{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T06:10:09Z","timestamp":1792131009820,"version":"4.4.0"},"reference-count":46,"publisher":"BMJ","issue":"10","license":[{"start":{"date-parts":[[2025,10,27]],"date-time":"2025-10-27T00:00:00Z","timestamp":1761523200000},"content-version":"unspecified","delay-in-days":26,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100021914","name":"Grand Challenges in Global Health","doi-asserted-by":"publisher","award":["OPP1128001"],"award-info":[{"award-number":["OPP1128001"]}],"id":[{"id":"10.13039\/100021914","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100021914","name":"Grand Challenges in Global Health","doi-asserted-by":"publisher","award":["OPP1196642"],"award-info":[{"award-number":["OPP1196642"]}],"id":[{"id":"10.13039\/100021914","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Glob Health"],"accepted":{"date-parts":[[2025,9,25]]},"published-print":{"date-parts":[[2025,10]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Stillbirth rates remain unacceptably high in low- and middle-income countries (LMICs). Understanding the causes of death (CoD) is mandatory to develop effective strategies to reduce this high mortality. Minimally invasive tissue sampling (MITS) is a promising alternative to conventional autopsy (CA) but its validation in stillbirths remains limited. Existing evidence indicates that most samples of conventional MITS (c-MITS) lack diagnostic relevance in stillbirths. This study aimed to validate c-MITS against CA in stillbirths and design and assess a cost-efficient, simplified MITS (s-MITS) protocol.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      The study comprised two subsets of stillbirths occurring at Maputo Central Hospital, Mozambique. The CaDMIA-Plus cohort (\n                      <jats:italic>Cause of Death investigation using Minimally Invasive Autopsy<\/jats:italic>\n                      , n=90; 2017\u20132018), in which both c-MITS and CA were performed, was used to validate c-MITS against the gold standard and to determine the diagnostic value of each sample and design a s-MITS. The MIBio cohort (\n                      <jats:italic>Mortality Identification Biomarkers<\/jats:italic>\n                      , n=98; 2021\u20132022), which included only s-MITS, was used to evaluate the performance and cost of the s-MITS in comparison to c-MITS in an independent cohort.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Almost perfect overall agreement (Kappa=0.82) was observed between the c-MITS and CA-attributed CoD. Lung and placenta samples were identified as the most informative in c-MITS. When using only lung and placenta results to model an s-MITS, substantial agreement (Kappa=0.79) was found between the s-MITS-derived CoD and those attributed by CA. Similar CoD distributions were observed when applying the s-MITS to the MIBio cohort, while costs were reduced by 55.7%. The leading CoDs were primarily related to maternal conditions and pregnancy complications (70.0\u201372.4%) and infectious diseases (25.6\u201327.6%).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>c-MITS is a simpler and cost-effective alternative to CA for determining CoD in stillbirths. s-MITS has a diagnostic accuracy similar to that of c-MITS, while significantly reducing costs, making it adequate for implementation in routine clinical practice in LMICs.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjgh-2024-018380","type":"journal-article","created":{"date-parts":[[2025,10,28]],"date-time":"2025-10-28T10:10:27Z","timestamp":1761646227000},"page":"e018380","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Diagnostic accuracy of a simplified minimally invasive tissue sampling protocol for stillbirths in low-resource settings"],"prefix":"10.1136","volume":"10","author":[{"given":"N\u00faria","family":"Pe\u00f1uelas","sequence":"first","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adela","family":"Saco","sequence":"additional","affiliation":[{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"},{"name":"Department of Pathology, Hospital Cl\u00ednic de Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9519-6082","authenticated-orcid":false,"given":"Juan Carlos","family":"Hurtado","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"},{"name":"Department of Microbiology, Hospital Cl\u00ednic de Barcelona, Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorena","family":"Marimon","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"},{"name":"Department of Pathology, Hospital Cl\u00ednic de Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rosauro","family":"Varo","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Centro de Investiga\u00e7\u00e3o em Sa\u00fade de Manhi\u00e7a, Manhi\u00e7a, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1078-2187","authenticated-orcid":false,"given":"Inacio","family":"Mandomando","sequence":"additional","affiliation":[{"name":"Centro de Investiga\u00e7\u00e3o em Sa\u00fade de Manhi\u00e7a, Manhi\u00e7a, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica","family":"Navero-Castillejos","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Department of Microbiology, Hospital Cl\u00ednic de Barcelona, Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carla","family":"Carrilho","sequence":"additional","affiliation":[{"name":"Department of Pathology, Maputo Central Hospital, Maputo, Mozambique"},{"name":"Department of Pathology, Universidade Eduardo Mondlane, Maputo, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fabiola","family":"Fernandes","sequence":"additional","affiliation":[{"name":"Department of Pathology, Maputo Central Hospital, Maputo, Mozambique"},{"name":"Department of Pathology, Universidade Eduardo Mondlane, Maputo, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Assucena","family":"Guisseve","sequence":"additional","affiliation":[{"name":"Department of Pathology, Maputo Central Hospital, Maputo, Mozambique"},{"name":"Department of Pathology, Universidade Eduardo Mondlane, Maputo, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mamudo