Estimates Of Causes Research Articles

Estimation and Causes of Informal Economy in Pakistan

This study purposes to estimate the Pakistan’s informal economy by indirect methods and estimate the causes behind the informal economy. Ordinary least square is used for estimation of causes behind the informal economy. From GDP approach, conclude that informal economy is increasing while employment approach shows decreasing informal economy. The estimated result shows tax evasion is the main reason behind the informal economy in Pakistan. In our study, particular implications of the informal economy are identified. Informal economy plays a main role in income inequality and reducing the poverty. It limits implementing the operative public policy. The government should make such policies to control the informal economy and increasing tax evasion and corruption. If government formalize the informal economy by registering them at low cost, make the registration process easier and lower the amount of taxes imposed on them, the country’s growth will be doubled.

Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis.

In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%-4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9-14)]; respiratory [9 (95% CI 5-13)]; and gastrointestinal [9 (95% CI 6-11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231-280)]; infectious [214 (95% CI 193-234)]; and gastrointestinal [166 (95% CI 143-190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.

Fundamentals of in situ postmortem magnetic resonance spectroscopy of the brain in the forensic framework - a review and outlook

• Postmortem magnetic resonance spectroscopy is a promising technique for the determination of the postmortem interval. • Postmortem magnetic resonance spectroscopy is feasible for the detection and quantification of ethanol. • Postmortem magnetic resonance spectroscopy is feasible for the detection and quantification of glucose and ketone bodies. • The simultaneous quantification of more than 25 metabolites enables machine learning techniques in postmortem metabolomics, for example in the classification of the cause of death. This review contextualizes the collective research on in situ proton postmortem magnetic resonance spectroscopy of the brain and derives the basic approaches for its application in forensic pathology. The basic concepts of magnetic resonance spectroscopy are outlined for a target audience in forensic pathology. A major application of postmortem in situ magnetic resonance spectroscopy is the prediction of the postmortem interval, which has been demonstrated in animal studies. Current research has directly quantified relevant metabolites such as ethanol, glucose, and beta-hydroxybutyrate to draw conclusions for forensic casework. This application is currently limited to a few relevant metabolites. A future potential of postmortem in situ magnetic resonance spectroscopy is the analysis of the entire metabolomic pattern. Estimation of cause of death based on the postmortem metabolome could be the next milestone in postmortem in situ magnetic resonance spectroscopy.

Aetiology and outcome of non-traumatic coma in African children: protocol for a systematic review and meta-analysis

BackgroundNon-traumatic coma is a common acute childhood presentation to healthcare facilities in Africa and is associated with high morbidity and mortality. Historically, the majority of cases were attributed to cerebral malaria (CM). With the recent drastic reduction in malaria incidence, non-malarial coma is becoming a larger proportion of cases and determining the aetiology is diagnostically challenging, particularly in resource-limited settings. The purpose of this study will be to evaluate the aetiology and prognosis of non-traumatic coma in African children.MethodsWith no date restrictions, systematic searches of MEDLINE, Embase, and Scopus will identify prospective and retrospective studies (including randomised controlled trials, cluster randomised trials, cohort studies, cross-sectional, and case-control studies) recruiting children (1 month–16 years) with non-traumatic coma (defined by Blantyre Coma Score ≤ 2 or comparable alternative) from any African country. Disease-specific studies will be included if coma is associated and reported. The primary outcome is to determine the aetiology (infectious and non-infectious) of non-traumatic coma in African children, with pooled prevalence estimates of causes (e.g., malaria). Secondary outcomes are to determine overall estimates of morbidity and mortality of all-cause non-traumatic coma and disease-specific states of non-traumatic coma, where available. Random effects meta-analysis will summarise aetiology data and in-hospital and post-discharge mortality. Heterogeneity will be quantified with τ2, I2, and Cochran’s Q test.DiscussionThis systematic review will provide a summary of the best available evidence on the aetiology and outcome of non-traumatic coma in African children.Systematic review registrationPROSPERO CRD42020141937

Child mortality in Bangladesh - why, when, where and how? A national survey-based analysis.

