Maternal, newborn, and children under-five health surveillance system: a scoping review protocol.

BACKGROUND: Public health surveillance is crucial in monitoring the progress of maternal, newborn, and children under-five health outcomes (MNCH). Consequently, mapping the existing surveillance system from countries with different income and development levels is needed to learn and compare the effectiveness of surveillance. However, the current COVID-19 pandemic has disrupted the health system, including the healthcare services for pregnant women, neonates, infants, and children under five, as well as the recording, reporting, and surveillance system. The need to adapt to the new normal during the pandemic has stimulated innovation while incorporating new COVID-19-related indicators into the existing public health system. Therefore, this review aims to describe the existing implementation and the COVID-19 pandemic's influence on the MNCH surveillance system. METHODS: We will search published literature (from MEDLINE, Embase, and Portal Garuda), manually search from all reference lists of included studies, and conduct a targeted search of relevant gray literature. This review will include studies of surveillance systems or describe COVID-19 surveillance or routine reports involving MNCH (morbidity and mortality). The studies included will be in English or Indonesian language, observational study designs, and published or documented from 2010 to 2023. Two investigators will independently screen the title and abstract, including each full article to determine the eligibility of studies. The data will be assessed using a narrative approach. Data will be reported in simple descriptive tables. DISCUSSION: Our findings are expected to map the existing implementation of MNCH surveillance systems before and during the pandemic, including the influence of the COVID-19 pandemic on MNCH surveillance across countries with different income levels. This may contribute to existing knowledge on the MNCH health surveillance system that could be integrated into the surveillance of emerging diseases, such as COVID-19. SYSTEMATIC REVIEW REGISTRATION: The protocol has been registered on the Open Science Framework ( https://osf.io/bc6t4 ).

Modified Pathway to Survival highlights importance of rapid access to quality institutional delivery care to decrease neonatal mortality in Serang and Jember districts, Java, Indonesia.

Background: Three-quarters of births in Indonesia occur in a health facility, yet the neonatal mortality rate remains high at 15 per 1000 live births. The Pathway to Survival (P-to-S) framework of steps needed to return sick neonates and young children to health focuses on caregiver recognition of and care-seeking for severe illness. In view of increased institutional delivery in Indonesia and other low- and middle-income countries, a modified P-to-S is needed to assess the role of maternal complications in neonatal survival. Methods: We conducted a retrospective cross-sectional verbal and social autopsy study of all neonatal deaths from June through December 2018, identified by a proven listing method in two districts of Java, Indonesia. We examined care-seeking for maternal complications, delivery place, and place and timing of neonatal illness onset and death. Results: The fatal illnesses of 189/259 (73%) neonates began in their delivery facility (DF), 114/189 (60%) of whom died before discharge. Mothers whose neonate's illness started at their delivery hospital and lower-level DF were more than six times (odds ratio (OR) = 6.5; 95% confidence interval (CI) = 3.4-12.5) and twice (OR = 2.0; 95% CI = 1.01-4.02) as likely to experience a maternal complication as those whose neonates fell fatally ill in the community, and illness started earlier (mean = 0.3 vs 3.6 days; P < 0.001) and death came sooner (3.5 vs 5.3 days; P = 0.06) to neonates whose illness started at any DF. Despite going to the same number of providers/facilities, women with a labour and delivery (L/D) complication who sought care from at least one other provider or facility on route to their DF took longer than those without a complication to reach their DF (median = 3.3 vs 1.3 hours; P = 0.01). Conclusions: Neonates' fatal illness onset in their DF was strongly associated with maternal complications. Mothers with a L/D complication experienced delays in reaching their DF, and nearly half the neonatal deaths occurred in association with a complication, suggesting that mothers with complications first seeking care at a hospital providing emergency maternal and neonatal care might have prevented some deaths. A modified P-to-S highlights the importance of rapid access to quality institutional delivery care in settings where many births occur in facilities and/or there is good care-seeking for L/D complications.

Care-seeking and health insurance among pregnancy-related deaths: A population-based study in Jember District, East Java Province, Indonesia.

