Neonatal mortality during the war in Tigray: a cross-sectional community-based study.

BACKGROUND: Neonatal mortality is among the key national and international indicators of health services. The global Sustainable Development Goal target for neonatal mortality is fewer than 12 deaths per 1000 livebirths, by 2030. Neonatal mortality estimates in the 2019 Ethiopian Demographic Health Survey found 25·7 deaths per 1000 livebirths. Subnational surveys specific to Tigray, Ethiopia, reported a neonatal mortality lifetime prevalence of 7·13 deaths. Another government report from the Tigray region estimated a neonatal mortality rate of ten deaths per 1000 livebirths in 2020. Despite the numerous interventions in Ethiopia's Tigray region to achieve the Sustainable Development Goals, the war has disrupted most health services, but the effect on neonatal mortality is unknown. Thus, this study aimed to investigate the magnitude and causes of neonatal mortality during the war in Tigray. METHODS: A cross-sectional community-based study was conducted in Tigray to evaluate neonatal mortality that occurred from Nov 4, 2020, to May 30, 2022. Among the 31 districts, 121 tabias were selected using computer-generated random sampling, and 189 087 households were visited. We adopted a validated WHO 2022 verbal autopsy tool, and data were collected using an interviewer-administrated Open Data Kit. In the absence of the mother, other respondents to the verbal autopsy interview were household members aged 18 years and older who provided care during the final illness that led to death. FINDINGS: 29 761 livebirths were recorded during the screening of 189 087 households. Verbal autopsy was administered for 1158 households with neonatal deaths. 317 neonates were stillborn, and 841 neonatal deaths were recorded with the WHO 2022 verbal autopsy tool from Nov 4, 2020, to May 30, 2022, in 31 districts. The neonatal mortality rate was 28·2 deaths per 1000 livebirths. 476 (57%) of the 841 neonatal deaths occurred at home and 296 (35%) in health facilities. A high rate of neonatal deaths was reported in rural districts (80% [673 of 841]) compared with urban districts (20% [168 of 841]), and 663 (79%) deaths occurred during the early neonatal period, in the first week of life (0-6 days). The leading causes of neonatal death were asphyxia (35% [291 of 834]), prematurity (30% [247 of 834]), and infection (12% [104 of 834]). Asphyxia (37% [246 of 663]) and infection (28% [50 of 178]) were the leading causes of death for early and late neonatal period deaths, respectively. INTERPRETATION: Neonatal mortality in Tigray is high due to preventable causes. An urgent response is needed to prevent the high number of neonatal deaths associated with the depleted health resources and services resulting from the war, and to achieve the Sustainable Development Goal on neonatal mortality. FUNDING: UNICEF and United Nations Fund for Population Activities. TRANSLATION: For the Tigrigna translation of the abstract see Supplementary Materials section.

Reduced fetal cerebral blood flow predicts perinatal mortality in a mouse model of prenatal alcohol and cannabinoid exposure.

BACKGROUND: Children exposed prenatally to alcohol or cannabinoids individually can exhibit growth deficits and increased risk for adverse birth outcomes. However, these drugs are often co-consumed and their combined effects on early brain development are virtually unknown. The blood vessels of the fetal brain emerge and mature during the neurogenic period to support nutritional needs of the rapidly growing brain, and teratogenic exposure during this gestational window may therefore impair fetal cerebrovascular development. STUDY DESIGN: To determine whether prenatal polysubstance exposure confers additional risk for impaired fetal-directed blood flow, we performed high resolution in vivo ultrasound imaging in C57Bl/6J pregnant mice. After pregnancy confirmation, dams were randomly assigned to one of four groups: drug-free control, alcohol-exposed, cannabinoid-exposed or alcohol-and-cannabinoid-exposed. Drug exposure occurred daily between Gestational Days 12-15, equivalent to the transition between the first and second trimesters in humans. Dams first received an intraperitoneal injection of either cannabinoid agonist CP-55,940 (750 µg/kg) or volume-equivalent vehicle. Then, dams were placed in vapor chambers for 30 min of inhalation of either ethanol or room air. Dams underwent ultrasound imaging on three days of pregnancy: Gestational Day 11 (pre-exposure), Gestational Day 13.5 (peri-exposure) and Gestational Day 16 (post-exposure). RESULTS: All drug exposures decreased fetal cranial blood flow 24-hours after the final exposure episode, though combined alcohol and cannabinoid co-exposure reduced internal carotid artery blood flow relative to all other exposures. Umbilical artery metrics were not affected by drug exposure, indicating a specific vulnerability of fetal cranial circulation. Cannabinoid exposure significantly reduced cerebroplacental ratios, mirroring prior findings in cannabis-exposed human fetuses. Post-exposure cerebroplacental ratios significantly predicted subsequent perinatal mortality (p = 0.019, area under the curve, 0.772; sensitivity, 81%; specificity, 85.70%) and retroactively diagnosed prior drug exposure (p = 0.005; AUC, 0.861; sensitivity, 86.40%; specificity, 66.7%). CONCLUSIONS: Fetal cerebrovasculature is significantly impaired by exposure to alcohol or cannabinoids, and co-exposure confers additional risk for adverse birth outcomes. Considering the rising potency and global availability of cannabis products, there is an imperative for research to explore translational models of prenatal drug exposure, including polysubstance models, to inform appropriate strategies for treatment and care in pregnancies affected by drug exposure.

