An analysis of maternal deaths in British Columbia: 1963 to 1970

There were 132 maternal deaths in British Columbia in the years 1963 to 1970. The mean maternal mortality rate for these eight years was 0.317. Sixty of these deaths (45.5%) were due to direct obstetrical causes. Indirect and nonrelated deaths accounted for 21.2 and 33.3% of the total, respectively. The most common causes of direct obstetrical deaths were hemorrhage, infection and vascular accidents, in that order; pre-eclampsia ranked a distant fourth. Ninety-five percent of direct obstetrical deaths were probably avoidable. Approximately 27% of all direct obstetrical deaths were abortion-related. Hemorrhage continues to be a major problem, in particular among the native Indian women of the province.If further reduction in maternal mortality is to be achieved, obstetrical hemorrhage must be better managed and deaths due to abortions reduced. Future studies should reveal if the liberalized abortion laws will assist in the realization of the latter goal.     

The role of maternal toxicity in lovastatin-induced developmental toxicity

The role of maternal toxicity in lovastatin-induced developmental toxicity in rats was examined in a series of studies. The first study administered lovastatin at 100, 200, 400, or 800 mg/kg/day (mkd) orally to mated rats from Gestation Day (GD) 6 through 20. Maternal toxicity was observed as transient dose-related body weight losses at the initiation of dosing; there were also deaths and/or morbidity at 400 and 800 mkd. These toxicities occurred in conjunction with forestomach lesions. Mean fetal weights were decreased in all groups (-5 to -16%), and the incidence of skeletal malformations, variations, and incomplete ossifications was increased. The 2 highest doses produced the most severe maternal and developmental effects. Using the same dosages, the second study avoided gestational maternal weight losses and morbidity by starting treatment 14 days before mating with dosing continued to GD 20. There were transient dose-related body weight losses after the start of dosing and deaths in the 400- and 800-mkd groups; however, there was no evidence of maternal toxicity during gestation. Developmental toxicity was evident only as slight, but generally significant (p< or =0.05) decreases in mean fetal weights in groups given > or =200 mkd (-2 to -5%). Significantly, no skeletal abnormalities were observed. A third study administered the pharmacologically active metabolite of lovastatin subcutaneously at dose levels that matched oral maternal drug exposures. In the high-dose group, maternal weight gain and mean fetal weight were slightly decreased but there were no treatment-related skeletal abnormalities. Finally, a series of toxicokinetic studies assessed whether the 2 different developmental toxicity profiles were due to differences in drug exposure between the developmentally toxic and non-toxic dosing regimes. The data showed that groups with no skeletal abnormalities had maternal and embryonic/fetal drug concentrations similar to or even greater than the groups with fetal abnormalities. These results indicate that fetal skeletal abnormalities observed at lovastatin dose levels > or =100 mkd are not due to a direct teratogenic effect, but are the result of excessive maternal toxicity, which most likely involves a nutritional deficiency associated with forestomach lesions and reduced maternal food intake.     

Rising mortality from cryptogenic fibrosing alveolitis.

