Assessment of maternal mortality in Tanzania

Maternal mortality in Ifakara Health and Demographic Surveillance System: Spatial patterns, trends and risk factors, 2006 - 2010

Introduction

Maternal mortality was the subject of the United Nations’ fifth Millennium Development Goal which was to reduce the maternal mortality ratio by three quarters from 1990 to 2015. The Sustainable Development Goals (SDGs), target 3.1 requires participating countries to reduce their maternal mortality ratio to less than 70 deaths per 100,000 live births by 2030. Although much research has been conducted, knowing the spatial patterns and risk factors associated with maternal mortality in developing countries helps target scarce resources and intervention programmes to high risk areas for the greatest impact.

Methods

Data were analysed from a longitudinal open cohort of women aged 15 to 49 years, enrolled from 2006 to 2010. An inverse distance weighted method of interpolation was used to assess spatial patterns of maternal mortality. Cox proportional hazards regression analysis was used to identify risk factors associated with maternal mortality.

Results

The overall maternal mortality rate for the 36 792 study participants for the five years was 0.79 per 1000 person years. The trend declined from 90.42 in 2006 to 57.42 in 2010. Marked geographical differences were observed in maternal mortality patterns. The main causes of maternal death were eclampsia (23%), haemorrhage (22%) and abortion-related complications (10%). There was a reduced risk of 82% (HR = 0.18, 95% CI:0.05–0.74) and 78% (HR = 0.22, 95% CI:0.05–0.92) for women aged 20–29 and 30–39 years, respectively, compared with those younger than 20 years. While being married had a protective effect of 94% (HR = 0.06, 95% CI: 0.01–0.51) compared with being single, women who were widowed had an increased risk of maternal death of 913% (HR = 9.13, 95% CI: 1.02–81.94). Women who belong to poorer, poor and least poor socioeconomic quintile had 84%, 71% and 72% reduction in risk of maternal mortality respectively compared to those in the poorest category (HR = 0.16, 95% CI: 0.06–0.42; HR = 0.29, 95% CI: 0.12–0.69; HR = 0.28, 95% CI: 0.10–0.80).

Conclusion

Maternal mortality has declined in rural southern Tanzania since 2006, with geographical differences in patterns of death. Eclampsia, haemorrhage and abortion-related complications are the three leading causes of maternal death in the region, with risk factors being younger than 20 years, being single or widowed, and having a low socioeconomic status.

Magnitude of maternal and neonatal mortality in Tanzania: A systematic review

BACKGROUND

Maternal and neonatal mortality remains a serious challenge in Tanzania. Progress is tracked through maternal mortality ratios (MMR) and neonatal mortality rates (NMR), yet robust national data on these outcomes is difficult and expensive to ascertain, and mask wide variation.

SEARCH STRATEGY

We searched EMBASE, MEDLINE, Popline, and EBSCO online databases, basing search terms on ("maternal" OR "neonatal") AND ("mortality" OR "cause of death") AND "Tanzania."

SELECTION CRITERIA

Nationally representative or population representative from the subnational context were eligible, providing NMR, MMR, or numbers of maternal deaths or early neonatal deaths or neonatal deaths and live births.

DATA COLLECTION AND ANALYSIS

Data were extracted on study context, time period, number of deaths and live births, definition of maternal and neonatal death, study design, and completeness and representativeness of data. NMR and MMR were extracted or calculated and study quality was assessed. Nationally representative data were compared with modelled national data from international agencies.

MAIN RESULTS

2107 records were screened yielding 21 maternal mortality and 15 neonatal mortality datasets. There were high mortality levels with wide subnational MMR and NMR variation. National survey data differed from the modelled estimates, with wide uncertainty ranges.

CONCLUSION

Subnational data quality was generally poor with no observable trends and geographical clustering across several regions. Combined MMR and NMR reporting is uncommon. Modelled national estimates lack precision and are complex to interpret. Results suggest that aggregate national data are inadequate for policy generation and progress monitoring. We recommend strengthening of vital registration and Health Management Information Systems with complementary use of process indicators, for improved monitoring of, and accountability for maternal and newborn health.

