Classifying maternal deaths in Suriname using WHO ICD-MM: different interpretation by Physicians, National and International Maternal Death Review Committees.

The World Health Organization (WHO) provides a framework (ICD-MM) to classify pregnancy-related deaths systematically, which enables global comparison among countries. We compared the classification of pregnancy-related deaths in Suriname by the attending physician and by the national maternal death review (MDR) committee and among the MDR committees of Suriname, Jamaica and the Netherlands. There were 89 possible pregnancy-related deaths in Suriname between 2010 and 2014. Nearly half (47%) were classified differently by the Surinamese MDR committee as compared to the classification of the attending physicians. All three MDR committees agreed that 18% (n = 16/89) of the cases were no maternal deaths. Out of the remaining 73 cases, there was disagreement regarding whether 15% (n = 11) were maternal deaths. The Surinamese and Jamaican MDR committees achieved greater consensus in classification than the Surinamese and the Netherlands MDR committees. The Netherlands MDR committee classified more deaths as unspecified than Surinamese and the Jamaican MDR committees. Underlying causes that achieved a high level of agreement among the three committees were abortive outcomes and obstetric hemorrhage, while little agreement was reported for unspecified and other direct causes. The issues encountered during maternal death classification using the ICD-MM guidelines included classification of suicide during early pregnancy; when to assume pregnancy without objective evidence; how to count maternal deaths occurring outside the country of residence; the relevance of direct or indirect cause attribution; and how to select the underlying cause when direct and indirect conditions or multiple comorbidities co-occur. Addressing these classification barriers in future revisions of the ICD-MM guidelines could enhance the feasibility of maternal death classification and facilitate global comparison. BACKGROUND: Insight into the underlying causes of pregnancy-related deaths is essential to develop policies to avert preventable deaths. The WHO International Classification of Diseases-Maternal Mortality (ICD-MM) guidelines provide a framework to standardize maternal death classifications and enable comparison in and among countries over time. However, despite the implementation of these guidelines, differences in classification remain. We evaluated consensus on maternal death classification using the ICD-MM guidelines. METHODS: The classification of pregnancy-related deaths in Suriname during 2010-2014 was compared in the country (between the attending physician and the national maternal death review (MDR) committee), and among the MDR committees from Suriname, Jamaica and the Netherlands. All reviewers applied the ICD-MM guidelines. The inter-rater reliability (Fleiss kappa [κ]) was used to measure agreement. RESULTS: Out of the 89 cases certified by attending physicians, 47% (n = 42) were classified differently by the Surinamese MDR committee. The three MDR committees agreed that 18% (n = 16/89) of these cases were no maternal deaths, and, therefore, excluded from further analyses. However, opinions differed whether 15% (n = 11) of the remaining 73 cases were maternal deaths. The MDR committees achieved moderate agreement classifying the deaths into type (direct, indirect and unspecified) (κ = 0.53) and underlying cause group (κ = 0.52). The Netherlands MDR committee classified more maternal deaths as unspecified (19%), than the Jamaican (7%) and Surinamese (4%) committees did. The mutual agreement between the Surinamese and Jamaican MDR committees (κ = 0.69 vs κ = 0.63) was better than between the Surinamese and the Netherlands MDR committees (κ = 0.48 vs κ = 0.49) for classification into type and underlying cause group, respectively. Agreement on the underlying cause category was excellent for abortive outcomes (κ = 0.85) and obstetric hemorrhage (κ = 0.74) and fair for unspecified (κ = 0.29) and other direct causes (κ = 0.32). CONCLUSIONS: Maternal death classification differs in Suriname and among MDR committees from different countries, despite using the ICD-MM guidelines on similar cases. Specific challenges in applying these guidelines included attribution of underlying cause when comorbidities occurred, the inclusion of deaths from suicides, and maternal deaths that occurred outside the country of residence.

Reliability of self-reported data from the 2011 Ja-Kids birth cohort study: demographic, social, obstetric history, medical and outcome indicators.