R","family":"Ismail","sequence":"additional","affiliation":[{"name":"Department of Pathology, Maputo Central Hospital, Maputo, Mozambique"},{"name":"Department of Pathology, Universidade Eduardo Mondlane, Maputo, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alba","family":"Morat\u00f3","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cesaltina","family":"Lorenzoni","sequence":"additional","affiliation":[{"name":"Department of Pathology, Maputo Central Hospital, Maputo, Mozambique"},{"name":"Department of Pathology, Universidade Eduardo Mondlane, Maputo, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aida","family":"Tivane","sequence":"additional","affiliation":[{"name":"Department of Pathology, Maputo Central Hospital, Maputo, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laia","family":"Diez-Ahijado","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jesus","family":"Lopez-Diaz","sequence":"additional","affiliation":[{"name":"Department of Pathology, Hospital Cl\u00ednic de Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katarzyna","family":"Darecka","sequence":"additional","affiliation":[{"name":"Department of Pathology, Hospital Cl\u00ednic de Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tacilta","family":"Nhampossa","sequence":"additional","affiliation":[{"name":"Centro de Investiga\u00e7\u00e3o em Sa\u00fade de Manhi\u00e7a, Manhi\u00e7a, Mozambique"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0875-7596","authenticated-orcid":false,"given":"Quique","family":"Bassat","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Centro de Investiga\u00e7\u00e3o em Sa\u00fade de Manhi\u00e7a, Manhi\u00e7a, Mozambique"},{"name":"ICREA, Barcelona, Pg. Llu\u00eds Companys 23, 08010, Spain"},{"name":"Consorcio de Investigaci\u00f3n Biom\u00e9dica en Red de Epidemiolog\u00eda y Salud P\u00fablica, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mikel","family":"Martinez","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"},{"name":"Department of Microbiology, Hospital Cl\u00ednic de Barcelona, Barcelona, Barcelona, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Clara","family":"Men\u00e9ndez","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Centro de Investiga\u00e7\u00e3o em Sa\u00fade de Manhi\u00e7a, Manhi\u00e7a, Mozambique"},{"name":"Consorcio de Investigaci\u00f3n Biom\u00e9dica en Red de Epidemiolog\u00eda y Salud P\u00fablica, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5487-801X","authenticated-orcid":false,"given":"Raquel","family":"Gonzalez","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"},{"name":"Centro de Investiga\u00e7\u00e3o em Sa\u00fade de Manhi\u00e7a, Manhi\u00e7a, Mozambique"},{"name":"Consorcio de Investigaci\u00f3n Biom\u00e9dica en Red de Epidemiolog\u00eda y Salud P\u00fablica, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaume","family":"Ordi","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"},{"name":"Department of Pathology, Hospital Cl\u00ednic de Barcelona, Barcelona, Spain"},{"name":"Consorcio de Investigaci\u00f3n Biom\u00e9dica en Red de Epidemiolog\u00eda y Salud P\u00fablica, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5030-3526","authenticated-orcid":false,"given":"Natalia","family":"Rakislova","sequence":"additional","affiliation":[{"name":"ISGlobal, Barcelona, Spain"},{"name":"Facultat de Medicina, Universitat de Barcelona, Barcelona, Spain"},{"name":"Department of Pathology, Hospital Cl\u00ednic de Barcelona, Barcelona, Spain"},{"name":"Consorcio de Investigaci\u00f3n Biom\u00e9dica en Red de Epidemiolog\u00eda y Salud P\u00fablica, Madrid, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,10,28]]},"reference":[{"key":"2025120102354263000_10.10.e018380.1","unstructured":"Stillbirths and stillbirth rates - UNICEF DATA. Available: https:\/\/data.unicef.org\/topic\/child-survival\/stillbirths\/ [Accessed 9 Apr 2025]."},{"key":"2025120102354263000_10.10.e018380.2","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(21)01112-0"},{"key":"2025120102354263000_10.10.e018380.3","doi-asserted-by":"crossref","first-page":"e195","DOI":"10.1016\/S2214-109X(21)00515-5","article-title":"Global, regional, and national trends in under-5 mortality between 1990 and 2019 with scenario-based projections until 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation","volume":"10","author":"Sharrow","year":"2022","journal-title":"Lancet Glob Health"},{"key":"2025120102354263000_10.10.e018380.4","unstructured":"Standing Up for Stillbirth: Current estimates and key interventions - UNICEF DATA, Available: https:\/\/data.unicef.org\/resources\/standing-up-for-stillbirth-report\/ [Accessed 9 Apr 2025]."},{"key":"2025120102354263000_10.10.e018380.5","doi-asserted-by":"crossref","first-page":"e125","DOI":"10.1016\/S2214-109X(13)70037-8","article-title":"Development of a post-mortem procedure to reduce the uncertainty regarding causes of death in developing countries","volume":"1","author":"Bassat","year":"2013","journal-title":"Lancet Glob Health"},{"key":"2025120102354263000_10.10.e018380.6","doi-asserted-by":"crossref","first-page":"55","DOI":"10.12688\/gatesopenres.13132.1","article-title":"Limitations to current methods to estimate cause of death: a validation study of a verbal autopsy model","volume":"4","author":"Men\u00e9ndez","year":"2020","journal-title":"Gates Open Res"},{"key":"2025120102354263000_10.10.e018380.7","doi-asserted-by":"crossref","unstructured":"Rakislova N , Jordao D , Ismail MR , et al . Accuracy of verbal autopsy, clinical data and minimally invasive autopsy in the evaluation of malaria-specific mortality: an observational study. BMJ Glob Health 2021;6. doi:10.1136\/bmjgh-2021-005218","DOI":"10.1136\/bmjgh-2021-005218"},{"key":"2025120102354263000_10.10.e018380.8","doi-asserted-by":"crossref","unstructured":"Ordi J , Castillo P , Garcia-Basteiro AL , et al . Clinico-pathological discrepancies in the diagnosis of causes of death in adults in Mozambique: A retrospective observational study. 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