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Maternal Mortality Then, Now, and Tomorrow: The Experience of Tigray Region, Northern Ethiopia
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
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 [en]
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: urn:nbn:se:umu:diva-128117ISBN: 978-91-7601-510-0OAI: oai:DiVA.org:umu-128117DiVA: diva2:1049162
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
List of papers
1. Understanding maternal mortality from top-down and bottom-up perspectives: case of Tigray Region, Ethiopia
Open this publication in new window or tab >>Understanding maternal mortality from top-down and bottom-up perspectives: case of Tigray Region, Ethiopia
2015 (English)In: Journal of Global Health, ISSN 2047-2978, E-ISSN 2047-2986, Vol. 5, no 1, 83-90 p., 010404Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Unacceptably high levels of preventable maternal mortality persist as a problem across sub-Saharan Africa and much of south Asia. Currently, local assessments of the magnitude of maternal mortality are not often made, so the best available information for health planning may come from global estimates and not reflect local circumstances.

METHODS: A community-based cross-sectional survey was designed to identify all live births together with all deaths among women aged 15-49 years retrospectively over a one-year period in six randomly selected districts of Tigray Region, northern Ethiopia. After birth and death identification, Health Extension Workers trained to use the WHO 2012 verbal autopsy (VA) tool visited households to carry out VAs on all deaths among women aged 15-49 years. All pregnancy-related deaths were identified after processing the VA material using the InterVA-4 model, which corresponds to the WHO 2012 VA. A maternal mortality ratio (MMR) was calculated for each District and expressed with a 95% confidence interval (CI).

RESULTS: The MMRs across the six sampled Districts ranged from 37 deaths per 100 000 live births (95% CI 1 to 207) to 482 deaths per 100 000 live births (95% CI 309 to 718). The overall MMR for Tigray Region was calculated at 266 deaths per 100 000 live births (95% CI 198 to 350). Direct obstetric causes accounted for 61% of all pregnancy-related deaths. Haemorrhage was the major cause of pregnancy-related death (34%). District-level MMRs were strongly inversely correlated with population density (r(2) = 0.86).

CONCLUSION: This simple but well-designed survey approach enabled estimation of maternal mortality in Tigray Region on a local, contemporary basis. It also provided insights into possible local variations in MMR and their determinants. Consequently, this approach could be implemented at regional level in other large sub-Saharan African countries, or at national level in smaller ones to monitor and evaluate maternal health service interventions.

Place, publisher, year, edition, pages
The University of Edinburgh, Global Health Society, 2015
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-110017 (URN)10.7189/jogh.05.010404 (DOI)000370619100009 ()25674351 (PubMedID)
Available from: 2015-10-12 Created: 2015-10-12 Last updated: 2016-11-23Bibliographically approved
2. Risk Factors for Maternal Mortality in Rural Tigray, Northern Ethiopia: A Case-Control Study
Open this publication in new window or tab >>Risk Factors for Maternal Mortality in Rural Tigray, Northern Ethiopia: A Case-Control Study
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2015 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 10, no 12, e0144975Article in journal (Refereed) Published
Abstract [en]

Background: Maternal mortality continues to have devastating impacts in many societies, where it constitutes a leading cause of death, and thus remains a core issue in international development. Nevertheless, individual determinants of maternal mortality are often unclear and subject to local variation. This study aims to characterise individual risk factors for maternal mortality in Tigray, Ethiopia. Methods: A community-based case-control study was conducted, with 62 cases and 248 controls from six randomly-selected rural districts. All maternal deaths between May 2012 and September 2013 were recruited as cases and a random sample of mothers who delivered in the same communities within the same time period were taken as controls. Multiple logistic regression was used to identify independent determinants of maternal mortality. Results: Four independent individual risk factors, significantly associated with maternal death, emerged. Women who were not members of the voluntary Women's Development Army were more likely to experience maternal death (OR 2.07, 95% CI 1.04-4.11), as were women whose husbands or partners had below-median scores for involvement during pregnancy (OR 2.19, 95% CI 1.14-4.18). Women with a pre-existing history of other illness were also at increased risk (OR 5.58, 95% CI 2.17-14.30), as were those who had never used contraceptives (OR 2.58, 95% CI 1.37-4.85). Previous pregnancy complications, a below-median number of antenatal care visits and a woman's lack of involvement in health care decision making were significant bivariable risks that were not significant in the multivariable model. Conclusions: The findings suggest that interventions aimed at reducing maternal mortality need to focus on encouraging membership of the Women's Development Army, enhancing husbands' involvement in maternal health services, improving linkages between maternity care and other disease-specific programmes and ensuring that women with previous illnesses or non-users of contraceptive services are identified and followed-up as being at increased risk during pregnancy and childbirth.

Place, publisher, year, edition, pages
Public library science, 2015
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-114620 (URN)10.1371/journal.pone.0144975 (DOI)000366723400038 ()26678047 (PubMedID)
Available from: 2016-02-05 Created: 2016-01-25 Last updated: 2016-11-23Bibliographically approved
3. Can innovative ambulance transport avert pregnancy-related deaths? One-year operational assessment in Ethiopia
Open this publication in new window or tab >>Can innovative ambulance transport avert pregnancy-related deaths? One-year operational assessment in Ethiopia
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.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-127315 (URN)10.7189/jogh.06.010410 (DOI)
Available from: 2016-11-07 Created: 2016-11-07 Last updated: 2016-11-24Bibliographically approved
4. Assessing the performance of the Ethiopian family folder system for collecting community-based health information
Open this publication in new window or tab >>Assessing the performance of the Ethiopian family folder system for collecting community-based health information
Show others...
(English)Article in journal (Refereed) Submitted
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-127316 (URN)
Available from: 2016-11-07 Created: 2016-11-07 Last updated: 2016-11-23

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