The Ja-Kids Longitudinal Study (JA-Kids) aims to improve the health and development of Jamaican children by identifying social, demographic, environmental and clinical factors that help or hinder these processes. As clinical indicators relied on maternal reporting, we aim to evaluate the quality of the self-reported data. Women were recruited across Jamaica during pregnancy or at delivery from July 1-30 September 2011. Indicators were compared between women recruited while pregnant and at delivery to understand possible differences between the sub-populations. Variables reported more than once between pregnancy and delivery were assessed to evaluate level of agreement (reliability). Clinical indicators from the literature were contrasted with study findings to determine how maternal reporting align with published prevalence (validity). Intra-class correlation and the kappa (κ) statistic were used to assess reliability while chi-squared, Fisher's-exact or students-t were used to compare differences over time; p values ≤0.05 were considered statistically significant. Women recruited during pregnancy (n = 3970) were younger, less parous and possibly more socially disadvantaged than those recruited at delivery (n = 5803). Socio-demographic and selected clinical indicators showed good to moderate (0.421 < κ < 0.681) reporting consistency between pregnancy and delivery for previous C-section (κ = 0.681), pre-existing diabetes mellitus (κ = 0.616) and prior twin gestations (0.580). Most conditions however showed only fair agreement (0.21 < κ < 0.40) including previous gestational hypertension (κ = 0.387), asthma (κ = 0.365), premature rupture of membranes (κ = 0.324), eclampsia (κ = 0.257) and essential hypertension (κ = 0.213). Infectious conditions had poor reliability. Prevalence rates for most conditions, except sickle cell disease, were lower than the published literature. Complications and outcomes which were well defined for women were better reported than those requiring clinical judgment (e.g. prior C-section versus specific hypertensive disorders of pregnancy). NCDs with only episodic acute effects were not well reported, e.g. asthma, hypertension and sickle cell disease. Maternal reporting of pregnancy complications needs to be interpreted with caution.

Central adiposity at diagnosis may reduce prostate cancer-specific mortality in African-Caribbean men with prostate cancer: 10-year follow-up of participants in a case-control study.

PURPOSE: General and central adiposity are associated with the risk of developing prostate cancer (PCa), but the role of these exposures on PCa survival among men of African ancestry are less studied. This study aimed to investigate the association of anthropometry at diagnosis with all-cause and PCa-specific mortality and evaluate whether androgen deprivation therapy (ADT) modulated this risk. METHODS: Associations between body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) at diagnosis and mortality were examined in 242 men with newly diagnosed PCa enrolled between 2005 and 2007 and re-evaluated 10.9 years later. Multi-variable Cox proportional hazard models were used to examine associations of body size variables (using standard WHO cut-points and as continuous variables) with mortality, adjusted for sociodemographic characteristics, Gleason score, smoking, diabetes, primary treatment, and ADT therapy. RESULTS: A total of 139 deaths (all-cause mortality 6.98/100 person-years) occurred (PCa-specific deaths, 56; other causes, 66; causes unknown, 17). In multi-variable analysis BMI, WC and WHR categories at diagnosis were not associated with all-cause mortality even after adjusting for ADT. While WHR (but not BMI or WC) when included as a continuous variable predicted lower PCa-specific mortality (multi-variable adjusted WHR per 0.1 difference: HR, 0.50; 95%CI 0.28, 0.93), the effect disappeared with ADT covariance and excluding deaths within the first 2 years. CONCLUSION: Our study suggests that central adiposity as measured by WHR may improve long-term survival among men of African ancestry. Metabolic studies to understand the mechanism for this association are needed.

Measurement of maternal functioning during pregnancy and postpartum: findings from the cross-sectional WHO pilot study in Jamaica, Kenya, and Malawi.

