Causes and circumstances of maternal death: a secondary analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials cohort

CLIP Trials Study Group

doi:10.1016/S2214-109X(21)00263-1

Causes and circumstances of maternal death: a secondary analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials cohort

CLIP Trials Study Group

Women & Children's Health

Research output: Contribution to journal › Article › peer-review

15 Citations (Scopus)

Abstract

Background: Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods: The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12–49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings: Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193–268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43–0·66]) or InterVA-5 (κ=0·44 [0·30–0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60–0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38–0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27–0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59–0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00–0·15]). Interpretation: Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding: University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

Original language	English
Pages (from-to)	e1242-e1251
Journal	The Lancet Global Health
Volume	9
Issue number	9
DOIs	https://doi.org/10.1016/S2214-109X(21)00263-1
Publication status	Published - Sept 2021

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10.1016/S2214-109X(21)00263-1

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@article{7208c5fb65bd4738a8fd64eb4799012b,

title = "Causes and circumstances of maternal death: a secondary analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials cohort",

abstract = "Background: Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods: The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12–49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings: Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193–268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43–0·66]) or InterVA-5 (κ=0·44 [0·30–0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60–0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38–0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27–0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59–0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00–0·15]). Interpretation: Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding: University of British Columbia (grantee of the Bill & Melinda Gates Foundation).",

author = "{CLIP Trials Study Group} and Aukes, {Annet M.} and Kristina Arion and Bone, {Jeffrey N.} and Jing Li and Marianne Vidler and Bellad, {Mrutyunjaya B.} and Umesh Charantimath and Goudar, {Shivaprasad S.} and Zahra Hoodbhoy and Geetanjali Katageri and Sal{\'e}sio Macuacua and Mallapur, {Ashalata A.} and Kh{\'a}tia Munguambe and Qureshi, {Rahat N.} and Charfudin Sacoor and Esperan{\c c}a Sevene and Sana Sheikh and Anifa Val{\'a} and Gwyneth Lewis and Bhutta, {Zulfiqar A.} and {von Dadelszen}, Peter and Magee, {Laura A.} and {Woo Kinshella}, {Mai Lei} and Hubert Wong and Faustino Vilanculo and Ukah, {Ugochi V.} and Tu, {Domena K.} and Lehana Thabane and Corsino Tchavana and Jim Thornton and Sotunsa, {John O.} and Joel Singer and Sumedha Sharma and Nadine Schuurman and Diane Sawchuck and Revankar, {Amit P.} and Farrukh Raza and Ramdurg, {Umesh Y.} and Rosa Pires and Payne, {Beth A.} and Vivalde Nobela and Cl{\'a}udio Nkumbula and Ariel Nhancolo and Zefanias Nhamirre and Mungarwadi, {Geetanjali I.} and Dulce Mulungo and Sibone Mocumbi and Craig Mitton and Mario Merialdi and Javed Memon",

note = "Funding Information: The CLIP trials were funded as part of the PRE-EMPT initiative by the University of British Columbia, as the grantee of the Bill & Melinda Gates Foundation (grant number OPP1017337). We thank all women who participated in the CLIP trials. In particular, we thank the families of the 143 women who died during the study period and who were willing to share their stories despite their grief. We thank the Government of Mozambique, the Government of Sindh, and the Government of India for their permission to integrate the CLIP trials into their health systems with in-kind support. We thank the members of the CLIP Data Safety Monitoring Board (appendix p 2). Funding Information: The CLIP trials were funded as part of the PRE-EMPT initiative by the University of British Columbia, as the grantee of the Bill & Melinda Gates Foundation ( grant number OPP1017337 ). We thank all women who participated in the CLIP trials. In particular, we thank the families of the 143 women who died during the study period and who were willing to share their stories despite their grief. We thank the Government of Mozambique, the Government of Sindh, and the Government of India for their permission to integrate the CLIP trials into their health systems with in-kind support. We thank the members of the CLIP Data Safety Monitoring Board ( appendix p 2 ). Publisher Copyright: {\textcopyright} 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Copyright: Copyright 2021 Elsevier B.V., All rights reserved.",

year = "2021",

month = sep,

doi = "10.1016/S2214-109X(21)00263-1",

language = "English",

volume = "9",

pages = "e1242--e1251",

journal = "The Lancet Global Health",

issn = "2214-109X",

publisher = "Elsevier BV",

number = "9",

}

TY - JOUR

T1 - Causes and circumstances of maternal death

T2 - a secondary analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials cohort

AU - CLIP Trials Study Group

AU - Aukes, Annet M.

