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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., In an observational study, Clara Menéndez and colleagues assess the concordance of minimally invasive autopsy with complete diagnostic autopsy in cases of maternal death., Author summary Why was this study done? Since 1990, the maternal mortality ratio (MMR) has dropped by 43%, but despite this progress, hundreds of women still die every day in large parts of the world due to pregnancy or childbirth complications. A reliable knowledge of the causes of maternal death is a necessary condition to reduce this burden through adequate health planning. Current methods, such as verbal autopsies or the review of clinical data, have shown a high degree of misclassification in this specific group of deaths. We aimed to validate a minimally invasive autopsy (MIA) approach as a possible complement to verbal autopsies by comparing its performance against the complete diagnostic autopsy, the gold standard for cause of death investigation. What did the researchers do and find? We performed paired MIA and CDA in 57 maternal deaths that occurred at the Maputo Central Hospital, Mozambique, and assessed the concordance between both methods. Indirect obstetric diseases caused 56% of all deaths and direct obstetric complications accounted for 42% of deaths. Infectious diseases and obstetric hemorrhage were the most common causes of death among indirect and direct obstetric conditions, respectively. The overall concordance of the MIA with the CDA was moderate and both methods agreed in 68% of the diagnostic categories. The etiological microorganisms in infectious diseases causes of death were identified in 67% of the MIAs. What do these findings mean? The MIA procedure could be a valuable tool to determine the causes of maternal death, especially in indirect obstetric conditions, most of which are infectious diseases. This information may be helpful for decision-making on health planning and prioritization of interventions to reduce maternal mortality and for monitoring progress towards achieving global health targets.

Background In recent decades, the world has witnessed unprecedented progress in child survival. However, our knowledge of what is killing nearly 6 million children annually in low- and middle-income countries remains poor, partly because of the inadequacy and reduced precision of the methods currently utilized in these settings to investigate causes of death (CoDs). The study objective was to validate the use of a minimally invasive autopsy (MIA) approach as an adequate and more acceptable substitute for the complete diagnostic autopsy (CDA) for pediatric CoD investigation in a poor setting. Methods and findings In this observational study, the validity of the MIA approach in determining the CoD was assessed in 54 post-neonatal pediatric deaths (age range: ≥1 mo to 15 y) in a referral hospital of Mozambique by comparing the results of the MIA with those of the CDA. Concordance in the category of disease obtained by the two methods was evaluated by the Kappa statistic, and the sensitivity, specificity, and positive and negative predictive values of the MIA diagnoses were calculated. A CoD was identified in all cases in the CDA and in 52/54 (96%) of the cases in the MIA, with infections and malignant tumors accounting for the majority of diagnoses. The MIA categorization of disease showed a substantial concordance with the CDA categorization (Kappa = 0.70, 95% CI 0.49–0.92), and sensitivity, specificity, and overall accuracy were high. The ICD-10 diagnoses were coincident in up to 75% (36/48) of the cases. The MIA allowed the identification of the specific pathogen deemed responsible for the death in two-thirds (21/32; 66%) of all deaths of infectious origin. Discrepancies between the MIA and the CDA in individual diagnoses could be minimized with the addition of some basic clinical information such as those ascertainable through a verbal autopsy or clinical record. The main limitation of the analysis is that both the MIA and the CDA include some degree of expert subjective interpretation. Conclusions The MIA showed substantial concordance with CDA for CoD identification in this series of pediatric deaths in Mozambique. This minimally invasive approach, simpler and more readily acceptable than the more invasive CDA, could provide robust data for CoD surveillance, especially in resource-limited settings, which could be helpful for guiding child survival strategies in the future., Quique Bassat and colleagues examine the validity of a standardized minimally invasive autopsy approach by comparison with that of the complete diagnostic autopsy in a series of children who died at Maputo Central Hospital in Mozambique., Author summary Why was this study done? Child mortality has been steadily decreasing globally in the last 25 years, but nearly 6 million child deaths still occur every year, predominantly in low- and middle-income countries. In these settings, current knowledge on the specific causes of child death is jeopardized by the scarcity of good-quality mortality data. Complete diagnostic autopsies, indisputably considered the reference method for cause of death investigation, are seldom conducted in poor settings, both on account of their limited acceptability and because of a generalized scarcity of the required pathological technical expertise. We aimed to validate a simpler and potentially much more acceptable minimally invasive autopsy (MIA) approach, by comparing its performance against the complete diagnostic autopsy for cause of death investigation in pediatric deaths. What did the researchers do and find? In this study, 54 deaths in Mozambican children

