Abastecimiento de Agua

5.5.1 Classification of MD from death of WRA during field work

During the data collection period, each death of a WRA was classified as maternal or non-

maternal by the PI, based on the definition of a MD by the 10th revision of the International

Statistical Classification of Diseases and related health problems (ICD-10) (WHO, 1992b). Among the deaths identified, 36.8% (156/424) were classified as MDs and 63.2% (268/424) were non-MDs [Figure 5.3]. Following the field classification, all the 424 deaths identified were reviewed by panel of three experts (two obstetrician-gynaecologists and a midwife) to re- classify deaths, into maternal or non-maternal death.

5.5.2 Classification of maternal deaths by expert panel

The panel of three experts reviewed all the 424 deaths of WRA and assigned cause of death using the ICD-MM (WHO, 2012c). Table 5.7 shows documents used by panel of experts to review deaths of WRA. For deaths that occurred at facility level; all (347/424) had health facility data identification form (Appendix 4a], 94/347 deaths had case notes and 86/347 had MDA2 forms [Appendix 1]. All 86 deaths who had MDA2 forms were the MDs reported in the HMIS during the study period

For deaths which occurred at community; all (77/424) had information recorded on the community death identification form [Appendix 4b], 7/77 deaths had additional verbal autopsy (VA) information [Appendix 5) and 45/77 women had some information copied from their health passport [Table 5.7]

Table 5.7: Sources of data used for cause attribution by panel of experts by place of death

Document Place where the woman died Total

Case notes

Health facility level Community

94 0 94

MDA 2 forms 86 0 86

Case review form 86 0 86

Facility data extraction form 347 0 347

Community data extraction form 0 77 77

Copies health passports or information from health passport

98 45 143

VA 94 57 151

A panel of experts (Two physicians and a midwife), reviewed each death independently to assign causes of death, by applying ICD-MM and subsequently met to reach consensus for cases where there were differences in opinion. The panel agreed on causes of 390/424 deaths and causes of 8% (34/424) of the deaths were reached after consensus. Consensus was reached

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for all the 34 cases by the three-member panel with no further external inputs required by the fourth expert.

Following the panel review, (268/424) deaths were classified as non-maternal deaths, 35.6% (151/424) were confirmed as maternal deaths. Five (5) deaths were reclassified as deaths of women during pregnancy, childbirth and puerperium (incidental /not maternal deaths) [Table 5.8]. The five deaths were all reclassified as “HIV-related deaths during pregnancy, delivery or puerperium” (not MDs) and were assigned codes in block B20-B24 of ICD-10. For these 5 cases, pregnancy was incidental and HIV or AIDS was the underlying cause of death. HIV- related death was defined as death of a woman in pregnancy, childbirth and puerperium due to fatal complications of HIV or AIDS (World Health Organisation, 2012). Among deaths of WRA, the five deaths have been added to the group of non-MDs thereby increasing the proportion of non-MDs from 63.2% (268/424) to 64.4% (273/424) [Figure 5.3). Details of the five deaths are provided in [Table 5.9].

Table 5.8: Classifications of deaths of women of reproductive age by panel of experts

Type Number Percentage (%)

Non-maternal deaths 268 63.2

Maternal deaths -direct 113 26.7

Maternal death - indirect 26 6.1

Maternal Deaths unspecified 12 2.8

Deaths during pregnancy child birth and the puerperium (Coincidental causes)

5 1.2

Total 424 100

Intra-panel agreement on causes of deaths

We calculated level of agreement among the three experts using kappa statistic. Kappa statistics revealed a substantial agreement between the raters were as follows:

a) Experts 1 and 2 agreed on 82 .12% of the cases (κ= 0.8053) b). Experts 1 and 3 agreed on 84.11% of the cases (κ= 0.8276)

c). Experts 2 and 3 agreed on 87.42% of cases (κ-0.925)

The overall of level agreement among the three using Fleiss’s kappa statistic was also high (κ= 0.8321).

Table 5.9: Summary of cases reclassified as non-maternal deaths by panel of experts

No. Summary of case Assigned cause of

death

1 A 40 years gravida 7, para 6 who reported at a facility at 28 weeks gestation. She was HIV positive, stage 4 according to WHO-staging. The woman became pregnant six months after she was started on HAART. She was also on anti-tuberculosis treatment on last admission in hospital (6 months ago). She reported at the facility while breathless, no fever, oral thrush, bilateral crepitation, wasted and had pneumonia. Foetus was viable.

HIV disease resulting in multiple infections

(B20.7)

2 A 34 years para 4, reported at a facility 32 days after delivery with history of generalised lymphadenopathy, weight loss, fever, convulsions and body lesions. She was on HAART; urine protein was negative, no fever, lochia dry and no history of epilepsy. Blood pressure was 110/70. She was classified as HIV stage 4 according to WHO- classification of HIV. She lost weight, and was wasted. The baby was alive

AIDS-related complex (B24)

3 A 30 years para 4 reported to a health facility 39 days after delivery of a live full term infant at a facility. Uterus was well contracted, normal lochia, no fever and malaria negative. She came to facility aggressive, confused, refusing to eat, history of headache, seizures, weight loss and was on HAART due to stage 3-4 of HIV. She was admitted three months prior to this admission due to meningitis; she was unconscious for three weeks and was brought to hospital in a critical condition.

HIV encephalitis (HIV disease resulting in encephalopathy) (B22.0)

4 18 years para 2 admitted with history of oral thrush, confusion and heart palpitation 25 days after delivery at a health centre. She had black dots all over the body and history of frequent diarrhoeas. She was on HAART for 2 years. Had normal vital signs, was not speaking. Normal lochia and uterus well contracted.

HIV disease resulting in Kaposi , HIV Stage 3-4 (B21.0)

5 A 29 years para 4, on HAART since 2008. History of coughing for three months, fever, weakness, vomiting after food, difficulties in breathing, chest tightness and oral thrush. She was on andante- TB treatment at the time of death. She died at home.

HIV related (Pneumocystis jiroveci)

pneumonia, HIV end stage B20.6.,

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Figure 5.3: Classification of deaths of women of reproductive age in Mangochi district

5.6 Comparing maternal and non-maternal deaths demographic