BACKGROUND: The World Health Organization's definition of maternal morbidity refers to "a negative impact on the woman's wellbeing and/or functioning". Many studies have documented the, mostly negative, effects of maternal ill-health on functioning. Although conceptually important, measurement of functioning remains underdeveloped, and the best way to measure functioning in pregnant and postpartum populations is unknown. METHODS: A cross-sectional study among women presenting for antenatal (N = 750) and postpartum (N = 740) care in Jamaica, Kenya and Malawi took place in 2015-2016. Functioning was measured through the World Health Organization Disability Assessment Schedule (WHODAS-12). Data on health conditions and socio-demographic characteristics were collected through structured interview, medical record review, and clinical examination. This paper presents descriptive data on the distribution of functioning status among pregnant and postpartum women and examines the relationship between functioning and health conditions. RESULTS: Women attending antenatal care had a lower level of functioning than those attending postpartum care. Women with a health condition or associated demographic risk factor were more likely to have a lower level of functioning than those with no health condition. However, the absolute difference in functioning scores typically remained modest. CONCLUSIONS: Functioning is an important concept which integrates a woman-centered approach to examining how a health condition affects her life, and ultimately her return to functioning after delivery. However, the WHODAS-12 may not be the optimal tool for use in this population and additional components to capture pregnancy-specific issues may be needed. Challenges remain in how to integrate functioning outcomes into routine maternal healthcare at-scale and across diverse settings.

Maternal morbidity: a longitudinal study of women's health during and up to 22 months after pregnancy in Jamaica.

Our study evaluated factors associated with ill-health in a population-based longitudinal study of women who delivered a singleton live-born baby in a 3-month period across Jamaica. Socio-demographics, perception of health, chronic illnesses, frequency and reasons for hospital admission were assessed. Relationships between ill-health and maternal characteristics were estimated using log-normal regression analysis. Of 9,742 women interviewed at birth, 1,311 were assessed at four stages, 27.7% of whom reported ill-health at least once. Hospitalization rates were 20.9% during pregnancy, 6.1% up to 12 months and 0.5% up to 22 months after childbirth. Ill-health, reported by 11% of women, was less likely with better education (RR=0.62, 95%; 0.42-0.84). Hospital admission was associated with higher socio-economic status (RR=1.33, 95% 1.04-1.70) and Caesarean section [CS] (RR=1.57, 95%; 1.21-2.04). One in three (33.7%) women reported chronic illnesses, and the likelihood increased with age, parity and delivery by elective CS (RR=1.44, 95%; 1.20-1.73). In multivariable analyses, ill-health was more likely with chronic illness (RR=2.06, 95%; CI: 1.71-2.48) and hospital admission from 12 to 22 months after childbirth (RR=1.54, 95% CI: 1.12-2.12). Ill-health during pregnancy and after childbirth represent a significant burden of disease and requires a standardised comprehensive approach to measuring and addressing this disease burden.

Maternal morbidity measurement tool pilot: study protocol.

BACKGROUND: While it is estimated that for every maternal death, 20-30 women suffer morbidity, these estimates are not based on standardized methods and measures. Lack of an agreed-upon definition, identification criteria, standardized assessment tools, and indicators has limited valid, routine, and comparable measurements of maternal morbidity. The World Health Organization (WHO) convened the Maternal Morbidity Working Group (MMWG) to develop standardized methods to improve estimates of maternal morbidity. To date, the MMWG has developed a definition and provided input into the development of a set of measurement tools. This protocol outlines the pilot test for measuring maternal morbidity in antenatal and postnatal clinical populations using these new tools. METHODS: In each setting, the tools will be piloted on approximately 250 women receiving antenatal care (ANC) (at least 28 weeks pregnant) and 250 women receiving postpartum care (PPC) (at least 6 weeks postpartum). The tools will be administered by trained health care workers. Each tool has three modules as follows: 1. personal history - socio-economic information, and risk-factors (such as violence and substance abuse) 2. patient symptoms - WHO Disability Assessment Schedule (WHODAS) 12-item, and mental health questionnaires, General Anxiety Disorder, 7-item (GAD-7) and Personal Health Questionnaire, 9-item (PHQ-9) 3. physical examination - signs, laboratory tests and results. DISCUSSION: This pilot (planned for Jamaica, Kenya and Malawi) will allow for comparing the types of morbidities women experience between and across settings, and determine the feasibility, acceptability and utility of using a modified, streamlined tool for routine measurement and summary estimates of morbidity to inform resource allocation and service provision. As part of the post-2015 Sustainable Development Goals (SDGs) estimating and measuring maternal morbidity will be essential to ensure appropriate resources are allocated to address its impact and improve well-being.