BackgroundUpdated information on the cause of childhood mortality is essential for developing policies and designing programmes targeting the major burden of disease. There is a paucity of evidence regarding the current estimates of the cause of death in Bangladesh, which is essential for reinvigorating the current policies and reshaping existing strategies to avert preventable deaths. This paper aims to address this critical evidence gap and report the cause, timing and place of death among children under-five years of age using a nationally representative sample.MethodsThe present study was undertaken to provide updated estimates of causes of death among children under-five years of age using data from the 2017-18 round of the Bangladesh Demographic and Health Survey (BDHS). The verbal autopsy (VA) questionnaire of the 2017-18 BDHS was adapted from the standardised WHO 2016 instruments. Specially trained physicians reviewed the responses of the VA questionnaire and assigned the cause of death based on the online-2016-version of the International Classification of Diseases (ICD-10). We included 456 deaths among children under-five years of age in our analysis. Descriptive statistics were used to present the causes, timing and places of death with uncertainty ranges (UR).ResultsPneumonia is the major killer (19%), accounting for approximately 24 268 (UR = 21 626-26 695) under-five deaths per-year. It is followed by birth asphyxia (16%), prematurity and low-birth-weight (11%), serious infections including sepsis (8%) causing 20 882 (UR = 18 608-22 970), 14 956 (UR = 13 327-16,452), and 10 723 (UR = 9555-11,795) deaths per-year, respectively. Drowning (8%) caused 10 441 (UR = 9304-11 485) deaths and congenital anomaly (7%) resulted in d 8748 (UR = 7795-9623) deaths per-year. Around 29% of all deaths occurred on the first day, 52% within the first week, and 66% within the first month of life. Around 70% of birth asphyxia, prematurity, and low birth weight-related deaths happen on the day of birth. Approximately 43% of pneumonia-related deaths occur in age 1-11 months, and around 51% of drowning-related deaths happen in age 12-23 months.ConclusionsPneumonia with other serious infections, birth asphyxia, prematurity and low-birth-weight are responsible for more than half of all deaths among children under-five years of age. Strengthening the existing maternal, neonatal and child health programmes may be helpful in averting the majority of these preventable deaths. A multisectoral approach is required for the prevention of childhood deaths, especially drowning-related fatalities. Special measures need to be taken to prevent and control emerging public health challenges like birth defects and congenital anomalies.

Diversity of epidemiological transition in the Pacific: Findings from the application of verbal autopsy in Papua New Guinea and the Solomon Islands

BackgroundCause of death data are essential for rational health planning yet are not routinely available in Papua New Guinea (PNG) and Solomon Islands. Indirect estimation of cause of death patterns suggests these populations are epidemiologically similar, but such assessments are not based on direct evidence. MethodsVerbal autopsy (VA) interviews were conducted at three sites in PNG and nationwide in Solomon Islands. Training courses were also facilitated to improve data from medical certificates of cause of death (MCCODs) in both countries. Data were categorised into broad groups of endemic and emerging conditions to aid assessment of the epidemiological transition. FindingsBetween 2017 and 2020, VAs were collected for 1,814 adult deaths in PNG and 819 adult deaths in Solomon Islands. MCCODs were analysed for 662 deaths in PNG and 1,408 deaths in Solomon Islands. The VA data suggest lower NCD mortality (48.8% versus 70.3%); higher infectious mortality (27.0% versus 18.3%) and higher injury mortality (24.5% versus 11.4%) in PNG compared to Solomon Islands. Higher infectious mortality in PNG was evident for both endemic and emerging infections. Higher NCD mortality in Solomon Islands reflected much higher emerging NCDs (43.6% vs 21.4% in PNG). A similar pattern was evident from the MCCOD data. InterpretationThe cause of death patterns suggested by VA and MCCOD indicate that PNG is earlier in its epidemiological transition than Solomon Islands, with relatively higher infectious mortality and lower NCD mortality. Injury mortality was also particularly high in PNG.This study was funded by Bloomberg Philanthropies.

Research Progress on MicroRNA in Forensic Medicine as Molecular Markers.

