Vital Registration Research Articles

Global, regional, and national mortality trends in youth aged 15–24 years between 1990 and 2019: a systematic analysis

SummaryBackgroundThe global health community is devoting considerable attention to adolescents and young people, but risk of death in this population is poorly measured. We aimed to reconstruct global, regional, and national mortality trends for youths aged 15–24 years between 1990 and 2019.MethodsIn this systematic analysis, we used all publicly available data on mortality in the age group 15–24 years for 195 countries, as compiled by the UN Inter-agency Group for Child Mortality Estimation. We used nationally representative vital registration data, estimated the completeness of death registration, and extracted mortality rates from surveys with sibling histories, household deaths reported in censuses, and sample registration systems. We used a Bayesian B-spline bias-reduction model to generate trends in 10q15, the probability that an adolescent aged 15 years would die before reaching age 25 years. This model treats observations of the 10q15 probability as the product of the actual risk of death and an error multiplier that varies depending on the data source. The main outcome that we assessed was the levels of and trends in youth mortality and the global and regional mortality rates from 1990 to 2019.FindingsGlobally, the probability of an individual dying between age 15 years and 24 years was 11·2 deaths (90% uncertainty interval [UI] 10·7–12·5) per 1000 youths aged 15 in 2019, which is about 2·5 times less than infant mortality (28·2 deaths [27·2–30·0] by age 1 year per 1000 live births) but is higher than the risk of dying from age 1 to 5 (9·7 deaths [9·1–11·1] per 1000 children aged 1 year). The probability of dying between age 15 years and 24 years declined by 1·4% per year (90% UI 1·1–1·8) between 1990 and 2019, from 17·1 deaths (16·5–18·9) per 1000 in 1990; by contrast with this total decrease of 34% (27–41), under-5 mortality declined by 59% (56–61) in this period. The annual number of deaths declined from 1·7 million (90% UI 1·7–1·9) in 1990 to 1·4 million (1·3–1·5) in 2019. In sub-Saharan Africa, the number of deaths increased by 20·8% from 1990 to 2019. Although 18·3% of the population aged 15–24 years were living in sub-Saharan Africa in 2019, the region accounted for 37·9% (90% UI 34·8–41·9) of all worldwide deaths in youth.InterpretationIt is urgent to accelerate progress in reducing youth mortality. Efforts are particularly needed in sub-Saharan Africa, where the burden of mortality is increasingly concentrated. In the future, a growing number of countries will see youth mortality exceeding under-5 mortality if current trends continue.FundingUN Children's Fund, Bill & Melinda Gates Foundation, United States Agency for International Development.

Methods for estimating tuberculosis incidence and mortality by age and sex

AimsTo develop methods to disaggregate World Health Orgagnization estimates of tuberculosis (TB) incidence and mortality for each country by sex and age.MethodsFor countries where incidence estimates derived from a factor adjustment of notifications and case detection ratio over 0.85, or with <1000 reported TB cases, we disaggregated incidence proportional to notifications. For each other country, a prior was constructed using a hierarchical model of age-stratified prevalence survey data, meta-analysis of sex ratios, and mathematical modelling for children under 15 years. Samples from this prior were used to disaggregate incidence and accepted if incidence exceeded notifications in each age/sex category. Results were inspected and, if implausible, incidence was disaggregated proportional to notifications. Mortality was disaggregated proportional to patterns in vital registration (VR) data in countries with VR data. Where VR data were lacking, a case-fatality ratio (CFR) approach was applied to estimated incidence, with separate CFRs by HIV/ART status, child/adult age groups, and anti-TB treatment status. Uncertainty in all disaggregated country estimates was constructed to be consistent with corresponding overall uncertainty.ResultsWe generated disaggregated results for 216 countries. For 125 countries, incidence disaggregation was based on notifications. Of the rest, accepted samples from the prior were considered implausible in 4 countries. For 72 countries, mortality disaggregation was based on VR data; the rest were based on the CFR approach.ConclusionsWhile multi-stage, this approach is comparatively simple in overall logic. Disaggregated estimates have relatively larger uncertainty and should be used with caution.

