Critical Aprraisal Worksheet

Section A : Reference of Article

1. Author[s) and Affiliation[sJ :
a. Leona Burke1
b. Dwi Linna Suswardany
c. Keryl Michener
d. Setiawaty Mazurki
e. Timothy Adair
f. Catur Elmiyati
g. Chalapati Raol
2. Tittle of Article :
Utility of local health registers in measuring perinatal mortality: A case study in rural
Indonesia
3. Journal:
BMC Pregnancy and Childbirth 2011
4. Volume and Page Number:
The page number are eight (8 page)
5. Year of Publication:
Published: 17 March 2011
Section B : Review the Result's
1. Did the review address a clearly focused question ?
Answer,
YES
CAN'T TELL NO

Reason:
Field activities were conducted in 23 villages in Pekalongan district, Central Java Province,
Indonesia. Pekalongan was selected as three of its subdistricts (Kajen 1, Kedungwuni 1,
andmWonokerto), covering a total of 1759 deliveries that occurred in 2007. the midwife
registers were found to have recorded 74% of perinatal deaths identified in the study
population, including 19 out of 23 stillbirths (83%), and 9 of the 15 early neonatal deaths
(60%). In contrast, the village administration death register (official source for local vital
statistics) recorded only 15 out of the 38 perinatal deaths; about 40%.
It is clear that interventions should be given where a recent evaluation of community-based
interventions to improve the quality of newborn care and reduce perinatal mortality identified
that the most successful interventions, resulted in a significant reduction in stillbirth rates, but
no effect on early neonatal death. This suggests that the decrease in perinatal mortality will

require community-based interventions in combination with other clinical care intervention

package that will require more advanced facilities, technology, and skilled human resources.
HINT:
An issue can be 'focused' ln terms of :
- The Population studied
- The intervention given
- The outcome considered
2. Did the authors looks the right type of paper ?
Answer:
YES
CANT TELL
NO

Reason:
The study included the use of qualitative research methods to study the experiences of
midwives in recording and reporting perinatal deaths with retrospective study design
HINT:
The best sort studies'would :
- Address the rewiews questions
- Have an appropriate study design
3. Do you think the important relevant study was included?
Answer:
YES
CANT TELL
NO

Reason:
a. Wu Z, Viisainen K, Wang Y, Hemminki E: Perinatal mortality in rural China:
retrospective cohort study. BMJ 2003, 327(7427):1319-23.
b. Anthony S, van der Pal-de Bruin KM, Graafmans WC, Dorrepaal CA, Borkent- Polet M,
van Hemel OJ, Jansen FH, den Ouden AL: The reliability of perinatal and neonatal
mortality rates: differential under-reporting in linked professional registers vs. Dutch civil
registers. Paediatr Perinat Epidemiol 2001, 15(3):306-314.
This bibliographic review in accordance with the theory put forward in the discussion of
researchers who claim that our approach to explore the potential to measure perinatal
mortality using information from local health registers is novel, but similar to the Chinese
investigation using detailed records of family planning programs, or in the Netherlands,
using electronic registers managed by different stakeholders.

c. Rao C, Soemantri S, Djaja S, Suhardi S, Adair T, Wiryawan Y, Pangaribuan L, Irianto J,

Koesen S, Lopez AD: Mortality in Central Java: Results from the Indonesian Mortality
Registration System Strengthening Project. BMC Research Notes 2010, 3(1):325.
This is in accordance with pembahsan on Improved identification of perinatal events may
also lead to further investigation into the possible causes of the distribution of maternal
and fetal stillbirth and early neonatal death, through the use of verbal autopsy methods
adaptation Indonesia, as developed and described elsewhere.
HINT:
Look for:
- Which bibliographyc databases were used
- Follow up from reference lists
- Personal contact with experts
- Search for unpublished as well as published studies
4. Did the review's authors do enougt to assess the quality of the included studies?
Answer:
YES
CANT TELL
NO

