Testing the assumptions of an indicator of unmet need for obstetric surgery in Ghana: A cross-sectional study of linked hospital and population-based delivery data.

BACKGROUND: The Unmet Obstetric Need (UON) indicator has been widely used to estimate unmet need for life-saving surgery at birth; however, its assumptions have not been verified. The objective of this study was to test two UON assumptions: (a) Absolute maternal indications (AMIs) require surgery for survival and (b) 1%-2% of deliveries develop AMIs, implying that rates of surgeries for AMIs below this threshold indicate excess mortality from these complications. METHODS: We used linked hospital and population-based data in central Ghana. Among hospital deliveries, we calculated the percentage of deliveries with AMIs who received surgery, and mortality among AMIs who did not. At the population level, we assessed whether the percentage of deliveries with surgeries for AMIs was inversely associated with mortality from these complications, stratified by education. RESULTS: A total of 380 of 387 (98%) hospital deliveries with recorded AMIs received surgery; an additional eight women with no AMI diagnosis died of AMI-related causes. Among the 50 148 deliveries in the population, surgeries for AMIs increased from 0.6% among women with no education to 1.9% among women with post-secondary education (P < .001). However, there was no association between AMI-related mortality and education (P = .546). Estimated AMI prevalence was 0.84% (95% CI: 0.76%-0.92%), below the assumed 1% minimum threshold. DISCUSSION: Obstetric providers consider AMIs absolute indications for surgery. However, low rates of surgeries for AMIs among less educated women were not associated with higher mortality. The UON indicator should be used with caution in estimating the unmet need for life-saving obstetric surgery; innovative approaches are needed to identify unmet need in the context of rising cesarean rates.

Effect of early infant feeding practices on infection-specific neonatal mortality: an investigation of the causal links with observational data from rural Ghana.

BACKGROUND: Strong associations between delayed initiation of breastfeeding and increased neonatal mortality (2-28 d) were recently reported in rural Ghana. Investigation into the biological plausibility of this relation and potential causal pathways is needed. OBJECTIVE: The objective was to assess the effect of early infant feeding practices (delayed initiation, prelacteal feeding, established neonatal breastfeeding) on infection-specific neonatal mortality in breastfed neonates aged 2-28 d. DESIGN: This prospective observational cohort study was based on 10 942 breastfed singleton neonates born between 1 July 2003 and 30 June 2004, who survived to day 2, and whose mothers were visited in the neonatal period. Verbal autopsies were used to ascertain the cause of death. RESULTS: One hundred forty neonates died from day 2 to day 28; 93 died of infection and 47 of noninfectious causes. The risk of death as a result of infection increased with increasing delay in initiation of breastfeeding from 1 h to day 7; overall late initiation (after day 1) was associated with a 2.6-fold risk [adjusted odds ratio (adj OR): 2.61; 95% CI: 1.68, 4.04]. Partial breastfeeding was associated with a 5.7-fold adjusted risk of death as a result of infectious disease (adj OR: 5.73; 95% CI: 2.75, 11.91). No obvious associations were observed between these feeding practices and noninfection-specific mortality. Prelacteal feeding was not associated with infection (adj OR: 1.11; 95% CI: 0.66, 1.86) or noninfection-specific (adj OR: 1.33; 95% CI: 0.55, 3.22) mortality. CONCLUSIONS: This study provides the first epidemiologic evidence of a causal association between early breastfeeding and reduced infection-specific neonatal mortality in young human infants.

Effect of socioeconomic deprivation and health service utilisation on antepartum and intrapartum stillbirth: population cohort study from rural Ghana.

BACKGROUND: No studies have examined the effect of socioeconomic deprivation on antepartum and intrapartum stillbirths in the poorest women in low income countries. METHODOLOGY/ PRINCIPAL FINDINGS: This study used data from a prospective population based surveillance system involving all women of childbearing age and their babies in rural Ghana. The primary objective was to evaluate associations between household wealth and risk of antepartum and intrapartum stillbirth. The secondary objective was to assess whether any differences in risk were mediated by utilisation of health services during pregnancy. Data were analysed using multivariable logistic regression. Random effect models adjusted for clustering of women who delivered more than one infant. There were 80267 babies delivered from 1 July 2003 to 30 September 2008: 77666 live births and 2601 stillbirths. Of the stillbirths 1367 (52.6%) were antepartum, 989 (38.0%) were intrapartum and 245 (9.4%) had no data on the timing of death. 94.8% of the babies born in the study (76129/80267) had complete data on all covariates and outcomes. 36 878 (48.4%) of babies were born to women in the two poorest quintiles and 3697 (4.9%) had no pregnancy care. There was no association between wealth and antepartum stillbirths. There was a marked 'dose response' of increasing risk of intrapartum stillbirth with increasing levels of socioeconomic deprivation (adjOR 1.09 [1.03-1.16] p value 0.002). Women in the poorest two quintiles had greater risk of intrapartum stillbirth (adjOR 1.19 [1.02-1.38] p value 0.023) compared to the richest women. Adjusting for heath service utilisation and other variables did not alter results. CONCLUSIONS/ SIGNIFICANCE: Poor women had a high risk of intrapartum stillbirth and this risk was not influenced by health service utilisation. Health system strengthening is required to meet the needs of poor women in our study population.

Long-term effects of reproductive history on all-cause mortality among adults in rural Bangladesh.

A woman's risk of dying is altered during pregnancy and immediately postpartum. Moreover, physiological and social changes associated with pregnancy may have long-term effects on mortality. Comparing these long-term associations among women and their husbands may provide insights into the nature of such a relationship. In this cohort study, we examine the association between reproductive history and all-cause mortality among ever-married women and men after age 45 in Matlab, Bangladesh, using data collected between 1982 and 1998 for a unique demographic surveillance system. No association was found between parity and mortality among women, but a small decrease in men's mortality was found to be associated with their wives' parity. Survival for both sexes was greatly enhanced by an increasing number of surviving children, regardless of parity or other social factors. A "healthy pregnant woman effect" coupled with the social and economic advantages of having surviving children may explain the observed effects.