Using the new ICD-MM classification system for attribution of cause of maternal death--a pilot study.

Understanding the causes of and factors contributing to maternal deaths is critically important for development of interventions that reduce the global burden of maternal mortality and morbidity. The International Classification of Diseases-Maternal Mortality (ICD-MM) classification of cause of death during pregnancy, childbirth and the puerperium was applied to data obtained from maternal death reviews (MDR) for 4558 maternal deaths from five countries in sub-Saharan Africa. None of the data sets identified type of maternal death. Information obtained via MDR is generally sufficient to agree on classification of cause of death to the levels of type and group. The terms 'underlying cause of death' and 'contributing conditions' were used differently in different settings and a specific underlying cause of death was frequently not recorded. Application of ICD-MM resulted in the reclassification of 3.1% (9/285) of cases to the group 'unanticipated complications of management', previously recorded as obstetric haemorrhage or unknown. An increased number of cases were assigned to the groups pregnancy-related infection (5.6-10.2%) and pregnancies with abortive outcome (3.4-4.9%) when a clear distinction was made between women who died 'with' HIV/AIDS of obstetric causes (direct maternal death) and AIDS-related indirect maternal deaths (group 'non-obstetric complications'). Similarly, anaemia and obstructed labour were more frequently identified as contributing factors than underlying cause of death. It would be helpful if MDR forms could have explicitly stated variables called: type, group and underlying cause of death as well as a dedicated section to the most frequently occurring contributing conditions recognised in that setting.

Establishing cause of maternal death in Malawi via facility-based review and application of the ICD-MM classification.

Maternal death review (MDR) is an accepted process that is implemented across Malawi and 'underlying cause of death' is assigned by healthcare providers using a standard MDR form. Mixed-methods approach. Key informant interviews with eight stakeholders involved in MDR. Secondary analysis of MDR forms for 54 maternal deaths. Comparison of assigned cause of death by healthcare providers conducting MDR at health facility level with cause assigned by researchers using the International Classification of Diseases Maternal Mortality (ICD-MM) classification. MDR teams, analysts and policymakers reported facing challenges in completing the forms, analysing and using information. The concepts of underlying (primary) and contributing (secondary) causes of death are often misunderstood. Healthcare providers using only MDR forms reported cause of death as non-obstetric complications in 39.6% and pregnancy-related infection in 11.3% of cases. For 30.2% of cases, no clear clinical cause of death was recorded. The most commonly assigned underlying cause of death using ICD-MM was obstetric haemorrhage (32.1%), non-obstetric complications (24.5%) and pregnancy-related infection (22.6%). There was poor agreement between cause(s) of maternal death assigned by healthcare providers in the field and trained researchers using the new ICD-MM classification (κ statistic; 0.219). The majority of cases could be reclassified using the ICD-MM and this provided a more specific cause of death. A more structured and user-friendly MDR form is required. Accurate classification of cause of death is important. Dissemination of, and training in the use of the new ICD-MM classification system will be helpful to healthcare providers conducting MDR in Malawi.

Hysterosalpingographic tubal abnormalities and HIV infection among black women with tubal infertility in sub-Saharan Africa.

BACKGROUND: Tubal factor remains a common cause of infertility. The association of HIV infection and tubal infertility is a cause for concern. OBJECTIVE: To determine hysterosalpingographic tubal abnormalities and HIV infection among patients with tubal infertility. RESULTS: Over a 4-year period, 207 patients were analyzed. Of these, 174 (84.1%) presented with secondary infertility and 33 (15.9%) with primary infertility. The patients' age range was 21-48 years and mean age was 36.2 years. One hundred and two (49.3%) patients had a history of induced abortion. Concordant bilateral tubal occlusion was found in 139 (67.2%) patients while 68 (32.8%) had discordant bilateral tubal occlusion. Of the 414 fallopian tubes studied, proximal tubal occlusion was found in 66 (15.9%) cases and distal tubal occlusive pathology occurred in 348 (84.1%). An HIV positivity rate of 13.5% was recorded. Distal tubal occlusion with hydrosalpinx was more associated with HIV infection in this series. CONCLUSION: A high HIV positivity rate was recorded among the patients with tubal infertility compared to the general population. There is prepondence of distal tubal occlusion in infertile women with tubal factor.