Effectiveness of an intervention on uptake of maternal care in four counties in Ningxia,China

Objectives To understand the utilisation of prenatal care and hospitalised delivery among pregnant Muslim women in Ningxia, China, and to explore the effectiveness of the integrated interventions to reduce maternal mortality. Methods Cross‐sectional surveys before and after the intervention were carried out. Using multistage sampling, 1215 mothers of children <5 years old were recruited: 583 in the pre‐intervention survey and 632 in the post‐intervention study. Data on prenatal care and delivery were collected from face‐to‐face interviews. Maternal mortality ratio (MMR) data were obtained from the local Maternal and Child Mortality Report System. Results After the intervention, the MMR significantly decreased (45.5 deaths per 100 000 live births to 32.7 deaths). Fewer children were born at home after the intervention than before the intervention (OR, 0.11; 95% CI, 0.08–0.15). The proportion of women who attended prenatal care at least once increased from 78.2% to 98.9% (OR, 24.55; 95% CI, 11.37–53.12). The proportion of women who had prenatal visit(s) in the first trimester of pregnancy increased from 35.1% to 82.6% (OR, 8.77; 95% CI, 6.58–11.69). The quality of prenatal care was greatly improved. Effects of the intervention on the utilisation of maternal care remained significant after adjusting for education level and household possessions. Conclusions The findings suggest that integrated strategies can effectively reduce maternal mortality.     

Using the three delays model to understand why newborn babies die in eastern Uganda

Objectives To investigate causes of and contributors to newborn deaths in eastern Uganda using a three delays audit approach. Methods Data collected on 64 neonatal deaths from a demographic surveillance site were coded for causes of deaths using a hierarchical model and analysed using a modified three delays model to determine contributing delays. A survey was conducted in 16 health facilities to determine capacity for newborn care. Results Of the newborn babies, 33% died in a hospital/health centre, 13% in a private clinic and 54% died away from a health facility. 47% of the deaths occurred on the day of birth and 78% in the first week. Major contributing delays to newborn death were caretaker delay in problem recognition or in deciding to seek care (50%, 32/64); delay to receive quality care at a health facility (30%; 19/64); and transport delay (20%; 13/64). The median time to seeking care outside the home was 3 days from onset of illness (IQR 1–6). The leading causes of death were sepsis or pneumonia (31%), birth asphyxia (30%) and preterm birth (25%). Health facilities did not have capacity for newborn care, and health workers had correct knowledge on only 31% of the survey questions related to newborn care. Conclusions Household and health facility‐related delays were the major contributors to newborn deaths, and efforts to improve newborn survival need to address both concurrently. Understanding why newborn babies die can be improved by using the three delays model, originally developed for understanding maternal death.     

Barriers to conducting effective obstetric audit in Ifakara: a qualitative assessment in an under‐resourced setting in Tanzania

Objective To explore barriers to and solutions for effective implementation of obstetric audit at Saint Francis Designated District Hospital in Ifakara, Tanzania, where audit results have been disappointing 2 years after its introduction. Methods Qualitative study involving participative observation of audit sessions, followed by 23 in‐depth interviews with health workers and managers. Knowledge and perceptions of audit were assessed and suggestions for improvement of the audit process explored. Results During the observational period, audit sessions were held irregularly and only when the head of department of obstetrics and gynaecology was available. Cases with evident substandard care factors were audited. In‐depth interviews revealed inadequate knowledge of the purpose of audit, despite the fact that participants regarded obstetric audit as a potentially useful tool. Insufficient staff commitment, managerial support and human and material resources were mentioned as reasons for weak involvement of health workers and poor implementation of recommendations resulting from audit. Suggestions for improvement included enhancing feedback to all staff and managers to attend sessions and assist with the effectuation of audit recommendations. Conclusion Obstetric staff in Ifakara see audit as an important tool for quality improvement. They recognise, however, that in their own situation, insufficient staff commitment and poor managerial support are barriers to successful implementation. They suggested training in concept and principles of audit as well as strengthening feedback of audit outcomes, to achieve structural health care improvements through audit.     