OBJECTIVE--To determine the pattern of mortality ascribed to cryptogenic fibrosing alveolitis and to identify factors that might be important in the aetiology of the disease; and to assess the validity of death certification of the disease. DESIGN--A retrospective examination of mortality ascribed to cryptogenic fibrosing alveolitis in England and Wales between 1979 and 1988 with analysis, by multiple logistic regression, of independent effects of age, sex, region of residence, and social class as indicated by occupation on data for 1979-87; also a retrospective review of hospital records of patients certified as having died of cryptogenic fibrosing alveolitis in Nottingham and of the certified cause of death of patients known to have had the disease. MAIN OUTCOME MEASURES--Time trends in mortality nationally; effects on mortality of age, sex, and region of residence; validity of death certification in Nottingham. RESULTS--The annual number of deaths ascribed to cryptogenic fibrosing alveolitis doubled from 336 in 1979 to 702 in 1988, the increase occurring mainly at ages over 65. Mortality standardised for age for both sexes likewise increased steadily over the period. Deaths due to cryptogenic fibrosing alveolitis were commoner in men (odds ratio 2.24, 95% confidence interval 2.11 to 2.33) and increased substantially with age, being 7.84 (7.24 to 8.49) times higher in subjects aged much greater than 75 than those aged 45-64. Odds ratios of death due to cryptogenic fibrosing alveolitis adjusted for age and sex were increased in the traditionally industrialised central areas of England and Wales (p less than 0.02, maximum odds ratio between regions 1.25), but no significant increase in odds of death was found for manual occupations. Of 23 people whose deaths were registered in Nottingham as having been due to cryptogenic fibrosing alveolitis, 19 were ascertained from clinical records to have had the disease. Only 17 of 45 patients known to have had cryptogenic fibrosing alveolitis in life were recorded as having died from the disease. CONCLUSIONS--The diagnostic accuracy of death certification of cryptogenic fibrosing alveolitis is high, but the number of deaths recorded as being due to the disease may underestimate the number of patients dying with the disease by up to half. Mortality due to the disease is increasing, and the male predominance and regional differences in mortality suggest that environmental factors are important in its aetiology.     

The influence of parity and maternal preimmunization on fetal survival in mice

It is known that as parity increases, cell-mediated immunity to paternal antigens increases in mice. The article reports an experiment designed to compare the results of normal parity with artificial immunization simulating maternal sensitization to paternal antigens in mice. Virgin females were immunized at weekly intervals by intraperitoneal injections of 50 mcl of heparinized blood from males with whom they would eventually be mated. The immunized virgins and multiparous females were mated for 4 to 6 weeks after their last injection or litter. The total and live litter size increased with immunization; the total size with natural parity also increased though the live litter size slightly decreased with parity. The mean fetal death rate was relatively the same for both groups. Fetal weight increased with parity but not change was observed in placental weight. Both fetal and placental weight did not change with immunization. There was no increase in the expected number of male fetuses. The increased litter size in the immunized group may be due to increased ovulation rates.     

Maternal and Perinatal Mortality Associated with Cesarean Section in Alberta (1955-1959)

A province-wide study of perinatal mortality was initiated in Alberta (population 1,283,000) in 1955. The period 1955-1959 covered 182,028 total births and 4219 perinatal deaths of which 260 were from 3813 Cesarean sections.The perinatal mortality rate in Cesarean-section births in rural hospitals (101.4 per thousand Cesarean births) was compared with that for urban hospitals (55.7 per thousand).Examination of the indications for primary Cesarean section in which a perinatal death occurred showed that hemorrhage accounted for 54 out of 85 of these deaths in rural hospitals, and 49 out of 110 similar urban deaths. Of 33 perinatal deaths associated with elective repeat sections, 17 were of premature babies.Eleven of the 85 maternal deaths during 1955-1959 were associated with Cesarean section, a maternal mortality rate of 28.8 per 10,000 Cesarean section births. Preventable factors were present in 8 of the 11 cases. Hemorrhage was the primary cause of death.     

Maternal Mortality in Taiwan: A Nationwide Data Linkage Study

Background

To examine the changes in the maternal mortality ratio (MMR) and causes of maternal death in Taiwan based on nationwide linked data sets.

Methods

We linked four population-based data sets (birth registration, birth notification, National Health Insurance inpatient claims, and cause of death mortality data) to identify maternal deaths for 2004–2011. Subsequently, we calculated the MMR (deaths per 100,000 live births) and the proportion of direct and indirect causes of maternal death by maternal age and year.

Findings

Based on the linked data sets, we identified 236 maternal death cases, of which only 102 were reported in officially published mortality data, with an underreporting rate of 57% [(236−102) × 100 / 236]. The age-adjusted MMR was 18.4 in 2004–2005 and decreased to 12.5 in 2008–2009; however, the MMR leveled off at 12.6 in 2010–2011. The MMR increased from 5.2 in 2008–2009 to 7.1 in 2010–2011 for patients aged 15–29 years. Women aged 15–29 years had relatively lower proportion in dying from direct causes (amniotic fluid embolism and obstetric hemorrhage) compared with their counterpart older women.