BACKGROUND: Despite the increased access to facility-based delivery in Indonesia, the country's maternal mortality remains unacceptably high. Reducing maternal mortality requires a good understanding of the care-seeking pathways for maternal complications, especially with the government moving toward universal health coverage. This study examined care-seeking practices and health insurance in instances of pregnancy-related deaths in Jember District, East Java, Indonesia. METHODS: This was a community-based cross-sectional study to identify all pregnancy-related deaths in the district from January 2017 to December 2018. Follow-up verbal and social autopsy interviews were conducted to collect information on care-seeking behavior, health insurance, causes of death, and other factors. FINDINGS: Among 103 pregnancy-related deaths, 40% occurred after 24 hours postpartum, 36% during delivery or within the first 24 hours postpartum, and 24% occurred while pregnant. The leading causes of deaths were hemorrhage (38.8%), pregnancy-induced hypertension (20.4%), and sepsis (16.5%). Most deaths occurred in health facilities (81.6%), primarily hospitals (74.8%). Nearly all the deceased sought care from a formal health provider during their fatal illness (93.2%). Seeking any care from an informal provider during the fatal illness was more likely among women who died after 24 hours postpartum (41.0%, OR 7.4, 95% CI 1.9, 28.5, p = 0.049) or during pregnancy (29.2%, OR 4.4, 95% CI 1.0, 19.2, p = 0.003) than among those who died during delivery or within 24 hours postpartum (8.6%). There was no difference in care-seeking patterns between insured and uninsured groups. CONCLUSIONS: The fact that women sought care and reached health facilities regardless of their insurance status provides opportunities to prevent deaths by ensuring that every woman receives timely and quality care. Accordingly, the increasing demand should be met with balanced readiness of both primary care and hospitals to provide quality care, supported by an effective referral system.

Neonatal mortality in two districts in Indonesia: Findings from Neonatal Verbal and Social Autopsy (VASA).

BACKGROUND: The Government of Indonesia is determined to follow global commitments to reduce the neonatal mortality rate. Yet, there is a paucity of information on contributing factors and causes of neonatal deaths, particularly at the sub-national level. This study describes care-seeking during neonates' fatal illnesses and their causes of death. METHODS: We conducted a cross-sectional community-based study to identify all neonatal deaths in Serang and Jember Districts, Indonesia. Follow-up interviews were conducted with the families of deceased neonates using an adapted verbal and social autopsy instrument. Cause of death was determined using the InSilicoVA algorithm. RESULTS: The main causes of death of 259 neonates were prematurity (44%) and intrapartum-related events (IPRE)-mainly birth asphyxia (39%). About 83% and 74% of the 259 neonates were born and died at a health facility, respectively; 79% died within the first week after birth. Of 70 neonates whose fatal illness began at home, 59 (84%) sought care during the fatal illness. Forty-eight of those 59 neonates went to a formal care provider; 36 of those 48 neonates (75%) were moderately or severely ill when the family decided to seek care. One hundred fifteen of 189 neonates (61%) whose fatal illnesses began at health facilities were born at a hospital. Among those 115, only 24 (21%) left the hospital alive-of whom 16 (67%) were referred by the hospital. CONCLUSIONS: The high proportion of deaths due to prematurity and IPRE suggests the need for improved management of small and asphyxiated newborns. The moderate to severe condition of neonates at the time when care was sought from home highlights the importance of early illness recognition and appropriate management for sick neonates. Among deceased neonates whose fatal illness began at their delivery hospital, the high proportion of referrals may indicate issues with hospital capability, capacity, and/or cost.

Impact of time-to-treatment on overall survival of non-small cell lung cancer patients-an analysis of the national cancer database.

BACKGROUND: The association between time-to-treatment and outcomes for lung cancer has not been conclusively established. In this study, we evaluated the effect of time-to-treatment on the overall 5-year survival of patients with non-small cell lung cancer (NSCLC) with cancer stage at diagnosis. METHODS: We analyzed data in the National Cancer Data Base for adult patients newly diagnosed with NSCLC in 2003-2011 (N=693,554). Extended Cox regression with counting process was used to model the effect of time-to-treatment on survival, adjusted for demographic and clinical factors. Multivariable analyses were performed separately for the groups with different stages at diagnosis. Time-to-treatment was defined as the interval between diagnosis and treatment initiation, with the categories of (I) 0 day, (II) 1 day-4 weeks, (III) 4.1-6.0 weeks, and (IV) >6 weeks (the 1 day-4 weeks group was considered the reference group). RESULTS: Compared to treatment initiated between 1 day and 4 weeks after diagnosis, time-to-treatment at 4.1-6.0 weeks was associated with a lower risk of death for patients with early-stage cancer [adjusted HR (aHR), 0.84 (95% CI, 0.82-0.85)], with locally advanced cancer [aHR, 0.82 (95% CI, 0.80-0.83)], and with metastatic cancer [aHR, 0.75 (95% CI, 0.74-0.76)]. Similarly, a lower risk of death was associated with time-to-treatment longer than 6 weeks for patients with any cancer stage at diagnosis. However, a subset analysis for early-stage patients who received surgery only showed that extended time-to-surgery was associated a higher risk of death [aHR 4.1-6.0 weeks, 1.06 (95% CI, 1.03-1.09); aHR>6 weeks 1.17 (95% CI, 1.14-1.20)]. CONCLUSIONS: The findings show that, although time-to-treatment should not be compromised, it is imperative to ensure that patients receive optimal pre-treatment assessments rather than rushing the treatment. Future research should focus on examining clinical characteristics to determine an optimal time-to-treatment to achieve the best possible survival for NSCLC patients.

