Maternal MortalityMaternal Mortality
Trend in EthiopiaTrend in Ethiopia
Ahmed AbdellaAhmed Abdella
MD, MSc (PHDC)MD, MSc (...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 22
Magnitude of the proble...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 33
Magnitude of the proble...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 44
Underlying factorsUnder...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 55
The tragedyThe tragedy
...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 66
Data sourcesData source...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 77
Maternal mortality and ...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 88
Data source: 4 10 12 13...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 99
Trend of Maternal Morta...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1010
Causes of maternal de...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1111
Trends in Proportion ...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1212
AbortionAbortion
Prop...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1313
EclampsiaEclampsia--p...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1414
Case FatalityRate of ...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1515
Ruptured UterusRuptur...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1616
HemorrhageHemorrhage
...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1717
SepsisSepsis
Proporti...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1818
Hepatitis, HIV, Malar...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1919
Factors Affecting Use...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2020
Example: Effect of Di...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2121
Examples: Effect of D...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2222
ConclusionsConclusion...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2323
Conclusions & Recomme...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2424
Recommendation (cont)...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2525
Recommendations (cont...
12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2626
Recommendations (cont...
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Maternal mortality in ethiopia

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Maternal mortality in ethiopia

  1. 1. 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
  2. 2. 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
  3. 3. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 33 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
  4. 4. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 44 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.
  5. 5. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 55 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.
  6. 6. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 66 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)
  7. 7. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 77 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
  8. 8. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 88 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
  9. 9. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 99 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
  10. 10. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1010 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
  11. 11. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1111 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
  12. 12. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1212 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
  13. 13. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1313 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.
  14. 14. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1414 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
  15. 15. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1515 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%
  16. 16. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1616 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).
  17. 17. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1717 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.
  18. 18. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1818 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
  19. 19. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 1919 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
  20. 20. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2020 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
  21. 21. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2121 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
  22. 22. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2222 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
  23. 23. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2323 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
  24. 24. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2424 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.
  25. 25. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2525 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.
  26. 26. 12 May 200912 May 2009 Maternal Mortality Trend in EthiopiaMaternal Mortality Trend in Ethiopia 2626 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.
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