Impact of Place of Delivery on Neonatal Mortality in Rural Tanzania

OBJECTIVES

Studies on factors affecting neonatal mortality have rarely considered the impact of place of delivery on neonatal mortality. This study provides epidemiological information regarding the impact of place of delivery on neonatal deaths.

METHODS

We analyzed data from the Rufiji Health and Demographic Surveillance System (RHDSS) in Tanzania. A total of 5,124 live births and 166 neonatal deaths were recorded from January 2005 to December 2006. The place of delivery was categorized as either in a health facility or outside, and the neonatal mortality rate (NMR) was calculated as the number of neonatal deaths per 1,000 live births. Univariate and multivariate logistic regression models were used to assess the association between neonatal mortality and place of delivery and other maternal risk factors while adjusting for potential confounders.

RESULTS

Approximately 67% (111) of neonatal deaths occurred during the first week of life. There were more neonatal deaths among deliveries outside health facilities (NMR = 43.4 per 1,000 live births) than among deliveries within health facilities (NMR = 27.0 per 1,000 live births). The overall NMR was 32.4 per 1,000 live births. Mothers who delivered outside a health facility experienced 1.85 times higher odds of experiencing neonatal deaths (adjusted odds ratio = 1.85; 95% confidence interval = 1.33-2.58) than those who delivered in a health facility.

CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS

Place of delivery is a significant predictor of neonatal mortality. Pregnant women need to be encouraged to deliver at health facilities and this should be done by intensifying education on where to deliver. Infrastructure, such as emergency transport, to facilitate health facility deliveries also requires urgent attention.

Repetition of a sisterhood survey at district level in Malawi: the challenge to achieve MDG 5

Objective To evaluate progress made at district level in Malawi towards reaching the 5th Millennium Development Goal, the reduction of maternal mortality. Methods In 2006, community-based maternal mortality in Thyolo, Malawi was calculated by applying the 'sisterhood method', a survey that relies on participants responding to basic questions about maternal mortality in their families. Results were compared with a 1989 sisterhood study in the same district. Information on facility-based maternal mortality in 2005 was extracted from district hospital records. Results The community-based maternal mortality ratio (MMR) was calculated as 558 per 100 000 live births (95% CI 260 to 820). A comparison with the MMR from the 1989 survey (409 per 100 000 live births) shows that maternal mortality had not declined. The hospital-based MMR was 994 per 100 000 live births in 2005. Conclusion Maternal mortality in this district has not reduced and may actually have increased. The threat of failure to achieve Millennium Development Goal 5 increases the moral obligation to improve access to quality health care.

Use of A Clean Delivery Kit and Factors Associated with Cord Infection and Puerperal Sepsis in Mwanza, Tanzania

Our objective was to determine the effectiveness of an intervention that incorporated education about the "six cleans" with the use of a clean delivery kit in preventing cord infection and puerperal sepsis. A stepped-wedge, cross-sectional study was conducted in 10 surveillance sites across two rural districts of Mwanza Region, Tanzania. A total of 3262 pregnant women between the ages of 17 and 45 years were enrolled in the study. Village health workers administered questionnaires to each mother at 5 days postpartum and inspected the infants' umbilical cord stumps for signs of infection. Newborns whose mothers used the delivery kit were 13.1 times less likely to develop cord infection than infants whose mothers did not use the kit. Furthermore, women who used the kit for delivery were 3.2 times less likely to develop puerperal sepsis than women who did not use the kit. Women who bathed before delivery were 2.6 times less likely to develop puerperal sepsis than women who did not bathe, and their infants were 3.9 times less likely to develop cord infection. Single-use delivery kits, when combined with education about clean delivery, can have a positive impact on the health of women and their newborns by significantly decreasing the likelihood of developing puerperal sepsis or cord infection.