Health workers’ perceptions of obstetric critical incident audit in Thyolo District,Malawi

Objective To assess perceptions held by health workers in a Malawian district about obstetric critical incident audit. Insight into factors contributing to participation and endorsement may help to improve the audit process and reduce facility‐based maternal and neonatal mortality and morbidity. Methods This study involves semi‐structured interviews with 25 district health workers, a focus group discussion and observation of audit sessions in health facilities in Thyolo District, Malawi, between August 2009 and January 2010. Data were analysed with maxqda 2010. Results Findings were categorized into four major areas: (i) general knowledge of audit, (ii) participation in local audit and feedback sessions, (iii) the ability to reproduce the local audit cycle and (iv) effects and outcomes of audit and feedback. All health workers were familiar with the concept of audit and could reproduce the local cycle. Most health workers classified audit as an instructive and helpful tool to improve the quality of their work, provided that it is performed in a manner that enhances motivation and on‐the‐job learning. Conclusions Contradictory to recent reports from other African settings, which showed negative effects of audit on health workers’ motivation, staff in this district considered audit and feedback valuable tools to enhance the quality of the care they provide. Audit has become part of the professional routine in the district, and its educational value was considered its most important appeal.     

Substandard emergency obstetric care – a confidential enquiry into maternal deaths at a regional hospital in Tanzania

Objective (i) To identify clinical causes of maternal deaths at a regional hospital in Tanzania and through confidential enquiry (CE) assess major substandard care and make a comparison to the findings of the internal maternal deaths audits (MDAs); (ii) to describe hospital staff reflections on causes of substandard care. Methods A CE into maternal deaths was conducted based on information available from written sources supplemented with participatory observations and interviews with staff. The compiled information was summarized and presented anonymously for external expert review to assess for major substandard care. Hospital based maternal deaths between 2006 and 2008 (35 months) were included. Of 68 registered maternal deaths sufficient information for reviewing was retrieved for 62 cases (91%). As a supplement, in‐depth interviews with staff about the underlying causes of substandard care were performed. Results The causes of death were infection (40%), abortion (25%), eclampsia (13%), post‐partum haemorrhage (12%), obstructed labour (6%) and others (4%). The median time available for hospital staff to manage the fatal complication was 47 h. The CE identified major substandard care in 46 (74%) of the 62 cases reviewed. During the same time period MDA identified substandard care in 18 cases. Staff perceived poor organization of work and lack of training as important causes for substandard care. Local MDA was considered useful although time‐consuming and sometimes threatening, and staff dedication to the process was questioned. Conclusion Quality assurance of emergency obstetric care might be strengthened by supplementing internal MDA with external CE.     

Health policy for sickle cell disease in Africa: experience from Tanzania on interventions to reduce under‐five mortality

Tanzania has made considerable progress towards reducing childhood mortality, achieving a 57% decrease between 1980 and 2011. This epidemiological transition will cause a reduction in the contribution of infectious diseases to childhood mortality and increase in contribution from non‐communicable diseases (NCDs). Haemoglobinopathies are amongst the most common childhood NCDs, with sickle cell disease (SCD) being the commonest haemoglobinopathy in Africa. In Tanzania, 10 313 children with SCD under 5 years of age (U5) are estimated to die every year, contributing an estimated 7% of overall deaths in U5 children. Key policies that governments in Africa are able to implement would reduce mortality in SCD, focusing on newborn screening and comprehensive SCD care programmes. Such programmes would ensure that interventions such as prevention of infections using penicillin plus prompt diagnosis and treatment of complications are provided to all individuals with SCD.     

Effects of severe obstetric complications on women’s health and infant mortality in Benin

Objective To document the impact of severe obstetric complications on post‐partum health in mothers and mortality in babies over 12 months in Benin and to assess whether severe complications associated with perinatal death are particularly likely to lead to adverse health consequences. Methods Cohort study which followed women and their babies after a severe complication or an uncomplicated childbirth. Women were selected in hospitals and interviewed at home at discharge, and at 6 and 12 months post‐partum. Women were invited for a medical check‐up at 6 months and 12 months. Results The cohort includes 205 women with severe complications and a live birth, 64 women with severe complications and perinatal death and 440 women with uncomplicated delivery. Women with severe complications and a live birth were not dissimilar to women with a normal delivery in terms of post‐partum health, except for hypertension [adjusted OR = 5.8 (1.9–17.0)], fever [adjusted OR = 1.71 (1.1–2.8)] and infant mortality [adjusted OR = 11.0 (0.8–158.2)]. Women with complications and perinatal death were at increased risk of depression [adjusted OR = 3.4 (1.3–9.0)], urine leakages [adjusted OR = 2.7 (1.2–5.8)], and to report poor health [adjusted OR = 5.27 (2.2–12.4)] and pregnancy’s negative effects on their life [adjusted OR = 4.11 (1.9–9.0)]. Uptake of post‐natal services was poor in all groups. Conclusion Women in developing countries face a high risk of severe complications during pregnancy and delivery. These can lead to adverse consequences for their own health and that of their offspring. Resources are needed to ensure that pregnant women receive adequate care before, during and after discharge from hospital. Near‐miss women with a perinatal death appear a particularly high‐risk group.     

