Determinants of Maternal Death in a Pastoralist Area of Borena Zone, Oromia Region, Ethiopia: Unmatched Case-Control Study

Maternal near miss hospitalizations in the Borana Zone, Ethiopia: A facility-based longitudinal cross-sectional study

Background

Maternal near miss refers to a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of pregnancy termination. While there has been considerable progress in reducing maternal mortality rates, maternal near miss cases can provide valuable insights into the quality of maternal healthcare and help identify areas for improvement. However, there is limited evidence on the factors contributing to maternal near miss cases, including health system failures, delays in care, and provider-related factors. Therefore, this study aimed to assess the incidence, causes, and factors associated with maternal near misses in public Hospitals of Borena Zone.

Methods

A facility-based longitudinal cross-sectional study design was employed at four Public Hospitals in Borena Zone from August 15, 2022, to November 15, 2022, using the WHO criteria for maternal near miss event. In total, 117 participants were included in the study. Eligibility was determined using key clinical, organ dysfunction, laboratory, and management criteria, as per the WHO guidelines for near-miss events. Underlying and contributing causes of maternal near misses were documented from each participant's records.

Result

There were 1421 deliveries during the study period and 117 eligible women developed potentially life-threatening conditions. Only 61 women experienced severe maternal outcomes (55 near misses and six maternal deaths). The maternal near miss incidence ratio was 38.7 per 1000 live births, with a mortality index of 9.8%. Hypertensive disorders and obstetric hemorrhage are the leading underlying causes of maternal near misses.

Conclusion

The incidence of maternal near miss was remarkably high when compared to previous studies. Giving special emphasis to life-saving interventions, critical care, reducing delays and improving the referral system are critical to improve quality of care.

Assessment of Place of Delivery and Associated Factors among Pastoralists in Ethiopia: A Systematic Review and Meta-Analysis Evaluation

Background

Pastoralist communities rely on their livestock for at least 50% of their food supply and source of income. Home births raise the risk of maternal morbidity and death, whereas institutional births lessen the likelihood of difficulties during labor. Around 70% of labors in pastoralist regions of Ethiopia were assisted by traditional birth attendants.

Methods

Studies done from January 2004 to January 2023, accessed in PubMed, EMBASE, Medline, and other search engines, were included. PRISMA guidelines and JBI critical appraisal checklist were used to assure the quality of the review. Ten articles were included in this review. Data were extracted with Excel and exported to STATA 16 for analysis. Heterogeneity of literatures was evaluated using I2 statistics and publication bias using the Egger regression asymmetry test and the Duval and Tweedie trim-fill analysis. Statistical significance was declared at p value less than 0.05.

Result

The pooled estimate of institutional delivery among the pastoralist community in Ethiopia is 21.2% (95% CI: 16.2-26.1). Husbands who were involved to decide place of delivery (OR = 3.47; 95% CI: 1.61, 7.50), women with good knowledge of MCH services (OR = 2.283; 95% CI: 1.51, 3.44), women who had a positive attitude towards MCH services (OR = 1.69; 95% CI: 0.79, 3.6), availability of health institutions (OR = 2.6; 95% CI: 0.95, 7.20), and women who had an ANC follow-up (OR = 2.78; 95% CI: 2.07, 3.73) were higher institutional delivery prevalence among pastoralist women. Moreover, institutional delivery among women who were educated above the college level was more than two times (OR = 2.56; 95% CI: 1.985, 3.304) higher than among women who were not educated.

Conclusion

Pastoralist women in Ethiopia were found to be a disadvantaged group for institutional delivery at national level. Husband involvement, educational level, ANC visit, knowledge and attitude for MCH service, and health facility distance were identified to have significant association with institutional delivery.

Client retention in the continuum of maternal health services in Ethiopia

BACKGROUND

Even though the global maternal mortality has shown an impressive decline over the last three decades, the problem is still pressing in low-income countries. To bring this to an end, women in a continuum of maternity care should be retained. This study aimed to assess the status of Ethiopian women's retention in the continuum of maternity care with their possible predictors.

METHODS

We used data from the 2019 Ethiopian Mini-Demographic and Health Survey. The outcome variable in this study was retention in the continuum of maternity care, which consists of at least four ANC contacts, delivery in a health facility, and postnatal check within 48 h of delivery. We analyzed the data using STATA version 14 and a binary logistic regression model was used. In the multiple logistic regression model, variables with a p-value ≤ 0.05 were considered as significantly associated with the outcome variable. A weighted analysis was also done.