Patient-Defined Treatment Success: Perspectives of Patients With Advanced-Stage Lung Cancer.

PURPOSE: In the United States, lung cancer accounts for 14% of cancer diagnoses and 28% of cancer deaths annually. Because no cure exists for advanced lung cancer, the primary treatment goal is to prolong survival. OBJECTIVES: The study aim was to determine whether individual preferences, characteristics, and treatment experiences affect the meaning of treatment success. MATERIALS AND METHODS: A quantitative study using an observational, longitudinal cohort of patients with advanced stage non-small-cell lung cancer was conducted. Data sources included medical records and patient interviews. Data were analyzed using χ2, Fisher's exact, and McNemar's tests, as well as logistic regressions. RESULTS: At the first interview of 235 individuals, 12% considered survival alone as their definition of treatment success; others defined treatment success as survival plus other aspects, such as quality of life and reaching an important personal goal. As they moved through chemotherapy, 47% of the patients changed their definition of treatment success. Bivariate analysis showed that patients with lower incomes tended to be more likely to change their definition of treatment success compared with their counterparts with higher income (P = .0245). CONCLUSION: By taking chemotherapy, patients expect to increase their odds of survival and want to maintain the quality of life and functionality. A patient's definition of treatment success is often changing as treatment continues, making it appropriate to ensure patient-provider communication throughout their clinical care. The study results are limited to patients with advanced non-small-cell lung cancer and drawn from a predominantly white patient population, mainly from the US Midwest.

Maternal characteristics and obstetrical complications impact neonatal outcomes in Indonesia: a prospective study.

BACKGROUND: We investigated associations between maternal characteristics, access to care, and obstetrical complications including near miss status on admission or during hospitalization on perinatal outcomes among Indonesian singletons. METHODS: We prospectively collected data on inborn singletons at two hospitals in East Java. Data included socio-demographics, reproductive, obstetric and neonatal variables. Reduced multivariable models were constructed. Outcomes of interest included low and very low birthweight (LBW/VLBW), asphyxia and death. RESULTS: Referral from a care facility was associated with a reduced risk of LBW and VLBW [AOR = 0.28, 95% CI = 0.11-0.69, AOR = 0.18, 95% CI = 0.04-0.75, respectively], stillbirth [AOR = 0.41, 95% CI = 0.18-0.95], and neonatal death [AOR = 0.2, 95% CI = 0.05-0.81]. Mothers age <20 years increased the risk of VLBW [AOR = 6.39, 95% CI = 1.82-22.35] and neonatal death [AOR = 4.10, 95% CI = 1.29-13.02]. Malpresentation on admission increased the risk of asphyxia [AOR = 4.65, 95% CI = 2.23-9.70], stillbirth [AOR = 3.96, 95% CI = 1.41-11.15], and perinatal death [AOR = 3.89 95% CI = 1.42-10.64], as did poor prenatal care (PNC) [AOR = 11.67, 95%CI = 2.71-16.62]. Near-miss on admission increased the risk of neonatal [AOR = 11.67, 95% CI = 2.08-65.65] and perinatal death [AOR = 13.08 95% CI = 3.77-45.37]. CONCLUSIONS: Mothers in labor should be encouraged to seek care early and taught to identify early danger signs. Adequate PNC significantly reduced perinatal deaths. Improved hospital management of malpresentation may significantly reduce perinatal morbidity and mortality. The importance of hospital-based prospective studies helps evaluate specific areas of need in training of obstetrical care providers.

Comorbidity and Survival in Lung Cancer Patients.

