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Understanding maternal mortality from top-down and bottom-up perspectives: case of Tigray Region, Ethiopia
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK; MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
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. Vol. 5, no 1, 83-90 p., 010404
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-110017DOI: 10.7189/jogh.05.010404ISI: 000370619100009PubMedID: 25674351OAI: oai:DiVA.org:umu-110017DiVA: diva2:860354
Available from: 2015-10-12 Created: 2015-10-12 Last updated: 2017-12-01Bibliographically 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: 2017-10-26Bibliographically approved

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