EC Gynaecology

Introduction: Maternal, infectious and non-communicable causes of death combine to be simultaneously a major health problem for women of reproductive age (WRA) in low and middle-income countries (LMICs), particularly sub-Saharan Africa (SSA). Yet, little is known about the relative risk of each of them when considered together and their demographic impact. Consequently, the focus of research and funding has been on maternal health. However, the evolving demographic and health transitions in LMICs suggest a need for a comprehensive methodology to addressing women’s health challenges beyond maternal causes.

Objective: To examine the relative risks of women of reproductive age dying from maternal, infectious or non-communicable causes, using a competing risks analysis.

Methods: This is a fifteen-year study of the Kintampo North Municipality and the Kintampo South District, of the Bono East Region of Ghana which are the study sites of the Kintampo Health and Demographic Surveillance System (KHDSS), administered by the Kintampo Health Research Centre (KHRC). Deaths and person-years of exposure were calculated by age for WRA (15 - 49) of the KHDSS area from January 2005 to December 2019. Causes of death were diagnosed by means of the physician coding and the 10^th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), using the verbal autopsy questionnaire. Identified causes of death were categorised into three broad groups: maternal, infectious and non-communicable diseases. The gains in life expectancy as well as the decomposition of the total gains by age were estimated, using multiple decrements together with the associated single decrement life table methods.

Discussion: The study uses competing risks analysis technique to examine the relative risk of women of reproductive age dying from maternal, infectious or non-communicable causes in the Kintampo North Municipality and Kintampo South District of Ghana. The study will provide valuable information on the relative risk of women dying from the three causes of death among the women. Both research and policy on mortality among women focus on maternal death. Meanwhile, cause of death by NCDs has been rising globally and among women in low and middle-income countries. This study aimed at examining death among WRA more comprehensively, using data on the three causes of death. The research evidence from the study will be useful for adopting policies and developing and implementing programmes where life expectancy returns will be highest. In addition, reliable data on causes of death is not readily available in most low-income countries, including Ghana. The verbal autopsy method used in this study provides valuable information on causes of death that are essential for monitoring and evaluating the targets of the health indicators of the Sustainable Development Goals.

Keywords: Verbal Autopsy; Women of Reproductive Age; Health and Demographic Surveillance System; Low and Middle-Income Countries