Predictors of health workers' knowledge of maternal and perinatal deaths surveillance and response system in Morogoro region, Tanzania: An analytical cross-sectional study.

This study aimed at assessing the predictors of knowledge about the Maternal and Perinatal Deaths Surveillance and Response (MPDSR) system among health workers in the Morogoro region. It was an analytical cross-sectional study, conducted from April 27 to May 29, 2020. A multistage sampling technique was used to recruit 360 health workers. A semi-structured questionnaire was used to collect the data. Statistical Package for Social Science (SPSS v.20) software was used for data entry and analysis. Bivariate and multivariate logistic regression analyses were used to assess factors associated with knowledge of MPDSR. A total of 105 (29.2%) health workers in the Morogoro region had adequate knowledge of the MPDSR system. After controlling for confounders, predictors of knowledge on the MPDSR system were the level of health facility a health worker was working (n [hospital [adjusted odds ratio [AOR] = 2.668 at 95% confidence intervals [CI] = 1.497-4.753, P = .001]), level of education of a health worker (diploma [AOR = 0.146 at 95% CI = 0.038-0.561, P = .005]), and status of training on MPDSR (trained [AOR = 7.253 at 95% CI = 3.862-13.621, P ≤ .001]). The proportion of health workers with adequate knowledge about the MPDSR system in the Morogoro region is unacceptably low. Factors associated with adequate knowledge were those working in hospitals with higher levels of professional training and those who had ever had training in MPDSR. A cost-effective strategy to improve the level of knowledge regarding MPDSR in this region is highly recommended.

Professional approach to the care of women who have suffered a perinatal loss.

To understand the experience, training, and needs of midwives in their approach to perinatal grief. A descriptive cross-sectional study was carried out using an online questionnaire with 26 questions related to institutional management and individual clinical practices in the care of a perinatal loss was developed by a team of midwives from the Hospital "La Mancha-Centro" of Alcazar de San Juan (Ciudad Real). Strobe checklist was followed. A total of 267 midwives participated. A total of 92.1% (246) of the centers had specific protocols for action, but each professional applied their own criteria. The presence of a perinatal psychology team was nonexistent according to 88% (235) of those surveyed. Regarding their training and professional experience, 16.5% (44) of the midwives had never received training. Only 4.1% (11) of the midwives felt very prepared to care for women with a perinatal loss. Among the factors associated with greater application of recommended practices in the face of perinatal death by midwives were being a woman, having prior training on care during perinatal death, and a greater perception of preparation (p < 0.05). The perception of lack of preparation on the part of midwives in the accompaniment of these families was high.

Evaluating health workers attitude towards implementation of maternal and perinatal deaths surveillance and response system in Morogoro region; analytical cross-sectional study.

Maternal and Perinatal Deaths Review and Surveillance (MPDSR) is a technical system which was issued by the World Health Organization in 2013 to help developing countries improve maternal health. The major purpose of the system was to reduce the ongoing high numbers of maternal deaths and perinatal deaths from avertable causes. Tanzania adopted MPDSR system in 2015. The study aimed to assess health workers attitude towards implementation of MPDSR system in Morogoro Region. This analytical cross-sectional study was conducted in three districts of Morogoro region from April 27, 2020 to May 29, 2020 involving 360 health workers from 38 health facilities. A semi-structured questionnaire was used for data collection. SPSS software version 25 was used to analyze the obtained data. Descriptive analysis was done to describe the characteristics of study participants. Binary logistic regression analysis was used to assess predictors of health workers attitude towards the MPDSR system. A total of 255(70.8%) of respondents had positive attitude towards MPDSR system. After controlling of confounders predictor of positive attitude were location of health facility [rural (AOR = 0.216 at 95% CI = 0.121-0.387, p = <0.001)], Age group [Below 30(AOR = 0.459 at 95%CI = 0.264-0.796, p = 0.006)] and status of training on MPDSR [Yes (AOR = 4.892 at 95%CI = 2.187-10.942, P = <0.001)]. Substantial number of health workers had positive attitude towards the MPDSR system. Health workers who were residing in rural settings and younger than 30 years were less likely to have positive attitude towards the system. Health workers who had access to be trained about the system were more likely to have positive attitude towards MPDSR system. The study recommends the training of health workers about the system so as to increase their attitude and hence the use of the system.

Predictors of neonatal mortality among neonates admitted to the neonatal intensive care unit at Hawassa University Comprehensive Specialized Hospital, Sidama regional state, Ethiopia.

