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Tholandi M, Zethof S, Kim YM, Tura AK, Ket J, Willcox M, van den Akker T, Ilozumba O. Approaches to improve and adapt maternal mortality estimations in low- and middle-income countries: A scoping review. Int J Gynaecol Obstet 2024; 165:94-106. [PMID: 37712620 DOI: 10.1002/ijgo.15103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/10/2023] [Accepted: 08/22/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND In the absence of robust vital registration systems, many low- and middle-income countries (LMICs) rely on national surveys or routine surveillance systems to estimate the maternal mortality ratio (MMR). Although the importance of MMR estimates in ending preventable maternal deaths is acknowledged, there is limited research on how different approaches are used and adapted, and how these adaptations function. OBJECTIVES To assess methods for estimating maternal mortality in LMICs and the rationale for these modifications. SEARCH STRATEGY A literature search with the terms "maternal death", "surveys" and "low- and middle-income countries" was performed in Medline, Embase, Web of Science, Scopus, CINAHL, APA PsycINFO, ERIC, and IBSS from January 2013 to March 17, 2023. SELECTION CRITERIA Studies were eligible if their main focus was to compare, adapt, or assess methods to estimate maternal mortality in LMICs. DATA COLLECTION AND ANALYSIS Titles and abstracts were screened using Rayyan. Relevant articles were independently reviewed by two reviewers against inclusion criteria. Data were extracted on mortality measurement methods, their context, and results. MAIN RESULTS Nineteen studies were included, focusing on data completeness, subnational estimates, and community involvement. Routinely generated MMR estimates are more complete when multiple data sources are triangulated, including data from public and private health facilities, the community, and local authorities (e.g. vital registration, police reports). For subnational estimates, existing (e.g. the sisterhood method and reproductive-age mortality surveys [RAMOS]) and adapted methods (e.g. RAMOS 4 + 2 and Pictorial Sisterhood Method) provided reliable confidence intervals. Community engagement in data collection increased community awareness of maternal deaths, provided local ownership, and was expected to reduce implementation costs. However, most studies did not include a cost-effectiveness analysis. CONCLUSION Household surveys with community involvement and RAMOS can be used to increase data validity, improve local awareness of maternal mortality estimates, and reduce costs in LMICs.
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Affiliation(s)
- Maya Tholandi
- Faculty of Science, Athena Institute, VU University, Amsterdam, The Netherlands
| | - Siem Zethof
- Department of Internal Medicine, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Young-Mi Kim
- Jhpiego, Johns Hopkins University, Baltimore, Maryland, USA
| | - Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Johannes Ket
- Medical Library, VU University, Amsterdam, The Netherlands
| | - Merlin Willcox
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Onaedo Ilozumba
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Singh K, Li Q, Ahsan KZ, Curtis S, Weiss W. A comparison of approaches to measuring maternal mortality in Bangladesh, Mozambique, and Bolivia. Popul Health Metr 2022; 20:5. [PMID: 35033093 PMCID: PMC8760829 DOI: 10.1186/s12963-022-00281-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 01/02/2022] [Indexed: 11/19/2022] Open
Abstract
Background Many low- and middle-income countries cannot measure maternal mortality to monitor progress against global and country-specific targets. While the ultimate goal for these countries is to have complete civil registrations systems, other interim strategies are needed to provide timely estimates of maternal mortality. Objective The objective is to inform on potential options for measuring maternal mortality. Methods This paper uses a case study approach to compare methodologies and estimates of pregnancy-related mortality ratio (PRMR)/maternal mortality ratio (MMR) obtained from four different data sources from similar time periods in Bangladesh, Mozambique, and Bolivia—national population census; post-census mortality survey; household sample survey; and sample vital registration system (SVRS). Results For Bangladesh, PRMR from the 2011 census falls closely in line with the 2010 household survey and SVRS estimates, while SVRS’ MMR estimates are closer to the PRMR estimates obtained from the household survey. Mozambique's PRMR from household survey method is comparable and shows an upward trend between 1994 and 2011, whereas the post-census mortality survey estimated a higher MMR for 2007. Bolivia's DHS and post-census mortality survey also estimated comparable MMR during 1998–2003. Conclusions Overall all these data sources presented in this paper have provided valuable information on maternal mortality in Bangladesh, Mozambique, and Bolivia. It also outlines recommendations to estimate maternal mortality based on the advantages and disadvantages of several approaches. Contribution Recommendations in this paper can help health administrators and policy planners in prioritizing investment for collecting reliable and contemporaneous estimates of maternal mortality while progressing toward a complete civil registration system. Supplementary Information The online version contains supplementary material available at 10.1186/s12963-022-00281-8.