Achieving progress in maternal and neonatal health through integrated and comprehensive healthcare services - experiences from a programme in northern Tanzania

BACKGROUND

An integrated and comprehensive hospital/community based health programme is presented, aimed at reducing maternal and child mortality and morbidity. It is run as part of a general programme of health care at a rural hospital situated in northern Tanzania. The purpose was through using research and statistics from the programme area, to illustrate how a hospital-based programme with a vision of integrated healthcare may have contributed to the lower figures on mortality found in the area. Such an approach may be of interest to policy makers, in relation to the global strategy that is now developed in order to meet the MDGs 4 and 5.

PROGRAMME SETTING

The hospital provides reproductive and child health services, PMTCT-plus, comprehensive emergency obstetric care, ambulance, radio and transport services, paediatric care, an HIV/AIDS programme, and a generalised healthcare service to a population of approximately 500 000.

PROGRAMME DESCRIPTION AND OUTCOMES

We describe these services and their potential contribution to the reduction of the maternal and neonatal mortality ratios in the study area. Several studies from this area have showed a lower maternal mortality and neonatal mortality ratio compared to other studies from Tanzania and the national estimates. Many donor-funded programmes focusing on maternal and child health are vertical in their framework. However, the hospital, being the dominant supplier of health services in its catchment area, has maintained a horizontal approach through a comprehensive care programme. The total cost of the comprehensive hospital programme described is 3.2 million USD per year, corresponding to 6.4 USD per capita.

CONCLUSION

Considering the relatively low cost of a comprehensive hospital programme including outreach services and the lower mortality ratios found in the catchment area of the hospital, we argue that donor funds should be used for supporting horizontal programmes aimed at comprehensive healthcare services. Through a strengthening of the collaboration between government and voluntary agency facilities, with clinical, preventive and managerial capabilities of the health facilities, the programmes will have a more sustainable impact and will achieve greater progress in the reduction of maternal and neonatal mortality, as opposed to vertical and segregated programmes that currently are commonly adopted for averting maternal and child deaths. Thus, we conclude that horizontal and comprehensive services of the type described in this article should be considered as a prerequisite for sustainable health care delivery at all policy and decision-making levels of the local, national and international health care delivery pyramid.

Risk factors for maternal death in the highlands of rural northern Tanzania: a case-control study

Background

Tanzania has one of the highest maternal mortality ratios in sub-Saharan Africa. Due to the paucity of epidemiological information on maternal deaths, and the high maternal mortality estimates found earlier in the study area, our objective was to assess determinants of maternal deaths in a rural setting in the highlands of northern Tanzania by comparing the women dying of maternal causes with women from the same population who had attended antenatal clinics in the same time period.

Methods

A case-control study was done in two administrative divisions in Mbulu and Hanang districts in rural Tanzania. Forty-five cases of maternal death were found through a comprehensive community- and health-facility based study in 1995 and 1996, while 135 antenatal attendees from four antenatal clinics in the same population, geographical area, and time-span of 1995–96 served as controls. The cases and controls were compared using multivariate logistic regression analyses. Odds ratios, with 95% confidence intervals, were used as an approximation of relative risk, and were adjusted for place of residence (ward) and age. Further adjustment was done for potentially confounding variables.

Results

An increased risk of maternal deaths was found for women from 35–49 years versus 15–24 years (OR 4.0; 95%CI 1.5–10.6). Women from ethnic groups other than the two indigenous groups of the area had an increased risk of maternal death (OR 13.6; 95%CI 2.5–75.0). There was an increased risk when women or husbands adhered to traditional beliefs, (OR 2.1; 95%CI 1.0–4.5) and (OR 2.6; 95%CI 1.2–5.7), respectively. Women whose husbands did not have any formal education appeared to have an increased risk (OR 2.2; 95%CI 1.0–5.0).

Conclusion

Increasing maternal age, ethnic and religious affiliation, and low formal education of the husbands were associated with increased risk of maternal death. Increased attention needs to be given to formal education of both men and women. In addition, education of the male decision-makers should be given high priority in the community, especially in matters concerning pregnancy and delivery preparedness, since their choice greatly affects the survival of the pregnant and delivering women.