Continuum of care for maternal, newborn, and child health: from slogan to service delivery

The continuum of care has become a rallying call to reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths, and 6 million child deaths. The continuum for maternal, newborn, and child health usually refers to continuity of individual care. Continuity of care is necessary throughout the lifecycle (adolescence, pregnancy, childbirth, the postnatal period, and childhood) and also between places of caregiving (including households and communities, outpatient and outreach services, and clinical-care settings). We define a population-level or public-health framework based on integrated service delivery throughout the lifecycle, and propose eight packages to promote health for mothers, babies, and children. These packages can be used to deliver more than 190 separate interventions, which would be difficult to scale up one by one. The packages encompass three which are delivered through clinical care (reproductive health, obstetric care, and care of sick newborn babies and children); four through outpatient and outreach services (reproductive health, antenatal care, postnatal care and child health services); and one through integrated family and community care throughout the lifecycle. Mothers and babies are at high risk in the first days after birth, and the lack of a defined postnatal care package is an important gap, which also contributes to discontinuity between maternal and child health programmes. Similarly, because the family and community package tends not to be regarded as part of the health system, few countries have made systematic efforts to scale it up or integrate it with other levels of care. Building the continuum of care for maternal, newborn, and child health with these packages will need effectiveness trials in various settings; policy support for integration; investment to strengthen health systems; and results-based operational management, especially at district level.     

Relative and absolute addressability of global disease burden in maternal and perinatal health by investment in R&D

Maternal and perinatal disease accounts for nearly 10% of the global burden of disease, with only modest progress towards achievement of the Millennium Development Goals. Despite a favourable new global health landscape in research and development (R&D) to produce new drugs for neglected diseases, R&D investment in maternal/perinatal health remains small and non-strategic. Investment in obstetric R&D by industry or the not-for-profit sector has lagged behind other specialties, with the number of registered pipeline drugs only 1-5% that for other major disease areas. Using a Delphi exercise with maternal/perinatal experts in global and translational research, we estimate that equitable pharmaceutical R&D and public sector research funding over the next 10-20 years could avert 1.1% and 1.9% of the global disease burden, respectively. In contrast, optimal uptake of existing research would prevent 3.0%, justifying the current focus on health service provision. Although R&D predominantly occurs in high-income countries, more than 98% of the estimated reduction in disease burden in this field would be in developing countries. We conclude that better pharmaceutical and public sector R&D would prevent around 1/3 and 2/3, respectively, of the disease burden addressable by optimal uptake of existing research. Strengthening R&D may be an important complementary strategy to health service provision to address global maternal and perinatal disease burden.     

Geospatial distribution and determinants of child mortality in rural western Kenya 2002–2005

Objective To describe local geospatial variation and geospatial risk factors for child mortality in rural western Kenya. Methods We calculated under‐5 mortality rates (U5MR) in 217 villages in a Health and Demographic Surveillance System (HDSS) area in western Kenya from 1 May 2002 through 31 December 2005. U5MRs by village were mapped. Geographical positioning system coordinates of residences at the time of death and distances to nearby locations were calculated. Multivariable Poisson regression accounting for clustering at the compound level was used to evaluate the association of geospatial factors and mortality for infants and children aged 1–4 years. Results Among 54 057 children, the overall U5MR was 56.5 per 1000 person‐years and varied by village from 21 to 177 per 1000 person‐years. High mortality villages occurred in clusters by location and remained in the highest mortality quintile over several years. In multivariable analysis, controlling for maternal age and education as well as household crowding, higher infant mortality was associated with living closer to streams and further from public transport roads. For children 1–4 years, living at middle elevations (1280–1332 metres), living within lower population densities areas, and living in the northern section of the HDSS were associated with higher mortality. Conclusions Childhood mortality was significantly higher in some villages. Several geospatial factors were associated with mortality, which might indicate variability in access to health care or exposure and transmission of infectious diseases. These results are useful in prioritising areas for further study and implementing directed public health interventions.     