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Affiliation(s)
- Kavita Singh
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Qingfeng Li
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Karar Zunaid Ahsan
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sian Curtis
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William Weiss
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.,Public Health Institute, Oakland, CA, USA
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3
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Berrueta M, Ciapponi A, Bardach A, Cairoli FR, Castellano FJ, Xiong X, Stergachis A, Zaraa S, Meulen AST, Buekens P. Maternal and neonatal data collection systems in low- and middle-income countries for maternal vaccines active safety surveillance systems: A scoping review. BMC Pregnancy Childbirth 2021; 21:217. [PMID: 33731029 PMCID: PMC7968860 DOI: 10.1186/s12884-021-03686-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Most post-licensure vaccine pharmacovigilance in low- and middle-income countries (LMICs) are passive reporting systems. These have limited utility for maternal immunization pharmacovigilance in LMIC settings and need to be supplemented with active surveillance. Our study's main objective was to identify existing perinatal data collection systems in LMICs that collect individual information on maternal and neonatal health outcomes and could be developed to inform active safety surveillance of novel vaccines for use during pregnancy. METHODS A scoping review was performed following the Arksey and O'Malley six-stage approach. We included studies describing electronic or mixed paper-electronic data collection systems in LMICs, including research networks, electronic medical records, and custom software platforms for health information systems. Medline PubMed, EMBASE, Global Health, Cochrane Library, LILACS, Bibliography of Asian Studies (BAS), and CINAHL were searched through August 2019. We also searched grey literature including through Google and websites of existing relevant perinatal data collection systems, as well as contacted authors of key studies and experts in the field to validate the information and identify additional sources of relevant unpublished information. RESULTS A total of 11,817 records were identified. The full texts of 264 records describing 96 data collection systems were assessed for eligibility. Eight perinatal data collection systems met our inclusion criteria: Global Network's Maternal Newborn Health Registry, International Network for the Demographic Evaluation of Populations and their Health; Perinatal Informatic System; Pregnancy Exposure Registry & Birth Defects Surveillance; SmartCare; Open Medical Record System; Open Smart Register Platform and District Health Information Software 2. These selected systems were qualitatively characterized according to seven different domains: governance; system design; system management; data management; data sources, outcomes and data quality. CONCLUSION This review provides a list of active maternal and neonatal data collection systems in LMICs and their characteristics as well as their outreach, strengths, and limitations. Findings could potentially help further understand where to obtain population-based high-quality information on outcomes to inform the conduct of maternal immunization active vaccine safety surveillance activities and research in LMICs.