Low-Dose Aspirin in Early Gestation for Prevention of Preeclampsia and Small-for-Gestational-Age Neonates: Meta-analysis of Large Randomized Trials.

Objectives Meta-analyses of small to moderate size randomized controlled trials (RCTs) suggested that aspirin started before 17 weeks' gestation reduces the risk of preeclampsia and small-for-gestational-age (SGA) neonates. We evaluated data from large randomized trials originally excluded from meta-analyses. Methods We performed meta-analyses of RCTs including more than 350 participants that compared aspirin to placebo during pregnancy. Corresponding authors were contacted to obtain data according to gestational age. Outcomes included preeclampsia, severe preeclampsia, and SGA. Relative risks (RRs) with their 95% confidence intervals (CIs) were calculated. Results Data for women recruited before 17 weeks' gestation were obtained for three (50%) of the six eligible trials for a total of 11,949 participants including 3,293 recruited before 17 weeks' gestation with available data. We observed no impact of low-dose aspirin (60 mg) started before 17 weeks' gestation on the risk of preeclampsia (RR: 0.93; 95% CI: 0.75-1.15), severe preeclampsia (RR: 0.96; 95% CI: 0.71-1.28), or SGA (RR: 0.84; 95% CI: 0.56-1.26) and it was not statistically different than when started at or after 17 weeks' gestation. Conclusion Data from large randomized trials do not support greater benefits of low-dose aspirin (at 60 mg daily) when started before 17 weeks' gestation for the prevention of preeclampsia or SGA.

Prevention of Preeclampsia with Aspirin in Multiple Gestations: A Systematic Review and Meta-analysis.

Objective The objective of this study was to estimate the effect of low-dose aspirin in multiple gestations to prevent preeclampsia and small for gestational age (SGA) neonates. Methods A systematic review and meta-analysis were performed through electronic database searches. Randomized controlled trials (RCTs) of women with multiple gestations assigned to receive aspirin or placebo or no treatment were included. Outcomes included preeclampsia (mild and severe) and SGA neonates. Relative risks (RR) with their 95% confidence intervals (CI) were calculated. Result Out of 6,853 citations, 6 RCTS, including 898 pregnancies, were included. We observed a significant reduction in the risk of preeclampsia (RR, 0.67; 95% CI, 0.48-0.94) and mild preeclampsia (RR, 0.44; 95% CI, 0.24-0.82) but not severe preeclampsia (RR, 1.02; 95% CI, 0.61-1.72) with low-dose aspirin. The risk of SGA was not changed (RR, 1.09; 95% CI, 0.80-1.47). The reduction of preeclampsia was not different between women randomized before (RR, 0.86; 95% CI, 0.41-1.81) or after 16 weeks' gestation (RR, 0.64; 95% CI, 0.43-0.96) (p = 0.50). Conclusion There is low level of evidence supporting the use of low-dose aspirin for the prevention of preeclampsia and SGA neonates in multiple gestations.

Effect of aerobic exercise (walking) training on functional status and health-related quality of life in chronic stroke survivors: a randomized controlled trial.

BACKGROUND AND PURPOSE: Little is known about the effects of community-based walking programs in persons with chronic stroke. The purpose of this study was to determine the effects of aerobic (walking) training on functional status and health-related quality of life in stroke survivors. METHODS: A single-blind randomized controlled trial was conducted. The intervention group (n=64) walked overground for 30 minutes, 3 times per week for 12 weeks. The control group (n=64) received massage to the affected side. Medical Outcomes Short Form, 36-Item Short Form Health Survey (SF-36), was used to assess health-related quality of life; Barthel Index and Older Americans Resource and Services scale for functional status; 6-minute walk test for endurance; and Motricity Index for lower extremity strength. RESULTS: There was a trend toward greater improvement over time for the Physical Health Component of the SF-36 (P=0.077) and significantly greater improvement over time for distance walked in 6 minutes in favor of the walking group (P<0.001). CONCLUSIONS: Aerobic walking improves the physical health component of quality of life and endurance in persons with chronic stroke. It should form part of a comprehensive health promotion strategy. Clinical Trial Registration- Trial was not registered as enrollment commenced before 2005.