AU - Arion, Kristina

AU - Bone, Jeffrey N.

AU - Li, Jing

AU - Vidler, Marianne

AU - Bellad, Mrutyunjaya B.

AU - Charantimath, Umesh

AU - Goudar, Shivaprasad S.

AU - Hoodbhoy, Zahra

AU - Katageri, Geetanjali

AU - Macuacua, Salésio

AU - Mallapur, Ashalata A.

AU - Munguambe, Khátia

AU - Qureshi, Rahat N.

AU - Sacoor, Charfudin

AU - Sevene, Esperança

AU - Sheikh, Sana

AU - Valá, Anifa

AU - Lewis, Gwyneth

AU - Bhutta, Zulfiqar A.

AU - von Dadelszen, Peter

AU - Magee, Laura A.

AU - Woo Kinshella, Mai Lei

AU - Wong, Hubert

AU - Vilanculo, Faustino

AU - Ukah, Ugochi V.

AU - Tu, Domena K.

AU - Thabane, Lehana

AU - Tchavana, Corsino

AU - Thornton, Jim

AU - Sotunsa, John O.

AU - Singer, Joel

AU - Sharma, Sumedha

AU - Schuurman, Nadine

AU - Sawchuck, Diane

AU - Revankar, Amit P.

AU - Raza, Farrukh

AU - Ramdurg, Umesh Y.

AU - Pires, Rosa

AU - Payne, Beth A.

AU - Nobela, Vivalde

AU - Nkumbula, Cláudio

AU - Nhancolo, Ariel

AU - Nhamirre, Zefanias

AU - Mungarwadi, Geetanjali I.

AU - Mulungo, Dulce

AU - Mocumbi, Sibone

AU - Mitton, Craig

AU - Merialdi, Mario

AU - Memon, Javed

N1 - Funding Information: The CLIP trials were funded as part of the PRE-EMPT initiative by the University of British Columbia, as the grantee of the Bill & Melinda Gates Foundation (grant number OPP1017337). We thank all women who participated in the CLIP trials. In particular, we thank the families of the 143 women who died during the study period and who were willing to share their stories despite their grief. We thank the Government of Mozambique, the Government of Sindh, and the Government of India for their permission to integrate the CLIP trials into their health systems with in-kind support. We thank the members of the CLIP Data Safety Monitoring Board (appendix p 2). Funding Information: The CLIP trials were funded as part of the PRE-EMPT initiative by the University of British Columbia, as the grantee of the Bill & Melinda Gates Foundation ( grant number OPP1017337 ). We thank all women who participated in the CLIP trials. In particular, we thank the families of the 143 women who died during the study period and who were willing to share their stories despite their grief. We thank the Government of Mozambique, the Government of Sindh, and the Government of India for their permission to integrate the CLIP trials into their health systems with in-kind support. We thank the members of the CLIP Data Safety Monitoring Board ( appendix p 2 ). Publisher Copyright: © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

PY - 2021/9

Y1 - 2021/9

N2 - Background: Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods: The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12–49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings: Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193–268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43–0·66]) or InterVA-5 (κ=0·44 [0·30–0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60–0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38–0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27–0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59–0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00–0·15]). Interpretation: Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding: University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