Conclusions

Approximately two-thirds of maternal deaths were not reported in officially published mortality data. Routine surveillance of maternal mortality by using enhanced methods is necessary to monitor the health status of reproductive-age women. Furthermore, a comprehensive maternal death review is necessary to explore the preventability of these maternal deaths.     

Measuring Maternal Mortality: Three Case Studies Using Verbal Autopsy with Different Platforms

Background

Accurate measurement of maternal mortality is needed to develop a greater understanding of the scale of the problem, to increase effectiveness of program planning and targeting, and to track progress. In the absence of good quality vital statistics, interim methods are used to measure maternal mortality. The purpose of this study is to document experience with three community-based interim methods that measure maternal mortality using verbal autopsy.

Methods

This study uses a post-census mortality survey, a sample vital registration with verbal autopsy, and a large-scale household survey to summarize the measures of maternal mortality obtained from these three platforms, compares and contrasts the different methodologies employed, and evaluates strengths and weaknesses of each approach. Included is also a discussion of issues related to death identification and classification, estimating maternal mortality ratios and rates, sample sizes and periodicity of estimates, data quality, and cost.

Results

The sample sizes vary considerably between the three data sources and the number of maternal deaths identified through each platform was small. The proportion of deaths to women of reproductive age that are maternal deaths ranged from 8.8% to 17.3%. The maternal mortality rate was estimable using two of the platforms while obtaining an estimate of the maternal mortality ratio was only possible using one of the platforms. The percentage of maternal deaths due to direct obstetric causes ranged from 45.2% to 80.4%.

Conclusions

This study documents experiences applying standard verbal autopsy methods to estimate maternal mortality and confirms that verbal autopsy is a feasible method for collecting maternal mortality data. None of these interim methods are likely to be suitable for detecting short term changes in mortality due to prohibitive sample size requirements, and thus, comprehensive and continuous civil registration systems to provide high quality vital statistics are essential in the long-term.     

Cumulative risk adjusted mortality chart for detecting changes in death rate: observational study of heart surgery

Objective: To detect changes in mortality after surgery, with allowance being made for variations in case mix. Design: Observational study of postoperative mortality from January 1992 to August 1995. Setting: Regional cardiothoracic unit. Subjects: 3983 patients aged 16 and over who had open heart operations. Main outcome measures: Preoperative risk factors and postoperative mortality in hospital within 30 days were recorded for all surgical heart operations. Mortality was adjusted for case mix using a preoperative estimate of risk based on additive Parsonnet factors. The number of operations required for statistical power to detect a doubling of mortality was examined, and control limits at a nominal significance level of P=0.01 for detection of an adverse trend were determined. Results: Total mortality of 7.0% was 26% below the Parsonnet predictor (P<0.0001). There was a highly significant variation in annual case mix (Parsonnet scores 8.7-10.6, P<0.0001). There was no significant variation in mortality after adjustment for case mix (odds ratio 1-1.5, P=0.18) with monitoring by calendar year. With continuous monitoring, however, nominal 99% control limits based on 16 expected deaths were crossed on two occasions. Conclusions: Hospital league tables for mortality from heart surgery will be of limited value because year to year differences in death rate can be large (odds ratio 1.5) even when the underlying risk or case mix does not change. Statistical quality control of a single series with adjustment for case mix is the only way to take into account recent performance when informing a patient of the risk of surgery at a particular hospital. If there is an increase in the number of deaths the chances of the next patient surviving surgery can be calculated from the last 16 deaths.

Key messages

• Changes in the patient population affect a hospital’s annual death rate
• Year to year differences in death rate can be large even when there is no change in the underlying risk or case mix
• It takes surprisingly many operations before an increase in death rate can be distinguished from random fluctuation
• A formal inquiry should take place in a hospital if the death rate rises above control limits
• The chances of the next patient surviving surgery should be calculated using the surgeon’s most recent results

     

Maternal Mortality in India: Causes and Healthcare Service Use Based on a Nationally Representative Survey

Background

Data on cause-specific mortality, skilled birth attendance, and emergency obstetric care access are essential to plan maternity services. We present the distribution of India''s 2001–2003 maternal mortality by cause and uptake of emergency obstetric care, in poorer and richer states.