RESULTS

Of the 3917 women included in this study, only 20.8% of women completed all of the recommended services. Besides, the use of maternal health services favors women living in the biggest city administrations, followed by women living in agrarian regions; however, those living in the pastoralist area were disadvantaged. Having four or more ANC was explained by the maternal secondary level of education [AOR: 2.54; 95% CI: 1.42, 4.54], wealth status [AOR: 2.59; 95% CI: 1.45, 4.62], early initiation of ANC [AOR: 3.29; 95% CI: 2.55, 4.24], and being in a union [AOR: 1.95; 95% CI: 1.16,3.29]. After having four ANC, factor-affecting delivery in a health facility was wealth status [AOR: 8.64; 95% CI: 4.07, 18.36]. The overall completion of care was associated with women's higher level of education [AOR: 2.12; 95% CI: 1.08, 4.25], richest wealth status [AOR: 5.16; 95% CI: 2.65, 10.07], timeliness of the first ANC visit [AOR: 2.17; 95% CI: 1.66, 2.85], and third birth order [AOR: 0.58; 95% CI: 0.35, 0.97].

CONCLUSIONS

Despite the efforts by the Ethiopian government and other stakeholders, the overall completion of care was quite low. There is also a clear inequality because of women's background characteristics and regional variation. Strategies aiming to empower women through improved educational experience and economic standing have to be implemented in collaboration with other relevant sectors.

Association between iron-folic acid supplementation and pregnancy-induced hypertension among pregnant women in public hospitals, Wolaita Sodo, Ethiopia 2021: a case- control study

BACKGROUND

Pregnancy-induced hypertension is the new onset of high blood pressure after 20 weeks of gestation in women with previously normal blood pressure. To the best of our knowledge, no study has been conducted in our country to investigate the association between this pregnancy problem and iron-folic acid supplementation. The aim of this study was to determine the association between iron-folic acid supplementation and pregnancy-induced hypertension (PIH) in pregnant women at public hospitals in the Wolaita Sodo zone.

METHODS

An institution-based case-control study was conducted among pregnant women who visited public hospitals in the Wolaita Sodo zone from March 3, 2022, to August 30, 2022. A consecutive sampling method was used to select the study participants. The total sample size was 492, of which 164 were cases and 328 were controls. The data were collected by conducting face-to-face interviews and measurements. The data were entered into EpiData version 4.6 and exported to STATA 14 for analysis. Those variables with a p-value less than 0.05 were considered statistically significant. Descriptive statistics and odds ratios were presented using texts, tables, and figures.

RESULTS

A total of 471 women participated in this study, yielding a response rate of 96%. The cases had a mean age of 25 ± 4.43, while the controls had a mean age of 25 ± 3.99. The mean age at first pregnancy among cases was 20 ± 2.82 and among controls was 20 ± 2.97. The average number of deliveries for cases and controls was 1.97 ± 1.41 and 1.95 ± 1.38, respectively. There is no significant association between iron-folic acid supplementation and PIH. Pregnant women with high hemoglobin levels had higher odds of PIH as compared to those without it (AOR = 3.65; 95% CI: 1.0-12.9). Eating kocho (AOR = 14.4; 95% CI: 1.2-16.7) was positively associated with PIH.

CONCLUSIONS

There is no association between iron-folic acid supplementation during pregnancy and pregnancy-induced hypertension. Pregnant women with high hemoglobin levels had higher odds of PIH as compared to those without it. There is an association between kocho consumption and PIH. More research should be done using stronger designs.

Factors associated with home delivery preference among pregnant women in Ethiopia: a cross-sectional study

Background

Home delivery is associated with a high risk of maternal and neonatal mortality. The prevalence and factors associated with home delivery have been studied retrospectively among women in Ethiopia. However, no national studies have assessed pregnant women’s preferences for home delivery.

Objective

To assess factors associated with preferences for home delivery among pregnant women in Ethiopia.

Methods

We analysed a sample of 678 pregnant women derived from the 2019 performance monitoring for action cross-sectional survey. The association between pregnant women’s preferences for home delivery and several individual, household, healthcare, and community factors were explored through log-Poisson regression with robust variance.