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Affiliation(s)
- Mabel Berrueta
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina.
| | - Agustin Ciapponi
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina
| | - Ariel Bardach
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina
| | - Federico Rodriguez Cairoli
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina
| | - Fabricio J Castellano
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina
| | - Xu Xiong
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, 70112, USA
| | | | - Sabra Zaraa
- University of Washington, Seattle, WA, 98195-7631, USA
| | | | - Pierre Buekens
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, 70112, USA
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Paul RC, Gidding HF, Nazneen A, Banik KC, Sumon SA, Paul KK, Luby SP, Gurley ES, Hayen A. A Low-Cost, Community Knowledge Approach to Estimate Maternal and Jaundice-Associated Mortality in Rural Bangladesh. Am J Trop Med Hyg 2019; 99:1633-1638. [PMID: 30298803 DOI: 10.4269/ajtmh.17-0974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In the absence of a civil registration system, a house-to-house survey is often used to estimate cause-specific mortality in low- and middle-income countries. However, house-to-house surveys are resource and time intensive. We applied a low-cost community knowledge approach to identify maternal deaths from any cause and jaundice-associated deaths among persons aged ≥ 14 years, and stillbirths and neonatal deaths in mothers with jaundice during pregnancy in five rural communities in Bangladesh. We estimated the method's sensitivity and cost savings compared with a house-to-house survey. In the five communities with a total of 125,570 population, we identified 13 maternal deaths, 60 deaths among persons aged ≥ 14 years associated with jaundice, five neonatal deaths, and four stillbirths born to a mother with jaundice during pregnancy over the 3-year period before the survey using the community knowledge approach. The sensitivity of community knowledge method in identifying target deaths ranged from 80% for neonatal deaths to 100% for stillbirths and maternal deaths. The community knowledge approach required 36% of the staff time to undertake compared with the house-to-house survey. The community knowledge approach was less expensive but highly sensitive in identifying maternal and jaundice-associated mortality, as well as all-cause adult mortality in rural settings in Bangladesh. This method can be applied in rural settings of other low- and middle-income countries and, in conjunction with hospital-based hepatitis diagnoses, used to monitor the impact of programs to reduce the burden of cause-specific hepatitis mortality, a current World Health Organization priority.
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Affiliation(s)
- Repon C Paul
- School of Public Health and Community Medicine, UNSW Medicine, Sydney, Australia.,International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Heather F Gidding
- School of Public Health and Community Medicine, UNSW Medicine, Sydney, Australia
| | - Arifa Nazneen
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Kajal C Banik
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shariful A Sumon
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Kishor K Paul
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Stephen P Luby
- Infectious Diseases and Geographic Medicine, Stanford University, Stanford, California
| | - Emily S Gurley
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Andrew Hayen
- Australian Centre for Public and Population Health, Research, University of Technology Sydney, Sydney, Australia
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5
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Alam N, Ali T, Razzaque A, Rahman M, Zahirul Haq M, Saha SK, Ahmed A, Sarder AM, Moinuddin Haider M, Yunus M, Nahar Q, Kim Streatfield P. Health and Demographic Surveillance System (HDSS) in Matlab, Bangladesh. Int J Epidemiol 2018. [PMID: 28637343 DOI: 10.1093/ije/dyx076] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nurul Alam
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - Taslim Ali
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - Abdur Razzaque
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - Mahfuzur Rahman
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - M Zahirul Haq
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - Sajal K Saha
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - Ali Ahmed
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - A M Sarder
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - M Moinuddin Haider
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - Mohammad Yunus
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - Quamrun Nahar
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
| | - Peter Kim Streatfield
- Initiative for Climate Change and Health (ICCH)-icddr,b, Matlab HDSS, Dhaka, Bangladesh
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Odimegwu C, Chisumpa VH, Somefun OD. Adult mortality in sub-Saharan Africa using 2001-2009 census data: does estimation method matter? GENUS 2018; 74:10. [PMID: 30147126 PMCID: PMC6097801 DOI: 10.1186/s41118-017-0025-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/24/2017] [Indexed: 11/25/2022] Open
Abstract
Adult mortality is an important development and public health issue that continues to attract the attention of demographers and public health researchers. Controversies exist about the accurate level of adult mortality in sub-Saharan Africa (SSA), due to different data sources and errors in data collection. To address this shortcoming, methods have been developed to accurately estimate levels of adult mortality. Using three different methods (orphanhood, widowhood, and siblinghood) of indirect estimation and the direct siblinghood method of adult mortality, we examined the levels of adult mortality in 10 countries in SSA using 2001–2009 census and survey data. Results from the different methods vary. Estimates from the orphanhood data show that adult mortality rates for males are in decline in South Africa and West African countries, whilst there is an increase in adult mortality in the East African countries, for the period examined. The widowhood estimates were the lowest and reveal a marked increase in female adult mortality rates compared to male. A notable difference was observed in adult mortality estimates derived from the direct and indirect siblinghood methods. The method of estimation, therefore, matters in establishing the level of adult mortality in SSA.
