Abstract
BackgroundWorldwide, an estimated 5.1 million stillbirths and neonatal deaths occur annually, 98% in low- and middle-income countries. Limited coverage of civil and vital registration systems necessitates reliance on women’s retrospective reporting in household surveys for data on these deaths. The predominant platform, Demographic and Health Surveys (DHS), has evolved over the last 35 years and differs by country, yet no previous study has described these differences and the effects of these changes on stillbirth and neonatal death measurement.MethodsWe undertook a review of DHS model questionnaires, protocols and methodological reports from DHS-I to DHS-VII, focusing on the collection of information on stillbirth and neonatal deaths describing differences in approaches, questionnaires and geographic reach up to December 9, 2019. We analysed the resultant data, applied previously used data quality criteria including ratios of stillbirth rate (SBR) to neonatal mortality rate (NMR) and early NMR (ENMR) to NMR, comparing by country, over time and by DHS module.ResultsDHS has conducted >320 surveys in 90 countries since 1984. Two types of maternity history have been used: full birth history (FBH) and full pregnancy history (FPH). A FBH collecting information only on live births has been included in all model questionnaires to date, with data on stillbirths collected through a reproductive calendar (DHS II-VI) or using additional questions on non-live births (DHS-VII). FPH collecting information on all pregnancies including live births, miscarriages, abortions and stillbirths has been used in 17 countries. We found no evidence of variation in stillbirth data quality assessed by SBR:NMR over time for FBH surveys with reproductive calendar, some variation for surveys with FBH in DHS-VII and most variation among the surveys conducted with a FPH. ENMR:NMR ratio increased over time, which may reflect changes in data quality or real epidemiological change.ConclusionDHS remains the major data source for pregnancy outcomes worldwide. Although the DHS model questionnaire has evolved over the last three and half decades, more robust evidence is required concerning optimal methods to obtain accurate data on stillbirths and neonatal deaths through household surveys and also to develop and test standardised data quality criteria.
Highlights
Worldwide, an estimated 5.1 million stillbirths and neonatal deaths occur annually, 98% in low- and middle-income countries
Demographic and Health Surveys (DHS) has systematically captured stillbirths and neonatal deaths in low- and middle-income countries (LMICs) throughout most of its history, and this paper focuses on the approaches taken over time by DHS to capture these outcomes
Two types of full maternity histories have been implemented in DHS: full birth history (FBH) and full pregnancy history (FPH) [30]
Summary
An estimated 5.1 million stillbirths and neonatal deaths occur annually, 98% in low- and middle-income countries. 98% of these deaths occurred in low- and middle-income countries (LMICs), with over 75% in sub-Saharan Africa and South Asia [1,2,3,4,5] These deaths have an impact on women, families, health-workers and wider society [6], yet the majority are preventable through high quality antenatal, childbirth and newborn care [1, 7, 8]. Whilst high-income countries have national civil and vital registration statistics (CRVS) systems that record these outcomes in a timely and reliable way, CRVS systems in most LMICs are limited in coverage and quality Even when such CRVS systems capture adult outcomes, there is known to be selective underreporting of neonatal deaths (especially preterm neonates) and even more so of stillbirths [11]. As LMICs account for the majority of the world’s births and an even higher proportion of child deaths and stillbirths, such survey data are the main input for estimating over two thirds of the burden worldwide
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