Shed some light on darkness: will Tanzania reach the millennium development goals?

The overall picture of health in sub-Saharan Africa can easily be painted in dark colours. The aim of this viewpoint is to discuss epidemiological data from Tanzania on overall health indicators and the burden of malaria and HIV. Is the situation in Tanzania improving or deteriorating? Are the health-related millennium development goals (MDG) on reducing under-five mortality, reducing maternal mortality and halting HIV and malaria within reach?

CONCLUSION

Child mortality and infant mortality rates are decreasing quite dramatically. Malaria prevention strategies and new effective treatment are being launched. The MDG 4 on child mortality is clearly within reach, and the same optimism may apply to MDG 6 on combating malaria.

Death by survey: Estimating adult mortality without selection bias from sibling survival data

The widely used methods for estimating adult mortality rates from sample survey responses about the survival of siblings, parents, spouses, and others depend crucially on an assumption that, as we demonstrate, does not hold in real data. We show that when this assumption is violated so that the mortality rate varies with sib ship size, mortality estimates can be massively biased. By using insights from work on the statistical analysis of selection bias, survey weighting, and extrapolation problems, we propose a new and relatively simple method of recovering the mortality rate with both greatly reduced potential for bias and increased clarity about the source of necessary assumptions.

Análisis de la ocurrencia de la Mortalidad Materna en la Provincia de Santa Fe - Argentina, a propósito de una intervención

INTRODUCCÍON: La Mortalidad Materna (MM) muestra diferencias en las condiciones de salud y de vida de las poblaciones, constituyéndose en un buen indicador socio-económico, así como de la cobertura y calidad de los servicios de atención a la mujer en edad fértil. Las estadísticas oficiales de salud no revelan la magnitud del problema de la MM debido al subregistro que posee esta causa de muerte. Dicha falencia se señala especialmente para los países subdesarrollados. Se estima que la República Argentina no escapa al fenómeno del subregistro. La provincia de Santa Fe en el año 1994 decidió incorporar a su Certificado de Defunción un ITEM específico para la causa Muerte Materna con el fin de corregir el subregistro. OBJETIVOS: El objetivo principal de este estudio fue evaluar los cambios que registró la Razón de Mortalidad Materna (RMM) en el período 1988-2001, como consecuencia de la introducción del "ITEM 33" referido a la Muerte Materna, en el Certificado de Defunción de la Provincia de Santa Fe a partir del año 1995. MATERIAL Y MÉTODOS: Se revisó la bibliografía respecto del subregistro de la MM. Se estudió la ocurrencia de la MM en la Provincia de Santa Fe en el período 1988-2001. Se analizaron los cambios producidos por la presencia del "ITEM 33" en el Certificado de Defunción de la Provincia de Santa fe en el período 1995-2001. RESULTADOS: Se observó un aumento en las cifras absolutas de MM y por ende de las razones de MM (41 %) en el período 1995-2001, a diferencia de la tendencia descendente de este indicador tanto a nivel nacional como a nivel provincial en el período anterior (pre "ITEM 33"). Se observó además, una modificación en la distribución de las muertes respecto a su incidencia en los grupos etáreos. Otro dato de interés es que se modificó la frecuencia de las patologías que originaron la muerte (causa de muerte) siendo el Aborto la causa más frecuente, a diferencia de los períodos anteriores donde aparecía la Hipertensión Arterial ocupando el primer lugar. CONCLUSIÓN: La introducción del "ITEM 33" en el Certificado de Defunción de la Provincia de Santa Fe produjo modificaciones importantes en los datos sobre MM. Estas modificaciones pueden ser atribuidas a la disminución del subregistro, ya que no se encuentran razones valederas para pensar en un aumento real en la ocurrencia de muertes maternas. Por lo cual se concluye que: este instrumento de recolección de datos permitiría corregir el subregistro y obtener datos de mayor calidad que, en consecuencia, posibiliten la implementación de políticas y programas de salud basados en datos que reflejen la verdadera situación sanitaria.