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Affiliation(s)
- Clifford Odimegwu
- Demography and Population Studies, School of Public Health and Social Sciences Faculty of Humanities, University of the Witwatersrand, Johannesburg, 2000 South Africa
| | - Vesper H Chisumpa
- Demography and Population Studies, School of Public Health and Social Sciences Faculty of Humanities, University of the Witwatersrand, Johannesburg, 2000 South Africa
| | - Oluwaseyi Dolapo Somefun
- Demography and Population Studies, School of Public Health and Social Sciences Faculty of Humanities, University of the Witwatersrand, Johannesburg, 2000 South Africa
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Anwar J, Torvaldsen S, Sheikh M, Taylor R. Under-estimation of maternal and perinatal mortality revealed by an enhanced surveillance system: enumerating all births and deaths in Pakistan. BMC Public Health 2018; 18:428. [PMID: 29609571 PMCID: PMC5880001 DOI: 10.1186/s12889-018-5363-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/22/2018] [Indexed: 11/10/2022] Open
Abstract
Background Reliable and timely data on maternal and neonatal mortality is required to implement health interventions, monitor progress, and evaluate health programs at national and sub-national levels. In most South Asian countries, including Pakistan, vital civil registration and health information systems are inadequate. The aim of this study is to determine accurate maternal and perinatal mortality through enhanced surveillance of births and deaths, compared with prior routinely collected data. Methods An enhanced surveillance system was established that measured maternal, perinatal and neonatal mortality rates through more complete enumeration of births and deaths in a rural district of Pakistan. Data were collected over a period of 1 year (2015/16) from augmentation of the existing health information system covering public healthcare facilities (n = 19), and the community through 273 existing Lady Health Workers; and with the addition of private healthcare facilities (n = 10), and 73 additional Community Health Workers to cover a total study population of 368,454 consisting of 51,690 eligible women aged 18 to 49 years with 7580 pregnancies and 7273 live births over 1 year. Maternal, neonatal, perinatal and stillbirth rates and ratios were calculated, with comparisons to routine reporting from the previous period (2014–15). Results Higher maternal mortality, perinatal mortality and neonatal mortality rates were observed through enhanced surveillance compared to mortality rates in the previous 1.5 years from the routine monitoring system from increased completeness and coverage. Maternal mortality was 247 compared to 180 per 100, 000 live births (p = 0.36), neonatal mortality 40 compared to 20 per 1, 000 live births (p < 0.001), and perinatal mortality 60 compared to 47 per 1000 live births (p < 0.001). All the mortality rates were higher than provincial and national estimates proffered by international agencies based on successive Pakistan Demographic and Health Surveys and projections. Conclusion Extension of coverage and improvement in completeness through reconciliation of data from health information systems is possible and required to obtain accurate maternal, perinatal and neonatal mortality for assessment of health service interventions at a local level.