1. Global burden of diseases in low and middle income countries. World Health Organization (10/23) (2019a).
2. Asamoah BO., et al. “Distribution of causes of maternal mortality among different socioeconomic status”. BMC Public Health 159 (2011).
3. World Health Statistics, Monitoring Health For the SDGs (2019b).
4. The Top 10 Causes of Death: Leading Causes of Death by Economy Income Group (2020).
5. Alkema L., et al. “Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: A systematic analysis by the un Maternal Mortality Estimation Inter-Agency Group”. The Lancet 100117 (2016): 462-474.
6. Bawah A., et al. “The evolving demographic and health transition in four low- and middle-income countries: Evidence from four sites in the INDEPTH Network of longitudinal health and demographic surveillance systems”. PLoS ONE 6 (2016): 1-16.
7. Say L., et al. “Global causes of maternal death: A WHO systematic analysis”. The Lancet Global Health 6 (2014): 323-333.
8. Maternal mortality fact sheet (2015).
9. Narh-Bana SA., et al. “Adult deaths and the future: A cause-specific analysis of adult deaths from a longitudinal study in rural Tanzania 2003-2007”. Tropical Medicine and International Health 11 (2012): 1396-1404.
10. Van Eijk AM., et al. “Causes of deaths using verbal autopsy among adolescents and adults in rural western Kenya”. Tropical Medicine and International Health 10 (2008): 1314-1324.
11. Labrique AB., et al. “Beyond pregnancy - The neglected burden of mortality in young women of reproductive age in Bangladesh: A prospective cohort study”. BJOG: An International Journal of Obstetrics and Gynaecology 9 (2013): 1085-1089.
12. Melaku YA., et al. “Causes of death among females-investigating beyond maternal causes: a community-based longitudinal study”. BMC Research Notes 7 (2014): 629.
13. Global Status Report on Noncommunicable Diseases, 2014: Attaining the nine global noncommunicable diseases targets; a shared responsibility. Geneva: WHO (2014).
14. Zimmet PZ., et al. “Diabetes: a 21st century challenge”. The Lancet Diabetes and Endocrinology 1 (2014): 56-64.
15. Noncommunicable Diseases Key Facts (2021).
16. Bal Kishan Gulati and Anil Kumar AP. “Cause of death by verbal autopsy among women of reproductive age in Rajasthan India 1.1 (2015): 56-60.
17. Nettey OEA., et al. “Knowledge, Attitudes and Preventive Practices on Ebola Virus Disease in the Kintampo Districts of Ghana”. Health (2016).
18. Owusu-Agyei S., et al. “Demographic patterns and trends in Central Ghana: baseline indicators from the Kintampo Health and Demographic Surveillance System”. Global Health Action 5 (2014): 1-11.
19. INDEPTH Network. “INDEPTH Network, Better Health Information for Better Health Policy”. MEMBER HDSSs (2022).
20. Dalal S., et al. Non-communicable diseases in sub-Saharan Africa: what we know now (2011): 885-901.
21. Ramroth H., et al. “Cause of death distribution with InterVA and physician coding in a rural area of Burkina Faso”. Tropical Medicine and International Health 7 (2012): 904-913.
22. Ye Y., et al. “Health and demographic surveillance systems: a step towards full civil registration and vital statistics system in sub-Sahara Africa?” BMC Public Health 1 (2012): 741.
23. Mathers CD and Loncar D. “Projections of global mortality and burden of disease from 2002 to 2030”. PLoS Medicine 11 (2006): 2011-2030.
24. Moyer CA., et al. “PREventing Maternal and Neonatal Deaths (PREMAND): a study protocol for examining social and cultural factors contributing to infant and maternal deaths and near-misses in rural northern Ghana”. Reproductive Health 1 (2016): 20.
25. Sankoh O and Byass P. “The INDEPTH network: Filling vital gaps in global epidemiology”. International Journal of Epidemiology 3 (2012): 579-588.
26. Setel PW., et al. Sample registration of vital events with verbal autopsy: innovative approaches to measuring and monitoring vital statistics 014969.04 (2004).
27. Murray CJL., et al. “Using verbal autopsy to measure causes of death: the comparative performance of existing methods”. BMC Medicine 1 (2014): 5.
28. Baiden F., et al. “Setting international standards for verbal autopsy”. Bulletin of the World Health Organisation 10 (2007): 570-571.
29. Houle B., et al. “The impacts of maternal mortality and cause of death on children ’ s risk of dying in rural South Africa : evidence from a population based surveillance study (1992-2013)”. Reproductive Health 1 (2015): S7.
30. Abubakari SW., et al. “Socio-economic, physical and health-related determinants of causes of death among women in the Kintampo districts of Ghana”. Cogent Public Health 1 (2022): 2109300.
31. Abubakari SW., et al. “A Competing Risk Analysis of Women Dying of Maternal, Infectious, or Non-Communicable Causes in the Kintampo Area of Ghana”. Frontiers in Global Women's Health 2 (2021): 690870.
32. Abubakari SW., et al. “Young people’s experiences in accessing sexual and reproductive health services in sub-Saharan Africa from 1994 to 2019 - A content analysis”. International Journal of Sexual and Reproductive Health Care 1 (2020): 017-026.
33. Tunstall-Pedoe H. “Preventing Chronic Diseases. A Vital Investment: WHO Global Report. Geneva: World Health Organization, 2005. pp 200. CHF 30.00. ISBN 92 4 1563001”. International Journal of Epidemiology 4 (2005): 1563001-1563001.
34. Bloom DE., et al. The Global Economic Burden of Noncommunicable Diseases (2011): 1-46.
35. NCD Alliance. Non-Communicable Diseases: A Priority for Women’s Health and Development (2010): 1-20.
36. Langer A., et al. “Women and Health: The key for sustainable development”. The Lancet 9999 (2015): 1165-1210.
37. Byass P., et al. “Reflections on the Global Burden of Disease 2010 Estimates”. PLoS Medicine 7 (2013).
38. Kinney MV., et al. “Sub-Saharan Africa’s mothers, newborns, and children: Where and why do they die?” PLoS Medicine 6 (2010): 1-9.
39. Murray CJL. “Shifting to Sustainable Development Goals- Implications for Global Health”. New England Journal of Medicine 15 (2015): 1388-1390.
40. Mahapatra P., et al. “Civil registration systems and vital statistics: successes and missed opportunities”. Lancet 9599 (2007): 1653-1663.