MicroRNA （miRNA） belongs to a class of endogenous non-coding small RNA molecules with a length of 18-24 nucleotides. The expression of miRNA is highly conservative, has time sequence and is highly tissue-specific. MiRNA could not be easily degraded by ribonuclease, and is resistant to changes in environmental factors such as temperature and pH value. Moreover, miRNA can even be detected in corrupt tissue. As a result, miRNA has broad application prospects in many fields of forensic medicine such as source identification of body fluid and estimation of cause of death. This article briefly summarizes the application of miRNA in forensic practice, such as body fluid identification, determination of postmortem interval and cause of death analysis.

Epidemiology of facial fractures: incidence, prevalence and years lived with disability estimates from the Global Burden of Disease 2017 study

BackgroundThe Global Burden of Disease Study (GBD) has historically produced estimates of causes of injury such as falls but not the resulting types of injuries that occur. The objective of...

Mortality Surveillance Methods to Identify and Characterize Deaths in Child Health and Mortality Prevention Surveillance Network Sites.

Despite reductions over the past 2 decades, childhood mortality remains high in low- and middle-income countries in sub-Saharan Africa and South Asia. In these settings, children often die at home, without contact with the health system, and are neither accounted for, nor attributed with a cause of death. In addition, when cause of death determinations occur, they often use nonspecific methods. Consequently, findings from models currently utilized to build national and global estimates of causes of death are associated with substantial uncertainty. Higher-quality data would enable stakeholders to effectively target interventions for the leading causes of childhood mortality, a critical component to achieving the Sustainable Development Goals by eliminating preventable perinatal and childhood deaths. The Child Health and Mortality Prevention Surveillance (CHAMPS) Network tracks the causes of under-5 mortality and stillbirths at sites in sub-Saharan Africa and South Asia through comprehensive mortality surveillance, utilizing minimally invasive tissue sampling (MITS), postmortem laboratory and pathology testing, verbal autopsy, and clinical and demographic data. CHAMPS sites have established facility- and community-based mortality notification systems, which aim to report potentially eligible deaths, defined as under-5 deaths and stillbirths within a defined catchment area, within 24–36 hours so that MITS can be conducted quickly after death. Where MITS has been conducted, a final cause of death is determined by an expert review panel. Data on cause of death will be provided to local, national, and global stakeholders to inform strategies to reduce perinatal and childhood mortality in sub-Saharan Africa and South Asia.

Potential of Minimally Invasive Tissue Sampling for Attributing Specific Causes of Childhood Deaths in South Africa: A Pilot, Epidemiological Study.

BackgroundCurrent estimates for causes of childhood deaths are mainly premised on modeling of vital registration and limited verbal autopsy data and generally only characterize the underlying cause of death (CoD). We investigated the potential of minimally invasive tissue sampling (MITS) for ascertaining the underlying and immediate CoD in children 1 month to 14 years of age.MethodsMITS included postmortem tissue biopsies of brain, liver, and lung for histopathology examination; microbial culture of blood, cerebrospinal fluid (CSF), liver, and lung samples; and molecular microbial testing on blood, CSF, lung, and rectal swabs. Each case was individually adjudicated for underlying, antecedent, and immediate CoD by an international multidisciplinary team of medical experts and coded using the International Classification of Diseases, Tenth Revision (ICD-10).ResultsAn underlying CoD was determined for 99% of 127 cases, leading causes being congenital malformations (18.9%), complications of prematurity (14.2%), human immunodeficiency virus/AIDS (12.6%), diarrheal disease (8.7%), acute respiratory infections (7.9%), injuries (7.9%), and malignancies (7.1%). The main immediate CoD was pneumonia, sepsis, and diarrhea in 33.9%, 19.7%, and 10.2% of cases, respectively. Infection-related deaths were either an underlying or immediate CoD in 78.0% of cases. Community-acquired pneumonia deaths (n = 32) were attributed to respiratory syncytial virus (21.9%), Pneumocystis jirovecii (18.8%), cytomegalovirus (15.6%), Klebsiella pneumoniae (15.6%), and Streptococcus pneumoniae (12.5%). Seventy-one percent of 24 sepsis deaths were hospital-acquired, mainly due to Acinetobacter baumannii (47.1%) and K. pneumoniae (35.3%). Sixty-two percent of cases were malnourished.ConclusionsMITS, coupled with antemortem clinical information, provides detailed insight into causes of childhood deaths that could be informative for prioritization of strategies aimed at reducing under-5 mortality.