Four decades of measuring stillbirths and neonatal deaths in Demographic and Health Surveys: historical review

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.

Burden of Diarrheal Disease among under Five Children in Ethiopia, 2000-2016: Findings from the Global Health Estimates 2016

Introduction: Globally diarrhea among under five children remains one of the high burden diseases particularly in developing countries. Ethiopia is one of the sub-Saharan countries highly under five mortality due to diarrhea. Ethiopia has made remarkable progress in reducing child mortality over the last two decades. However, the under-5 mortality and morbidity rate related to diarrhea still magnificently a burden. Objective: This study aimed to assess the burden of diarrheal for under five children in terms of death and Disability-Adjusted Life Years lost (DALY) between 2000 and 2016. Patients and methods: The research used data from Global Health Estimate 2016; that originally collected the information through vital registration, verbal autopsy, surveys, reports, published scientific articles, Global Burden of Disease study (GBD 2016) and modeling. The magnitude of Diarrheal disease death was estimated 14,894 under five children in 2016. Death from diarrheal disease has also contributed to 38.4% (14894/38777) of deaths from infectious and parasitic diseases and 7.96% (14894/187,065) of the total death reported by the same year. Meanwhile, YLD, YLL and DALYs for under five children were 61,709 and 1408.4 thousand respectively in 2016. Themagnitudeof deaths due to diarrheal disease was declined by 76.7% from the2000’s record of 49,021 deaths within 16 years. In 2016, Mortality due to Diarrheal disease was highest among males. Of the 14,894 diarrheal disease related mortalities, more than 1405 deaths were among males. Conclusion: Even if the burden of diarrhea for under five mortality is sharply declining in Ethiopia; but, it still remained one of the public health problems and second leading cause of morbidity. Therefore, strengthening hand washing practice and accessing prevention program is important to eliminate death within the target period.

Mapping subnational HIV mortality in six Latin American countries with incomplete vital registration systems

BackgroundHuman immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. In this analysis, we address this gap and provide novel estimates of the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico.MethodsWe performed an ecological study using VR data ranging from 2000 to 2017, dependent on individual country data availability. We modeled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017.ResultsAll countries displayed over a 40-fold difference in HIV mortality between municipalities with the highest and lowest age-standardized HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in national HIV mortality in all countries—apart from Ecuador—across the period of study, we found broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. In all six countries included in this analysis, 50% or more HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. In addition, national age patterns reflected shifts in mortality to older age groups—the median age group among decedents ranged from 30 to 45 years of age at the municipality level in Brazil, Colombia, and Mexico in 2017.ConclusionsOur subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age. This analysis provides a framework for incorporating data and uncertainty from incomplete VR systems and can help guide more geographically precise public health intervention to support HIV-related care and reduce HIV-related deaths.

Estimation of All-Cause Excess Mortality by Age-Specific Mortality Patterns of COVID-19 Pandemic in Peru in 2020

Background: All-cause excess mortality is a comprehensive measure of the combined direct and indirect effects of COVID-19 on mortality. Estimates are usually derived from Civil Registration and Vital Statistics (CRVS) systems, but these do not include non-registered deaths, which may be affected by changes in vital registration coverage over time.Methods: We use quasi-Poisson models to estimate excess registered mortality in Peru during the first wave of the COVID-19 pandemic during 2020. We use logistic mixed-effects models to estimate the completeness of the new online registration system (SINADEF) at this time.Findings: We estimate that registered mortality nationally underestimates mortality by 30·1% (95% CI 28·9% - 32·7%). We estimate total all-cause excess mortality during the period of analysis at 142,875 (95% CI 127,163 - 155,739) of which 99,814 (95% CI 85,605 - 110,738) were captured by the vital registration system. Deaths at age 60 and over accounted for 74·9% (95% CI 74·9% - 75·0%) of total excess deaths, while there were fewer deaths than expected in younger age groups. Lima region, on the Pacific coast and including the national capital, accounts for 76,158 (95% CI 72,740 - 79,212) excess deaths, while the regions of Apurimac and Pasco account for less than 300 excess deaths.Interpretation: Estimating excess mortality in low- and middle-income countries (LMICs) such as Peru must take under-registration of mortality into account. Combining demographic trends with data from administrative registries reduces uncertainty and measurement errors. In countries like Peru, this is likely to produce significantly higher estimates of excess mortality than studies that do not take these effects into account.Funding Statement: None.Declaration of Interests: RM is a staff member of the Pan American Health Organization. The author alone is responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the Pan American Health Organization. All other authors declare no competing interests.

