Maternal mortality in ethiopia

Maternal MortalityMaternal Mortality
Trend in EthiopiaTrend in Ethiopia
Ahmed AbdellaAhmed Abdella
MD, MSc (PHDC)MD, MSc (PHDC)
Obstetrics & Gynecology DepartmentObstetrics & Gynecology Department
Addis Ababa UniversityAddis Ababa University

12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 22
Magnitude of the problemMagnitude of the problemMagnitude of the problemMagnitude of the problemMagnitude of the problemMagnitude of the problemMagnitude of the problemMagnitude of the problem
• Global Maternal Deaths: 585,000
• In Africa five direct obstetric cause
account for 60.7% of MD:
• Hemorrhage
• Infection
• Unsafe abortion
• Hypertensive disorders of
pregnancy
• Obstructed labor
• Most of the direct causes of MD
are unpredictable and occur intra-
partum & in early postpartum.
Causes of maternal death in Africa Percentage
Haemorrhage 33.9
Other indirect
causes of deaths
16.7
Sepsis 9.7
Hypertensive
disorders
9.1
HIV/AIDS 6.2
Unclassified
deaths
5.4
Other direct
causes of deaths
4.9
Obstructed labour 4.1
Abortion 3.9
Anaemia 3.7
Embolism 2.0
Ectopic pregnancy 0.5

Magnitude of the problem (cont)Magnitude of the problem (cont)Magnitude of the problem (cont)Magnitude of the problem (cont)Magnitude of the problem (cont)Magnitude of the problem (cont)Magnitude of the problem (cont)Magnitude of the problem (cont)
14% of pregnancies suffer serious or long term14% of pregnancies suffer serious or long term
complications from pregnancycomplications from pregnancy--related healthrelated health
problems and disabilities including anemia,problems and disabilities including anemia,
uterine prolapse, fistula, PID, and infertility.uterine prolapse, fistula, PID, and infertility.
The poor health and nutrition of women andThe poor health and nutrition of women and
the lack of care also compromise the healththe lack of care also compromise the health
and survival of the infants and children theyand survival of the infants and children they
leave behindleave behind

Underlying factorsUnderlying factorsUnderlying factorsUnderlying factorsUnderlying factorsUnderlying factorsUnderlying factorsUnderlying factors
The underlying factors of maternal deaths and disabilityThe underlying factors of maternal deaths and disability
contribute to womencontribute to women’’s health and nutritional problems before,s health and nutritional problems before,
during, and after pregnancy, and are integrally linked toduring, and after pregnancy, and are integrally linked to
womenwomen’’s low utilization of available health services.s low utilization of available health services.
The factors are a range of social, economic, and culturalThe factors are a range of social, economic, and cultural
factors include education, low social status, and lack offactors include education, low social status, and lack of
income and employment opportunities.income and employment opportunities.
Almost 90% of the maternal deaths occur in subAlmost 90% of the maternal deaths occur in sub--SaharanSaharan
Africa and Asia, making maternal mortality the health statisticAfrica and Asia, making maternal mortality the health statistic
with the largest discrepancy between developed andwith the largest discrepancy between developed and
developing countries.developing countries.
Risk of MD:Risk of MD:
North Europe: 1:4,000North Europe: 1:4,000
Africa 1:16.Africa 1:16.

The tragedyThe tragedy
Most of these women die during the normal,Most of these women die during the normal,
lifelife--enhancing process of procreation thatenhancing process of procreation that
could be prevented if adequate care werecould be prevented if adequate care were
available.available.
Maternal death is an indicator of disparity andMaternal death is an indicator of disparity and
inequity between men and women and itsinequity between men and women and its
extent is a sign of womenextent is a sign of women’’s place in societys place in society
and their access to social, health, and nutritionand their access to social, health, and nutrition
services and to economic opportunities.services and to economic opportunities.