BACKGROUND: As the population of the United States ages, there will be increasing numbers of lung cancer patients with comorbidities at diagnosis. Comorbid conditions are important factors in both the choice of the lung cancer treatment and outcomes. However, the impact of individual comorbid conditions on patient survival remains unclear. METHODS: A population-based cohort study of 5,683 first-time diagnosed lung cancer patients was captured using the Nebraska Cancer Registry (NCR) linked with the Nebraska Hospital Discharge Data (NHDD) between 2005 and 2009. A Cox proportional hazards model was used to analyze the effect of comorbidities on the overall survival of patients stratified by stage and adjusting for age, race, sex, and histologic type. RESULTS: Of these patients, 36.8% of them survived their first year after lung cancer diagnosis, with a median survival of 9.3 months for all stages combined. In this cohort, 26.7% of the patients did not have any comorbidity at diagnosis. The most common comorbid conditions were chronic pulmonary disease (52.5%), diabetes (15.7%), and congestive heart failure (12.9%). The adjusted overall survival of lung cancer patients was negatively associated with the existence of different comorbid conditions such as congestive heart failure, diabetes with complications, moderate or severe liver disease, dementia, renal disease, and cerebrovascular disease, depending on the stage. CONCLUSIONS: The presence of comorbid conditions was associated with worse survival. Different comorbid conditions were associated with worse outcomes at different stages. IMPACT: Future models for predicting lung cancer survival should take individual comorbid conditions into consideration.

An option for measuring maternal mortality in developing countries: a survey using community informants.

BACKGROUND: The maternal mortality ratio (MMR) remains high in most developing countries. Local, recent estimates of MMR are needed to motivate policymakers and evaluate interventions. But, estimating MMR, in the absence of vital registration systems, is difficult. This paper describes an efficient approach using village informant networks to capture maternal death cases (Maternal Deaths from Informants/Maternal Death Follow on Review or MADE-IN/MADE-FOR) developed to address this gap, and examines its validity and efficiency. METHODS: MADE-IN used two village informant networks - heads of neighbourhood units (RTs) and health volunteers (Kaders). Informants were invited to attend separate network meetings - through the village head (for the RT) and through health centre for the kaders. Attached to the letter was a form with written instructions requesting informants list deaths of women of reproductive age (WRA) in the village during the previous two years. At a 'listing meeting' the informants' understanding on the form was checked, informants could correct their forms, and then collectively agreed a consolidated list. MADE-FOR consisted of visits relatives of likely pregnancy related deaths (PRDs) identified from MADE-IN, to confirm the PRD status and gather information about the cause of death. Capture-recapture (CRC) analysis enabled estimation of coverage rates of the two networks, and of total PRDs. RESULTS: The RT network identified a higher proportion of PRDs than the kaders (estimated 0.85 vs. 0.71), but the latter was easier and cheaper to access. Assigned PRD status amongst identified WRA deaths was more accurate for the kader network, and seemingly for more recent deaths, and for deaths from rural areas. Assuming information on live births from an existing source to calculate the MMR, MADE-IN/MADE-FOR cost only $0.1 (US) per women-year risk of exposure, substantially cheaper than alternatives. CONCLUSIONS: This study shows that reliable local, recent estimates of MMR can be obtained relatively cheaply using two independent informant networks to identify cases. Neither network captured all PRDs, but capture-recapture analysis allowed self-calibration. However, it requires careful avoidance of false-positives, and matching of cases identified by both networks, which was achieved by the home visit.

A practical approach to identifying maternal deaths missed from routine hospital reports: lessons from Indonesia.

BACKGROUND: Accurate estimates of the number of maternal deaths in both the community and facility are important, in order to allocate adequate resources to address such deaths. On the other hand, current studies show that routine methods of identifying maternal deaths in facilities underestimate the number by more than one-half. OBJECTIVE: To assess the utility of a new approach to identifying maternal deaths in hospitals. METHOD: Deaths of women of reproductive age were retrospectively identified from registers in two district hospitals in Indonesia over a 24-month period. Based on information retrieved, deaths were classified as 'maternal' or 'non-maternal' where possible. For deaths that remained unclassified, a detailed case note review was undertaken and the extracted data were used to facilitate classification. RESULTS: One hundred and fifty-five maternal deaths were identified, mainly from the register review. Only 67 maternal deaths were recorded in the hospitals' routine reports over the same period. This underestimation of maternal deaths was partly due to the incomplete coverage of the routine reporting system; however, even in the wards where routine reports were made, the study identified twice as many deaths. CONCLUSION: The RAPID method is a practical method that provides a more complete estimate of hospital maternal mortality than routine reporting systems.