Methods and Findings

The Registrar General of India surveyed all deaths occurring in 2001–2003 in 1.1 million nationally representative homes. Field staff interviewed household members about events that preceded the death. Two physicians independently assigned a cause of death. Narratives for all maternal deaths were coded for variables on healthcare uptake. Distribution of number of maternal deaths, cause-specific mortality and uptake of healthcare indicators were compared for poorer and richer states. There were 10 041 all-cause deaths in women age 15–49 years, of which 1096 (11.1%) were maternal deaths. Based on 2004–2006 SRS national MMR estimates of 254 deaths per 100 000 live births, we estimated rural areas of poorer states had the highest MMR (397, 95%CI 385–410) compared to the lowest MMR in urban areas of richer states (115, 95%CI 85–146). We estimated 69 400 maternal deaths in India in 2005. Three-quarters of maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated live births in India. Most maternal deaths were attributed to direct obstetric causes (82%). There was no difference in the major causes of maternal deaths between poorer and richer states. Two-thirds of women died seeking some form of healthcare, most seeking care in a critical medical condition. Rural areas of poorer states had proportionately lower access and utilization to healthcare services than the urban areas; however this rural-urban difference was not seen in richer states.

Conclusions

Maternal mortality and poor access to healthcare is disproportionately higher in rural populations of the poorer states of India.     

Snowmobile-related deaths in Ontario: a 5-year review.

OBJECTIVES: To investigate the demographic characteristics and circumstances surrounding fatal snowmobile accidents in Ontario, to examine the risk factors and to observe any fatality trends over the study period. DESIGN: Case series. PATIENTS: All 131 people who died accidentally while operating a snowmobile in Ontario from 1985-86 to 1989-90. Records were obtained from the chief coroner''s office; registration data were obtained from the Ministry of Transportation. RESULTS: Although the absolute number of deaths increased each year, owing to a rapid increase in the number of registered snowmobiles, the risk of death from snowmobile accidents remained relatively constant. Deaths occurred most frequently in northeastern Ontario. Youths and men predominated among the victims. Fatal accidents occurred more often on lakes (in 66% of the cases in which this information was known) than on roads (in 26%) or trails (in 8%). Weekend fatalities predominated, and deaths occurred most often during times of suboptimal lighting (from 4 pm to 8 am). The driver was killed in 84% of the cases in which the person''s role was known. Alcohol use before death was implicated in 69% of the cases, the level exceeding the Ontario legal limit in 59%. CONCLUSION: Snowmobile-related deaths result from factors that are generally avoidable. Strategies need to be instituted to reduce the rate of these events.     

CYSTIC FIBROSIS

To determine the actual number of deaths from cystic fibrosis reported in 1957 in California, all death certificates mentioning any one of the various terms used to describe the condition were reviewed.As a cause of death, cystic fibrosis is infrequently mentioned on death certificates. In 1957, only 42 of a total of 124,082 death certificates mentioned cystic fibrosis. Half of the deaths occurred in persons less than 12 months of age. There was no significant difference by sex between deaths due to cystic fibrosis and deaths from all causes. All deaths occurred in the white population.     

Regression analysis of recent changes in cardiovascular morbidity and mortality in The Netherlands.