BACKGROUND: Despite promising efforts, substantial deaths occurred during the neonatal period. According to estimates from the World Health Organization (WHO), Ethiopia is among the top 10 nations with the highest number of neonatal deaths in 2020 alone. This staggering amount makes it difficult to achieve the SDG (Sustainable Development Goals) target that calls for all nations to work hard to meet a neonatal mortality rate target of ≤ 12 deaths per 1,000 live births by 2030. We evaluated neonatal mortality and it's contributing factors among newborns admitted to the Neonatal Intensive Care Unit (NICU) at Hawassa University Comprehensive Specialized Hospital (HUCSH). METHODS: A hospital-based retrospective cross-sectional study on neonates admitted to the NICU from May 2021 to April 2022 was carried out at Hawassa University Comprehensive Specialized Hospital. From the admitted 1044 cases over the study period, 225 babies were sampled using a systematic random sampling procedure. The relationship between variables was determined using bivariate and multivariable analyses, and statistically significant relations were indicated at p-values less than 0.05. RESULTS: The magnitude of neonatal death was 14.2% (95% CI: 0.099-0.195). The most common causes of neonatal death were prematurity 14 (43.8%), sepsis 9 (28.1%), Perinatal asphyxia 6 (18.8%), and congenital malformations 3 (9.4%). The overall neonatal mortality rate was 28 per 1000 neonate days. Neonates who had birth asphyxia were 7.28 times more probable (AOR = 7.28; 95% CI: 2.367, 9.02) to die. Newborns who encountered infection within the NICU were 8.17 times more likely (AOR = 8.17; 95% CI: 1.84, 36.23) to die. CONCLUSION: The prevalence of newborn death is excessively high. The most common causes of mortality identified were prematurity, sepsis, perinatal asphyxia and congenital anomalies. To avert these causes, we demand that antenatal care services be implemented appropriately, delivery care quality be improved, and appropriate neonatal care and treatment be made available.

Midwife continuity of care models versus other models of care for childbearing women.

BACKGROUND: Midwives are primary providers of care for childbearing women globally and there is a need to establish whether there are differences in effectiveness between midwife continuity of care models and other models of care. This is an update of a review published in 2016. OBJECTIVES: To compare the effects of midwife continuity of care models with other models of care for childbearing women and their infants. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Trials Register, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (17 August 2022), as well as the reference lists of retrieved studies. SELECTION CRITERIA: All published and unpublished trials in which pregnant women are randomly allocated to midwife continuity of care models or other models of care during pregnancy and birth. DATA COLLECTION AND ANALYSIS: Two authors independently assessed studies for inclusion criteria, scientific integrity, and risk of bias, and carried out data extraction and entry. Primary outcomes were spontaneous vaginal birth, caesarean section, regional anaesthesia, intact perineum, fetal loss after 24 weeks gestation, preterm birth, and neonatal death. We used GRADE to rate the certainty of evidence. MAIN RESULTS: We included 17 studies involving 18,533 randomised women. We assessed all studies as being at low risk of scientific integrity/trustworthiness concerns. Studies were conducted in Australia, Canada, China, Ireland, and the United Kingdom. The majority of the included studies did not include women at high risk of complications. There are three ongoing studies targeting disadvantaged women. Primary outcomes Based on control group risks observed in the studies, midwife continuity of care models, as compared to other models of care, likely increase spontaneous vaginal birth from 66% to 70% (risk ratio (RR) 1.05, 95% confidence interval (CI) 1.03 to 1.07; 15 studies, 17,864 participants; moderate-certainty evidence), likelyreduce caesarean sections from 16% to 15% (RR 0.91, 95% CI 0.84 to 0.99; 16 studies, 18,037 participants; moderate-certainty evidence), and likely result in little to no difference in intact perineum (29% in other care models and 31% in midwife continuity of care models, average RR 1.05, 95% CI 0.98 to 1.12; 12 studies, 14,268 participants; moderate-certainty evidence). There may belittle or no difference in preterm birth (< 37 weeks) (6% under both care models, average RR 0.95, 95% CI 0.78 to 1.16; 10 studies, 13,850 participants; low-certainty evidence). We arevery uncertain about the effect of midwife continuity of care models on regional analgesia (average RR 0.85, 95% CI 0.79 to 0.92; 15 studies, 17,754 participants, very low-certainty evidence), fetal loss at or after 24 weeks gestation (average RR 1.24, 95% CI 0.73 to 2.13; 12 studies, 16,122 participants; very low-certainty evidence), and neonatal death (average RR 0.85, 95% CI 0.43 to 1.71; 10 studies, 14,718 participants; very low-certainty evidence). Secondary outcomes When compared to other models of care, midwife continuity of care models likely reduce instrumental vaginal birth (forceps/vacuum) from 14% to 13% (average RR 0.89, 95% CI 0.83 to 0.96; 14 studies, 17,769 participants; moderate-certainty evidence), and may reduceepisiotomy 23% to 19% (average RR 0.83, 95% CI 0.77 to 0.91; 15 studies, 17,839 participants; low-certainty evidence). When compared to other models of care, midwife continuity of care models likelyresult in little to no difference inpostpartum haemorrhage (average RR 0.92, 95% CI 0.82 to 1.03; 11 studies, 14,407 participants; moderate-certainty evidence) and admission to special care nursery/neonatal intensive care unit (average RR 0.89, 95% CI 0.77 to 1.03; 13 studies, 16,260 participants; moderate-certainty evidence). There may be little or no difference in induction of labour (average RR 0.92, 95% CI 0.85 to 1.00; 14 studies, 17,666 participants; low-certainty evidence), breastfeeding initiation (average RR 1.06, 95% CI 1.00 to 1.12; 8 studies, 8575 participants; low-certainty evidence), and birth weight less than 2500 g (average RR 0.92, 95% CI 0.79 to 1.08; 9 studies, 12,420 participants; low-certainty evidence). We are very uncertain about the effect of midwife continuity of care models compared to other models of care onthird or fourth-degree tear (average RR 1.10, 95% CI 0.81 to 1.49; 7 studies, 9437 participants; very low-certainty evidence), maternal readmission within 28 days (average RR 1.52, 95% CI 0.78 to 2.96; 1 study, 1195 participants; very low-certainty evidence), attendance at birth by a known midwife (average RR 9.13, 95% CI 5.87 to 14.21; 11 studies, 9273 participants; very low-certainty evidence), Apgar score less than or equal to seven at five minutes (average RR 0.95, 95% CI 0.72 to 1.24; 13 studies, 12,806 participants; very low-certainty evidence) andfetal loss before 24 weeks gestation (average RR 0.82, 95% CI 0.67 to 1.01; 12 studies, 15,913 participants; very low-certainty evidence). No maternal deaths were reported across three studies. Although the observed risk of adverse events was similar between midwifery continuity of care models and other models, our confidence in the findings was limited. Our confidence in the findings was lowered by possible risks of bias, inconsistency, and imprecision of some estimates. There were no available data for the outcomes: maternal health status, neonatal readmission within 28 days, infant health status, and birth weight of 4000 g or more. Maternal experiences and cost implications are described narratively. Women receiving care from midwife continuity of care models, as opposed to other care models, generally reported more positive experiences during pregnancy, labour, and postpartum. Cost savings were noted in the antenatal and intrapartum periods in midwife continuity of care models. AUTHORS' CONCLUSIONS: Women receiving midwife continuity of care models were less likely to experience a caesarean section and instrumental birth, and may be less likely to experience episiotomy. They were more likely to experience spontaneous vaginal birth and report a positive experience. The certainty of some findings varies due to possible risks of bias, inconsistencies, and imprecision of some estimates. Future research should focus on the impact on women with social risk factors, and those at higher risk of complications, and implementation and scaling up of midwife continuity of care models, with emphasis on low- and middle-income countries.

