Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations. METHODS The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds. FINDINGS The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles. INTERPRETATION Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere. FUNDING Bill & Melinda Gates Foundation

Patterns and Clinico-Radiological Characteristics of Primary Liver Masses in Children Treated at a Tertiary Referral Hospital, in Ethiopia

Melese Ayllo,1 Abebe Habtamu Tamire,2 Mohammed Bereinto Legas,3 Gashaw Arega2 1Department of Pediatrics and Child Health, University of Gondar, Gondar, Ethiopia; 2Department of Pediatrics and Child Health, Addis Ababa University, Addis Ababa, Ethiopia; 3Department of Maternity and Reproductive Health, Tikur Anbessa Hospital, Addis Ababa, EthiopiaCorrespondence: Gashaw Arega, Email [email protected]: Liver masses are a cause of morbidity and mortality in children worldwide. Although the patterns and clinical-radiological characteristics of primary liver masses have been studied in developed countries, few studies have been conducted in developing countries. Studying the patterns of liver mass in children helps to improve the outcome of liver masses and to design preventive strategies if the identified risk factors are preventable.Material and Method: A hospital-based cross-sectional study was conducted on children who met the inclusion criteria, using a self-administered structured questionnaire. The collected data were analyzed using the Statistical Package for Social Sciences (SPSS) version 25. Statistical significance was set at P < 0.05. Descriptive and logistic regression analyses were used to assess the determinant factors.Results: A total of 74 children were included, with most patients being males (60.8%). More than one-third (n = 27) of the participants were between 1 and 4 years of age and the mean age at diagnosis of the liver mass was 4.6 years. The duration of illness at presentation to Tikur Anbessa Specialized Hospital was between 4 and 8 weeks, in 42% of the patients. The most common presenting symptom was abdominal swelling, accounting for 70.3% (n = 52) of the patients. Benign hepatic mass lesions accounted for 57.5% (n = 42), and 43.2% (n = 32) were malignant liver masses. Most lesions were solitary and involved the right lobe of the liver. The common benign hepatic masses were pyogenic liver abscesses (38.1%), and the most common malignant hepatic masses were hepatoblastomas (78.1%).Conclusion: Pyogenic liver abscess was the most common benign hepatic mass and hepatoblastoma was the most common malignant hepatic mass in our study. Most lesions were solitary and involved the right lobe. Understanding the patterns of liver masses will help in the early diagnosis and improve treatment outcomes in children with liver masses.Keywords: liver mass, liver abscess, hepatoblastoma, TASH, Ethiopi

Process Evaluation of Health System Responsiveness Level and Associated Factors Among Mothers Gave Birth at Obstetric Ward in a Tertiary Hospital, Southwest of Ethiopia: Mixed Study Methods