Collecting verbal autopsies: improving and streamlining data collection processes using electronic tablets

BackgroundThere is increasing interest in using verbal autopsy to produce nationally representative population-level estimates of causes of death. However, the burden of processing a large quantity of surveys collected with paper and pencil has been a barrier to scaling up verbal autopsy surveillance. Direct electronic data capture has been used in other large-scale surveys and can be used in verbal autopsy as well, to reduce time and cost of going from collected data to actionable information.MethodsWe collected verbal autopsy interviews using paper and pencil and using electronic tablets at two sites, and measured the cost and time required to process the surveys for analysis. From these cost and time data, we extrapolated costs associated with conducting large-scale surveillance with verbal autopsy.ResultsWe found that the median time between data collection and data entry for surveys collected on paper and pencil was approximately 3 months. For surveys collected on electronic tablets, this was less than 2 days. For small-scale surveys, we found that the upfront costs of purchasing electronic tablets was the primary cost and resulted in a higher total cost. For large-scale surveys, the costs associated with data entry exceeded the cost of the tablets, so electronic data capture provides both a quicker and cheaper method of data collection.ConclusionsAs countries increase verbal autopsy surveillance, it is important to consider the best way to design sustainable systems for data collection. Electronic data capture has the potential to greatly reduce the time and costs associated with data collection. For long-term, large-scale surveillance required by national vital statistical systems, electronic data capture reduces costs and allows data to be available sooner.

Making stillbirths visible: a systematic review of globally reported causes of stillbirth.

Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention. To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM. We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016. Reports of stillbirth causes in unselective cohorts. Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC). Eighty-five reports from 50 countries (489089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes. There is a paucity of quality information on causesof stillbirth globally. Improving investigation of stillbirthsand standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings. HR, SH, SHL, and AW were supported by an NHMRC-CRE grant (APP1116640). VF was funded by an NHMRC-CDF (APP1123611). Urgent need to improve data on causes of stillbirths across all settings to meet global targets. Background and methods Nearly three million babies are stillborn every year. These deaths have deep and long-lasting effects on parents, healthcare providers, and the society. One of the major challenges to preventing stillbirths is the lack of information about why they happen. In this study, we collected reports on the causes of stillbirth from high-, middle-, and low-income countries to: (1) Understand the causes of stillbirth, and (2) Understand how to improve reporting of stillbirths. Findings We found 85 reports from 50 different countries. The information available from the reports was inconsistent and often of poor quality, so it was hard to get a clear picture about what are the causes of stillbirth across the world. Many different definitions of stillbirth were used. There was also wide variation in what investigations of the mother and baby were undertaken to identify the cause of stillbirth. Stillbirths in all income settings (low-, middle-, and high-income countries) were most frequently reported as Unexplained, Other, and Haemorrhage (bleeding). Unexplained and Other are not helpful in understanding why a baby was stillborn. In low-income countries, stillbirths were often attributed to Infection and Complications during labour and birth. In middle- and high-income countries, stillbirths were often reported as Placental complications. Limitations We may have missed some reports as searches were carried out in English only. The available reports were of poor quality. Implications Many countries, particularly those where the majority of stillbirths occur, do not report any information about these deaths. Where there are reports, the quality is often poor. It is important to improve the investigation and reporting of stillbirth using a standardised system so that policy makers and healthcare workers can develop effective stillbirth prevention programs. All stillbirths should be investigated and reported in line with the World Health Organization standards.

Characteristics of a global classification system for perinatal deaths: a Delphi consensus study.