Determinants of externally visible birth defects among perinatal deaths at Adama Comprehensive Specialized Hospital: a case-control study.

BACKGROUND: Birth defects (BDs) are the major causes of infant morbidity and mortality in both developed and developing countries. Regardless of their clinical importance, few studies on predisposing factors have been conducted in Ethiopia. However, due to a lack of advanced diagnostic materials, we only considered the externally visible BDs. OBJECTIVE: To assess the determinants of externally visible birth defects among perinatal deaths at Adama Comprehensive Specialized Hospital. METHODS: A retrospective unmatched case-control study design was conducted from November 01 to 30, 2021. The sample size was determined by Epi Info version 7 software considering sample size calculation for an unmatched case-control study. A total of 315 participants (63 cases, and 252 controls) were selected by simple random sampling. Data were collected by an open data kit (ODK) and transported to a statical package for social sciences (SPSS) version 26 software for analysis. The bivariate followed by multivariable logistic regression analyses were done to determine the factors associated with the BD. RESULTS: This study showed that drinking alcohol during pregnancy (AOR = 6.575; 95% CI: 3.102,13.937), lack of antenatal care (ANC) follow-up during pregnancy (AOR = 2.794; 95% CI: 1.333, 5.859), having a history of stillbirth in a previous pregnancy (AOR = 3.967; 95% CI: 1.772, 8.881), exposure to pesticides during pregnancy (AOR = 4.840; 95% CI: 1.375, 17.034), having a history of BDs in a previous pregnancy (AOR = 4.853; 95% CI: 1.492, 15.788), and lack of folic acid supplementation during early pregnancy (AOR = 4.324; 95% CI: 2.062, 9.067) were significant determinants of externally visible BDs among perinatal deaths. CONCLUSION: In this study, alcohol use, exposure to pesticides, and lack of folic acid supplementation during pregnancy were identified as the major determinants of externally visible BDs among perinatal deaths. Thus, health education regarding the associated factors of BDs and their preventive strategies should be given to pregnant mothers.

Analysis and prediction of central nervous system tumor burden in China during 1990-2030.

Central nervous system (CNS) tumors, due to their unique locations, pose a serious threat to human health and present challenges to modern medicine. These tumors exhibit notable epidemiological characteristics across various ethnicities, regions, and age groups. This study investigated the trend of disease burden of CNS tumors in China from 1990-2019 and predicted the incidence and death rate from 2020-2030. Employing data from the 2019 Global Burden of Disease (GBD) database, we utilized key indicators to scrutinize the disease burden associated with CNS tumors in China. The analysis employed the Joinpoint model to track the trend in disease burden, calculating both the annual percentage change (APC) and average annual percentage change (AAPC). Additionally, the Matlab software facilitated the creation of a gray model to forecast the incidence and death rate of CNS tumors in China spanning from 2020 to 2030." In 2019, the age-standardized incidence rate, prevalence rate, death rate, and disability-adjusted life years (DALYs) associated with CNS tumors in China were among the high level in the world. The standardized prevalence rate and DALYs of CNS tumors in China residents showed a stable fluctuation trend with age; however, age-standardized death and incidence rate demonstrated a generally upward trend with age. In China, the age-standardized prevalence and incidence rate of males were lower than those for female residents, while the age-standardized death rate and DALYs among males surpassed those of females. From 1990-2019, the age-standardized prevalence and incidence rate of CNS tumors in China exhibited an increasing trend. The age-standardized death rate and DALYs showed a contrasting trend. According to the gray model's prediction, incidence rate of CNS tumors would continue rising while the death rate is expected to decline in China from 2020-2023. The burden of CNS tumors in China has shown an upward trajectory, posing significant challenges to their treatment. It is necessary to pay attention to tertiary prevention, start from the perspective of high-risk groups and high-risk factors to reduce the burden of disease, and achieve "early detection, early diagnosis, and early treatment".