Background Over 5 million stillbirths and neonatal deaths occur annually. Limited and imprecise information on the cause of these deaths hampers progress in achieving global health targets. Complete diagnostic autopsies (CDAs)—the gold standard for cause of death determination—are difficult to perform in most high-burden settings. Therefore, validation of simpler and more feasible methods is needed. Methods and findings In this observational study, the validity of a minimally invasive autopsy (MIA) method in determining the cause of death was assessed in 18 stillbirths and 41 neonatal deaths by comparing the results of the MIA with those of the CDA. Concordance between the categories of diseases obtained by the 2 methods was assessed by the Kappa statistic, and the sensitivity, specificity, positive, and negative predictive values of the MIA diagnoses were calculated. A cause of death was identified in 16/18 (89%) and 15/18 (83%) stillborn babies in the CDA and the MIA, respectively. Fetal growth restriction accounted for 39%, infectious diseases for 22%, intrapartum hypoxia for 17%, and intrauterine hypoxia for 11% of stillborn babies. Overall, the MIA showed in this group a substantial concordance with the CDA (Kappa = 0.78, 95% CI [0.56–0.99]). A cause of death was identified in all (100%) and 35/41 (85%) neonatal deaths in the CDA and the MIA, respectively. In this group, the majority of deaths were due to infectious diseases (66%). The overall concordance of the MIA with the CDA in neonates was moderate (Kappa = 0.40, 95% CI [0.18–0.63]). A high percentage of accuracy was observed for the MIA in all the diagnostic categories in both stillbirths and neonates (>75%). The main limitation of this study is that some degree of subjective interpretation is inherent to cause-of-death attribution in both the MIA and the CDA; this is especially so in stillbirths and in relation to fetal growth restriction. Conclusions The MIA could be a useful tool for cause-of-death determination in stillbirths and neonatal deaths. These findings may help to accelerate progress towards meeting global health targets by obtaining more accurate information on the causes of death in these age groups, which is essential in guiding the design of new interventions and increasing the effectiveness of those already implemented., Clara Menendez and colleagues examine the validity of a minimally invasive autopsy to determine cause of death in stillborn babies and neonates compared with complete diagnostic autopsy in Mozambique., Author summary Why was this study done? Over 5 million stillbirths and neonatal deaths occur annually. The vast majority of these deaths (99%) take place in low- and middle-income countries, where vital registration systems are inadequate or nonexistent and rarely medically certified. Verbal autopsies, the main source of information in these areas, are subject to a high degree of misclassification errors for conditions with poor clinical specificity such as most peri-neonatal deaths. Limited and imprecise information on the cause of these deaths hampers progress in achieving global health targets. Complete diagnostic autopsies—the gold standard for cause-of-death determination—are difficult to perform in most high-burden settings. We developed a simplified minimally invasive autopsy method, which would be feasible in middle- and low-income countries, and validated it against the complete autopsy, the gold standard, in a series of stillborn babies and neonates who died in Mozambique. What did the researchers do and find? The validity of a minimally invasive autopsy method in determining the cause of death was assessed in 18 stillbirths and 41 neonatal deaths. Concordance between the diagnosis obtained with the minimally invasive and the complete diagnostic autopsy was evaluated. The minimally invasive autopsy showed a substantial concordance with the complete autopsy in stillborn babies and a moderate concordance in neonates. The agreement was particularly high for infectious diseases. Moreover, the specific microorganisms causing death were accurately identified in the minimally invasive autopsy samples. What do these findings mean? The minimally invasive autopsy could be a useful tool for cause of death determination in stillbirths and neonatal deaths. These findings may help to accelerate progress towards meeting global health targets by obtaining more accurate information on the causes of death in these age groups, which is essential in guiding the design of new interventions and increasing the effectiveness of those already implemented.