死亡率：每 1000 例活产 43.0 例，95%CI 39.0-47.3 比每 1000 例活产 20.1 例，14.6-27.6）。两个地区妊娠相关死亡、死产和新生儿死亡的 40-45%发生在分娩期间、分娩时和产后 24 小时内。产科出血、非产科并发症、妊娠高血压疾病和妊娠相关感染占孕产妇死亡和死产的 75%以上。新生儿死亡的最常见原因是围产期窒息（南亚 40%，95%CI 39-42；撒哈拉以南非洲 34%，32-36）和严重新生儿感染（南亚 35%，34-36；撒哈拉以南非洲 37%，34-39），其次是早产并发症（南亚 19%，18-20；撒哈拉以南非洲 24%，22-26）。
这些结果将有助于改进全球关于孕产妇和新生儿死亡及死产的发生率、时间和原因的估计数。我们的发现表明，撒哈拉以南非洲和南亚的方案需要进一步加强努力，以降低死亡率，死亡率仍然很高。必须进一步加强对改善产妇分娩期间和新生儿即刻护理质量的关注。为实现可持续发展目标时代的生存目标，必须努力解决围产期窒息和新生儿感染以及早产问题。
比尔及梅琳达·盖茨基金会。