The Quality of Vital Registration of the Jews in East-Central Europe in the Nineteenth Century

Vital records are one of the main sources providing insight into the demographic past. For most of the nineteenth century, however, the degree of under-registration of vital events among Jews was much higher than among non-Jews. These omissions undermine the credibility of demographic data on fertility and mortality published in contemporary statistical yearbooks. The analysis shows that the male-to-female ratio at birth aggregated on a regional level reveals the highest under-registration among Jews in the Russian Empire, including Congress Poland, until World War I. On the other hand, Prussian registration covers the Jewish population most completely and already in the 1820s shows no signs of under-registration. Despite the general low quality of registration systems, records from selected individual towns still pass quality tests. Top-down imposition of the registration duties, corporatism, defective legal regulations, bureaucratic inefficiency and personal characteristics of civil registrars were the main reasons for under-registration.

Global mortality from dementia: Application of a new method and results from the Global Burden of Disease Study 2019.

IntroductionDementia is currently one of the leading causes of mortality globally, and mortality due to dementia will likely increase in the future along with corresponding increases in population growth and population aging. However, large inconsistencies in coding practices in vital registration systems over time and between countries complicate the estimation of global dementia mortality.MethodsWe meta‐analyzed the excess risk of death in those with dementia and multiplied these estimates by the proportion of dementia deaths occurring in those with severe, end‐stage disease to calculate the total number of deaths that could be attributed to dementia.ResultsWe estimated that there were 1.62 million (95% uncertainty interval [UI]: 0.41–4.21) deaths globally due to dementia in 2019. More dementia deaths occurred in women (1.06 million [0.27–2.71]) than men (0.56 million [0.14–1.51]), largely but not entirely due to the higher life expectancy in women (age‐standardized female‐to‐male ratio 1.19 [1.10–1.26]). Due to population aging, there was a large increase in all‐age mortality rates from dementia between 1990 and 2019 (100.1% [89.1–117.5]). In 2019, deaths due to dementia ranked seventh globally in all ages and fourth among individuals 70 and older compared to deaths from other diseases estimated in the Global Burden of Disease (GBD) study.DiscussionMortality due to dementia represents a substantial global burden, and is expected to continue to grow into the future as an older, aging population expands globally.

The Effects of Drought Severity and Its Aftereffects on Mortality in Bangladesh

Drought has been a considerable problem for many years in northern Bangladesh. However, the health impacts of drought in this region are not well understood. This study analyzed the impact of drought duration and severity on select causes of mortality in northern Bangladesh. Rainfall data from three meteorological stations (Rangpur, Dinajpur and Nilphamari) in northern Bangladesh were used to assess drought and non-drought periods, and the Standardized Precipitation Index was used to categorize mild, moderate, severe, and extreme drought. Mortality data from 2007 to 2017 for the three areas were collected from the Sample Vital Registration System, which is a survey of 1 million people. The generalized linear model with Poisson regression link was used to identify associations between mortality and the drought severity and 1-month preceding SPI. Only severe and extreme drought in the short-term drought periods affected mortality. Long-term drought was not associated with natural cause mortality in Rangpur and Nilphamari. In Dinajpur, mild and moderate drought was associated with circulatory- and respiratory-related mortality. The impact of drought on mortality varied by region. This study improves our understanding of how droughts affect specific causes of mortality and will help policy makers to take appropriate measures against drought impacts on selected cause of mortality. Future research will be critical to reduce drought-related risks of health.