OBJECTIVES: To test whether recent declines in mortality from coronary heart disease were associated with increased mortality from other cardiovascular diseases. DESIGN: Poisson regression analysis of national data on causes of death and hospital discharges. SETTING AND SUBJECTS: Population of the Netherlands, 1969-93. MAIN OUTCOME MEASURES: Annual changes in mortality from coronary heart disease, stroke, and other cardiovascular diseases and annual changes in hospital discharge rates for acute coronary events, stroke, and congestive heart failures. RESULTS: Patterns of cardiovascular mortality changed abruptly in 1987-93. Annual decline in mortality from coronary heart disease increased sharply for women and men: from -1.9% (95% confidence interval -2.2% to -1.6%) and -1.7% (-1.9% to -1.4%) respectively in 1979-86 to -3.1% (-3.5% to -2.6%) and -4.2% (-4.6% to -3.9%) in 1987-93. The longstanding decline in mortality from stroke levelled off: from annual change of -3.3% (-3.7% to -2.8%) and -3.2% (-3.7% to -2.8%) in 1979-86 to -0.1% (-0.7% to 0.4%) and -1.1% (-1.7% to -0.5%) in 1987-93. Mortality from other cardiovascular diseases, however, started to increase: from -2.0% (-2.4% to -1.6%) and -0.2% (-0.5% to 0.2%) in 1979-86 to 1.5% (1.0% to 2.0%) and 1.9% (1.5% to 2.3%) in 1987-93. Hospital discharge rates for acute coronary heart disease, congestive heart failure, and stroke increased during 1980-6. During 1987-93 discharge rates for stroke and coronary heart disease stabilised but rates for congestive heart failure increased. CONCLUSION: Improved management of coronary heart disease seems to have reduced mortality, but some of the gains are lost to deaths from stroke and other cardiovascular diseases. The increasing numbers of patients with coronary heart disease who survive will increase demands on health services for long term care.     

Unrecognised HIV related deaths.

OBJECTIVES--To establish whether follow up of deaths from selected HIV related causes could increase the number of cases of HIV infection reported to the Public Health Laboratory Service Communicable Disease Surveillance Centre (CDSC), and to estimate the proportion of deaths among HIV positive men that occurred in men who were not known to be HIV positive at the time of death by the person who signed the death certificate. DESIGN--Follow up of draft death entries received by the Office of Population Censuses and Surveys on which one of 11 medical or external causes likely to be related to HIV was stated; letters were sent to the people who signed the certificates. The respondents were invited to report men known to have been HIV positive who were not already on the CDSC register. SETTING--England and Wales. SUBJECTS--Men aged 15-54 who died in February 1989 to July 1989 with one of the 11 selected HIV related diseases as cause of death on their death certificates. MAIN OUTCOME MEASURES--Number of men reported to the CDSC as a result of this follow up; estimate of excess deaths due to an HIV related cause; estimate of the proportion of excess deaths that occurred in those who were not known to be HIV positive at the time of death. RESULTS--Replies were received for 473 deaths (86%). Forty were for men known to have been HIV positive, 31 of whom had been reported to CDSC by the time they died; six were subsequently reported. The respondent did not know that the decreased was HIV positive for 20 (35%) of the 57 excess deaths in men for whom one of the medical causes was stated and 41 (93%) of the 44 excess deaths in men for whom one of the external causes was stated. CONCLUSION--Follow up of death registrations is not an efficient way of increasing the number of cases of HIV infection reported to CDSC. Between 35% and 60% of HIV positive people for whom certain causes are stated may be dying without HIV positivity having been diagnosed. There may be implications for those caring for people with these conditions and those who carry out postmortem examinations.     

Leading causes of childhood death

The over-all rates of death in childhood decreased five to ten fold during the first half of the century, with the greatest drop occurring in deaths due to infections. The death rate due to accidents has shown a relatively slight decrease; hence, accidents are now the leading cause of childhood death, and in California account for 32 per cent of the deaths in the group 1 to 15 years of age. In California, and among certain insured groups of children, cancer is the leading or second leading cause of death due to disease. There is indication that the incidence of leukemia is increasing in early childhood and in the older age groups.Accidents, the leading cause of childhood death, do not happen; they are caused, and so can be prevented. The medical profession should concern itself much more actively in the field of accident prevention.     