Reason:
This study set out to explore the potential to derive local measures of perinatal mortality
using routine data sources at the village and sub district level in Indonesia. The research
identified that despite several limitations in the maintenance of records and in current
reporting systems, there is adequate information available at the local level for this purpose.
Also, although not described here, the qualitative research conducted in association with this
study confirms the changing and complementary relationship between the government,
private and traditional antenatal and birth assistance services in rural Indonesia, at least in
rural areas of Java.
Of course, such goals could be realised only if the limitations in the routine data collection
systems identified by this study are addressed through appropriate interventions to strengthen
the local maternal and child health information systems, and improved data sharing
mechanisms with the non-government sector as well as with the local civil registration of
stillbirths, births, and deaths.Another important limitation was the availability of information
on duration of gestation at pregnancy outcome, which hampered accurate determination of

stillbirths. We identified a total of 50 cases of fetal death, but we were able to confirm
gestation 7 months ( 28 weeks) in only 23 cases.
There is also potential for bias from misclassification between stillbirths and early neonatal
deaths, however, the perinatal mortality rate adequately accounts for such misclassification.
HINT:
The authors need to consider the rigour of the studies they have identified. Lack of rigour
may affect the studies' results. ("Al! that glisters is not gold" Merchant of Venice - Act II
Scene?)
5. If the results of the review have been combined, was it reasonable to do so?
Answer:
YES
CANT TELL
NO

Reason:
The results of this study have a value to be learned because this study includes discussions
obvious and sensible thing to do as a proof that the approach in this study to measure the
potential of perinatal mortality using information from local health registers is novel, but
similar to the Chinese investigation using detailed planning program notes, or in the
Netherlands, using electronic registers are managed by different stakeholders.
HINT:
Consider whether :
- The results were similar from study to study
- The results of all the included studies are clearly displayed
- The results of the different studies are similar
- The reasons for any variations in results are discussed
6. What are the overall results of the review?
Answer:
Overall result of the review, the midwife registers were found to have recorded 74% of
perinatal deaths identified in the study population, including 19 out of 23 stillbirths (83%),
and 9 of the 15 early neonatal deaths (60%). In contrast, the village administration death
register (official source for local vital statistics) recorded only 15 out of the 38 perinatal
deaths; about 40%.

The study findings on births and deaths from linked registers with the reported MCH
program data for each sub district. The comparison shows serious under reporting in the
MCH program data. For the 23 villages comprising our study population, we measured a
stillbirth rate of 13.5 per 1000 total births, which was over four times the stillbirth rate
(8/2228; or 3.5 per 1000 births) reported to the district health department for all 34 villages
located in the three sub district. In terms of perinatal mortality rates, our measures for Kajen
1 and Kedungwuni 1 are marginally higher than the point estimate of perinatal mortality rate
from the Indonesian Demographic Health Survey for Central Java during 2003-2006, which
was 20.3 per 1000 total births (95% CI 8.7 - 31.8)
HINT: Consider
- If you are clear about the review's 'bottom line' results
- What these are (numerically if oppropriate)
- How were the results expressed (NNT, odds ratioetc)
7. How precise are the results?
Answer:
Completeness of pregnancy registration in health registers A total of 1759 pregnancies that
resulted in delivery were identified after data linkage across the three health registers. The
distribution of pregnancies across the registers is illustrated in Figure 1. Data linkage
indicated that while each of the three registers had recorded between 65-73% of the total
pregnancies, only 695 (40%) were recorded in all three registers. Similar analyses conducted
at the sub district level identified variations in the proportion of births common to all three
registers with Kajen demonstrating the highest percentage (48%); followed by Kedungwuni
(38%) and Wonokerto the least (33%).
HINT: Look at the confidence intirvals, if given
8. Can the result be applied to the local population?
Answer:
YES
CANT TELL
NO

Reason:
The results of this study can be applied by health professionals in this case nurses and
midwives to implement the system registers in the data recording deaths listed in paragraph

stating that our findings call attention urgently to strengthen the MCH program performance
data reporting system, through appropriate guidance on the maintenance of the register local,
and accurate reporting of MCH services
HINT:
Consider whether :
- The patients covered by the review could be sufficiently different to your population ta
cause concern
- Your local setting is likely to differ much from that of the review
9. Were are important outcomes considered?
Answer:
YES
CANT TELL
NO

Reason:
In the study mentioned that in exploring the potential to measure perinatal mortality using
information from local health registers is novel, but similar to the Chinese investigation using
detailed records of family planning programs, or in the Netherlands. Important information I
wanted to know more about the program is in china and Dutch registers as indicators in
research on this recording mortality.
HINT:
Consider whether :
Is there other fnformation you would like to have seen
10. Are the benefits worth the harms and costs?
Answer:
YES
CANT TELL
NO

Reason:
The benefits of this research are very influential in the decline of perinatal mortality will
require community-based interventions in combination with other clinical care intervention
package that will require more advanced facilities, technology, and skilled human resources.
However, studies in other settings have shown that community-based primary health care or
interventions do have value in reducing perinatal mortality. It would be safe to conclude that
accurate measures of perinatal mortality is needed for the monitoring and planning of
interventions to improve birth outcomes.

HINT:
Consider:
Even if this is not addressed by the review, what do you think?