An evaluation of a community-based approach to safe motherhood in northwestern Tanzania

OBJECTIVES

We present an evaluation of the Community Capacity Building and Empowerment initiative, undertaken by the Community-Based Reproductive Health Project (CBRHP), designed to address high maternal morbidity and mortality.

METHODS

Qualitative data from group interviews and program data from CBRHP were used to assess progress in development and use of community level transport systems and support for the village health workers (VHWs).

RESULTS

Project activities increased community participation in maternal health. An increase was seen in knowledge of danger signs, birth planning, timely referrals, and transport of pregnant women to hospitals, as well as in support and retention of VHWs. More women with obstetrical problems are using the community-based transport system to get to hospitals.

CONCLUSIONS

Community participation and support for VHW activities and the transport systems have led to better care for pregnant women and sustained links between the communities and health facilities, which may reduce maternal and infant morbidity and mortality.

Trends in maternal mortality: a 13-year hospital-based study in rural Ghana

OBJECTIVE

To measure the impact of the Safe Motherhood Initiative (SMI) on hospital-based maternal mortality since its start in 1987.

STUDY DESIGN

Retrospective analysis of all 229 maternal deaths in a district hospital in rural Ghana, between 1 January 1987 and 1 January 2000. Main outcome measures were maternal mortality ratio and relative contribution of causes of maternal deaths to overall maternal mortality. Chi-square test was used to assess differences in proportions, and relative risks with confidence intervals were calculated.

RESULTS

The overall maternal mortality ratio of 1077/100,000 live births did not change significantly during the study period. However, the relative contributions of sepsis, hemorrhage, obstructed labor, anemia/sickle cell disease and (pre-) eclampsia diminished, while abortion complications increased significantly.

CONCLUSIONS

The Safe Motherhood Initiative in the study area has contributed to the reduction of maternal mortality due to causes against which interventions were directed. Abortion complications as cause of maternal mortality need to be included in interventions and research.

Maternal mortality in northern rural Tanzania: assessing the completeness of various information sources

BACKGROUND

To assess the completeness of various information sources and the subsequent estimates on maternal mortality.

METHODS

Maternal deaths in the study area, rural northern Tanzania, in 1995 were identified from hospital records, health centers and dispensaries, registration by village leaders, follow up of an antenatal cohort, and a household survey. Data from some of these sources were also obtained in 1996.

RESULTS

In 1995, 22 of a total of 26 maternal deaths were identified at the Haydom hospital. Three of the 15 deaths (20%) reported by the village leaders were not identified at any health facility. Four deaths were found in the antenatal cohort and one death in the household survey. Only two deaths were reported by the official statistics. Of the identified maternal deaths, 85% were found from health facility data. Including data from 1996, a total of 45 maternal deaths were identified; 13 of which were direct and 32 indirect obstetric deaths. The 1995 estimated maternal mortality ratio, based on reports from the multiple source registrations, was 382 (95% confidence interval 250-560) per 100 000 live births. The antenatal cohort yielded an estimate of 322 (95% confidence interval 160-580). The ratio based on official figures for 1995 and 1996 combined was 123 (95% confidence interval 70-200).

CONCLUSIONS

Even a high quality routine registration of maternal deaths will miss a small proportion of cases. Investing in better registration of direct and indirect obstetric deaths will give better insight into this important health problem. Estimates based on official reports showed substantial underreporting.

Deliveries at a district hospital in Rwanda, 1997-2000

OBJECTIVES

To obtain data on pregnancy outcomes and maternal mortality at a district hospital in Rwanda.

METHODS

All delivery records from January 1997 to December 2000 were reviewed.