BackgroundDespite the global burden of perinatal deaths, there is currently no single, globally-acceptable classification system for perinatal deaths. Instead, multiple, disparate systems are in use world-wide. This inconsistency hinders accurate estimates of causes of death and impedes effective prevention strategies. The World Health Organisation (WHO) is developing a globally-acceptable classification approach for perinatal deaths. To inform this work, we sought to establish a consensus on the important characteristics of such a system.MethodsA group of international experts in the classification of perinatal deaths were identified and invited to join an expert panel to develop a list of important characteristics of a quality global classification system for perinatal death. A Delphi consensus methodology was used to reach agreement. Three rounds of consultation were undertaken using a purpose built on-line survey. Round one sought suggested characteristics for subsequent scoring and selection in rounds two and three.ResultsThe panel of experts agreed on a total of 17 important characteristics for a globally-acceptable perinatal death classification system. Of these, 10 relate to the structural design of the system and 7 relate to the functional aspects and use of the system.ConclusionThis study serves as formative work towards the development of a globally-acceptable approach for the classification of the causes of perinatal deaths. The list of functional and structural characteristics identified should be taken into consideration when designing and developing such a system.

Prevalence and causes of hearing impairment in Africa.

To systematically assess the data on the prevalence and causes of hearing impairment in Africa. Systematic review on the prevalence and causes of hearing loss in Africa. We undertook a literature search of seven electronic databases (EMBASE, PubMed, Medline, Global Health, Web of Knowledge, Academic Search Complete and Africa Wide Information) and manually searched bibliographies of included articles. The search was restricted to population-based studies on hearing impairment in Africa. Data were extracted using a standard protocol. We identified 232 articles and included 28 articles in the final analysis. The most common cut-offs used for hearing impairment were 25 and 30 dB HL, but this ranged between 15 and 40 dB HL. For a cut-off of 25 dB, the median was 7.7% for the children- or school-based studies and 17% for population-based studies. For a cut-off of 30 dB HL, the median was 6.6% for the children or school-based studies and 31% for population-based studies. In schools for the deaf, the most common cause of hearing impairment was cryptogenic deafness (50%) followed by infectious causes (43%). In mainstream schools and general population, the most common cause of hearing impairment was middle ear disease (36%), followed by undetermined causes (35%) and cerumen impaction (24%). There are very few population-based studies available to estimate the prevalence of hearing impairment in Africa. Those studies that are available use different cut-offs, making comparison difficult. However, the evidence suggests that the prevalence of hearing impairment is high and that much of it is avoidable or treatable.

Direct estimates of national neonatal and child cause-specific mortality proportions in Niger by expert algorithm and physician-coded analysis of verbal autopsy interviews.

BackgroundThis study was one of a set of verbal autopsy investigations undertaken by the WHO/UNCEF–supported Child Health Epidemiology Reference Group (CHERG) to derive direct estimates of the causes of neonatal and child deaths in high priority countries of sub–Saharan Africa. The objective of the study was to determine the cause distributions of neonatal (0–27 days) and child (1–59 months) mortality in Niger.MethodsVerbal autopsy interviews were conducted of random samples of 453 neonatal deaths and 620 child deaths from 2007 to 2010 identified by the 2011 Niger National Mortality Survey. The cause of each death was assigned using two methods: computerized expert algorithms arranged in a hierarchy and physician completion of a death certificate for each child. The findings of the two methods were compared to each other, and plausibility checks were conducted to assess which is the preferred method. Comparison of some direct measures from this study with CHERG modeled cause of death estimates are discussed.FindingsThe cause distributions of neonatal deaths as determined by expert algorithms and the physician were similar, with the same top three causes by both methods and all but two other causes within one rank of each other. Although child causes of death differed more, the reasons often could be discerned by analyzing algorithmic criteria alongside the physician’s application of required minimal diagnostic criteria. Including all algorithmic (primary and co–morbid) and physician (direct, underlying and contributing) diagnoses in the comparison minimized the differences, with kappa coefficients greater than 0.40 for five of 11 neonatal diagnoses and nine of 13 child diagnoses. By algorithmic diagnosis, early onset neonatal infection was significantly associated (χ2 = 13.2, P < 0.001) with maternal infection, and the geographic distribution of child meningitis deaths closely corresponded with that for meningitis surveillance cases and deaths.ConclusionsVerbal autopsy conducted in the context of a national mortality survey can provide useful estimates of the cause distributions of neonatal and child deaths. While the current study found reasonable agreement between the expert algorithm and physician analyses, it also demonstrated greater plausibility for two algorithmic diagnoses and validation work is needed to ascertain the findings. Direct, large–scale measurement of causes of death complement, can strengthen, and in some settings may be preferred over modeled estimates.

