Provider-mother interactions are associated with birth outcome misclassifications in household surveys: A case-control study in Guinea-Bissau.

Background: Approximately 4.4 million children die peripartum annually, primarily in low- and middle-income countries. Accurate mortality tracking is essential to prioritising prevention efforts but is undermined by misclassification between stillbirths (SBs) and early neonatal deaths (ENNDs) in household surveys, which serve as key data sources. We explored and quantified associations between peripartum provider-mother interactions and misclassification of SBs and ENNDs in Guinea-Bissau. Methods: Using a case-control design, we followed up on women who had reported a SB or ENND in a retrospective household survey nested in the Bandim Health Project's Health and Demographic Surveillance Systems (HDSS). Using prospective HDSS registration as the reference standard, we linked the survey-reported deaths to the corresponding HDSS records and cross-tabulated SB/ENND classification to identify cases (discordant classification between survey and HDSS) and controls (concordant classification). We further interviewed cases and controls on peripartum provider-mother interactions and analysed data using descriptive statistics and logistic regressions. Results: We interviewed 278 women (cases: 63 (23%); controls: 215 (77%)). Most cases were SBs misclassified as ENNDs (n/N = 49/63 (78%)). Three-fourths of the interviewed women reported having received no updates on the progress of labour and baby's health intrapartum, and less than one-fourth inquired about this information. In comparison with births where women did inquire for information, misclassification was less likely when women did not inquire and recalled no doubts about progress of labour (odds ratio (OR) = 0.51; 95% confidence interval (CI) = 0.28-0.91), or baby's health (OR = 0.54; 95% CI = 0.30-0.97). Most women reported that service providers' death notifications lasted <5 minutes (cases: 23/27 (85%); controls: 61/71 (86%)), and most often encompassed neither events leading to the death (cases: 19/27 (70%); controls: 55/71 (77%)) nor causes of death (cases: 20/27 (74%); controls: 54/71 (76%)). Misclassification was more likely if communication lasted <1 compared to 1-4 minutes (OR = 1.83; 95% CI = 1.10-3.06) and if a formal service provider had informed the mother of the death compared to a family member (OR = 1.57; 95% CI = 1.04-2.36). Conclusions: Peripartum provider-mother interactions are limited in Guinea-Bissau and associated with birth outcome misclassifications in retrospective household surveys. In our study population, misclassification led to overestimated neonatal mortality.

Racial-ethnic disparities in case fatality ratio narrowed after age standardization: A call for race-ethnicity-specific age distributions in State COVID-19 data.

Importance: COVID-19 racial disparities have gained significant attention yet little is known about how age distributions obscure racial-ethnic disparities in COVID-19 case fatality ratios (CFR). Objective: We filled this gap by assessing relevant data availability and quality across states, and in states with available data, investigating how racial-ethnic disparities in CFR changed after age adjustment. Design/Setting/Participants/Exposure: We conducted a landscape analysis as of July 1st, 2020 and developed a grading system to assess COVID-19 case and death data by age and race in 50 states and DC. In states where age- and race-specific data were available, we applied direct age standardization to compare CFR across race-ethnicities. We developed an online dashboard to automatically and continuously update our results. Main Outcome and Measure: Our main outcome was CFR (deaths per 100 confirmed cases). We examined CFR by age and race-ethnicities. Results: We found substantial variations in disaggregating and reporting case and death data across states. Only three states, California, Illinois and Ohio, had sufficient age- and race-ethnicity-disaggregation to allow the investigation of racial-ethnic disparities in CFR while controlling for age. In total, we analyzed 391,991confirmed cases and 17,612 confirmed deaths. The crude CFRs varied from, e.g. 7.35% among Non-Hispanic (NH) White population to 1.39% among Hispanic population in Ohio. After age standardization, racial-ethnic differences in CFR narrowed, e.g. from 5.28% among NH White population to 3.79% among NH Asian population in Ohio, or an over one-fold difference. In addition, the ranking of race-ethnic-specific CFRs changed after age standardization. NH White population had the leading crude CFRs whereas NH Black and NH Asian population had the leading and second leading age-adjusted CFRs respectively in two of the three states. Hispanic population's age-adjusted CFR were substantially higher than the crude. Sensitivity analysis did not change these results qualitatively. Conclusions and Relevance: The availability and quality of age- and race-ethnic-specific COVID-19 case and death data varied greatly across states. Age distributions in confirmed cases obscured racial-ethnic disparities in COVID-19 CFR. Age standardization narrows racial-ethnic disparities and changes ranking. Public COVID-19 data availability, quality, and harmonization need improvement to address racial disparities in this pandemic.