Mortality, morbidity, and risk factors in Taiwan, 1990–2017: findings from the Global Burden of Disease Study 2017

Taiwan has implemented a national health insurance system since 1995 with high coverage and utilization rate. However, the health care system in Taiwan is facing immense challenges due to rapid population ageing. We have evaluated the landscape of population health by revisiting the results of GBD 2017 study. Taiwan vital registration data (1980-2016) and Taiwan national health insurance database (2016) were used. We also conducted benchmarking comparisons with selected countries in East Asia from 1990 to 2017. The age-standardized disability-adjusted life-year (DALY) rates decreased by one-quarter from 1990 to 2017; however, progress was relatively slow compared to the comparator countries and has been stagnant recently. The Social-demographic Index (SDI) level in Taiwan in 2017 was 0.86, which is similar to Japan, Singapore, and South Korea in 2017, while the SDI level of China in 2017 was similar to that of Taiwan (0.69) in 1990. Although Taiwan's SDI reached the same level as those in Japan, Singapore, and South Korea in 2017, modifiable risk factors still contributed to nearly half of Taiwan's total disease burden. Five leading risk factors (high fasting plasma glucose, high body-mass index, alcohol use, illicit drug use, and impaired kidney function) accounted for a higher DALY rate in Taiwan than comparator countries in 2017. Taiwan made marked progress in health from 1990 to 2017. However, interventions targeted on major modifiable disease risk factors should be prioritized to realize the full potential of heath improvement in the process of rapid socioeconomic development.

The 2020 IDS Release of the Antwerp COR*-Database. Evaluation, Development and Transformation of a Pre-Existing Database

The Antwerp COR*-IDS database 2020 is a transformed and harmonized historical demographic database in a cross-nationally comparable format designed to be open and easy to use for international researchers. The database is constructed from the 2010 release of the Antwerp COR*-historical demographic database, which was created using a letter sample of the whole district of Antwerp (Flanders, Belgium). It has a total sample size of +/- 33,000 residents of Antwerp. The sample spans nearly seven decades. The data is collected from historical records: including population registers and vital registration records covering births, marriages, in/external migrations and deaths. The database covers up to three linked generations (in some cases more), and contains micro-data on individual level life courses, and relationships deriving from addressbased household composition methods. An important characteristic is the sample's large migrant population, including the timings of their demographic events and living arrangements, whilst resident in the district of Antwerp. In addition, the sample also contains a large array of occupational level information. This paper presents the processes, methodologies and documentation regarding the evaluation and development of a pre-existing historical database. This includes the systematic evaluation of the original samples, methodologies for address based reconstructing of households, and the geocoding of a historical database which took place during the current development of this new version of the database.

Digital Framework for the History of the Austrian Military Border in Transylvania

"The study provides the documentation for the first public version of the database Digital Framework for the History of the Austrian Military Border in Transylvania by means of a detailed description and user manual. It includes: a short overview of the historical context of the establishment of the Austrian military border in this province, references to the international and Romanian state of the art, the detailing of primary sources issued by the military environment and starting from which the database was built and the main principles of construction and operation of the latter. The information in the database is extracted from the records of the military and administrative personnel of the Transylvanian border regiments between 1763 and 1850, including monthly staff records, information on salaries, enrollments, transfers, desertions, medical certificates, etc. The lists of conduct of the officers should also be mentioned, each of them including a detailed physical and psychological description of the respective person. The database serves two aims. On the one hand, to boost the use of and access to documents generated by the Austrian military and with this to bring the Romanian historical writing on the military border in Transylvania closer to the primary sources. On the other hand, to complement, for the territory of the former military border, the vital registration data provided by parish registers with social history data that can improve life course reconstruction and analysis. Keywords: Historical databases, Austrian Military Border, Transylvania, Habsburg Monarchy, Military history "

The impact of antenatal care utilization on admissions to neonatal intensive care units and perinatal mortality in Georgia.