Gender differences in the effects of urban neighborhood on depressive symptoms in Jamaica.

OBJECTIVE: To explore the mental health effects of the urban neighborhood on men and women in Jamaica and the implications for urban planning and social development. METHODS: A cross-sectional household sample of 2 848 individuals 15-74 years of age obtained from the Jamaica Health and Lifestyle Survey 2007-2008 was analyzed. Secondary analysis was undertaken by developing composite scores to describe observer recorded neighborhood features, including infrastructure, amenities/services, physical conditions, community socioeconomic status, and green spaces around the home. Depressive symptoms were assessed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Bivariate and multivariate methods were used to explore the associations among gender, neighborhood factors, and risk of depressive symptoms. RESULTS: While no associations were found among rural residents, urban neighborhoods were associated with increased risk of depressive symptoms. Among males, residing in a neighborhood with poor infrastructure increased risk; among females, residing in an informal community/unplanned neighborhood increased risk. CONCLUSIONS: The urban neighborhood contributes to the risk of depression symptomatology in Jamaica, with different environmental stressors affecting men and women. Urban and social planners need to consider the physical environment when developing health interventions in urban settings, particularly in marginalized communities.

Maternal mortality among women with sickle cell disease in Jamaica over two decades (1998-2017).

BACKGROUND: Sickle cell disease (SCD) affects 2.8% of Jamaican antenatal women. Between 1998-2007 their maternal mortality ratio was 7-11 times higher than women without these disorders. We aim to determine if outcomes improved between 2008 and 17 amid declining fertility and changes in referral obstetric care. METHODS: Maternal deaths in Jamaica's maternal mortality surveillance database (assembled since 1998) with SCD reported as underlying or associated cause of death were compared to those without known SCD, over two decades from 1998 to 2017. Social, demographic and health service variables were analysed using SPSS and EpiInfo Open. FINDINGS: Over the two decades from 1998 to 2017, 806 (74%) of the 1082 pregnancy-associated deaths documented by the Jamaican Ministry of Health and Wellness were maternal deaths. The maternal mortality ratio (MMR) did not statistically change over the two periods for women with (p = 0.502) and without SCD (p = 0.629). The MMR among women with and without SCD in 2008-17 was 378.1 (n = 41) and 89.2/100,000 live births (n = 336) respectively, an odds ratio of 4.24 (95% CI: 3.07-5.87). When deaths due to their blood disorders were excluded, risk remained elevated at 2.17 (95% CI: 1.36-3.32). There was an upward trend in direct deaths over the two decades (p [trend]=0.051). INTERPRETATION: MMRs were unchanged over two decades for Jamaicans with SCD. The high contribution to maternal mortality by women with SCD may explain some of the persistently higher mortality experience of women in the African diaspora. Multi-disciplinary evidence-based strategies need to be developed and tested which improve survival for women with SCD who want to have children. FUNDING: No external funding was provided.

Antenatal depressive symptoms in Jamaica associated with limited perceived partner and other social support: A cross-sectional study.

BACKGROUND: Antenatal depression is associated with adverse maternal and infant well-being. However, compared to postpartum depression, it has been less frequently explored globally or in Jamaica. This study aimed to determine the prevalence of, and factors associated with, antenatal depressive symptoms among Jamaican women in order to inform policy and build interventions that could improve their management and reduce their negative consequences. METHODS: This secondary analysis of data from the second Jamaican Birth Cohort Study (JA-Kids Birth Cohort) included 3,517 women enrolled during pregnancy. Information was extracted from interviewer-administered questionnaires which recorded social, demographic, medical and obstetric information during pregnancy. The Edinburgh Postnatal Depression scale (EPDS) was used to screen for depression, with scores ≥13 considered indicative of a high likelihood of depression. Bivariate analysis examined associations between depressive symptoms and: age, income, financial difficulties, perceived social support, perceived partner infidelity, previous child-bearing unions and children with the current partner. Obstetric factors were also explored and included gravidity, prior adverse pregnancy outcome and complications from previous pregnancies. Variables that predicted the likelihood of depression based on an EPDS cut score of 13 were evaluated using logistic regression. RESULTS: One in five participants (19.6%; 95% CI 18.3-20.9%) had a high likelihood of antenatal depression (EPDS ≥13). Significant predictors of high depressive symptom severity included four indicators of poor perceived social and partner support [ORs (95% CI) ranged from: 1.61 (1.07-2.43); p = 0.024 to 3.14(1.69-5.84); p< 0.001], perceived partner infidelity [1.86 (1.36, 2.54); p<0.001], exposure to violence [2.36 (1.66-3.38); p<0.001] and financial difficulties [1.39 (1.07, 1.80); p = 0.013]. CONCLUSIONS: Women's perceived social and partner support were strongly associated with depressive symptom severity. Within the Jamaican cultural context of unstable reproductive unions, efforts are needed to involve fathers in the antenatal care process to strategically improve the psychological well-being of new mothers which may positively influence long term developmental outcomes for their babies.