Gezu Girma,1 Aklilu Tamire,2 Gebeyehu Jeldu Edessa,3 Mesay Dechasa,4 Obsan Kassa Tefasa,2 Abraham Negash,5 Jerman Dereje,6 Awoke Masrie,2 Samrawit Shawel,2 Miheret Mandefro,2 Gelila Abraham3 1Department of Health Research, International Center for AIDS Care and Treatment Program (ICAP), Finfine, Ethiopia; 2School of Public Health, College of Health and Medical Science, Haramaya University, Harar, Harari, Ethiopia; 3Department of Health Policy and Management, Public Health Faculty, Institute of Health Jimma University, Jimma, Oromia, Ethiopia; 4Department of Clinical Pharmacy, School of Pharmacy, College of Health and Medical Science, Haramaya University, Harar, Ethiopia; 5School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia; 6Department of Psychiatry, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, EthiopiaCorrespondence: Aklilu Tamire, School of Public Health, College of Health and Medical Science, Haramaya University, P.O. Box 235, Harar, Harari, 3200, Ethiopia, Tel +251921211752, Email [email protected]: The term responsiveness emerged during the World Health Organization (WHO) report in 2000 as new and essential goals of the health systems to meet the needs of people to their expectations from different services being given in healthcare systems. Obstetric violence and childbirth mistreatment are global problems, but the worst obstetric violence usually occurs in underdeveloped countries. Thus, the main objective of this study was to evaluate the responsiveness of obstetric service at Jimma University Medical Center.Methods: A single-case study design with quantitative and qualitative data collection was employed. Availability with 17 indicators and health system responsiveness with 24 indicators were used. Consecutive sampling technique was used to select the clients and qualitative data were collected from key informants. SPSS version 25 was used for the analysis of quantitative data, whereas thematic analysis was conducted for qualitative data. A multiple linear regression model was fitted after all assumptions were checked and fit to ensure the relation of the dependent variable with independent variables.Results: The overall evaluation was 75.6% and judged good. The resource availability and health system responsiveness were 85.5% and 69.7%, which were judged very good and fair, respectively. A stethoscope and thermometer were not available, while 40% glucose, dexamethasone, and intravenous fluid were the most frequently stocked-out supplies. Dignity (72.1%), confidentiality (71.4%), and prompt attention (70%) were the top three good scores for the health system’s responsiveness. Health system responsiveness significantly associated with the following: Not attending formal education, attending college and above, place of delivery (health center), mode of delivery (cesarean section), and being merchant.Conclusion & Recommendation: The health system responsiveness of delivery service in study setting was good. All stakeholders should work for improving the health system’s responsiveness in delivery service.Keywords: obstetric, health system responsiveness, Jimma University Medical Center, Ethiopi

The Cost of Maternal Complications and Its Associated Factors Among Mothers Attending Public Hospitals in Harari Region and Dire Dawa City Administration, Eastern Ethiopia: An Institution-Based Cross-Sectional Study

Samrawit Shawel,1 Behailu Hawulte Ayele,1 Yadeta Dessie,1 Abera Kenay Tura,2 Gimaye Dinsa,1,3 Abainash Tekola,1 Miheret Mandefro,1 Awoke Masrie,1 Aklilu Tamire,1 Obsan Kassa Tefasa1 1School of Public Health, Haramaya University, Harar, Ethiopia; 2School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia; 3School of Population and Public Health, University of British Columbia, Vancouver, CanadaCorrespondence: Samrawit Shawel, Tel +251 913 705 953, Email [email protected]: Pregnant women face high costs for health-care services despite being advertised as free. These costs include non-medical expenses, lost productivity, difficulties caring for family members, and long-term financial impact from complications. Limited research has been done on the cost burden of maternal services and complications, despite numerous studies on maternal health service provision. This is notable considering the government’s claim of providing free maternal health-care services.Methods: A cross-sectional study was conducted in July (1– 30) 2022 among 425 randomly selected mothers in Harari and Dire Dawa City, Eastern Ethiopia. Data were collected through structured questionnaires and medical record reviews. The collected data was entered into Epi-Data version 3.02 and analyzed using STATA version 14.0 after data cleaning. Descriptive statistics and linear regression analysis were used to examine the data, ensuring assumptions of linearity, independence, homoscedasticity, and normality were met. The correlation coefficient was used to assess the strength of the association.Results: The median cost of maternal complications was around 4250 ETB (81.3 USD; IQR = 2900– 5833.3), factors that predicted cost were monthly family income of ≥ 3001 birr (β=1.13; 95% CI: 1.00, 1.26), distance from hospital (β=0.73; 95% CI = 0.64– 0.83), being admitted for less than 4 days (β=0.60; 95% CI = 0.53– 0.69), accompanied by relatives besides their husbands (β=1.93; 95% CI = 1.52– 2.46), caesarian sections delivery (β=1.17; 95% CI = 1.04– 1.31), and giving birth to a normal baby (β=0.86; 95% CI = 0.77– 0.97).Conclusion: Maternal complications incur significant costs, with factors such as family income, travel time, hospital stay, caregiver presence, mode of delivery, and neonatal outcome predicting these costs. The Ethiopian health system should address the additional expenses faced by mothers with complications and their caregivers.Keywords: direct cost, indirect cost, medical-cost, maternal complication, Eastern Ethiopi