Results

The weighted prevalence of pregnant women’s preferences for home delivery in Ethiopia was 33%. Pregnant women between the ages of 15–19 years (PR = 2.3; 95% CI: 1.43–4.00) had a higher preference for home delivery compared to those above 34 years. Those who had no Antenatal care (ANC) visit in the current pregnancy (PR = 1.5; 95% CI: 1.11–2.11), multipara women (PR = 1.8; 95% CI: 1.19–2.92) those who did not discuss place of delivery with their partners (PR = 1.5; 95% CI: 1.18–2.10), did not participate in a community-based program called ‘1 to 5’ network meetings (PR = 4.5; 95% CI: 1.09–18.95), and those who perceived low community support for facility delivery (PR = 2.2; 95% CI: 1.53–3.20) had a higher prevalence of home delivery preference compared to their references.

Conclusions

A significant proportion of pregnant women preferred home deliveries in Ethiopia. Household and community supporting factors such as not discussing place of delivery with a partner, not participating in women developmental army meetings, and perceived low community support were associated with preference for home delivery. Interventions should address these factors to increase facility deliveries in Ethiopia.

A systematic review of individual and ecological determinants of maternal mortality in the world based on the income level of countries

BACKGROUND

This systematic review was conducted to map the literature on all the existing evidence regarding individual and ecological determinants of maternal mortality in the world and to classify them based on the income level of countries. Such a systematic review had not been conducted before.

METHODS

We conducted an electronic search for primary and review articles using "Maternal Mortality" and "Determinant" as keywords or MeSH terms in their Title or Abstract, indexed in Scopus, PubMed, and Google with no time or geographical limitation and also hand searching was performed for most relevant journals. STROBE and Glasgow university critical appraisal checklists were used for quality assessment of the included studies. Data of the determinants were extracted and classified into individual or ecological categories based on income level of the countries according to World Bank classification.

RESULTS

In this review, 109 original studies and 12 review articles from 33 countries or at global level met the inclusion criteria. Most studies were published after 2013. Most literature studied determinants of low and lower-middle-income countries. The most important individual determinants in low and lower-middle-income countries were location of birth, maternal education, any delays in health services seeking, prenatal care and skilled birth attendance. Household-related determinants in low-income countries included improved water source and sanitation system, region of residence, house condition, wealth of household, and husband education. Additionally, ecological determinants including human resources, access to medical equipment and facilities, total fertility rate, health financing system, country income, poverty rate, governance, education, employment, social protection, gender inequality, and human development index were found to be important contributors in maternal mortality. A few factors were more important in higher-income countries than lower-income countries including parity, IVF births, older mothers, and type of delivery.

CONCLUSION

A comprehensive list of factors associated with maternal death was gathered through this systematic review, most of which were related to lower-income countries. It seems that the income level of the countries makes a significant difference in determinants of maternal mortality in the world.

Association of primary postpartum hemorrhage with inter-pregnancy interval in urban South Ethiopia: A matched nested case-control study

Background

Globally, postpartum hemorrhage is the leading preventable cause of maternal mortality. To decrease postpartum hemorrhage-related maternal mortalities, identifying its risk factors is crucial to suggest interventions. In this regard, little is known about the link between primary postpartum hemorrhage and inter-pregnancy interval in Ethiopia, where more than half of pregnancies occur shortly after the preceding childbirth. Therefore, we aimed to elucidate the association of primary postpartum hemorrhage with an inter-pregnancy interval in urban South Ethiopia.

Methods

A community-based matched nested case-control study was conducted among a cohort of 2548 pregnant women. All women with primary postpartum hemorrhage during the follow-up (n = 73) were taken as cases. Women who were randomly selected from those without primary postpartum hemorrhage (n = 292) were taken as controls. Cases were individually matched with controls (1:4 ratio) for age group and location. A conditional logistic regression analysis was done using R version 4.0.5 software. Statistically, a significant association was declared using 95% CI and p-value. Attributable fraction (AF) and population attributable fraction (PAF) were used to estimate the public health impacts of the inter-pregnancy interval.

Results

This study found out that more than half (66%) of primary postpartum hemorrhage was attributed to inter-pregnancy interval <24 months (AF = 66.3%, 95% CI: 37.5, 82.5%). This could be prevented if the inter-pregnancy interval was increased to 24–60 months. Likewise, nearly half (49%) of primary postpartum hemorrhage in the study population could be prevented if the inter-pregnancy interval <24 months was prevented. Additionally, primary postpartum hemorrhage was attributed to antepartum hemorrhage, prolonged labour and multiple pregnancies.

