Stillbirths and newborn deaths in slum settlements in Mumbai, India: a prospective verbal autopsy study.
BACKGROUND
Three million babies are stillborn each year and 3.6 million die in the first month of life. In India, early neonatal deaths make up four-fifths of neonatal deaths and infant mortality three-quarters of under-five mortality. Information is scarce on cause-specific perinatal and neonatal mortality in urban settings in low-income countries. We conducted verbal autopsies for stillbirths and neonatal deaths in Mumbai slum settlements. Our objectives were to classify deaths according to international cause-specific criteria and to identify major causes of delay in seeking and receiving health care for maternal and newborn health problems.


METHODS
Over two years, 2005-2007, births and newborn deaths in 48 slum areas were identified prospectively by local informants. Verbal autopsies were collected by trained field researchers, cause of death was classified by clinicians, and family narratives were analysed to investigate delays on the pathway to mortality.


RESULTS
Of 105 stillbirths, 65 were fresh (62%) and obstetric complications dominated the cause classification. Of 116 neonatal deaths, 87 were early and the major causes were intrapartum-related (28%), prematurity (23%), and severe infection (22%). Bereavement was associated with socioeconomic quintile, previous stillbirth, and number of antenatal care visits. We identified 201 individual delays in 121/187 birth narratives (65%). Overall, delays in receiving care after arrival at a health facility dominated and were mostly the result of referral from one institution to another. Most delays in seeking care were attributed to a failure to recognise symptoms of complications or their severity.


CONCLUSIONS
In Mumbai's slum settlements, early neonatal deaths made up 75% of neonatal deaths and intrapartum-related complications were the greatest cause of mortality. Delays were identified in two-thirds of narratives, were predominantly related to the provision of care, and were often attributable to referrals between health providers. There is a need for clear protocols for care and transfer at each level of the health system, and an emphasis on rapid identification of problems and communication between health facilities.


BACKGROUND
ISRCTN96256793.
Society for Nutrition, Education and Health Action (SNEHA), Urban Health Centre, Chota Sion Hospital, Dharavi, Mumbai, Maharashtra, India.
Ujwala
U
Bapat
Glyn
G
Alcock
Neena Shah
NS
More
Sushmita
S
Das
Wasundhara
W
Joshi
David
D
Osrin
D000328:Adult; D002423:Cause of Death; D057210:Delayed Diagnosis / Q000009:adverse effects; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006700:Home Childbirth / Q000706:statistics & numerical data; D016304:Hospitals, Private / Q000706:statistics & numerical data; D006779:Hospitals, Public / Q000706:statistics & numerical data; D006801:Humans; D007194:India / Q000453:epidemiology; D007226:Infant Mortality; D007231:Infant, Newborn; D008297:Male; D007744:Obstetric Labor Complications / Q000175:diagnosis / Q000401:mortality*; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data; D011204:Poverty Areas; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis / Q000401:mortality*; D047928:Premature Birth / Q000175:diagnosis / Q000401:mortality; D011446:Prospective Studies; D012017:Referral and Consultation / Q000706:statistics & numerical data; D050497:Stillbirth / Q000453:epidemiology*; D014505:Urban Population / Q000706:statistics & numerical data