Data sourcesData sources
Review of published and unpublishedReview of published and unpublished
Analysis of data to generate required proportion ifAnalysis of data to generate required proportion if
available such as case fatalityavailable such as case fatality
Note: Use of total deliveries Vs live birthsNote: Use of total deliveries Vs live births
MidMid--year use if a study covers more than one yearyear use if a study covers more than one year
Review of maternal deaths at TAH and GMHReview of maternal deaths at TAH and GMH
from 2007from 2007--2009 (unpublished)2009 (unpublished)

Maternal mortality and morbidity inMaternal mortality and morbidity in
EthiopiaEthiopia
Maternal Deaths: 25 000/ yearMaternal Deaths: 25 000/ year
Maternal Morbidity: 500, 000/ yearMaternal Morbidity: 500, 000/ year
Serious complications such as fistula, infertility,Serious complications such as fistula, infertility,
chronic painchronic pain

Data source: 4 10 12 13 16 26 27 28 31
MMR Trend in 'Community' Studies
0
500
1000
1500
2000
1980 1985 1990 1995 2000 2005 2010
Years
MMRper100,000LB
DHS00 DHS05

Trend of Maternal Mortality Ratio in Hospitals
0
500
1000
1500
2000
2500
3000
1970 1975 1980 1985 1990 1995 2000 2005 2010
Years
MMRper100,000LB
Data sources: 2 3 6 9 10 18 22 25 32 33

Causes of maternal deaths in EthiopiaCauses of maternal deaths in Ethiopia
Major causes of maternal deaths in Ethiopia areMajor causes of maternal deaths in Ethiopia are
similar to most developing countries:similar to most developing countries:
infection,infection,
hemorrhage,hemorrhage,
obstructed labor,obstructed labor,
AbortionAbortion
Hypertensive disease in pregnancyHypertensive disease in pregnancy
Two major changes noted:Two major changes noted:
Proportions of MD ascribed to major direct obstetric causesProportions of MD ascribed to major direct obstetric causes
Appearance of HIV and disappearance of infectiousAppearance of HIV and disappearance of infectious
hepatitis in recent yearshepatitis in recent years

Trends in Proportion of 5 Major Causes of Direct Maternal Deaths
(Hospital Data)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
1982 1983 1991 2001 2003 2008
Years
%ofallMaternal
Deaths
Abortion sepsis Rubtured uterus & OL
Hemorrhage Eclampsia & SPE

AbortionAbortion
Proportion of Maternal death due to abortion shows aProportion of Maternal death due to abortion shows a
declining trenddeclining trend
Earlier hospital and community studies: 20Earlier hospital and community studies: 20--50% of all MD50% of all MD
deathsdeaths
TAH & GMH:TAH & GMH:
20072007--2009: 3 abortion deaths among 42 MD deaths (7%)2009: 3 abortion deaths among 42 MD deaths (7%)
19811981--82: 37 abortion deaths (26.6%)82: 37 abortion deaths (26.6%)
Jimma Hospital:Jimma Hospital:
1980s: 40% of all the maternal death1980s: 40% of all the maternal death
1990s: 26.8%1990s: 26.8%
Case fatality rate of abortion ranges between 0.9 to 1.9%Case fatality rate of abortion ranges between 0.9 to 1.9%
Exceptional high from TAH of 4.9%Exceptional high from TAH of 4.9%
Public hospitals mainly provide PAC and little safePublic hospitals mainly provide PAC and little safe
abortionabortion

EclampsiaEclampsia--preeclampsiapreeclampsia
Trend of proportion of eclampsia/Trend of proportion of eclampsia/
preeclampsia related deaths is increasingpreeclampsia related deaths is increasing
TAH & GMH:TAH & GMH:
20072007--2009: 15 eclampsia2009: 15 eclampsia--SPE deaths (35.7%)SPE deaths (35.7%)
19811981--1983: 9 deaths (6.5%)1983: 9 deaths (6.5%)
Prevalence of eclampsia: 1.2% toPrevalence of eclampsia: 1.2% to 7.1%7.1%
In most studies about 3%In most studies about 3%
CFR of eclampsia generally shows anCFR of eclampsia generally shows an
increasing trend.increasing trend.

