title: A prospective study of maternal, fetal and neonatal deaths in low- and middle-income countries.
abstract: OBJECTIVE
  To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths.
  
  
  METHODS
  A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum.
  
  
  RESULTS
  Between 2010 and 2012, 214,070 of 220,235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100,000 live births, ranging from 69 per 100,000 in Argentina to 316 per 100,000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97-11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26-5.67) and 7-day (RR: 3.94; 95% CI: 2.74-5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54-9.77).
  
  
  CONCLUSIONS
  Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan .
authors.forename: Sarah
authors.initials: S
authors.lastname: Saleem
authors.affiliation: Social, Statistical and Environmental Sciences, RTI International, PO Box 12194, 3040 East Cornwallis Road, Durham, NC 27709-2194, United States of America (USA).
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: McClure
authors.affiliation: KLE University's JN Medical College, Belgaum, India .
authors.forename: Shivaprasad S
authors.initials: SS
authors.lastname: Goudar
authors.affiliation: Lata Medical Research Foundation, Nagpur, India .
authors.forename: Archana
authors.initials: A
authors.lastname: Patel
authors.affiliation: Department of Pediatrics, Moi University, Eldoret, Kenya .
authors.forename: Fabian
authors.initials: F
authors.lastname: Esamai
authors.affiliation: Universidad Francisco Marroquin, Guatemala City, Guatemala .
authors.forename: Ana
authors.initials: A
authors.lastname: Garces
authors.affiliation: Department of Pediatrics, University of Zambia, Lusaka, Zambia .
authors.forename: Elwyn
authors.initials: E
authors.lastname: Chomba
authors.affiliation: Institute of Clinical Effectiveness, Buenos Aires, Argentina .
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
authors.affiliation: Social, Statistical and Environmental Sciences, RTI International, PO Box 12194, 3040 East Cornwallis Road, Durham, NC 27709-2194, United States of America (USA).
authors.forename: Janet
authors.initials: J
authors.lastname: Moore
authors.affiliation: KLE University's JN Medical College, Belgaum, India .
authors.forename: Bhalachandra
authors.initials: B
authors.lastname: Kodkany
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan .
authors.forename: Omrana
authors.initials: O
authors.lastname: Pasha
authors.affiliation: Institute of Clinical Effectiveness, Buenos Aires, Argentina .
authors.forename: Jose
authors.initials: J
authors.lastname: Belizan
authors.affiliation: University of North Carolina at Chapel Hill, Chapel Hill, USA .
authors.forename: Albert
authors.initials: A
authors.lastname: Mayansyan
authors.affiliation: Department of Obstetrics and Gynecology, Christiana Health Care, Newark, USA .
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Derman
authors.affiliation: Department of Pediatrics, Massachusetts General Hospital for Children, Boston, USA .
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Hibberd
authors.affiliation: Department of Pediatrics, Indiana University School of Medicine, Indianapolis, USA .
authors.forename: Edward A
authors.initials: EA
authors.lastname: Liechty
authors.affiliation: Department of Pediatrics, University of Colorado Health Sciences Center, Denver, USA .
authors.forename: Nancy F
authors.initials: NF
authors.lastname: Krebs
authors.affiliation: Department of Pediatrics, University of Colorado Health Sciences Center, Denver, USA .
authors.forename: K Michael
authors.initials: KM
authors.lastname: Hambidge
authors.affiliation: Tulane University School of Public Health and Tropical Medicine, New Orleans, USA .
authors.forename: Pierre
authors.initials: P
authors.lastname: Buekens
authors.affiliation: University of North Carolina at Chapel Hill, Chapel Hill, USA .
authors.forename: Waldemar A
authors.initials: WA
authors.lastname: Carlo
authors.affiliation: Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, USA .
authors.forename: Linda L
authors.initials: LL
authors.lastname: Wright
authors.affiliation: Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, USA .
authors.forename: Marion
authors.initials: M
authors.lastname: Koso-Thomas
authors.affiliation: Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, USA .
authors.forename: Alan H
authors.initials: AH
authors.lastname: Jobe
authors.affiliation: Department of Obstetrics and Gynecology, Columbia University, New York, USA .
authors.forename: Robert L
authors.initials: RL
authors.lastname: Goldenberg
mesh_terms: D000328:Adult; D001118:Argentina / Q000453:epidemiology; D003906:Developing Countries; D005260:Female; D006166:Guatemala / Q000453:epidemiology; D006801:Humans; D007194:India / Q000453:epidemiology; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D007630:Kenya / Q000453:epidemiology; D008428:Maternal Mortality; D010154:Pakistan / Q000453:epidemiology; D066087:Perinatal Death; D011247:Pregnancy; D011256:Pregnancy Outcome; D011446:Prospective Studies; D012307:Risk Factors; D015024:Zambia / Q000453:epidemiology