Conclusions

Primary postpartum hemorrhage was associated with inter-pregnancy interval under 24 months, highlighting the need to improve postpartum modern contraceptive utilization in the community. Counseling couples about how long to wait until subsequent pregnancy and the risk when the inter-pregnancy interval is short need to be underlined.

Individual, health facility and wider health system factors contributing to maternal deaths in Africa: A scoping review

The number of women dying during pregnancy and after childbirth remains unacceptably high, with African countries showing the slowest decline. The leading causes of maternal deaths in Africa are preventable direct obstetric causes such as haemorrhage, infection, hypertension, unsafe abortion, and obstructed labour. There is an information gap on factors contributing to maternal deaths in Africa. Our objective was to identify these contributing factors and assess the frequency of their reporting in published literature. We followed the Arksey and O'Malley methodological framework for scoping reviews. We searched six electronic bibliographic databases: MEDLINE, SCOPUS, African Index Medicus, African Journals Online (AJOL), French humanities and social sciences databases, and Web of Science. We included articles published between 1987 and 2021 without language restriction. Our conceptual framework was informed by a combination of the socio-ecological model, the three delays conceptual framework for analysing the determinants of maternal mortality and the signal functions of emergency obstetric care. We included 104 articles from 27 African countries. The most frequently reported contributory factors by level were: (1) Individual-level: Delay in deciding to seek help and in recognition of danger signs (37.5% of articles), (2) Health facility-level: Suboptimal service delivery relating to triage, monitoring, and referral (80.8% of articles) and (3) Wider health system-level: Transport to and between health facilities (84.6% of articles). Our findings indicate that health facility-level factors were the most frequently reported contributing factors to maternal deaths in Africa. There is a lack of data from some African countries, especially those countries with armed conflict currently or in the recent past. Information gaps exist in the following areas: Statistical significance of each contributing factor and whether contributing factors alone adequately explain the variations in maternal mortality ratios (MMR) seen between countries and at sub-national levels.

Maternal near-miss and mortality in a teaching hospital in Tigray region, Northern Ethiopia

Objective:

This study seeks to examine the prevalence of maternal morbidities and deaths in Ayder Comprehensive Specialized Hospital from 1 July 2018 to 30 June 2019.

Methods:

This was a cross-sectional study. Total purposive sampling method was employed to collect data prospectively using modified World Health Organization criteria for baseline assessment of maternal near-miss and mortality. Pregnant women or those who are within 42 days postpartum/any form of pregnancy termination that satisfy the inclusion criteria were enrolled.

Results:

A total of 691 mothers were recorded as having severe maternal complications. Out of these, 170 women developed severe maternal outcome, ending with 146 maternal near-miss cases and 24 maternal deaths. The maternal near-miss ratio and maternal mortality ratio were 28.5 per 1000 live births and 469.1 per 100,000 live births, respectively. The overall mortality index was 14%. The top underlying causes of severe maternal complications were the infamous triads of preeclampsia (n = 303, 43.8%), obstetric hemorrhage (n = 166, 24.0%) and sepsis (n = 130, 18.8%). About 62.5% of mothers who died were not admitted to intensive care unit.

Conclusion:

This study found that the infamous triads of preeclampsia, obstetric hemorrhage and sepsis persist as the commonest causes of severe maternal complications in the study area. A significant number of women with severe maternal outcome were not admitted to intensive care unit. It also highlights that the severe maternal complications, severe maternal outcome, maternal near-miss ratio and mortality index in the study area are disproportionately higher than the global average. These staggering numbers call for a system re-thinking at multiple junctures.

Health system responsiveness in maternity care at Hadiya zone public hospitals in Southern Ethiopia: Users' perspectives

Background

Health system responsiveness refers to non-financial, non-clinical qualities of care that reflect respect for human dignity and interpersonal aspects of the care process. The non-clinical aspects of the health system are therefore essential to the provision of services to patients. Therefore, the main purpose of this study was to assess the responsiveness in maternity care, domain performance and factors associated with responsiveness in maternity care in the Hadiya Zone public Hospitals in Southern Ethiopia.

Methods

A hospital-based cross-sectional study was employed on 413 participants using a systematic sampling technique from 1 July to 1 August 2020. An exit interviewer–administered questionnaire was used to collect data. EpiData (version 3.1) and SPSS (version 24) software were used for data entry and analysis, respectively. Bivariate and multivariable logistic regression were computed to identify the associated factors of health system responsiveness in maternity care at 95% CI.

