Count every newborn: EN-BIRTH study improving facility-based coverage and quality measurement in routine information systems |
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Authors: | Moran Allisyn C Requejo Jennifer |
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Institution: | 1.Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK ;2.Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King’s College London, London, UK ;3.Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (iccdr,b), Dhaka, Bangladesh ;4.Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden ;5.Department of Health Systems, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania ;6.Research Division, Golden Community, Lalitpur, Nepal ; |
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Abstract: | Background An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording. MethodsThe EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017–2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity, percent agreement). We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission. Results23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was >?90%. The observed study stillbirth rate ranged from 3.8 (95%CI?=?2.0,7.0) to 50.3 (95%CI?=?43.6,58.0)/1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9–0.7). Specificity of register-recorded birth outcomes was >?99% and sensitivity varied between hospitals, ranging from 77.7–86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (>?98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use. ConclusionsOur results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths. |
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