IntroductionAppropriate antenatal care (ANC) utilization has direct, significant effects on perinatal mortality (PM). Georgia has one of the highest PM rates (11.7 per 1000 births) in Europe and launched a more intensive ANC programme in 2018.AimTo evaluate the associations between the Adequacy of Prenatal Care Utilization (APNCU) index and neonatal intensive care unit (NICU) admission and PM in Georgia.MethodsThe Georgian Birth Registry (GBR), with linkage to the Vital Registration System, was used as the main data source; 148,407 eligible mothers and singleton newborns were identified during the observation period (2017–2019). The main exposure was ANC utilization, measured by the APNCU index, and the hospitalization registry was used to validate NICU admissions. Logistic regression analysis was used to assess the associations between the exposure and outcomes while controlling for potential confounders.ResultsThe overall PM rate was 11.6/1000 births, and the proportion of newborns with a NICU admission was 7.8%. 85% of women initiated ANC before gestational age week 12. According to the APNCU index, 16% of women received inadequate, 10% intermediate, 38% adequate, and 36% intensive care. Women who received intermediate care had the lowest odds of PM (adjusted odds ratio [AOR] = 0.56, 95% confidence interval [CI] 0.45–0.70), and newborns of women who received inadequate care had the highest odds of NICU admission (AOR = 1.16, 95% CI 1.09–1.23) and PM (AOR = 1.18, 95% CI 1.02–1.36).ConclusionANC utilization is significantly associated with newborn asmissions to NICU and PM in Georgia. Women received inadequate care experienced the highest odds of newborn admissions to NICU and PM.

Estimating the global mortality from Alzheimer’s disease and other dementias: A new method and results from the Global Burden of Disease study 2019

AbstractBackgroundAlzheimer’s disease and other dementias (dementia) is currently a leading cause of mortality and morbidity globally, and the total number of individuals effected by dementia will likely increase in the future with corresponding increases in population growth and aging. However, inconsistencies in coding practices in vital registration systems both over time and between countries complicate the estimation of dementia mortality. This study updated and improved on previous methods developed for the Global Burden of Disease (GBD) study for the estimation of global dementia mortality.MethodWe conducted a systematic review on the excess risk of death in those with dementia, and analyzed these data using a Bayesian meta‐regression model. We calculated total excess deaths as the product of absolute risk and country‐by‐country prevalence estimates from the GBD study. We then multiplied the estimates of total excess deaths by the proportion of dementia deaths that occur in those with severe, end‐stage disease to calculate the total number of deaths that could be legitimately assigned to dementia as the underlying cause of death.ResultAttributable risk of dementia increased with age, reaching 0.17 (95% uncertainty interval, 0.05 to 0.58) in the 95+ age group. We estimated there were 1.55 (0.35 to 4.54) million deaths globally due to dementia in 2019. Far more deaths occurred in women (1.02 million; 0.23 to 2.96) than men (0.54 million: 0.12 to 1.58), giving a female to male ratio of 1.90 (1.82 to 1.99). Due to population aging, the all‐age mortality rates increased by 38.0%; 33.1 to 43.7 between 1990 and 2019.ConclusionThe increase in the number of dementia deaths will continue due to population aging. Given the rising volume of dementia mortality, the development of valid methods of mortality estimation for dementia is critical. This updated estimation method eliminated all dependency on estimates from vital registration systems, which are known to be biased. However, future efforts should aim to further strengthen this analysis in order to provide more accurate information on dementia mortality for use by both researchers and policy‐makers.

National Sample Vital Registration System: A sustainable platform for COVID-19 and other infectious diseases surveillance in low and middle-income countries.

National Sample Vital Registration System: A sustainable platform for COVID-19 and other infectious diseases surveillance in low and middle-income countries.

Effectiveness of training interventions to improve quality of medical certification of cause of death: systematic review and meta-analysis