Perinatal mortality in German dairy cattle: Unveiling the importance of cow-level risk factors and their interactions using a multifaceted modelling approach.

Perinatal mortality (PM) is a common issue on dairy farms, leading to calf losses and increased farming costs. The current knowledge about PM in dairy cattle is, however, limited and previous studies lack comparability. The topic has also primarily been studied in Holstein-Friesian cows and closely related breeds, while other dairy breeds have been largely ignored. Different data collection techniques, definitions of PM, studied variables and statistical approaches further limit the comparability and interpretation of previous studies. This article aims to investigate the factors contributing to PM in two underexplored breeds, Simmental (SIM) and Brown Swiss (BS), while comparing them to German Holstein on German farms, and to employ various modelling techniques to enhance comparability to other studies, and to determine if different statistical methods yield consistent results. A total of 133,942 calving records from 131,657 cows on 721 German farms were analyzed. Amongst these, the proportion of PM (defined as stillbirth or death up to 48 hours of age) was 6.1%. Univariable and multivariable mixed-effects logistic regressions, random forest and multimodel inference via brute-force model selection approaches were used to evaluate risk factors on the individual animal level. Although the balanced random forest did not incorporate the random effect, it yielded results similar to those of the mixed-effect model. The brute-force approach surpassed the widely adopted backwards variable selection method and represented a combination of strengths: it accounted for the random effect similar to mixed-effects regression and generated a variable importance plot similar to random forest. The difficulty of calving, breed and parity of the cow were found to be the most important factors, followed by farm size and season. Additionally, four significant interactions amongst predictors were identified: breed-calving ease, breed-season, parity-season and calving ease-farm size. The combination of factors, such as secondiparous SIM breed on small farms and experiencing easy calving in summer, showed the lowest probability of PM. Conversely, primiparous GH cows on large farms with difficult calving in winter exhibited the highest probability of PM. In order to reduce PM, appropriate management of dystocia, optimal heifer management and a wider use of SIM in dairy production are possible ways forward. It is also important that future studies are conducted to identify farm-specific contributors to higher PM on large farms.

A biosocial analysis of perinatal and late neonatal mortality among Indigenous Maya Kaqchikel communities in Tecpán, Guatemala: a mixed-methods study.

INTRODUCTION: Neonatal mortality is a global public health challenge. Guatemala has the fifth highest neonatal mortality rate in Latin America, and Indigenous communities are particularly impacted. This study aims to understand factors driving neonatal mortality rates among Maya Kaqchikel communities. METHODS: We used sequential explanatory mixed methods. The quantitative phase was a secondary analysis of 2014-2016 data from the Global Maternal and Newborn Health Registry from Chimaltenango, Guatemala. Multivariate logistic regression models identified factors associated with perinatal and late neonatal mortality. A number of 33 in-depth interviews were conducted with mothers, traditional Maya midwives and local healthcare professionals to explain quantitative findings. RESULTS: Of 33 759 observations, 351 were lost to follow-up. There were 32 559 live births, 670 stillbirths (20/1000 births), 1265 (38/1000 births) perinatal deaths and 409 (12/1000 live births) late neonatal deaths. Factors identified to have statistically significant associations with a higher risk of perinatal or late neonatal mortality include lack of maternal education, maternal height <140 cm, maternal age under 20 or above 35, attending less than four antenatal visits, delivering without a skilled attendant, delivering at a health facility, preterm birth, congenital anomalies and presence of other obstetrical complications. Qualitative participants linked severe mental and emotional distress and inadequate maternal nutrition to heightened neonatal vulnerability. They also highlighted that mistrust in the healthcare system-fueled by language barriers and healthcare workers' use of coercive authority-delayed hospital presentations. They provided examples of cooperative relationships between traditional midwives and healthcare staff that resulted in positive outcomes. CONCLUSION: Structural social forces influence neonatal vulnerability in rural Guatemala. When coupled with healthcare system shortcomings, these forces increase mistrust and mortality. Collaborative relationships among healthcare staff, traditional midwives and families may disrupt this cycle.

Birth and postnatal outcomes among infants of immigrant parents of different admission categories and parents born in Canada: a population-based retrospective study.

BACKGROUND: Most studies of disparities in birth and postnatal outcomes by parental birthplace combine all immigrants into a single group. We sought to evaluate heterogeneity among immigrants in Canada by comparing birth and postnatal outcomes across different immigration categories. METHODS: We conducted a population-based retrospective study using Statistics Canada data on live births and stillbirths (1993-2017) and infant deaths (1993-2018), linked to parental immigration data (1960-2017). We classified birthing parents as born in Canada, economic-class immigrants, family-class immigrants, or refugees, and evaluated differences in preterm births, small-for-gestational-age (SGA) and large-for-gestational-age (LGA) births, stillbirths, and infant deaths among singleton births by group. RESULTS: Among 7 980 650 births, 1 715 050 (21.5%) were to immigrants, including 632 760 (36.9%) in the economic class, 853 540 (49.8%) in the family class, and 228 740 (13.4%) refugees. Compared with infants of Canadian-born birthing parents, infants of each of the 3 immigrant groups had higher risk of preterm birth, SGA birth, and stillbirth, but lower risk of LGA birth and neonatal death. Compared with infants of economic-class immigrants, infants of refugees had higher risk of early preterm birth (0.9% v. 0.8%, adjusted risk ratio [RR] 1.08, 95% confidence interval [CI] 1.01-1.15) and LGA birth (9.2% v. 7.5%, adjusted RR 1.12, 95% CI 1.10-1.15), but lower risk of SGA birth (10.2% v. 11.0%, adjusted RR 0.92, 95% CI 0.90-0.94), while infants of family-class immigrants had higher risk of SGA birth (12.2% v. 11.0%, adjusted RR 1.01, 95% CI 1.00-1.02). Risk of stillbirth, neonatal death, and overall infant death did not differ significantly among immigrant groups. INTERPRETATION: Heterogeneity exists in outcomes of infants born to immigrants to Canada across immigration categories. These results highlight the importance of disaggregating immigrant populations in studies of health disparities.