Case FatalityRate of Abortion, Ruptured Uterus and Eclampsia/SPE
0
10
20
30
40
1968
1976
1990
1990
1991
1991
1995
1997
1998
1998
2000
2001
2002
Years
%CFR
Abortion Ruptured uterus Eclampsia/SPE

Ruptured UterusRuptured Uterus
No trend change in proportion of deaths dueNo trend change in proportion of deaths due
to uterine rupture/ obstructed labor (10to uterine rupture/ obstructed labor (10--34%)34%)
High than some African reports (4.1%)High than some African reports (4.1%)
Underreporting due to classification of rupturedUnderreporting due to classification of ruptured
uterusuterus--obstructed labor to hemorrhage or sepsisobstructed labor to hemorrhage or sepsis
Case fatality rate: increasing trendCase fatality rate: increasing trend
From 3 to14%From 3 to14%
Similar to findings in Africa 1Similar to findings in Africa 1––13%13%

HemorrhageHemorrhage
Increasing trend in the proportion:Increasing trend in the proportion:
From less than 10% to 17% (Ambo H) and 21%From less than 10% to 17% (Ambo H) and 21%
(TAH/GMH).(TAH/GMH).

SepsisSepsis
Proportion: slight declineProportion: slight decline
Infection complications are common in mostInfection complications are common in most
of the MD classified under other causes:of the MD classified under other causes:
For example, among 24 maternal deaths in the lastFor example, among 24 maternal deaths in the last
2 years at TAH, 12 (50%) of them had infection2 years at TAH, 12 (50%) of them had infection
complications such as pneumonia, postpartumcomplications such as pneumonia, postpartum
PID, HIV, TB.PID, HIV, TB.

Hepatitis, HIV, MalariaHepatitis, HIV, Malaria
Causes ofMaternalDeaths inHospitals
0.0
10.0
20.0
30.0
40.0
50.0
1982 1983 1991 2001 2003 2008
Years
%ofallMaternalDeaths
Abortion Sepsis Ruptured uterus/OL
Hemorrhge Eclampsia-PE Other Direct OC
Hepatitis OtherIndirec OC Malaria
HIV Accidental
Causes of MD in Regional & Community study
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
1982 2000
Years
%ofallMaternaldeaths
Abortion Sepsis
Ruptured U & Obstructed L. Hemorrhage
eclampsia & PE Other DO
Hepatitis Other IDO
Malaria HIV

Factors Affecting Use of Health FacilitiesFactors Affecting Use of Health Facilities
Economic status,Economic status,
Educational status,Educational status,
WomenWomen’’s status,s status,
Denial of pregnancy,Denial of pregnancy,
Cultural factors,Cultural factors,
Perception of illnessPerception of illness
DistanceDistance
RoadsRoads
TransportTransport
CostCost
Quality of careQuality of care
Delay I:Delay I:
Lack of information & InadequateLack of information & Inadequate
knowledge about danger signals duringknowledge about danger signals during
pregnancy and laborpregnancy and labor
Cultural/ traditional practices that restrictCultural/ traditional practices that restrict
women from seeking health carewomen from seeking health care
Lack of moneyLack of money
Delay II:Delay II:
Out of reach of health facilitiesOut of reach of health facilities
Poor road & communication networkPoor road & communication network
Poor community support mechanismsPoor community support mechanisms
Delay III:Delay III:
Inadequate skilled attendantsInadequate skilled attendants
Poorly motivated staffPoorly motivated staff
Inadequate equipment and suppliesInadequate equipment and supplies
Weak referral system, procedural guidesWeak referral system, procedural guides

Example: Effect of DistanceExample: Effect of Distance
Presentation in shock (TAH, 28 MD)Presentation in shock (TAH, 28 MD)
Addis Ababa: 0.0%Addis Ababa: 0.0%
Out of Addis Ababa: 70%Out of Addis Ababa: 70%
Case fatality rate of abortionCase fatality rate of abortion
Outside Jimma town: 3.6%Outside Jimma town: 3.6%
Jimma town: 1.2%Jimma town: 1.2%
Average duration of labor among women withAverage duration of labor among women with
(Adigrat Hospital):(Adigrat Hospital):
All ruptured uterus: 60 hours,All ruptured uterus: 60 hours,
Rupture uterus and died: 80 hoursRupture uterus and died: 80 hours