AB - Background: Incomplete vital registration systems mean that causes of death during pregnancy and childbirth are poorly understood in low-income and middle-income countries. To inform global efforts to reduce maternal mortality, we compared physician review and computerised analysis of verbal autopsies (interpreting verbal autopsies [InterVA] software), to understand their agreement on maternal cause of death and circumstances of mortality categories (COMCATs) in the Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised trials. Methods: The CLIP trials took place in India, Pakistan, and Mozambique, enrolling pregnant women aged 12–49 years between Nov 1, 2014, and Feb 28, 2017. 69 330 pregnant women were enrolled in 44 clusters (36 008 in the 22 intervention clusters and 33 322 in the 22 control clusters). In this secondary analysis of maternal deaths in CLIP, we included women who died in any of the 22 intervention clusters or 22 control clusters. Trained staff administered the WHO 2012 verbal autopsy after maternal deaths. Two physicians (and a third for consensus, if needed) reviewed trial surveillance data and verbal autopsies, and, in intervention clusters, community health worker-led visit data. They determined cause of death according to the WHO International Classification of Diseases-Maternal Mortality (ICD-MM). Verbal autopsies were also analysed by InterVA computer models (versions 4 and 5) to generate cause of death. COMCAT analysis was provided by InterVA-5 and, in India, by physician review of Maternal Newborn Health Registry data. Causes of death and COMCATs assigned by physician review, Inter-VA-4, and InterVA-5 were compared, with agreement assessed with Cohen's κ coefficient. Findings: Of 61 988 pregnancies with successful follow-up in the CLIP trials, 143 maternal deaths were reported (16 deaths in India, 105 in Pakistan, and 22 in Mozambique). The maternal death rate was 231 (95% CI 193–268) per 100 000 identified pregnancies. Most deaths were attributed to direct maternal causes (rather than indirect or undetermined causes as per ICD-MM classification), with fair to good agreement between physician review and InterVA-4 (κ=0·56 [95% CI 0·43–0·66]) or InterVA-5 (κ=0·44 [0·30–0·57]), and InterVA-4 and InterVA-5 (κ=0·72 [0·60–0·84]). The top three causes of death were the same by physician review, InterVA-4, and InterVA-5 (ICD-MM categories obstetric haemorrhage, non-obstetric complications, and hypertensive disorders); however, attribution of individual patient deaths to obstetric haemorrhage varied more between methods (physician review, 38 [27%] deaths; InterVA-4, 69 [48%] deaths; and InterVA-5, 82 [57%] deaths), than did attribution to non-obstetric causes (physician review, 39 [27%] deaths; InterVA-4, 37 [26%] deaths; and InterVA-5, 28 [20%] deaths) or hypertensive disorders (physician review, 23 [16%] deaths; InterVA-4, 25 [17%] deaths; and InterVA-5, 24 [17%] deaths). Agreement for all nine ICD-MM categories was fair for physician review versus InterVA-4 (κ=0·48 [0·38–0·58]), poor for physician review versus InterVA-5 (κ=0·36 [0·27–0·46]), and good for InterVA-4 versus InterVA-5 (κ=0·69 [0·59–0·79]). The most commonly assigned COMCATs by InterVA-5 were emergencies (68 [48%] of 143 deaths) and health systems (62 [43%] deaths), and by physician review (India only) were health systems (seven [44%] of 16 deaths) and inevitability (five [31%] deaths); agreement between InterVA-5 and physician review (India data only) was poor (κ=0·04 [0·00–0·15]). Interpretation: Our findings indicate that InterVA-5 is less accurate than InterVA-4 at ascertaining causes and circumstances of maternal death, when compared with physician review. Our results suggest a need to improve the next iteration of InterVA, and for researchers and clinicians to preferentially use InterVA-4 when recording maternal deaths. Funding: University of British Columbia (grantee of the Bill & Melinda Gates Foundation).

UR - http://www.scopus.com/inward/record.url?scp=85112556204&partnerID=8YFLogxK

U2 - 10.1016/S2214-109X(21)00263-1

DO - 10.1016/S2214-109X(21)00263-1

M3 - Article

AN - SCOPUS:85112556204

SN - 2214-109X

VL - 9

SP - e1242-e1251

JO - The Lancet Global Health

JF - The Lancet Global Health

IS - 9

ER -

Causes and circumstances of maternal death: a secondary analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials cohort

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