Examining time‐dependent effects of water,sanitation, and hygiene (WASH) interventions using an agent‐based model

The effects of water, sanitation, and hygiene (WASH) interventions have been well acknowledged to reduce the risk from diarrheal disease‐causing pathogens. In spite of the recognized importance of WASH interventions on the reduction of diarrheal disease, there are still gaps in the understanding of the time‐varying effects of interventions. To bridge this research gap, we developed agent‐based models (ABMs) of diarrheal disease transmission in a community context. In the model, infections occur via two pathways: (i) between household members within the household environment and (ii) from the community environment outside the household. To measure the effectiveness of WASH interventions, we performed global sensitivity analysis (GSA) at the macro and micro temporal scales, varying the level of intervention coverage in the community. We simulated three intervention strategies, implemented separately in the experiments. The clean drinking water intervention, sanitation intervention, and hand washing intervention had similar success rates in the long‐term. The handwashing intervention had the largest immediate effect. This highlights that proper short‐ and long‐term intervention strategies need to be considered for disease control and the effective management of limited resources.     

Access to a health facility and care‐seeking for danger signs in children: before and after a community‐based intervention in Lusaka,Zambia

Objective To assess the association of accessibility to a health facility with caregivers’ care‐seeking practices for children with danger signs before and after community‐based intervention in Lusaka, Zambia. Method Health education on childhood danger signs was started in September 2003 at the monthly Growth Monitoring Program Plus (GMP+) service through various channels of health talk and one‐on‐one communication in a peri‐urban area of Lusaka. Two repeated surveys were conducted: in 2003 to collect baseline data before the intervention and in 2006 for 3‐year follow‐up data. Caregivers who had perceived one or more danger signs in their children within 2 months of the surveys were eligible for the analysis. The association between appropriate and timely care‐seeking practices and socio‐demographic and socio‐economic factors, attendance at community‐based intervention and the distance to a health facility was examined with logistic regression analysis. Results The percentage of caregivers immediately seeking care from health professionals increased from 56.1% (106/189) at baseline to 65.8% (148/225) at follow‐up 3 years later (OR = 1.51, P < 0.05). Long distance to the health facility and low‐household income negatively influenced caregivers’ appropriate and timely care‐seeking practices at baseline, but 3 years later, after the implementation of a community‐based intervention, distance and household income were not significantly related to caregivers’ care‐seeking practices. Conclusion Poor accessibility to health facilities was a significant barrier to care‐seeking in a peri‐urban area. However, when caregivers are properly educated about danger signs and appropriate responses through community‐based intervention, this barrier can be overcome through behavioural change in caregivers.     

Systematic review: handwashing behaviour in low- to middle-income countries: outcome measures and behaviour maintenance

Objectives To describe global approaches to handwashing research in low‐ and middle‐income communities, schools and health care settings using behavioural outcome measurement and temporal study design. Methods Peer‐reviewed and grey literature was screened for handwashing studies that evaluated behaviour change. Relevant articles were assessed by their research approach, including the investigator’s selected outcome measure and time frame of various study components (e.g., formative research, intervention and evaluation). Results The initial search yielded 527 relevant articles. After application of exclusion criteria, we identified 27 unique studies (30 total articles). Of the 27 articles, most were focused in the community setting. Fifteen (56%) documented observed handwashing behaviour, while 18 (67%) used proxy measures (e.g., soap presence, diarrhoea) and 14 (52%) used self‐reported behaviour. Several studies used multiple outcome measures. While all studies had an evaluation of behaviour change, there was a dearth of studies that evaluated long‐term maintenance of behaviour change after the intervention’s conclusion. Conclusions While the literature is replete with a variety of handwashing studies in community, school and health care settings, none have been able to definitively document long‐term behaviour change, thereby challenging the sustainability of various interventions. Additionally, there is a need to better understand which research approach is most effective in promoting long‐term behaviour compliance in global low‐ and middle‐income settings.     

Costs,effects and cost‐effectiveness of breast cancer control in Ghana

Objective Breast cancer control in Ghana is characterised by low awareness, late‐stage treatment and poor survival. In settings with severely constrained health resources, there is a need to spend money wisely. To achieve this and to guide policy makers in their selection of interventions, this study systematically compares costs and effects of breast cancer control interventions in Ghana. Methods We used a mathematical model to estimate costs and health effects of breast cancer interventions in Ghana from the healthcare perspective. Analyses were based on the WHO‐CHOICE method, with health effects expressed in disability‐adjusted life years (DALYs), costs in 2009 US dollars (US$) and cost‐effectiveness ratios (CERs) in US$ per DALY averted. Analyses were based on local demographic, epidemiological and economic data, to the extent these data were available. Results Biennial screening by clinical breast examination (CBE) of women aged 40–69 years, in combination with treatment of all stages, seems the most cost‐effective intervention (costing $1299 per DALY averted). The intervention is also economically attractive according to international standards on cost‐effectiveness. Mass media awareness raising (MAR) is the second best option (costing $1364 per DALY averted). Mammography screening of women of aged 40–69 years (costing $12 908 per DALY averted) cannot be considered cost‐effective. Conclusions Both CBE screening and MAR seem economically attractive interventions. Given the uncertainty about the effectiveness of these interventions, only their phased introduction, carefully monitored and evaluated, is warranted. Moreover, their implementation is only meaningful if the capacity of basic cancer diagnostic, referral and treatment and possibly palliative services is simultaneously improved.     