Examples: Effect of Distance (cont)Examples: Effect of Distance (cont)
Tigray community study: 80% of the maternal deathsTigray community study: 80% of the maternal deaths
took place at hometook place at home
Obstacles in more than 50% of the deaths wasObstacles in more than 50% of the deaths was ““Poor healthPoor health
seeking behaviorsseeking behaviors”” and lack of transportationand lack of transportation
MD from outside of AA:MD from outside of AA:
2/3 of abortion deaths2/3 of abortion deaths
75% of ruptured uterus75% of ruptured uterus
8% eclampsia8% eclampsia
29% Hemorrhage29% Hemorrhage

ConclusionsConclusions
Though the MMR in Ethiopia might beThough the MMR in Ethiopia might be
declining, the MMR is still high:declining, the MMR is still high:
To achieve a threeTo achieve a three--fourth decline in MMR byfourth decline in MMR by
2015, efforts has to be strengthen2015, efforts has to be strengthen

Conclusions & Recommendations:Conclusions & Recommendations:
Specific issuesSpecific issues
Proportion of MD due to eclampsia/ SPE: increasingProportion of MD due to eclampsia/ SPE: increasing
Availing magnesium sulfate for treatment of eclampsia isAvailing magnesium sulfate for treatment of eclampsia is
essentialessential
Proportion of MD due to abortion: decliningProportion of MD due to abortion: declining
The distance factor and access issue in hospital statisticsThe distance factor and access issue in hospital statistics
may lead to underestimationmay lead to underestimation
Earlier studies showed thatEarlier studies showed that ““secondary school and out ofsecondary school and out of
marriagemarriage”” were common reasons for unsafe abortion:were common reasons for unsafe abortion:
Expect increase with more girls going to secondary school and agExpect increase with more girls going to secondary school and agee
marriage raising to 18 yearsmarriage raising to 18 years
Strengthening adolescent RH intervention: delaying sexual debut,Strengthening adolescent RH intervention: delaying sexual debut,
FP, safe abortion services (legality permitted for <18 age)FP, safe abortion services (legality permitted for <18 age) ……
PPH: Misopristol use at community levelPPH: Misopristol use at community level

Recommendation (cont)Recommendation (cont)
Ensuring skilled birth attendance at deliveryEnsuring skilled birth attendance at delivery
Delaying marriage and first birthDelaying marriage and first birth
Prevention of unwanted pregnancy and unsafe abortionPrevention of unwanted pregnancy and unsafe abortion
Recognize that every pregnancy faces risk and improve accessRecognize that every pregnancy faces risk and improve access
to good quality maternal health servicesto good quality maternal health services
Addressing barriers to accessAddressing barriers to access
Measure progressMeasure progress
Maternal death review to understand the slippery road of maternaMaternal death review to understand the slippery road of maternall
death and to enhance quality of services: strong governmental sudeath and to enhance quality of services: strong governmental support.pport.

Recommendations (cont)Recommendations (cont)
Reducing maternal mortality requiresReducing maternal mortality requires
coordinated longcoordinated long--term efforts.term efforts.
Interventions are required:Interventions are required:
with families & communities,with families & communities,
in society as a whole,in society as a whole,
in health system, andin health system, and
at the level of national legislation & policy.at the level of national legislation & policy.

Recommendations (cont)Recommendations (cont)
Addressing the causes of maternal mortality requiresAddressing the causes of maternal mortality requires
a wella well--functioning health system that encompasses allfunctioning health system that encompasses all
levelslevels –– from the community to referral facilitiesfrom the community to referral facilities ––
and provides accessible good quality care.and provides accessible good quality care.
Adequate supplies, skilled personnel, and an effectiveAdequate supplies, skilled personnel, and an effective
system for referral and transport are particularlysystem for referral and transport are particularly
important for managing obstetric emergencies, whichimportant for managing obstetric emergencies, which
can arise suddenly and without warning. Effortscan arise suddenly and without warning. Efforts
addressing underlying factors are also important toaddressing underlying factors are also important to
improve maternal health in the long term.improve maternal health in the long term.

Maternal mortality in ethiopia

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