Appendix 1: MANDATE model global and conditional variables for sub-Saharan Africa (SSA)/India
Variable
Definition
Value
Live Births
Number of live births in
SSA/India, 2008
SSA:
31,996,058
India:
27,731,570
Stillbirth Rate
Proportion of
pregnancies not resulting
in a birth
SSA: 2.90%
India: 2.20%
Number of
Pregnancies
Number of pregnancies
that result in a birth or
stillbirth
Proportion of births that
are preterm
Proportion
Preterm
Prenatal Care
Location
Delivery
Location
Intrapartum
Event Incidence
%
Home
%
Clinic
%
Hospital
Description
United Nations population estimates accessed via Spectrum
population projections (available at:
http://futuresinstitute.org/spectrum.aspx; accessed September 20,
2010), assuming medium total fertility rate and medium life
expectancy (United Nations. Department of Economic and Social
Affairs 2013)
Stillbirth rates are reported to be 2.9% in SSA and 2.2% in India
(Lawn, Blencowe et al. 2011). Stillbirth defined as pregnancy losses
at ≥1000 g birth weight or ≥ 28 weeks of gestation.
Calculated value: live births + stillbirths
SSA: 12.3%
India: 13.3%
Proportion of women
who seek prenatal care in
home, clinic or hospital
setting
Proportion of deliveries
that occur in home,
clinic or hospital setting
SSA:
30%
India:
10%
SSA:
50%
India:
35%
SSA:
65%
India:
40%
SSA:
35%
India:
25%
SSA:
5%
India:
50%
SSA:
15%
India:
40%
Proportion of deliveries
with an intrapartum
event that could result in
the need for
resuscitation, neonatal
encephalopathy, or
SSA:
7.5%
India:
7.0%
SSA:
6.5%
India:
5.1%
SSA:
5.4%
India:
3.1%
Preterm rates are reported to be 12.3% in SSA and 13.3% in India
(Lee, Katz et al. 2013). Preterm defined as babies born alive < 37
completed weeks.
(UNICEF 2010); Maternal Neonatal Health Registry Data Book
from Global Health Network (January 11, 2011), Table 9
(unpublished data)
SSA: Mean value of most recent Demographic Health Survey (DHS)
from 2000 to present for SSA reported (41 countries). UNICEF
global database reports 47% institutional delivery (2007-2012) in
SSA (http://www.childinfo.org/delivery_care.html).
India: Institutional delivery has increased rapidly due to Janani
Suraksha Yojana: 12.3% in 1992-3 (International Institute for
Population Sciences (IIPS) and Macro International 1995); 23.5% in
2005-6 (International Institute for Population Sciences (IIPS) and
Macro International 2007); 32.9% in 2007-8 (International Institute
for Population Sciences (IIPS) 2010); and, more recently, 72.6%
(Unicef 2009; Gupta, Pal et al. 2012).
The overall proportion of neonates experiencing an intrapartum
event is approximately 7.5% (5-10%) globally (Wiswell 2003;
Lawn, Rudan et al. 2008; Lee, Cousens et al. 2011). Lower rates are
reported in hospital settings (3-6%) compared to clinic settings, with
home-based settings having the highest rates of intrapartum events
(Deorari, Paul et al. 2001; Etuk and Etuk 2001; Dongol, Singh et al.
intrapartum-related
mortality
IntrapartumRelated Injury
- Incidence
Proportion of neonates
surviving an
intrapartum-related event
with intrapartum- related
injury, including
neonatal encephalopathy
or multi-organ
dysfunction
IntrapartumRelated Events
– Case Fatality
Rate (CFR)
IntrapartumRelated Injury
- Case Fatality
Rate
SSA: 15%
India: 15%
Term: 12.0%
Preterm:
18.0%
Case fatality rate of
untreated term and
preterm intrapartumrelated injury, including
neonatal encephalopathy
and multi-organ
dysfunction
Term:
15%
Preterm:
22.5%
2010; Ersdal, Mduma et al. 2011). MANDATE parameters are based
on the expected decrease from the assumed incidence of 7.5% based
on assumptions regarding the coverage of basic and comprehensive
emergency obstetric care in each setting (Ameh, Msuya et al. 2012),
which are assumed to reduce the incidence of intrapartum events by
40% and 80%, respectively (Lee, Cousens et al. 2011). E.g. We
assume that in SSA, 33% of women in clinics are having BEmOC
needs met (i.e. 7.5*.33*.4=1% reduction in incidence).
Data regarding intrapartum-related injury in low income countries
are sparse. In settings with high neonatal mortality, the median
incidence of neonatal encephalopathy is 12.1 per 1,000 births (range
3.6, 26.5) (Lee, Kozuki et al. 2013). Assuming intrapartum-related
events occur in approximately 7.5% of births and that neonatal
encephalopathy is the most common intrapartum-related injury, this
would result in approximately 15% of neonates with intrapartumrelated events having intrapartum-related injury, such as neonatal
encephalopathy.
Three quarters of neonates with intrapartum-related events were
classified as mild, with a CFR of 4%; those with multi-organ injury
or severe asphyxia have a CFR of nearly 40%, for a weighted
average of 12% (Bang, Bang et al. 2005). We assume 1.5 times the
CFR among preterm neonates with birth asphyxia based on a single
study in Nepal (Lee, Mullany et al. 2011).
All organs can be affected by intrapartum-related events; neonatal
encephalopathy is the most widely studied and has the most severe
outcomes. Case fatality rates for neonatal encephalopathy range
from 12% in high income countries to 31% in low income countries
(Lawn, Lee et al. 2009). MANDATE assumes a slightly lower CFR
for general asphyxia related injury (any organs) compared to
neonatal encephalopathy (Volpe 2008) and 1.5 times the CFR in
preterm neonates from a single study in Nepal (Lee, Mullany et al.
2008).
*where two estimates are provided, the first is India and the second is sub-Saharan Africa
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