Can mothers recognize neonatal illness correctly? comparison of maternal report and assessment by community health workers in rural Bangladesh

Objectives To validate maternal recognition of neonatal illnesses at home compared to assessment by community health workers (CHWs) during routine household surveillance for neonatal illness in rural Bangladesh. Methods Surveillance in the intervention arm of two cluster‐randomized, controlled trials of newborn interventions conducted in Sylhet and Mirzapur districts of Bangladesh. CHWs promoted birth and newborn care preparedness during two prenatal visits, including recognition of neonatal illnesses. CHWs assessed 8472 neonates on post‐natal days 0, 3, and 6 between 2004 and 2005 in Sylhet, and 7587 neonates on post‐natal days 0, 2, 5, and 8 between 2004 and 2006 in Mirzapur. In both sites, CHW identified neonates with very severe disease (VSD), using clinical algorithms that included ascertainment of illness history reported by mother and observation of clinical signs of illness. We calculated sensitivity, specificity, positive predictive value and negative predictive value of maternal report of any illness sign compared to CHWs’ assessments and classification of VSD. Analysis was restricted to mothers whose neonates were assessed by CHWs at home during the routine visit schedule. Results Maternal report of any signs had sensitivity of 24% and 20% and positive predictive value of 45% and 54% in Sylhet and Mirzapur, respectively. Conclusions Maternal recognition of neonatal illnesses at home was poor in two rural areas in Bangladesh. Interventions need to be designed to improve maternal recognition, and routine post‐natal assessment by CHWs at home may be an essential component of community‐based newborn care to improve care‐seeking for newborn illness.     

Moving from vertical to integrated child health programmes: experiences from a multi‐country assessment of the Child Health Days approach in Africa

Objectives To assess the effect of child health days (CHDs) on coverage of child survival interventions, to document country experiences with CHDs and to identify ways in which CHDs have strengthened or depleted primary health care (PHC) services. Methods Programme evaluation in six countries in sub‐Saharan Africa using both quantitative (review of routine child health indicators) and qualitative (key informant interviews) methods. Results We found that CHDs have raised the profile of child survival at different levels from central government to the community in all six countries. The approach has increased the coverage of vitamin A supplementation and immunizations, especially in previously poorly performing countries. However, similar improvements have not occurred in non‐CHD interventions, most notably exclusive breastfeeding. There were examples of duplication, especially in the capturing and use of health information. There was widespread evidence that PHC staff were being diverted from their usual PHC functions, and managers reported being distracted by the time required for the planning and execution of CHDs. Finally, there were examples of where the routine PHC system is becoming distorted through, for example, the payment of health worker incentives during CHD activities only. Conclusion Interventions such as CHDs can rapidly increase coverage of key child survival interventions; however, they need to do so in a manner that strengthens rather than depletes existing PHC services. Our findings suggest that stand alone child health day interventions may gradually need to be integrated with routine PHC through more general health system strengthening.     

Mortality measurement in transition: proof of principle for standardised multi‐country comparisons

Objective To demonstrate the viability and value of comparing cause‐specific mortality across four socioeconomically and culturally diverse settings using a completely standardised approach to VA interpretation. Methods Deaths occurring between 1999 and 2004 in Butajira (Ethiopia), Agincourt (South Africa), FilaBavi (Vietnam) and Purworejo (Indonesia) health and socio‐demographic surveillance sites were identified. VA interviews were successfully conducted with the caregivers of the deceased to elicit information on signs and symptoms preceding death. The information gathered was interpreted using the InterVA method to derive population cause‐specific mortality fractions for each of the four settings. Results The mortality profiles derived from 4784 deaths using InterVA illustrate the potential of the method to characterise sub‐national profiles well. The derived mortality patterns illustrate four populations with plausible, markedly different disease profiles, apparently at different stages of health transition. Conclusions Given the standardised method of VA interpretation, the observed differences in mortality cannot be because of local differences in assigning cause of death. Standardised, fit‐for‐purpose methods are needed to measure population health and changes in mortality patterns so that appropriate health policy and programmes can be designed, implemented and evaluated over time and place. The InterVA approach overcomes several longstanding limitations of existing methods and represents a valuable tool for health planners and researchers in resource‐poor settings.     