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Affiliation(s)
- Jasim Anwar
- School of Public Health and Community Medicine, the University of New South Wales, Sydney, Australia. .,Department of Community Medicine, Women Medical and Dental College, Abbottabad, Pakistan.
| | - Siranda Torvaldsen
- School of Public Health and Community Medicine, the University of New South Wales, Sydney, Australia.,Clinical and Population Perinatal Health Research, Kolling Institute, Sydney Medical School Northern, the University of Sydney, Sydney, New South Wales, Australia
| | - Mohamud Sheikh
- School of Public Health and Community Medicine, the University of New South Wales, Sydney, Australia
| | - Richard Taylor
- School of Public Health and Community Medicine, the University of New South Wales, Sydney, Australia
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Tessema GA, Laurence CO, Melaku YA, Misganaw A, Woldie SA, Hiruye A, Amare AT, Lakew Y, Zeleke BM, Deribew A. Trends and causes of maternal mortality in Ethiopia during 1990-2013: findings from the Global Burden of Diseases study 2013. BMC Public Health 2017; 17:160. [PMID: 28152987 PMCID: PMC5290608 DOI: 10.1186/s12889-017-4071-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 01/24/2017] [Indexed: 01/04/2023] Open
Abstract
Background Maternal mortality is noticeably high in sub-Saharan African countries including Ethiopia. Continuous nationwide systematic evaluation and assessment of the problem helps to design appropriate policy and strategy in Ethiopia. This study aimed to investigate the trends and causes of maternal mortality in Ethiopia between 1990 and 2013. Methods We used the Global Burden of Diseases and Risk factors (GBD) Study 2013 data that was collected from multiple sources at national and subnational levels. Spatio-temporal Gaussian Process Regression (ST-GPR) was applied to generate best estimates of maternal mortality with 95% Uncertainty Intervals (UI). Causes of death were measured using Cause of Death Ensemble modelling (CODEm). The modified UNAIDS EPP/SPECTRUM suite model was used to estimate HIV related maternal deaths. Results In Ethiopia, a total of 16,740 (95% UI: 14,197, 19,271) maternal deaths occurred in 1990 whereas there were 15,234 (95% UI: 11,378, 19,871) maternal deaths occurred in 2013. This finding shows that Maternal Mortality Ratio (MMR) in Ethiopia was still high in the study period. There was a minimal but insignificant change of MMR over the last 23 years. The results revealed Ethiopia is below the target of Millennium Development Goals (MGDs) related to MMR. The top five causes of maternal mortality in 2013 were other direct maternal causes such as complications of anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy (25.7%), complications of abortions (19.6%), maternal haemorrhage (12.2%), hypertensive disorders (10.3%), and maternal sepsis and other maternal infections such as influenza, malaria, tuberculosis, and hepatitis (9.6%). Most of the maternal mortality happened during the postpartum period and majority of the deaths occurred at the age group of 20–29 years. Overall trend showed that there was a decline from 708 per 100,000 live births in 1990 to 497 per 100,000 in 2013. The annual rate of change over these years was -1.6 (95% UI: -2.8 to -0.3). Conclusion The findings of the study highlight the need for comprehensive efforts using multisectoral collaborations from stakeholders for reducing maternal mortality in Ethiopia. It is worthwhile for policies to focus on postpartum period.
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Affiliation(s)
- Gizachew Assefa Tessema
- Institute of Public Health, University of Gondar, Gondar, Ethiopia. .,School of Public Health, The University of Adelaide, Adelaide, Australia.
| | | | - Yohannes Adama Melaku
- Population Research and Outcome Studies, School of Medicine, The University of Adelaide, Adelaide, Australia.,School of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Awoke Misganaw
- Institute of Health Metrics and Evaluation, University of Washington, Seattle, USA
| | - Sintayehu A Woldie
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Abiye Hiruye
- Maternal and Child Health Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Azmeraw T Amare
- School of Medicine, The University of Adelaide, Adelaide, Australia.,College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.,Department of Epidemiology, University of Groningen, Groningen, The Netherlands
| | - Yihunie Lakew
- Ethiopian Public Health Association, Addis Ababa, Ethiopia
| | - Berihun M Zeleke
- Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Amare Deribew
- Population KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,St. Paul Millennium Medical College, Addis Ababa, Ethiopia
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