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Castillo P, Hurtado JC, Martínez MJ, Jordao D, Lovane L, Ismail MR, Carrilho C, Lorenzoni C, Fernandes F, Mocumbi S, Jaze ZO, Mabota F, Cossa A, Mandomando I, Cisteró P, Mayor A, Navarro M, Casas I, Vila J, Maixenchs M, Munguambe K, Sanz A, Quintó L, Macete E, Alonso P, Bassat Q, Ordi J, Menéndez C. Validity of a minimally invasive autopsy for cause of death determination in maternal deaths in Mozambique: An observational study. PLoS Med 2017; 14:e1002431. [PMID: 29117196 PMCID: PMC5695595 DOI: 10.1371/journal.pmed.1002431] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 10/06/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Despite global health efforts to reduce maternal mortality, rates continue to be unacceptably high in large parts of the world. Feasible, acceptable, and accurate postmortem sampling methods could provide the necessary evidence to improve the understanding of the real causes of maternal mortality, guiding the design of interventions to reduce this burden. METHODS AND FINDINGS The validity of a minimally invasive autopsy (MIA) method in determining the cause of death was assessed in an observational study in 57 maternal deaths by comparing the results of the MIA with those of the gold standard (complete diagnostic autopsy [CDA], which includes any available clinical information). Concordance between the MIA and the gold standard diagnostic categories was assessed by the kappa statistic, and the sensitivity, specificity, positive and negative predictive values and their 95% confidence intervals (95% CI) to identify the categories of diagnoses were estimated. The main limitation of the study is that both the MIA and the CDA include some degree of subjective interpretation in the attribution of cause of death. A cause of death was identified in the CDA in 98% (56/57) of cases, with indirect obstetric conditions accounting for 32 (56%) deaths and direct obstetric complications for 24 (42%) deaths. Nonobstetric infectious diseases (22/32, 69%) and obstetric hemorrhage (13/24, 54%) were the most common causes of death among indirect and direct obstetric conditions, respectively. Thirty-six (63%) women were HIV positive, and HIV-related conditions accounted for 16 (28%) of all deaths. Cerebral malaria caused 4 (7%) deaths. The MIA identified a cause of death in 86% of women. The overall concordance of the MIA with the CDA was moderate (kappa = 0.48, 95% CI: 0.31-0.66). Both methods agreed in 68% of the diagnostic categories and the agreement was higher for indirect (91%) than for direct obstetric causes (38%). All HIV infections and cerebral malaria cases were identified in the MIA. The main limitation of the technique is its relatively low performance for identifying obstetric causes of death in the absence of clinical information. CONCLUSIONS The MIA procedure could be a valuable tool to determine the causes of maternal death, especially for indirect obstetric conditions, most of which are infectious diseases. The information provided by the MIA could help to prioritize interventions to reduce maternal mortality and to monitor progress towards achieving global health targets.
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Affiliation(s)
- Paola Castillo
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Pathology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Juan Carlos Hurtado
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Spain
| | - Miguel J. Martínez
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Spain
| | - Dercio Jordao
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
| | - Lucilia Lovane
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
| | - Mamudo R. Ismail
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Carla Carrilho
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Cesaltina Lorenzoni
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Fabiola Fernandes
- Department of Pathology, Maputo Central Hospital, Maputo, Mozambique
| | - Sibone Mocumbi
- Department of Gynecology and Obstetrics, Maputo Central Hospital, Maputo, Mozambique
| | - Zara Onila Jaze
- Department of Gynecology and Obstetrics, Maputo Central Hospital, Maputo, Mozambique
| | - Flora Mabota
- Department of Gynecology and Obstetrics, Maputo Central Hospital, Maputo, Mozambique
| | - Anelsio Cossa
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | | | - Pau Cisteró
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Alfredo Mayor
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Mireia Navarro
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Spain
| | - Isaac Casas
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Spain
| | - Jordi Vila
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Microbiology, Hospital Clinic of Barcelona, Universitat de Barcelona, Spain
| | - Maria Maixenchs
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Khátia Munguambe
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Ariadna Sanz
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Llorenç Quintó
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Pedro Alonso
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Quique Bassat
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- ICREA, Catalan Institution for Research and Advanced Studies, Pg. Lluís Companys, Barcelona, Spain
| | - Jaume Ordi
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Pathology, Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Clara Menéndez
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clinic of Barcelona, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- * E-mail:
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