Capturing the context of maternal deaths from verbal autopsies: a reliability study of the maternal data extraction tool (M-DET)

Background

The availability of quality data to inform policy is essential to reduce maternal deaths. To characterize maternal deaths in settings without complete vital registration systems, we designed and assessed the inter-rater reliability of a tool to systematically extract data and characterize the events that precede a nationally representative sample of maternal deaths in India.

Method/Principal Findings

Of 1017 nationally representative pregnancy-related deaths, which occurred between 2001 and 2003, we randomly selected 105 reports. Two independent coders used the maternal data extraction tool (questions with coding guidelines) to collect information on antenatal care access, final pregnancy outcome; planned place of birth and care provider; community consultation, transport, admission, hospital referral; and verification of cause of death assignment. Kappa estimated inter-rater agreement was calculated and classified as poor (K≤0.4), moderate (K = 0.4-≤0.6), substantial (K = 0.6-≤0.8) and high (K>0.8) using the criteria from Landis & Koch. The data extraction tool had high agreement for gestational age, pregnancy outcome, transport, death en route and admission to hospital; substantial agreement for receipt of antenatal care, planned place of birth, readmission and referral to higher level hospital, and whether or not death occurred in the intrapartum period; moderate to substantial agreement for classification of deaths as direct or indirect obstetric deaths or incidental deaths; moderate agreement for classification of community healthcare consultation and total number of healthcare contacts; and poor agreement for the classification of deaths as sudden deaths and other/unknown cause of death. The ability of the tool to identify the most-responsible-person in labour varied from moderate agreement to high agreement.

Conclusions

This data extraction tool achieved good inter-rater reliability and can be used to collect data on events surrounding maternal deaths and for verification/improvement of underlying cause of death.     

Time trends in twin perinatal mortality in northern England, 1982-94. Northern Region Perinatal Mortality Survey Steering Group.

The dynamics of perinatal mortality rates (PNMR) and causes of death in twin pregnancies over 13 years in the Northern Region of the National Health Service in England is described. All twin perinatal deaths occurring between 1982-1994 were identified from the Northern Region Perinatal Mortality Survey. The twinning rate increased from 9.9 per 1000 maternities in 1982 to 12.0 in 1994. There was a total of 10,734 twin pregnancies and of these 421 resulted in 530 perinatal deaths. The perinatal mortality rate in twins significantly decreased over time (1982-87, 55.4 per 1000; 1988-94, 44.4 per 1000; P = 0.01). The PNMR was significantly higher for twins from like-sexed than from unlike-sexed pairs (53.5 and 34.4 per 1000 respectively, P < 0.001). Despite no improvement in birthweight distribution in the twin population, birthweight-specific perinatal mortality rates for both like and unlike-sexed twins decreased for each birthweight category in 1988-94 compared with 1982-87. Twins with very low birthweight (< 1500 g) comprised 69%, and preterm twins (< 37 completed weeks of gestation) 74.9% of all twin perinatal deaths. The major immediate cause of early neonatal death was pulmonary immaturity (63%); antepartum anoxia caused 76.9% of antenatal deaths. Unexplained preterm labour and intrauterine death were the leading obstetric factors underlying death in twins. Despite a decrease over the 13 years, the perinatal mortality rate in twins in the Northern Region remains high. Continued monitoring of trends in twinning and mortality rates is needed to inform health care planning.     

Cortisol levels and control of inflammatory responses to toxic shock syndrome toxin-1 (TSST-1): the prevalence of night-time deaths in sudden infant death syndrome (SIDS)