Hierarchical Models for Multiple Outcomes

Hierarchical Models for Multiple OutcomesAbstract Number:2496 David Richardson* David Richardson* UNC SPH, United States, E-mail Address: [email protected] Search for more papers by this author AbstractIn an occupational or environmental cohort study, there may be interest in associations between an exposure primary interest and mortality due to a variety of causes. A standard approach involves fitting a separate regression model for each outcome type. However, estimated associations may be imprecise if there are few events for each outcome type. A commonly-used strategy to deal with sparse outcomes is to combine several outcome types into a broader category, such as all solid cancers, and perform regression analysis on this broader outcome group. However, this strategy does not allow inferences regarding effects of exposure on specific outcome types, is sensitive to decisions about how to combine outcome types, and imposes the assumption of homogeneity of the exposure effect across the combined outcome types. We describe an alternative to coalescing several outcomes: a hierarchical model for cause-specific hazards that can be used to estimate an exposure’s effects on different causes of death, while stabilizing the parameter estimates of interest. We address hierarchical models for estimation of the main effects of exposure, as well as for estimation of parameters that describe effect measure modification. The approach is illustrated in analyses of solid cancer mortality in a cohort of dioxin-exposed chemical workers. Compared to standard estimates of cause- specific exposure-mortality associations, hierarchical regression yielded estimates with improved precision that tended to have less extreme values. Moreover, the hierarchical approach allowed estimation of models with parameters to describe cause-specific effect measure modification, while estimates of these parameters were not possible to obtain in standard models fitted one outcome at-a-time. The proposed approach can yield estimates of association that outperform conventional regression methods when one wishes to estimate associations with multiple outcome types.

Global causes of maternal death: a WHO systematic analysis

Data for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes of maternal death during 2003-09, with a novel method, updating the previous WHO systematic review. We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model. We identified 23 eligible studies (published 2003-12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27·5% (672 000, 95% UI 19·7-37·5) of all deaths. Haemorrhage accounted for 27·1% (661 000, 19·9-36·2), hypertensive disorders 14·0% (343 000, 11·1-17·4), and sepsis 10·7% (261 000, 5·9-18·6) of maternal deaths. The rest of deaths were due to abortion (7·9% [193 000], 4·7-13·2), embolism (3·2% [78 000], 1·8-5·5), and all other direct causes of death (9·6% [235 000], 6·5-14·3). Regional estimates varied substantially. Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality.

Understanding causes of death of children under 5: a multi-country analysis using verbal autopsy