BackgroundValid cause of death data are essential for health policy formation. The quality of medical certification of cause of death (MCCOD) by physicians directly affects the utility of cause of death data for public policy and hospital management. Whilst training in correct certification has been provided for physicians and medical students, the impact of training is often unknown. This study was conducted to systematically review and meta-analyse the effectiveness of training interventions to improve the quality of MCCOD.MethodsThis review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; Registration ID: CRD42020172547) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. CENTRAL, Ovid MEDLINE and Ovid EMBASE databases were searched using pre-defined search strategies covering the eligibility criteria. Studies were selected using four screening questions using the Distiller-SR software. Risk of bias assessments were conducted with GRADE recommendations and ROBINS-I criteria for randomised and non-randomised interventions, respectively. Study selection, data extraction and bias assessments were performed independently by two reviewers with a third reviewer to resolve conflicts. Clinical, methodological and statistical heterogeneity assessments were conducted. Meta-analyses were performed with Review Manager 5.4 software using the ‘generic inverse variance method’ with risk difference as the pooled estimate. A ‘summary of findings’ table was prepared using the ‘GRADEproGDT’ online tool. Sensitivity analyses and narrative synthesis of the findings were also performed.ResultsAfter de-duplication, 616 articles were identified and 21 subsequently selected for synthesis of findings; four underwent meta-analysis. The meta-analyses indicated that selected training interventions significantly reduced error rates among participants, with pooled risk differences of 15–33%. Robustness was identified with the sensitivity analyses. The findings of the narrative synthesis were similarly suggestive of favourable outcomes for both physicians and medical trainees.ConclusionsTraining physicians in correct certification improves the accuracy and policy utility of cause of death data. Investment in MCCOD training activities should be considered as a key component of strategies to improve vital registration systems given the potential of such training to substantially improve the quality of cause of death data.

Associations between alcohol consumption trajectory and deaths due to cancer, cardiovascular diseases and all-cause mortality: a 30-year follow-up cohort study in Thailand

ObjectivesThis study examined the association between alcohol consumption trajectory and deaths due to cancer, cardiovascular diseases (CVDs) and all-cause mortality in Thailand.DesignData were obtained from a Thai prospective cohort study...

Engaging community health workers in maternal and infant death identification in Khayelitsha, South Africa: a pilot study

BackgroundEngaging community health workers in a formalised death review process through verbal and social autopsy has been utilised in different settings to estimate the burden and causes of mortality, where civil registration and vital statistics systems are weak. This method has not been widely adopted. We piloted the use of trained community health workers (CHW) to investigate the extent of unreported maternal and infant deaths in Khayelitsha and explored requirements of such a programme and the role of CHWs in bridging gaps.MethodsThis was a mixed methods study, incorporating both qualitative and quantitative methods. Case identification and data collection were done by ten trained CHWs. Quantitative data were collected using a structured questionnaire. Qualitative data were collected using semi-structured interview guides for key informant interviews, focus group discussions and informal conversations. Qualitative data were analysed thematically using a content analysis approach.ResultsAlthough more than half of the infant deaths occurred in hospitals (n = 11/17), about a quarter that occurred at home (n = 4/17) were unreported. Main causes of deaths as perceived by family members of the deceased were related to uncertainty about the quality of care in the facilities, socio-cultural and economic contexts where people lived and individual factors. Most unreported deaths were further attributed to weak facility-community links and socio-cultural practices. Fragmented death reporting systems were perceived to influence the quality of the data and this impacted on the number of unreported deaths. Only two maternal deaths were identified in this pilot study.ConclusionsCHWs can conduct verbal and social autopsy for maternal and infant deaths to complement formal vital registration systems. Capacity development, stakeholder’s engagement, supervision, and support are essential for a community-linked death review system. Policymakers and implementers should establish a functional relationship between community-linked reporting systems and the existing system as a starting point. There is a need for more studies to confirm or build on our pilot findings.

Predictive Modeling for Perinatal Mortality in Resource-Limited Settings

The overwhelming majority of fetal and neonatal deaths occur in low- and middle-income countries. Fetal and neonatal risk assessment tools may be useful to predict the risk of death. To develop risk prediction models for intrapartum stillbirth and neonatal death. This cohort study used data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Global Network for Women's and Children's Health Research population-based vital registry, including clinical sites in South Asia (India and Pakistan), Africa (Democratic Republic of Congo, Zambia, and Kenya), and Latin America (Guatemala). A total of 502 648 pregnancies were prospectively enrolled in the registry. Risk factors were added sequentially into the data set in 4 scenarios: (1) prenatal, (2) predelivery, (3) delivery and day 1, and (4) postdelivery through day 2. Data sets were randomly divided into 10 groups of 3 analysis data sets including training (60%), test (20%), and validation (20%). Conventional and advanced machine learning modeling techniques were applied to assess predictive abilities using area under the curve (AUC) for intrapartum stillbirth and neonatal mortality. All prenatal and predelivery models had predictive accuracy for both intrapartum stillbirth and neonatal mortality with AUC values 0.71 or less. Five of 6 models for neonatal mortality based on delivery/day 1 and postdelivery/day 2 had increased predictive accuracy with AUC values greater than 0.80. Birth weight was the most important predictor for neonatal death in both postdelivery scenarios with independent predictive ability with AUC values of 0.78 and 0.76, respectively. The addition of 4 other top predictors increased AUC to 0.83 and 0.87 for the postdelivery scenarios, respectively. Models based on prenatal or predelivery data had predictive accuracy for intrapartum stillbirths and neonatal mortality of AUC values 0.71 or less. Models that incorporated delivery data had good predictive accuracy for risk of neonatal mortality. Birth weight was the most important predictor for neonatal mortality.

