maternal mortality in ethiopia

Maternal Mortality Maternal Mortality Trend in EthiopiaTrend in Ethiopia

Ahmed AbdellaAhmed AbdellaMD, 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 term 14% of pregnancies suffer serious or long term complications from pregnancycomplications from pregnancy--related health related 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 and The poor health and nutrition of women and the lack of care also compromise the health the lack of care also compromise the health and survival of the infants and children they and 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 disability The 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 to during, 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 cultural The factors are a range of social, economic, and cultural

factors include education, low social status, and lack of factors 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--Saharan Saharan Africa and Asia, making maternal mortality the health statistic Africa and Asia, making maternal mortality the health statistic with the largest discrepancy between developed and with 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 that enhancing process of procreation that could be prevented if adequate care were could be prevented if adequate care were available.available.

�� Maternal death is an indicator of disparity and Maternal death is an indicator of disparity and inequity between men and women and its inequity between men and women and its extent is a sign of womenextent is a sign of women’’ s place in society s place in society and their access to social, health, and nutrition and 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 if Analysis 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 GMH Review of maternal deaths at TAH and GMH from 2007from 2007--2009 (unpublished)2009 (unpublished)


Maternal mortality and morbidity in Maternal 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

MM

R p

er 1

00,0

00 L

B

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

MM

R p

er 1

00,0

00 L

B

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 are Major 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 infectious Appearance of HIV and disappearance of infectious

hepatitis in recent yearshepatitis in recent years


Trends in Proportion of 5 Major Causes of Direct Ma ternal Deaths (Hospital Data)

0.0

10.0

20.0

30.0

40.0

50.0

60.0

1982 1983 1991 2001 2003 2008

Years

% o

f all

Mat

erna

l D

eath

s

Abortion sepsis Rubtured uterus & OL

Hemorrhage Eclampsia & SPE


AbortionAbortion

�� Proportion of Maternal death due to abortion shows a Proportion 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 MD 50% 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 safe Public hospitals mainly provide PAC and little safe

abortion abortion


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% to Prevalence of eclampsia: 1.2% to 7.1%7.1%�� In most studies about 3%In most studies about 3%

�� CFR of eclampsia generally shows an CFR of eclampsia generally shows an increasing trend. increasing trend.


Case Fatality Rate 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

% C

FR

Abortion Ruptured uterus Eclampsia/SPE


Ruptured UterusRuptured Uterus

�� No trend change in proportion of deaths due No 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 ruptured Underreporting 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 most Infection 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 last For example, among 24 maternal deaths in the last

2 years at TAH, 12 (50%) of them had infection 2 years at TAH, 12 (50%) of them had infection complications such as pneumonia, postpartum complications such as pneumonia, postpartum PID, HIV, TB.PID, HIV, TB.


Hepatitis, HIV, MalariaHepatitis, HIV, MalariaCauses of Maternal Deaths in Hospitals

0.0

10.0

20.0

30.0

40.0

50.0

1982 1983 1991 2001 2003 2008

Years

% o

f al

l Mat

ern

al D

eath

s

Abortion Sepsis Ruptured uterus/OLHemorrhge Eclampsia-PE Other Direct OCHepatitis Other Indirec OC MalariaHIV 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

% o

f all

Mat

ern

al d

eath

sAbortion SepsisRuptured U & Obstructed L. Hemorrhageeclampsia & PE Other DOHepatitis Other IDOMalaria 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 & Inadequate Lack of information & Inadequate

knowledge about danger signals during knowledge about danger signals during pregnancy and laborpregnancy and labor

�� Cultural/ traditional practices that restrict Cultural/ 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 with Average 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 deaths Tigray community study: 80% of the maternal deaths took place at hometook place at home�� Obstacles in more than 50% of the deaths was Obstacles in more than 50% of the deaths was ““ Poor health Poor 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 be Though 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 by fourth 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 is Availing 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 statistics The distance factor and access issue in hospital statistics

may lead to underestimationmay lead to underestimation�� Earlier studies showed that Earlier studies showed that ““ secondary school and out of secondary 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 age e

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 access Recognize 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 progress Measure progress

�� Maternal death review to understand the slippery road of maternaMaternal death review to understand the slippery road of maternal l 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 requires Reducing 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, and in 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 requires Addressing the causes of maternal mortality requires a wella well--functioning health system that encompasses all functioning health system that encompasses all levels levels –– from the community to referral facilities from the community to referral facilities ––and provides accessible good quality care.and provides accessible good quality care.

�� Adequate supplies, skilled personnel, and an effective Adequate supplies, skilled personnel, and an effective system for referral and transport are particularly system for referral and transport are particularly important for managing obstetric emergencies, which important for managing obstetric emergencies, which can arise suddenly and without warning. Efforts can arise suddenly and without warning. Efforts addressing underlying factors are also important to addressing underlying factors are also important to improve maternal health in the long term.improve maternal health in the long term.

maternal mortality in ethiopia

Health & Medicine

gmhreview of maternal

problem global maternal

year review of maternal

problem contmagnitude

s health

health statisticafrica

unclassified deaths

indirect causes of deaths