BackgroundDespite high levels of under-5 mortality in sub-Saharan Africa, reliable national estimates of causes of death are lacking for most countries. Most deaths occur outside of the health-care system. Information about causes of death is essential to inform policy and programme performance. In this study, we analysed the causes of death among children under-5 using verbal autopsy (VA) surveys implemented in Ghana, Mozambique, Rwanda, and Uganda. MethodsIn the four countries, VA surveys were conducted following Demographic and Health Surveys or National Censuses to gather nationally representative data on under-5 mortality. In all countries, two VA questionnaires were administered in households of a deceased child: one for neonatal deaths (0–28 days) and another for childhood deaths (29 days to 59 months). Questionnaires were reviewed by physicians trained in International Classification of Diseases-10 classification to determine cause of death. FindingsVerbal autopsies were conducted in Uganda (n=525), Rwanda, (n=361), Ghana (n=194), and Mozambique (n=3859). In Uganda, Rwanda, and Ghana, maternal factors and complications during pregnancy, labour, and delivery were the largest cause of neonatal deaths (deaths between 0 and 28 days of life; 20%, 42%, and 70%, respectively) while sepsis was the highest cause in Mozambique (35%). In all countries but Rwanda, malaria was the number one cause of childhood deaths (deaths between 29 days and 59 months), ranging from 42% to as high as 51% of all childhood deaths. In Rwanda, malaria was the third largest contributor to childhood deaths (15%), after pneumonia (19%) and diarrhoea (18%). Other major causes of childhood death were diarrhoea, pneumonia, and malnutrition. Analyses are weighted to account for study design and national representativeness. InterpretationMaternal factors and complications during pregnancy, labour, and delivery were the main cause of neonatal deaths in all countries but Mozambique, while malaria was the lead cause of childhood death in every country but Rwanda. Conducting VA through nationally representative surveys can provide valuable information on causes of death among children under age 5 years. FundingFunding for this study was provided to the MEASURE Evaluation Project by the United States Agency for International Development (USAID) through Cooperative Agreement GHA-A-00-08-00003-00. MEASURE Evaluation is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill, in partnership with Futures Group International, ICF Macro, John Snow, Inc., Management Sciences for Health, and Tulane University. USAID provided financial support for the implementation of the surveys on which this study is based through the MEASURE DHS programme implemented by IFC Macro. Local costs for the Ghana survey were partially funded by the Ghana Ministry of Health, the Ghana Statistical Service, the Ghana AIDS Commission, UNICEF, United Nations Population Fund United Nations Population Fund (UNFPA), and the Danish International Development Agency.

Introducing virtopsy into a country religiously opposed to autopsy

Purpose To evaluate accomplishments and challenges in introducing virtopsy to the pediatric forensic post-mortem examination. This in a country (Israel) requiring family consent, with religious opposition from most of the population (Jewish, Muslim, Christian and Druze) to autopsies and even to shipping the body from one location to another before final interment. What lessons can be learnt applicable to similar communities. Materials and methods Data was collected from the National Center of Forensic Medicine in Israel during the 18 month period introducing post-mortem imaging (Group A) carried out in a medical center located miles away from the Forensic Center. There was limited daytime access to imaging devices, resulting in interment delay. The data was compared to the previous 18 months (Group B). The examined parameters were cases submitted, those examined, autopsied or imaged depending on family consent. Results Out of all cases consent to autopsy was similar (A=56% vs. B=54%). Of all cases in Group A, consent for imaging was 24%. Of those imaged, 77% underwent autopsy. Of those examined externally only, 16% consented to imaging. For 7% of total cases in Group A, estimation of cause of death was based on virtopsy alone. Conclusion In a country with high religious opposition to post-mortem forensic procedure, there are challenges to making virtopsy an integral part of the pediatric forensic post-mortem protocol. At this point those consenting to post-mortem imaging are more likely to agree to the performance of autopsies. Even with the difficulties, some we have identified, there was an immediate increase of 7% of cases where a possible cause of death would not otherwise be given. Virtopsy does not breach religious doctrine in Israel, and might partially substitute autopsy.

Public's Responses to Aviation Accidents: The Role of Exemplification and Attributions

Although aviation accidents are due to various causes, the media may focus on particular causes, which is likely to contribute to the public's perceptions about aviation accidents. This research examines how the public's prevalence estimates of the causes of aviation accidents can vary when the media provides exemplars of internal causes (pilot error and mechanical failure) and on external causes (weather). The distribution of these exemplars varied between the two experimental messages: internal attribution message and external attribution message. Compared with the external attribution message, the internal attribution message resulted in higher prevalence estimates of internal causes. The internal attribution message had indirect effects on punitive opinions mediated by responsibility judgments. In addition, exemplification effects were observed two weeks after exposure, and the effects were greater among respondents who better recalled the exemplifying information. The results of this study suggest that journalists need to be cautious when using exemplars, corporate communication and public relations practitioners should actively respond to biased exemplification in the media, and the public would benefit from enhanced media exemplification literacy.