Assessing and projecting the global burden of thyroid cancer, 1990-2030: Analysis of the Global Burden of Disease Study.

Background: This study aims to assess the global incidence, mortality, and disability-adjusted life years (DALYs) of thyroid cancer between 1990 and 2030. Methods: Our study analysed Global Burden of Disease (GBD) 2019 data from 204 countries, spanning 1990-2019. It focused on age-standardised thyroid cancer incidence, mortality, and disability-adjusted life years (DALYs), using the sociodemographic index (SDI) for assessing socioeconomic levels. Generalised additive models (GAMs) projected thyroid cancer trends for 2020-2030. Results: The global burden of thyroid cancer is predicted to increase significantly from 1990 to 2030. The number of thyroid cancer incidence cases is projected to rise from 233 846.64 in 2019 to 305 078.08 by 2030, representing an approximate 30.46% increase. The ASIR (age-standardised incidence rate) is expected to continue its upward trend (estimated annual percentage change (EAPC) = 0.83). The age-standardised death rate (ASDR) for thyroid cancer is projected to decline in both genders, more notably in women (EAPC = -0.34) compared to men (EAPC = -0.17). The burden of disease escalates with advancing age, with significant regional disparities. Regions with lower SDI, particularly in South Asia, are anticipated to witness substantial increases in thyroid cancer incidence from 2020 to 2030. The overall disease burden is expected to rise, especially in countries with low to middle SDI, reflecting broader socio-economic and health care shifts. Conclusions: This study highlights significant regional and gender-specific variations in thyroid cancer, with notable increases in incidence rates, particularly in areas like South Asia. These trends suggest improvements in diagnostic capabilities and the influence of socio-economic factors. Additionally, the observed decline in mortality rates across various regions reflects advancements in thyroid cancer management. The findings underline the critical importance of regionally tailored prevention strategies, robust cancer registries, and public health initiatives to address the evolving landscape of thyroid cancer and mitigate health disparities globally.

Uncovering the causes and socio-demographic constructs of stillbirths and neonatal deaths in an urban slum of Karachi.

INTRODUCTION: Neonatal deaths and stillbirths are significant public health concerns in Pakistan, with an estimated stillbirth rate of 43 per 1,000 births and a neonatal mortality rate of 46 deaths per 1,000 live births. Limited access to obstetric care, poor health seeking behaviors and lack of quality healthcare are the leading root causes for stillbirths and neonatal deaths. Rehri Goth, a coastal slum in Karachi, faces even greater challenges due to extreme poverty, and inadequate infrastructure. This study aims to investigate the causes and pathways leading to stillbirths and neonatal deaths in Rehri Goth to develop effective maternal and child health interventions. METHODS: A mixed-method cohort study was nested with the implementation of large maternal, neonatal and child health program, captured all stillbirths and neonatal death during the period of May 2014 till June 2018. The Verbal and Social Autopsy (VASA) tool (WHO 2016) was used to collect primary data from all death events to determine the causes as well as the pathways. Interviews were conducted both retrospectively and prospectively with mothers and caregivers. Two trained physicians reviewed the VASA form and the medical records (if available) and coded the cause of death blinded to each other. Descriptive analysis was used to categorize stillbirth and neonatal mortality data into high- and low-mortality clusters, followed by chi-square tests to explore associations between categories, and concluded with a qualitative analysis. RESULTS: Out of 421 events captured, complete VASA interviews were conducted for 317 cases. The leading causes of antepartum stillbirths were pregnancy-induced hypertension (22.4%) and maternal infections (13.4%), while obstructed labor was the primary cause of intrapartum stillbirths (38.3%). Neonatal deaths were primarily caused by perinatal asphyxia (36.1%) and preterm birth complications (27.8%). The qualitative analysis on a subset of 40 death events showed that health system (62.5%) and community factors (37.5%) contributing to adverse outcomes, such as delayed referrals, poor triage systems, suboptimal quality of care, and delayed care-seeking behaviors. CONCLUSION: The study provides an opportunity to understand the causes of stillbirths and neonatal deaths in one of the impoverished slums of Karachi. The data segregation by clusters as well as triangulation with qualitative analysis highlight the needs of evidence-based strategies for maternal and child health interventions in disadvantaged communities.

Neonatal mortalities without detected risk factors before birth at Mtendeli hospital, Tanzania: a cross-sectional study.