RESULTS

Over the 4-year period, 3408 women delivered a total of 3497 neonates, and 349 stillbirths (10%) occurred. The mean birthweight (twins excluded) was 3097 g and decreased significantly from 3160 g in 1997 to 3043 g in 2000. The prevalence of low birthweight was 12.5%. The mean age of women was 26.2 years. Cesarean section was done in 26% of deliveries at the hospital, equaling a cesarean section rate of 1.1% in the population. Nineteen maternal deaths occurred, yielding a (hospital) maternal mortality rate of 600 per 100000 live births. Uterine rupture occurred in 52 women, of whom six died (11.5%).

CONCLUSIONS

Efforts to educate women at risk to deliver at a health center, and early referral of women to the hospital should be reinforced. The reduction of mean birthweight is of concern and reasons for this need to be analyzed.

Maternal mortality in rural India: a hospital based, 10 year retrospective analysis

OBJECTIVES

To estimate the maternal mortality ratio (MMR) in Ludhiana, a city of Northern India in order to determine the causes associated with MMR and to suggest ways to reduce it.

METHODS

Retrospective analysis of the mortality records of obstetrics cases in Christian Medical College, Ludhiana, India.

RESULTS

The mean MMR for the 10 year period was 785 per 100,000 live births. Of the total 116 reported maternal deaths, 44 (41.9%) were due to induced septic abortion. The reasons were unwanted pregnancy in 22 (50%) and 11 (25%) were female feticide.

CONCLUSIONS

In our hospital based analysis, MMR was very high. Most maternal deaths are preventable by intervention at the appropriate time and it is important for health professionals, policy makers and politicians to implement the introduction of programs for reducing maternal mortality. Special emphasis should be placed on antenatal care, the establishment of a registration system and measures to abolish illegal abortion.

Estimates of maternal mortality by the sisterhood method in rural nothern Tanzania: a household sample and an antenatal clinic sample

OBJECTIVE

To estimate maternal mortality in two samples of a population in northern Tanzania.

SETTING

Rural communities and antenatal clinics, Mbulu and Hanang districts, Arusha region, Tanzania.

POPULATION

From a household survey 2,043 men and women aged 15-60, and from an antenatal clinic survey 4,172 women aged 15-59.

METHOD

The indirect sisterhood method.

MAIN OUTCOME MEASURES

The risk of maternal deaths per 100,000 live births (maternal mortality ratio), and the lifetime risk of a maternal death.

RESULTS

The risk of a maternal death per 100,000 live births was 362 (95% CI 269-456) and 444 (95% CI 371-517) for the household and antenatal clinic surveys, respectively. The lifetime risk of maternal death was 1 in 38 and 1 in 31, respectively, for the two surveys. A significantly lower risk of maternal death was observed for the respondents attending antenatal clinics closer to the hospital than for those attending clinics further away: 325 (95% CI 237-413) compared with 561 (95% CI 446-677) per 100,000 live births. Lifetime risk of maternal death was 1 in 42 and 1 in 25, respectively.

CONCLUSIONS

The risk of maternal death per 100,000 live births in this area were comparatively high, but in our survey substantially lower than in previous surveys in Tanzania. Increasing distance from the antenatal clinics to the hospital was associated with higher maternal mortality. There was no significant difference between results based on household and antenatal clinic data, suggesting that accessible health facility data using the sisterhood method may provide a basis for local assessment of maternal mortality in developing countries.

Training health workers to assess anaemia with the WHO haemoglobin colour scale

WHO recommends that all pregnant women be screened for anaemia. In rural Africa this is often done by clinical examination which is known to have variable reliability. The recently developed WHO Haemoglobin Colour Scale may be the answer to this problem as it is simple and reliable. This study examines the training procedure recommended by WHO for the Haemoglobin Colour Scale when resources are very limited. We trained 7 laboratory technicians from the Medical Research Council Laboratories Hospital, Fajara, The Gambia and 13 Community Health Nurses (CHNs) from North Bank Division East, a rural area in The Gambia, to use the Colour Scale. The CHNs used the Scale to estimate haemoglobins on all new bookings to the antenatal clinics for a period of one month and recorded how they were managed. At the end of the study period they completed a qualitative questionnaire about the scale. Both groups of trainees were successfully trained although the WHO protocol for training was impossible to follow due to resource limitations. Eight of the 13 trained CHNs used the scale in practice and recorded 307 estimations with a mean haemoglobin of 9.1 g/dl. The results were normally distributed. Six of the 9 patients with Hb readings of < 4 g/dl were managed correctly. In response to the questionnaire the CHNs thought the scale was cheap, easy and quick to use and as good as the haemoglobinometer they had used previously. The main criticism was that it was not robust enough. The development of a low-technology, cheap, simple and reliable method for measuring haemoglobin is a welcome development. However, a simpler training procedure and a standard way of measuring observer performance are necessary.