Results

The findings indicated that 53.0% of users gave high ratings for responsiveness in delivery care. In the multivariable logistic regression analysis, mothers aged ≥ 35 (AOR = 0.4; 95% CI = 0.1–0.9), urban resident (AOR = 2.5; 95% CI = 1.5–4.8), obstetrics complications during the current pregnancy (AOR = 2.1; 95% CI = 1.1–3.0), and caesarean delivery (AOR = 0.4; 95% CI = 0.2–0.7) were factors associated with poor ratings for responsiveness in maternity care.

Conclusion

In the hospitals under investigation, responsiveness in maternity care was found to be good. The findings of this study suggest that the ministry of health and regional health bureau needs to pay attention to health system responsiveness as an indicator of the quality of maternity care.

Adverse birth outcomes and associated factors among mothers who delivered in Bale zone hospitals, Oromia Region, Southeast Ethiopia

Objective

Adverse birth outcomes, which include stillbirth, preterm birth, low birthweight, congenital abnormalities, and stillbirth, are the leading cause of neonatal and infant mortality worldwide. We assessed adverse birth outcomes and associated factors among mothers who gave birth in Bale zone hospitals, Oromia, Southeast Ethiopia.

Methods

We used systematic random sampling in this cross-sectional study. We identified factors associated with adverse birth outcomes using bivariate analysis and multivariable logistic regression analysis.

Results

The proportion of adverse birth outcomes among participants was 21%. Of 576 births, 70 (12.2%) were low birthweight, 49 (8.5%) were preterm birth, 45 (7.8%) were stillbirth, and 18 (3.1%) infants had congenital anomalies. Inadequate antenatal care (adjusted odds ratio [AOR] = 6.58, 95% confidence interval [CI] 3.25–13.32), multiple pregnancy (AOR  =  4.74, 95% CI 1.55–14.45), premature rupture of membranes in the current pregnancy (AOR = 2.31, 95% CI 1.26–4.21), hemoglobin level  < 11 g/dL (AOR = 3.22, 95% CI 1.85–5.58), and mid-upper arm circumference less than 23 cm (AOR = 5.93, 95% CI 3.49–10.08) were all significantly associated with adverse birth outcomes.

Conclusions

Approximately one in five study participants had adverse birth outcomes. Increasing antenatal care uptake, ferrous supplementation during pregnancy, and improving the quality of maternal health services are recommended.

Prevalence and predictors of primary postpartum hemorrhage: An implication for designing effective intervention at selected hospitals, Southern Ethiopia

Background

Primary postpartum hemorrhage is the leading cause of maternal mortality worldwide. Ethiopia has made significant progress in maternal health care services. Despite this, primary postpartum hemorrhage continues to remain the leading cause of maternal mortality in Ethiopia. This study aimed to assess the prevalence and predictors of primary postpartum hemorrhage among mothers who gave birth at selected hospitals in the Southern Ethiopia.

Methods

An institution-based cross-sectional study was employed from March 2–28, 2018. Four hundred and twenty-two study participants were obtained using the consecutive sampling method. A structured interviewer-administered questionnaire and chart review were used to collect data. Data were entered into Epi-data version 3.1 and analyzed using SPSS version 22. Multivariable logistic regression were used to determine the predictors of primary postpartum hemorrhage with 95% CI and p-value < 0.05.

Results

The overall prevalence of primary postpartum hemorrhage was 16.6%. Mothers aged 35 and above [AOR = 6.8, 95% CI (3.6, 16.0)], pre-partum anemia [AOR = 5.3, 95% CI (2.2, 12.8)], complications during labor [AOR = 1.8, 95% CI (2.8, 4.2)], history of previous postpartum hemorrhage [AOR = 2.7, 95% CI (1.1, 6.8)] and instrumental delivery [AOR = 5.3, 95% CI (2.2, 12.8)] were significant predictors of primary postpartum hemorrhage.

Conclusion

Primary postpartum hemorrhage is quite common in the study area. Mothers aged 35 and above, complications during labor, history of previous postpartum hemorrhage, and instrumental delivery were predictors of primary postpartum hemorrhage. Since postpartum hemorrhage being relatively common, all obstetrics unit members should be prepared to manage mothers who experience it.