Introduction: neonatal mortality rate (NMR) is defined as the probability of dying during the first 28 days of life expressed per 1,000 live births. The death of neonates without risk factors at the end of pregnancy could be an indicator of sub-optimal quality care during labor and care of sick neonates. Therefore, this study aimed to determine the factors associated with neonatal deaths happening without detected risks during prenatal period. Methods: a cross-sectional study was conducted from 2017 to 2021.The recruited pregnant women were those who had a live, term, single-intrauterine pregnancy without detectable fetal abnormality at the time of starting labor. The data were collected through open data kit (ODK) forms that were customized in kobo tool in the tablets. The data analysis was performed using STATA statistical software. The factors associated with neonatal mortality were analyzed in a multiple logistic regression and considered significant if p < 0.05. Results: among the 4401 enrolled mothers, neonatal deaths were 361 (8.2%). The factors associated with death of neonates without risk factors during prenatal period were low Apgar score [AOR = 4.38: 95%CI (2.33-7.72)], male sex [AOR=2.25: 95%CI (1.12-3.81)], gestational age above 40 weeks [AOR=4.79: (2.50-7.61)] and assisted vaginal delivery [AOR = 2.55: 95%CI (1.12-4.96)]. Conclusion: the increased number of neonatal deaths are associated with sex of neonates, low Apgar score, post maturity and assisted vaginal delivery. The hospital-based studies should be done to address the preventable neonatal deaths with no detected risk factors before birth.

Clinical cause of neonatal mortality in Iran: analysis of the national Iranian Maternal And Neonatal network.

BACKGROUND: The neonatal mortality rate is a main indicator of the health and development of a country. Having insight into the cause of neonatal deaths may be the first step to reducing it. This paper depicts the cause of newborn deaths in Iran. METHODS: This cross-sectional study was performed on data from the national Iranian Maternal And Neonatal network to investigate all neonatal deaths in the country during the year 2019. The cause of death data were reported according to categories of birth weight, gestational age (GA), death time and place. RESULTS: The main causes of the 9959 neonatal deaths during the study period were respiratory distress syndrome (RDS) (37%), malformation (21%), prematurity of <26 weeks (20%), others (12%), asphyxia (7%) and infection (3%). The major causes of neonatal mortality in delivery rooms were prematurity of <26 weeks and in the inpatient wards the RDS. By increasing the GA and birth weight towards term babies, the rate of RDS gets lower, while that of malformation gets higher. CONCLUSIONS: RDS was the main cause of neonatal mortality in Iran which is seen mainly in preterm babies. Prematurity of <26 weeks was another main cause. Thus, suggestions include reducing prematurity by preconception and pregnancy care and, on the other hand, improving the care of preterm infants in delivery rooms and inpatient wards.

The correlation between serum total bile acid and adverse perinatal outcomes in pregnant women with intrahepatic cholestasis of pregnancy (ICP) and non-ICP hypercholanemia of pregnancy.

BACKGROUND: The association between excessive serum total bile acid (TBA) and adverse perinatal outcomes in individuals with non-intrahepatic cholestasis of pregnancy (non-ICP) hypercholanemia has not been determined, and it is unclear if this link is similar to that observed in patients with ICP. OBJECTIVE: To examine the adverse perinatal outcomes in two specific subcategories: those with ICP and those with non-ICP, including individuals with liver disease and asymptomatic hypercholanemia of pregnancy (AHP), at different levels of TBA. Investigate the correlation between TBA levels and adverse perinatal outcomes of ICP, liver disease, and AHP. METHODS: From 2013 to 2021, pregnant women with excessive TBA levels were taken from the electronic medical record database of our hospital and categorized into three groups: ICP (n = 160), liver disease (n = 164), and AHP (n = 650). This was done as part of a retrospective cohort research project. Multivariable regression and subgroup analyses were performed to examine the association between TBA levels and adverse perinatal outcomes in each group. RESULTS: The study found no significant differences in adverse perinatal outcomes between the ICP and liver disease groups at different TBA levels. However, at moderate TBA levels, both groups had a higher risk of adverse perinatal outcomes than the AHP group (p < 0.017). Among liver disease cases with TBA ≥ 100µmol/L, three cases of perinatal deaths (6.67%) associated with moderate-to-severe acute hepatitis occurred between 27 and 33 weeks of gestation. A 59% higher chance of perinatal death was found for every 10 µmol/L rise in TBA, even after significant variables and confounders were taken into account (adjusted odds ratio (aOR) = 1.59; 95% confidence interval (CI): 1.06-2.40; p = 0.03). CONCLUSIONS: If a pregnant woman has moderate-to-severe liver disease and TBA ≥ 100µmol/L, preterm termination of pregnancy (before 34 weeks) may be considered.

If someone doesn't have ICP but does have moderate-to-severe hepatitis and TBA levels of 100 µmol/L or more, they should be treated more aggressively, and their pregnancies should be terminated earlier (before 34 weeks) than what is usually done for ICP.

Identifying avoidable causes of perinatal deaths in a district hospital in Lesotho.