A framework for healthcare interventions to address maternal morbidity.

The maternal health agenda is undergoing a paradigm shift from preventing maternal deaths to promoting women's health and wellness. A critical focus of this trajectory includes addressing maternal morbidity and the increasing burden of chronic and noncommunicable diseases (NCD) among pregnant women. The WHO convened the Maternal Morbidity Working Group (MMWG) to improve the scientific basis for defining, measuring, and monitoring maternal morbidity. Based on the MMWG's work, we propose paradigms for conceptualizing maternal health and related interventions, and call for greater integration between maternal health and NCD programs. This integration can be synergistic, given the links between chronic conditions, morbidity in pregnancy, and long-term health. Pregnancy should be viewed as a window of opportunity into the current and future health of women, and offers critical entry points for women who may otherwise not seek or have access to care for chronic conditions. Maternal health services should move beyond the focus on emergency obstetric care, to a broader approach that encompasses preventive and early interventions, and integration with existing services. Health systems need to respond by prioritizing funding for developing integrated health programs, and workforce strengthening. The MMWG's efforts have highlighted the changing landscape of maternal health, and the need to expand the narrow focus of maternal health, moving beyond surviving to thriving.

Standardizing the measurement of maternal morbidity: Pilot study results.

OBJECTIVE: To field test a standardized instrument to measure nonsevere morbidity among antenatal and postpartum women. METHODS: A cross-sectional study was conducted in Jamaica, Kenya, and Malawi (2015-2016). Women presenting for antenatal care (ANC) or postpartum care (PPC) were recruited if they were at least 28 weeks into pregnancy or 6 weeks after delivery. They were interviewed and examined by a doctor, midwife, or nurse. Data were collected and securely stored electronically on a WHO server. Diagnosed conditions were coded and summarized using ICD-MM. RESULTS: A total of 1490 women (750 ANC; 740 PPC) averaging 26 years of age participated. Most women (61.6% ANC, 79.1% PPC) were healthy (no diagnosed medical or obstetric conditions). Among ANC women with clinical diagnoses, 18.3% had direct (obstetric) conditions and 18.0% indirect (medical) problems. Prevalences among PPC women were lower (12.7% and 8.6%, respectively). When screening for factors in the expanded morbidity definition, 12.8% (ANC) and 11.0% (PPC) self-reported exposure to violence. CONCLUSION: Nonsevere conditions are distinct from the leading causes of maternal death and may vary across pregnancy and the puerperium. This effort to identify and measure nonsevere morbidity promotes a comprehensive understanding of morbidity, incorporating maternal self-reporting of exposure to violence, and mental health. Further validation is needed.

The impact of hypertension, hemorrhage, and other maternal morbidities on functioning in the postpartum period as assessed by the WHODAS 2.0 36-item tool.