Maternal mortality in a rural district of southeastern Tanzania: an application of the sisterhood method

BACKGROUND

Deaths from maternal causes represent the leading cause of death among women of reproductive age in most developing countries. It is estimated that the highest risk occurs in Africa, with 20% of world births but 40% of the world maternal deaths. The level of maternal mortality is difficult to assess especially in countries without an adequate vital registration system. Indirect techniques are an attractive cost-effective tool to provide estimates of orders of magnitude for maternal mortality.

METHOD

The level of maternal mortality estimated by the sisterhood method is presented for a rural district in the Morogoro Region of Southeastern Tanzania and the main causes of maternal death are studied. Information from region-specific data using the sisterhood method is compared to data from other sources.

RESULTS

The maternal mortality ratio (MMR) was 448 maternal deaths per 100,000 live births (95%CI : 363-534 deaths per 100,000 live births). Maternal causes accounted for 19% of total mortality in this age group. One in 39 women who survive until reproductive age will die before age 50 due to maternal causes. The main cause of death provided by hospital data was puerperal sepsis (35%) and postpartum haemorrhage (17%); this is compatible with the main causes reported for maternal death in settings with high levels of maternal mortality, and similar to data for other regions in Tanzania. The sisterhood method provides data comparable with others, together with a cost-effective and reliable estimate for the determination of the magnitude of maternal mortality in the rural Kilombero District.

Assessment of maternal mortality and late maternal mortality among a cohort of pregnant women in Bamako, Mali

OBJECTIVE

Few prospective studies have been undertaken of maternal mortality in sub-Saharan Africa. National statistics are inadequate, and data from hospitals are often the only source of information available. Reported maternal mortality ratios may therefore show large variations within the same country, as in Mali. This study was designed to produce an estimate of the maternal mortality ratio for the population of Bamako.

DESIGN

Prospective cohort study.

SETTING

Bankoni (population 59,000), a district of Bamako (population 700,000).

POPULATION

5782 pregnant women identified during quarterly household visits.

METHODS

After enrolment, two follow up visits, at six weeks and one year after delivery, were performed to collect information on the pregnancy, its outcome, the method of delivery, the puerperium and the first year after birth. Detailed inquiries on deaths were undertaken in the community, the maternity units and the reference hospital.

MAIN OUTCOME MEASURES

Maternal mortality ratio, late maternal mortality, likely cause of death.

RESULTS

Complete data at follow up were available on 4717 women (82%) (4653 single and 64 twin pregnancies). Most of the women had antenatal care were and delivered in a district maternity hospital. There were 4580 live births (96%). Fifteen maternal deaths were recorded, yielding an overall maternal mortality ratio of 327 per 100,000 live births. Hypertensive disorders and haemorrhage were the main causes of death. Five more deaths occurred within 42 days or one year after delivery.

CONCLUSIONS

This study gave an estimate of the maternal mortality ratio for the population of Bamako, and stressed the need of better emergency obstetric care and the importance of late maternal mortality.

Retrospective follow-up of maternal deaths and their associated risk factors in a rural district of Tanzania

OBJECTIVE

To determine the maternal mortality rate in a rural district of Tanzania and to measure the incidence of causes of maternal mortality, the presence of risk factors and the relationship with social and demographic factors.

METHOD

From January to December 1993 a retrospective recording of maternal deaths was completed using verbal autopsy and networking.