BACKGROUND:  Certain determinants can be associated with avoidable perinatal deaths, and audits are needed to establish what these determinants are, and what can be done to prevent such deaths. OBJECTIVES:  The study aimed at identifying and describing determinants associated with avoidable perinatal deaths at a district hospital in Lesotho and strategies to curb their occurrence. METHOD:  A retrospective descriptive study was conducted using 142 anonymised obstetric records from January 2018 to December 2020. A data collection tool was adopted from the Perinatal Problem Identification Programme. In this tool, avoidable determinants are referred to as 'factors' or 'problems'. RESULTS:  A concerning number of perinatal deaths were secondary to avoidable patient factors, namely a delay in seeking medical care, inappropriate responses to antepartum haemorrhage, and inadequate responses to poor foetal movements. Medical personnel factors are also worth observing, namely incorrect use of partograph, insufficient notes to comment on avoidable factors and 'other' medical personnel problems. Ranking highest among administrative problems were the unavailability of intensive care unit beds and ventilators and inadequate resuscitation equipment. Administrative problems accounted for more perinatal deaths than the patient-related factors and medical personnel factors. CONCLUSION:  There is an urgent need for periodic audits, health education for patients, staff competency and the necessary equipment to resuscitate neonates.Contribution: Avoidable determinants associated with perinatal deaths in a district hospital in Lesotho could be identified. This information provides an understanding of what can be done to limit avoidable perinatal deaths.

The effect of chorionicity on maternal and neonatal outcomes in triplet pregnancies.

OBJECTIVE: Triplet gestations are associated with increased maternal, fetal, and neonatal complications particularly early and extreme preterm delivery. Identifying and interrupting the preterm delivery cascade could prevent the fetal, neonatal, and long-term childhood complications. The shared circulation and placental vascular anastomosis are responsible for the occurrence of twin-to-twin transfusion syndrome, selective fetal growth restriction as well as the higher risk of morbidity and mortality observed in mono and dichorionic compared to trichorionic triplet gestations. Thus, the aim of this study was to determine the effect of chorionicity on maternal, fetal, and neonatal outcomes of triplet pregnancies as it has not been fully ascertained. STUDY DESIGN: A retrospective population-based cohort study of 125 parturient with triplets' pregnancy who delivered at a single tertiary hospital. RESULTS: 98 trichorionic and 27 dichorionic gestations were included. Maternal demographic and obstetric characteristics as well as pregnancy and postpartum complications were similar in the two study groups. The median gestational age at delivery was lower among dichorionic than trichorionic triplet gestations (median 31 vs 33 weeks, p < 0.046). Early (<32 weeks) and extreme preterm delivery (<28 weeks) were more prevalent in the dichorionic than the trichorionic group (early - 56 % vs 34 %, p < 0.038; extreme - 33.3 % vs 8 %, p < 0.002). We found no difference in fetal or newborns' complications and characteristics between the groups. However, the rate of neonatal death was significantly higher in the dichorionic compared to trichorionic triplet gestations (22 % vs 7 %, p < 0.038). A multivariate logistic regression model to determine the variables that contribute to early preterm delivery in triplet gestations showed that women who experienced a past preterm delivery had an independently higher risk for early preterm delivery in the triplet gestation (adj. OR 5.91, 95 % CI 1.16-30.03). Neither maternal age nor chorionicity were found to be independent risk factors for early preterm delivery. CONCLUSIONS: Dichorionic triplet gestations exhibit a higher rate of early (<32 weeks) and extreme (<28 weeks) preterm delivery and are more prone to neonatal death compared to trichorionic gestations. Past preterm delivery is an independent risk factor for early preterm delivery in a triplet gestation.

Risk factors associated with neonatal mortality among neonates admitted to neonatal intensive care unit of the University Teaching Hospital in Lusaka.

Globally, several children die shortly after birth and many more of them within the first 28 days of life. Sub-Sharan Africa accounts for almost half (43%) of the global neonatal death with slow progress in reduction. These neonatal deaths are associated with lack of quality care at or immediately after birth and in the first 28 days of life. This study aimed to determine the trends and risk factors of facility-based neonatal mortality in a major referral hospital in Lusaka, Zambia. We conducted retrospective analysis involving all neonates admitted in the University Teaching Hospital Neonatal Intensive Care Unit (UTH-NICU) in Lusaka from January 2018 to December 2019 (N = 2340). We determined the trends and assessed the factors associated with facility-based neonatal mortality using Generalized Linear Models (GLM) with a Poisson distribution and log link function. Overall, the facility-based neonatal mortality was 40.2% (95% CI 38.0-42.0) per 1000 live births for the 2-year period with a slight decline in mortality rate from 42.9% (95% CI 40.0-46.0) in 2018 to 37.3% (95% CI 35.0-40.0) in 2019. In a final multivariable model, home delivery (ARR: 1.70, 95% CI 1.46-1.96), preterm birth (ARR: 1.59, 95% CI 1.36-1.85), congenital anomalies (ARR: 1.59, 95% CI 1.34-1.88), low birthweight (ARR: 1.57, 95% CI 1.37-1.79), and health centre delivery (ARR: 1.48, 95% CI 1.25-1.75) were independently associated with increase in facility-based neonatal mortality. Conversely, hypothermia (ARR: 0.36, 95% CI 0.22-0.60), antenatal attendance (ARR: 0.76, 95% CI 0.68-0.85), and 1-day increase in neonatal age (ARR: 0.96, 95% CI 0.95-0.97) were independently associated with reduction in facility-based neonatal mortality. In this hospital-based study, neonatal mortality was high compared to the national and global targets. The improvement in neonatal survival observed in this study may be due to interventions including Kangaroo mother care already being implemented. Early identification and interventions to reduce the impact of risks factors of neonatal mortality in Zambia are important.