Disparities in the Burden of Stroke in Mexico: A National and Subnational Analysis of the Global Burden of Disease 1990–2017

Background: Stroke burden has been decreasing in high-income countries while increasing in low- to middle-income nations where ischaemic and haemorrhagic stroke are major causes of death and disability. The lack of updated epidemiological information on stroke in Mexico has motivated the development of new estimations based on available data sources and published research. Methods: Data of incidence, prevalence, deaths, premature mortality, disability, and DALYs due to cerebrovascular disease included in the Global Burden of Disease (GBD) 2017 study were analysed to identify differences on the burden of stroke types (i.e., ischaemic stroke [IS], intracerebral haemorrhage [ICH] and subarachnoid haemorrhage [SAH]), sex, age groups, and federal states from 1990 to 2017. To explore disparities due to social and health system variables, the federal states were classified using GBD’s Sociodemographic Index (SDI) and Health Access and Quality (HAQ) Index. Sources available from Mexico included vital registration data and information on stroke incidence, prevalence, and mortality from scientific literature, inpatient hospital data, population surveys, and mortality registries for the period 1990–2017. Findings: In the last 27 years, the number of stroke deaths in Mexico increased from 21,456 in 1990 to 36,653 in 2017, while the age-standardised mortality rate declined 35.8% during the period. Significant reductions in incidence, prevalence, disability, and mortality rates occurred from 1990 to 2005, with no significant changes in the declining trends from 2006 to 2017. Age-standardised mortality rates for IS and ICH were significantly reduced by 46.6% and 30%, respectively, mainly in the period 1990-2005, but not afterwards, while mortality from SAH showed non-significant changes during the whole period. DALYs and premature mortality (YLLs) age-standardised rates exhibited important decreases during the period (41.4% and 48.6%), respectively, also mainly during 1990-2005. The magnitude of decline in all metrics for ICH was more pronounced in women than men. In the case of SAH, females had higher differences in age-standardised mortality, DALYs, YLLs, YLDs, and prevalence rates at the beginning of the study (1990), but men presented higher increases during the whole period. Haemorrhagic stroke presented significantly higher age-standardised mortality, DALYs, YLLs, and incidence rates for ICH than SAH, as well as more important reductions accounted during the period. Stroke burden metrics varied widely by federal state, with less developed states (according to SDI) exhibiting the lowest improvements during the period. Interpretation: Stroke mortality in Mexico showed a decreasing trend without meaningful changes for incidence and prevalence. Reductions in DALYs were mostly explained by decrements in premature mortality and not by changes in disability burden, probably due to a precariously organised acute stroke care. During the last decade a modest declining trend on stroke burden was observed in comparison with the major reduction that occurred in the period 1900-2005. The less developed states showed the lowest reduction in stroke burden. These findings reveal the health disparities in the burden of stroke within the fragmented Mexican Healthcare System. Funding: Funding was provided by The Bill & Melinda Gates Foundation. Declaration of Interests: Vanessa De la Cruz-Gongora, D.Sc: none. Erwin Chiquete, MD, PhD: none. Hector Gomez–Dantes M.D., M.Sc: none. Lucero Cahuana-Hurtado Ph.D: none. Alejandra Montoya-Rodriguez, M.Sc: none. Carlos Cantu-Brito, M.D, Ph.D: none.