‘I never thought that this baby would survive; I thought that it would die any time’: perceptions and care for preterm babies in eastern Uganda

Objective To explore the current care for and perceptions about preterm babies among community members in eastern Uganda. Methods A neonatal midwife observed care of preterm babies in one general hospital and 15 health centres using a checklist and a field diary. In‐depth interviews were conducted with 11 community health workers (CHWs) and also with 10 mothers, six fathers and three grandmothers of preterm babies. Three focus group discussions were conducted with midwives and women and men in the community. Content analysis of data was performed. Results Community members mentioned many features which may correctly be used to identify preterm babies. Care practices for preterm babies at health facilities and community level were inadequate and potentially harmful. Health facilities lacked capacity for care of preterm babies in terms of protocols, health workers’ skills, basic equipment, drugs and other supplies. However, community members and CHWs stated that they accepted the introduction of preterm care practices such as skin‐to‐skin and kangaroo mother care. Conclusion In this setting, care for preterm babies is inadequate at both health facility and community level. However, acceptance of the recommended newborn care practices indicated by the community is a window of opportunity for introducing programmes for preterm babies. In doing so, consideration needs to be given to the care provided at health facilities as well as to the gaps in community care that are largely influenced by beliefs, perceptions and lack of awareness.     

Systematic scaling up of neonatal care in countries

Every year about 70% of neonatal deaths (almost 3 million) happen because effective yet simple interventions do not reach those most in need. Coverage of interventions is low, progress in scaling up is slow, and inequity is high, especially for skilled clinical interventions. Situations vary between and within countries, and there is no single solution to saving lives of newborn babies. To scale up neonatal care, two interlinked processes are required: a systematic, data-driven decision-making process, and a participatory, rights-based policy process. The first step is to assess the situation and create a policy environment conducive to neonatal health. The next step is to achieve optimum care of newborn infants within health system constraints; in the absence of strong clinical services, programmes can start with family and community care and outreach services. Addressing missed opportunities within the limitations of health systems, and integrating care of newborn children into existing programmes--eg, safe motherhood and integrated management of child survival initiatives--reduces deaths at a low marginal cost. Scaling up of clinical care is a challenge but necessary if maximum effect and equity are to be achieved in neonatal health, and maternal deaths are to be reduced. This step involves systematically strengthening supply of, and demand for, services. Such a phased programmatic implementation builds momentum by reaching achievable targets early on, while building stronger health systems over the longer term. Purposeful orientation towards the poor is vital. Monitoring progress and effect is essential to refining strategies. National aims to reduce neonatal deaths should be set, and interventions incorporated into national plans and existing programmes.     

The impact of first year adherence to antiretroviral therapy on long‐term clinical and immunological outcomes in the DART trial in Uganda and Zimbabwe

Objectives To describe associations between different summaries of adherence in the first year on antiretroviral therapy (ART) and the subsequent risk of mortality, to identify patients at high risk because of early adherence behaviour. Methods We previously described an approach where adherence behaviour at successive clinic visits during the first year on ART was seen as a Markov chain (MC), and the individually estimated transition probabilities between ‘good’, ‘poor’ and ‘non‐response’ adherence states were used to classify HIV‐infected adults in the DART trial into subgroups with similar behaviour. The impact of this classification and classifications based on traditional ‘averaged’ measures [mean drug possession ratio (DPR) and self‐reported adherence] were compared in terms of their impact on longer‐term mortality over the 2–5 years on ART using Cox proportional hazards models. Results Of 2960 participants in follow‐up after 1 year on ART, 29% had never missed pills in the last month and 11% had 100% DPR throughout the first year. The poorest adherers by self‐reported measures were more likely to have only none/primary education (P < 0.01). Being in the poorest adherence subgroup by MC and DPR was independently associated with increased mortality [HR = 1.57 (95% CI 1.02, 2.42); 1.82 (1.32, 2.51) respectively]. Conclusions Classification based on dynamic adherence behaviour is associated with mortality independently of DPR. The classifications could be useful in understanding adherence, targeting focused interventions and improving longer‐term adherence to therapy.