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

Coverage of completion of four ANC visits based on recommended time schedule in Northern Ethiopia: A community-based cross-sectional study design.

BACKGROUND:Despite decades of implementation of maternal health care programs, the uptake of antenatal care services based on the recommended gestational age continues to be below the national and regional targets. Thus, this study aimed to assess the prevalence and factors related to the completion of four antenatal care visits among mothers who gave birth 6 months preceding the study. METHOD:We conducted a community-based cross-sectional study using both quantitative and qualitative approaches. The quantitative component included administering a pre-tested structured questionnaire to 466 mothers who gave birth 6 months preceding the study using a simple random sampling technique from respective Tabias. The quantitative result was analyzed using SPSS version 22. Bivariate and multivariate analysis was done to determine the association between independent and dependent variables. Variables were declared as statistically significant at P ≤ 0.05 in multivariable logistic regression model. The qualitative interview data were collected from eight mothers and four key informants recruited through purposive sampling method. RESULTS:The overall prevalence of completion of four ANC visits based on the recommended time schedule was 9.9% (95% CI, 7.1-12.4). However, 63.9% of the participants attended four visits or more regardless of the recommended time schedule. Being member of community health insurance (AOR 2.140, 95% CI, 1.032-4.436), walking on foot less than or equal one hour to reach the health facility (AOR 3.921, 95% CI, 1.915-8.031), having workload at home (AOR 0.369, 95% CI, 0.182-0.751), and husband supported during antenatal care (AOR 2.561, 95% CI, 1.252-5.240) were independently associated with the completion of four ANC visits based on the recommended time schedule in multivariable analysis. CONCLUSION:The completion of four ANC contacts based on the recommended time schedule remains low in rural areas of Northern Ethiopia. Being a member of community health insurance, distance to the health facility, workload, and male involvement were associated with the completion of four ANC visits based on the recommended time schedule. The existing health system should consider improving the recommended ANC visits by integrating Community based interventions

Fistula in War-Torn Tigray: A Call to Action

Fistula is roaring in the ongoing war on Tigray. The potential risk factors for fistula in the conflict zone include obstructed labour due to limited or absent maternal care services, a correlation between malnutrition-stunted growth and birth difficulties and trauma, and sexually transmitted infections (STIs) due to conflict-related sexual violence. As a call to action to mitigate the unimaginable suffering that women and girls are facing in the region, concerted international effort is needed to provide treatment, rehabilitation, and re-integration; secure peace and stability; rebuild the health-care system; and ensure perpetrators are held accountable

Commonly missed nursing cares in the obstetrics and gynecologic wards of Tigray general hospitals; Northern Ethiopia.

BackgroundMissed nursing care is considered an error of omission and is defined as any aspect of required patient care that is omitted (either in part or whole) or significantly delayed. Nursing care missed in the perinatal setting can cause negative outcomes and repercussions for the quality and safety of care. This has been reported in multiple settings and countries and is tied to negative maternal outcomes. Preventing missed nursing care requires in-depth research considering the clinical setting.ObjectiveThe main aim of the study was to assess commonly missed nursing care elements, reasons, and factors for the omission in the obstetric and gynecologic units of general hospitals in Tigray 2017/18.Methods and materialsA cross-sectional study was conducted in eight randomly selected general hospitals in Tigray, Ethiopia. A total of 422 nurses and midwives were selected through simple random sampling using the staff list as a sampling frame. To identify the commonly missed nursing care and related factors, the MISSCARE survey tool was used. Descriptive, bivariate, and multivariate logistic regression analysis was performed to assess potential risk factors of nursing cares omission.ResultThe study results showed that 299 (74.6%) participants commonly missed at least one nursing care in the perinatal setting. Labor resources 386(96.3%), teamwork 365(91%), material resources 361 (90%) and communication 342 (85.3%) were the reasons identified for commonly missing care. In the multivariate analyses, sex (p-value ConclusionThe proportion of commonly missed nursing care was high. After adjusting for demographic variables, labor resources, material resources, and communication were reasons for commonly missed nursing care. Increasing male professional proportion, investing in nurses/midwives training, and harmonizing nursing service administration through appropriate working shift arrangement and timely assessment of professionals' stability and satisfaction could minimize frequent omission of nursing care

Early Implanon discontinuation rate and its associated factors in health institutions of Mekelle City, Tigray, Ethiopia 2016/17

Abstract Objective Contraceptive discontinuation rate is very common in most developing countries, especially removal in the first year of use is common (18–63%), and the majority of these discontinuations are among women who are still in need of contraception. So the objective of this study was assessing early Implanon discontinuation rate and its associated factors in the study area. Institutional based cross sectional study was conducted and systematic random sampling technique was employed to interview the study participants. A binary logistic regression model was used to test association. Result In this study early Implanon discontinuation rate was 38%, 95% CI (32%, 44%). women who attend secondary [AOR: 95% CI 0.35 (0.14, 0.82)] and more than secondary school [AOR: 95% CI 0.23 (0.09, 0.59)] were less likely to remove Implanon early as compared to those illiterate. Mothers who were not counseled [AOR: 95% CI 2.45 (1.05, 5.69)] and those mothers who had a side effect of the method [AOR: 95% CI 2.66 (1.23, 5.72)] discontinue the method early. The study revealed that early Implanon discontinuation rate was high. Women’s educational level, presence of side effect and effective counseling were independent predictors of early Implanon removal