OBJECTIVE: To assess the scores of postpartum women using the WHO Disability Assessment Schedule 2.0 36-item tool (WHODAS-36), considering different morbidities. METHODS: Secondary analysis of a retrospective cohort of women who delivered at a referral maternity in Brazil and were classified with and without severe maternal morbidity (SMM). WHODAS-36 was used to assess functioning in postpartum women. Percentile distribution of total WHODAS score was compared across three groups: Percentile (P)<10, 1090. Cases of SMM were categorized and WHODAS-36 score was assessed according to hypertension, hemorrhage, or other conditions. RESULTS: A total of 638 women were enrolled: 64 had mean scores below P<10 (1.09) and 66 were above P>90 (41.3). Of women scoring above P>90, those with morbidity had a higher mean score than those without (44.6% vs 36.8%, P=0.879). Women with higher WHODAS-36 scores presented more complications during pregnancy, especially hypertension (47.0% vs 37.5%, P=0.09). Mean scores among women with any complication were higher than those with no morbidity (19.0 vs 14.2, P=0.01). WHODAS-36 scores were higher among women with hypertensive complications (19.9 vs 16.0, P=0.004), but lower among those with hemorrhagic complications (13.8 vs 17.7, P=0.09). CONCLUSIONS: Complications during pregnancy, childbirth, and the puerperium increase long-term WHODAS-36 scores, demonstrating a persistent impact on functioning among women, up to 5 years postpartum.

The burden of obesity in women of reproductive age and in pregnancy in a middle-income setting: A population based study from Jamaica.

INTRODUCTION: Obesity is rising globally and is associated with increased risk of adverse pregnancy outcomes. This study aims to investigate overweight and obesity and its consequences among Jamaican women of reproductive age, particularly development of diabetes, hypertension and the risk of maternal death. MATERIALS AND METHODS: A national lifestyle survey (2007/8) of 1371 women of reproductive age provided data on the prevalence of high BMI, associated risk factors and co-morbidities. A national maternal mortality surveillance database (1998-2012) of 798 maternal deaths was used to investigate maternal deaths in obese women. Chi-squared and Fisher exact tests were used. RESULTS: High BMI (> = 25kg/m2) occurred in 63% of women aged between 15 and 49 years. It was associated with increasing age, high gravidity and parity, and full time employment (p<0.001). Of those with high BMI, 5.5% were diabetic, 19.3% hypertensive and 2.8% were both diabetic and hypertensive. Obesity was recorded in 10.5% of maternal deaths, with higher proportions of deaths due to hypertension in pregnancy (27.5%), circulatory/ cardiovascular disorders (13.0%), and diabetes (4.3%) compared to 21.9%, 6.9% and 2.6% respectively in non-obese women. CONCLUSIONS: This is one of a few studies from a middle-income setting to explore maternal burden of obesity during pregnancy, which contributes to improving the knowledge base, identifying the gaps in information and increasing awareness of the growing problem of maternal overweight and obesity. While survey diagnostic conditions require cautious interpretation of findings, it is clear that obesity and related medical conditions present a substantial public health problem for emerging LMICs like Jamaica. There is an urgent need for global consensus on routine measures of the burden and risk factors associated with obesity and development of culturally appropriate interventions.

Certification of Coroners cases by pathologists would improve the completeness of death registration in Jamaica.

OBJECTIVES: Describe the completeness and quality of Jamaica's 2008 vital registration mortality database. STUDY DESIGN AND SETTING: Multiple sources (hospitals, police, forensic pathologists, Coroners courts) were used to validate deaths registered as occurring in 2008. A 10% random sample was examined to evaluate the quality of certification and coding. Jamaica, a middle-income country of 2.7 million, began vital registration in 1877; however, the mortality database was considered of limited use, and the study was commissioned to understand the problem. RESULTS: Of 19,286 deaths identified, 76% were registered by 31.12.2009 for inclusion among 2008 demographic returns. Registration was highest among deaths not requiring autopsy (94%) and lowest among Coroners cases (22%) with only 41% of deaths among 15-44 year-olds registered. The leading causes of death were cerebrovascular disease, diabetes mellitus, and homicide. Fifteen percent were coded to ill-defined causes of death. Recoding the sample increased mortality from prematurity, pregnancy complications, homicide, selected cardiovascular disorders, and human immunodeficiency virus/AIDS. CONCLUSION: Delays registering Coroners cases, certification and coding errors, introduced biases into the disease profile limiting the data's value in informing clinical care. Issuance of medical certificates by pathologists who investigate Coroners cases and training physicians and coders would eliminate most underreporting and improve data quality.