There is evidence that inflammatory responses have been induced in the tissues and body fluids of many SIDS infants. We suggested that some of these deaths are due to uncontrolled inflammatory responses to infectious agents and possibly cigarette smoke. The majority of SIDS deaths occur during the 2-4 month age range when infants have decreasing levels of maternal antibodies to infectious agents. Most deaths occur during the early hours of the morning. Adults are more susceptible to inflammatory responses at night due to lower levels of cortisol associated with circadian rhythm patterns. Infants develop these patterns between the ages of 7 weeks and 4 months, at which time their night-time cortisol levels drop dramatically. The objective of this study was to use an in vitro model system to assess the effects of different cortisol levels on proinflammatory cytokine production in response to the staphylococcal toxic shock syndrome toxin-1 (TSST-1) which has been identified in a significant number of SIDS infants. Levels of cortisol present in infants at night and during the day before and after the development of the circadian rhythm pattern were examined. Human buffy coats (n = 9) were stimulated with TSST-1 and responses assessed over 72 hours by a bioassay for tumour necrosis factor-alpha (TNF-alpha) and an enzyme linked immunosorbent assay (ELISA) for interleukin-6 (IL-6). Cortisol levels present in an infant at night after development of circadian rhythm (< or = 5 microg dl(-1)), did not significantly increase or decrease production of either TNF-alpha or IL-6. Concentrations of cortisol greater than 5 microg dl(-1) usually found in infants during the day or at night prior to the physiological change significantly decreased production of TNF-alpha at 12 hours and of IL-6 at 12 and 16 hours. Only cortisol levels greater than 5 microg dl(-1) significantly decreased production of the pro-inflammatory cytokines by human buffy coats stimulated with TSST-1. If the switch to the circadian rhythm pattern occurs in an infant when maternal antibodies are still present or after they have developed their own active immunity, the infant could neutralise common viruses, toxins or bacteria: however, if this switch occurs in an infant when antibody levels are low, this could be a window of vulnerability during which infants are at an increased risk of death if uncontrolled inflammatory responses are induced by infectious agents or their products.     

Facility Death Review of Maternal and Neonatal Deaths in Bangladesh

Objectives

To explore the experiences, acceptance, and effects of conducting facility death review (FDR) of maternal and neonatal deaths and stillbirths at or below the district level in Bangladesh.

Methods

This was a qualitative study with healthcare providers involved in FDRs. Two districts were studied: Thakurgaon district (a pilot district) and Jamalpur district (randomly selected from three follow-on study districts). Data were collected between January and November 2011. Data were collected from focus group discussions, in-depth interviews, and document review. Hospital administrators, obstetrics and gynecology consultants, and pediatric consultants and nurses employed in the same departments of the respective facilities participated in the study. Content and thematic analyses were performed.

Results

FDR for maternal and neonatal deaths and stillbirths can be performed in upazila health complexes at sub-district and district hospital levels. Senior staff nurses took responsibility for notifying each death and conducting death reviews with the support of doctors. Doctors reviewed the FDRs to assign causes of death. Review meetings with doctors, nurses, and health managers at the upazila and district levels supported the preparation of remedial action plans based on FDR findings, and interventions were planned accordingly. There were excellent examples of improved quality of care at facilities as a result of FDR. FDR also identified gaps and challenges to overcome in the near future to improve maternal and newborn health.

Discussion

FDR of maternal and neonatal deaths is feasible in district and upazila health facilities. FDR not only identifies the medical causes of a maternal or neonatal death but also explores remediable gaps and challenges in the facility. FDR creates an enabled environment in the facility to explore medical causes of deaths, including the gaps and challenges that influence mortality. FDRs mobilize health managers at upazila and district levels to forward plan and improve healthcare delivery.     

Association between temperature and death in residential populations in Shanghai

The study is focused on patterns of daily deaths in Shanghai for the period from 1 May 1979 to 30 April 1980. From May to September the deaths in all age groups are lower, but increase gradually from October and reach to a peak in February. This confirms results found in other countries, namely the death rate is increased in winter. The peak for the population aged over 70 is the highest of the three different age groups. Correlation analyses were carried out on three temperature parameters (daily minimum, maximum and mean temperatures) and six categories of death (heart disease, coronary heart disease, cerebrovascular disease, cancer, respiratory disease and total deaths). The results reveal that the average daily temperature is very significant for the six categories of death. There are three correlations: straight line relationship, parabolic relationship and exponential relationship. These different types arise from the different morbidity rates. Death from the different disease is also increased during days when the daily maximum temperature is over 35° C or the daily minimum temperature is below 0°C. This shows, in general, that days of extreme temperature lead to an increase in the death rate.