RESULTS

A total of 76 deaths were found which is equivalent to a maternal mortality ratio of 961 per 100,000 live births for this 12-month period of time. The leading causes of death were postpartum haemorrhage with retained placenta, anaemia, postpartum haemorrhage without retained placenta, AIDS complex and obstructed labour (in descending order of frequency). Maternal deaths were seen irrespective of group factors such as access to a main road, presence of antenatal risk factors and contact with health care personnel or a nearby facility before death. Mortality was also present both in home and hospital deliveries (excluding hospital referrals). Antenatal care had been received by 97.2% of the mothers who died after the second trimester. The referral rate even in the presence of a known antenatal risk factor was 34.6%. Patient compliance to the referral was only 44.4%. Mothers and their families followed strong cultural beliefs even when they were detrimental to the mother's health. Maternal deaths were proportionately higher among women > 40 who were also gravid > or = 5, but there was no significant increase in deaths in women < 19 years of age.

CONCLUSION

Effective antenatal care, appropriate emergency treatment of complications, access to transportation and competent referral level care with adequate equipment encompass the most effective answers to reduction of maternal deaths at a district level.

Maternal mortality in the main referral hospital in The Gambia, west Africa

A retrospective analysis of 78 maternal deaths was performed during 1991-1992 to estimate maternal mortality at the maternity unit of the main tertiary level hospital in The Gambia. The non-abortion maternal mortality ratio (MMR) was 736 per 100 000 live births. Among the direct causes, haemorrhage caused most deaths (24%), followed by hypertensive disorders in pregnancy (HDP) (21%). Sepsis was the main cause of death in 15%. Anaemia led among the indirect causes of death (8%) and was a co-factor in 41% of all deaths. Substandard care factors other than medical causes were determined involving health care facilities, staff, drugs and equipment, and patient-related factors. Well known risk factors of low age (< or = 19 years) and nulliparity were highly represented in the maternal death group, and delivery by Caesarean section occurred more than threefold compared to the overall Caesarean section rate. Taking haemorrhage as an example, it is demonstrated that the way diagnoses are grouped significantly affects the statistical elaboration of maternal deaths.

Primary reproductive health care in Tanzania

The introduction of community based reproductive health care programmes in Tanzania integrated within primary health care (PHC) programmes is discussed. These programmes should address safe motherhood, fertility awareness and sexually transmitted diseases (STDs), including AIDS. It is argued that the proposed primary reproductive health care programmes will only be sustainable if community participation is achieved, and if combined with improved woman and child health programmes. Sensitized communities, who have learned how to prioritize the problems identified and the appropriate actions to take, will have to be linked at the local level with well trained and supervised health workers, having proper equipment and supplies. A limited number of measurable indicators should give feedback on progress at any given time to both communities and health workers on mutually agreed objectives. The requirements demanded for these programmes add to the difficulties of a health service which experiences already considerable financial and other constraints. Major improvement in the financial support will be needed to raise quality and confidence in the health care system. Supplementation of domestic resources by considerable long-term external donor assistance is essential for filling the resource gap. Further, a more efficient and effective use of resources is required. This makes substantial health system reform and reallocation of public spending important, as well as consistent and coordinated support for district health systems.

Maternal mortality in a Kenyan pastoralist population

OBJECTIVE

To measure maternal mortality among the Gabbra, a group of nomadic pastoralists living in a remote area of Kenya.

METHOD

As part of a survey of 851 households, information on the number of sisters of respondents who died of pregnancy-related causes was collected and the data were used to calculate maternal mortality statistics using the sisterhood (an indirect) method.

RESULTS

The maternal mortality ratio for this population was 599 deaths per 100,000 births (95% C.I. 424-775). The lifetime risk of dying around childbirth is 1 in 30, and the proportion of ever-married sisters that died under 50 years of age who died from maternal causes is 0.48 (95% C.I. 0.38-0.58).

CONCLUSION

The risk of dying of maternal causes is high in this population.