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Can innovative ambulance transport avert pregnancy-related deaths? One-year operational assessment in Ethiopia
Tigray Regional Health Bureau, Mekele, Ethiopia..
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0001-0003-1332-4138
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.ORCID iD: 0000-0001-5474-4361
2016 (English)In: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 6, no 1Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:

To maximise the potential benefits of maternity care services, pregnant women need to be able to physically get to health facilities in a timely manner. In most of sub-Saharan Africa, transport represents a major practical barrier. Here we evaluate the extent to which an innovative national ambulance service in Ethiopia, together with mobile phones, may have been successful in averting pregnancy-related deaths.

METHODS:

An operational assessment of pregnancy-related deaths in relation to utilisation of the new national ambulance service was undertaken in six randomly selected Districts in northern Ethiopia. All 183 286 households in the six randomly selected Districts were visited to identify live-births and deaths among women of reproductive age that occurred over a one-year period. The uptake of the new ambulance transport service for women's deliveries in the same six randomly selected Districts over the same period was determined retrospectively from ambulance log books. Pregnancy-related deaths as determined by the World Health Organization (WHO 2012) verbal autopsy tool [13] and the InterVA-4 model [14] were analysed against ambulance utilisation by District, month, local area, distance from health facility and mobile network coverage.

FINDINGS:

A total of 51 pregnancy-related deaths and 19 179 live-births were documented. Pregnancy-related mortality for Districts with above average ambulance utilisation was 149 per 100 000 live-births (95% confidence interval CI 77-260), compared with 350 per 100 000 (95% CI 249-479) for below average utilisation (P = 0.01). Distance to a health facility, mobile network availability and ambulance utilisation were all significantly associated with pregnancy-related mortality on a bivariable basis. On a multivariable basis, ambulance non-utilisation uniquely persisted as a significant determinant of mortality (mortality rate ratio 1.97, 95% CI 1.05-3.69; P = 0.03).

CONCLUSIONS:

The uptake of freely available transport in connection with women's obstetric needs correlated with substantially reduced pregnancy-related mortality in this operational assessment, though the design did not allow cause and effect to be attributed. However, the halving of pregnancy-related mortality associated with ambulance uptake in the sampled Districts suggests that the provision of transport to delivery facilities in Africa may be a key innovation for delivering maternal health care, which requires wider consideration.

Place, publisher, year, edition, pages
2016. Vol. 6, no 1
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-127315DOI: 10.7189/jogh.06.010410OAI: oai:DiVA.org:umu-127315DiVA: diva2:1044889
Available from: 2016-11-07 Created: 2016-11-07 Last updated: 2016-11-24Bibliographically approved
In thesis
1. Maternal Mortality Then, Now, and Tomorrow: The Experience of Tigray Region, Northern Ethiopia
Open this publication in new window or tab >>Maternal Mortality Then, Now, and Tomorrow: The Experience of Tigray Region, Northern Ethiopia
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Abstract

Background: Maternal mortality is one of the most sensitive indicators of the health disparities between poorer and richer nations. It is also one of the most difficult health outcomes to measure reliably. In many settings, major challenges remain in terms of both measuring and reducing maternal mortality effectively. This thesis aims to quantify overall levels, identify specific causes, and evaluate local interventions in relation to efforts to reduce maternal mortality in Tigray Region, Northern Ethiopia, thereby providing a strong empirical basis for decision making by the Tigray Regional Health Bureau using methods that can be scaled at national level.

 

Methods: This study employed a combination of community-based study designs to investigate the level and determinants of maternal mortality in six randomly selected rural districts of Tigray Region. A census of all households in the six districts was conducted to identify all live births and all deaths to women of reproductive age occurring between May 2012 and September 2013. Pregnancy-related deaths were screened through verbal autopsy with the data processed using the InterVA-4 model, which was used to estimate Maternal Mortality Ratio. To identify independent determinants of maternal mortality, a case-control study using multiple logistic regression analysis was done, taking all pregnancy-related deaths as cases and a random sample of geographical and age matched mothers as controls. Uptake of ambulance services in the six districts was determined retrospectively from ambulance logbooks, and the trends in pregnancy-related death were analyzed against ambulance utilization, distance from nearest health center, and mobile network coverage at local area level. Lastly, implementation of the Family Folder paper health register, and its potential for accurately capturing demographic and health events, were evaluated using a capture-recapture assessment.

 

Results: A total of 181 deaths to women of reproductive age and 19,179 live births were documented from May 2012 to April2013. Of the deaths, 51 were pregnancy-related. The maternal mortality ratio for Tigray region was calculated at 266 deaths per 100,000 live births (95% CI 198-350), which is consistently lower than previous “top down” MMR estimates. District–level MMRs showed strong inverse correlation with population density (r2 = 0.86). Direct obstetric causes accounted for 61% of all pregnancy–related deaths, with hemorrhage accounting for 34%. Non-membership in the voluntary Women’s Development Army (AOR 2.07, 95% CI 1.04-4.11), low husband or partner involvement during pregnancy (AOR 2.19, 95% CI 1.14-4.18), pre-existing history of other illness (AOR 5.58, 95% CI 2.17-14.30), and never having used contraceptives (AOR 2.58, 95% CI 1.37-4.85) were associated with increased risk of maternal death in a multivariable regression model. In addition, utilization of free ambulance transportation service was strongly associated with reduced MMR at district level. Districts with above-average ambulance utilization had an MMR of 149 per 100,000 LB (95% CI: 77-260) compared with 350 per 100,000 (95% CI: 249-479) in districts with below average utilization. The Family Folder implementation assessment revealed some inconsistencies in the way Health Extension Workers utilize the Family Folders to record demographic and health events.

 

Conclusion: This work contributes to understanding the status of and factors affecting maternal mortality in Tigray Region. It introduces a locally feasible approach to MMR estimation and gives important insights in to the effectiveness of various interventions that have been targeted at reducing maternal mortality in recent years.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2016. 90 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1819
Keyword
Maternal mortality, intervention, ambulance, family folder, case-control, cross-sectional survey, verbal autopsy, Tigray, Ethiopia
National Category
Medical and Health Sciences
Research subject
Epidemiology
Identifiers
urn:nbn:se:umu:diva-128117 (URN)978-91-7601-510-0 (ISBN)
Public defence
2016-12-16, Room 135, Family Medicine, Building 9A, Norrlands University Hospital, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2016-11-25 Created: 2016-11-23 Last updated: 2016-11-24Bibliographically approved

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