Maternal mortality, stillbirths, and neonatal mortality in a rural district of Pakistan

Introduction: Accurate and timely information on maternal and perinatal mortality is often lacking in developing countries but is important to recognise problems, monitor progress and evaluate the impact of intervention programmes. This study estimates maternal, perinatal and neonatal mortality rates by complete enumeration of all pregnancies, births, maternal, perinatal and neonatal deaths in a rural district of Pakistan, by enhancement of existing information systems and extension into areas without existing information systems. Methods: An enhanced surveillance system was established for one year (2015/16) and was the basis for a population-based prospective cohort study of 51,690 women aged 18–49 years, with 7,580 pregnancies. Maternal, perinatal and neonatal mortality rates were calculated, and risk factors for deaths determined. To assess the completeness of the enhanced surveillance data, capture-recapture methodology was applied. Results: Higher maternal, perinatal and neonatal mortality rates were observed from the enhanced surveillance data, compared to mortality rates in the previous 1.5 years from the routine monitoring system. Maternal mortality was 247 compared to 180 per 100,000 live births, early neonatal and neonatal mortality 30 and 40 compared to 15 and 20 per 1,000 live births respectively, and perinatal mortality 60 compared to 47 per 1,000 births. No difference was observed in stillbirth rate (32 compared 32 per 1,000 births). All the mortality rates were higher than provincial and national estimates proffered by international agencies. An estimated 99% of births, 90% of neonatal deaths, and 86% of early neonatal deaths were captured by the enhanced surveillance system (using capture recapture). Poverty, pre-existing chronic conditions, previous pregnancy complications, hypertensive disorders of pregnancy, unskilled birth attendants, infections, and haemorrhage are among the major risk factors for worse pregnancy outcomes. Conclusion: This study provided the most accurate maternal and perinatal mortality rates in a rural district of Pakistan to date. It demonstrated that extension of coverage and improvement in completeness through reconciliation of data from health information systems is possible and is required to obtain accurate maternal, perinatal and neonatal mortality for assessment of health service interventions at a local level. The identification of risk factors for maternal and perinatal mortality from this study may help to improve existing maternal and child health programs and help in the effective utilisation of resources in developing countries like Pakistan