By : B Gianetti, KE Musakanya, A Ngomah Moraes, C Chizuni, C Groeneveld, M Kapina, R Hamoonga, ML Mazaba, V Mukonka
Zambia National Public Health Institute
Globally, about 830 women die each day due to complications during pregnancy and childbirth [1]. In 2017 maternal associated causes were the fourth leading cause of death in Zambian women of childbearing age [2]. Zambia routinely reports maternal death occurrences and conducts investigations to determine causality. To understand trends in maternal deaths in Zambia, we performed a review of routinely reported maternal deaths using the 2018 Maternal Perinatal Death Surveillance Review. In 2018 Zambia reported 674 maternal deaths (MMR: 183 deaths per 100,000 live births). The primary causes of maternal deaths were obstetric hemorrhage and indirect causes. Obstetric hemorrhage was the most common cause of death among women ages 30-49 and women who had experienced more than one pregnancy, while indirect causes attributed to the most deaths among pregnant women ages 10-29 and first-time pregnant women. Despite committing to improve maternal health by endorsing the United Nations Sustainable Development Goals (SDG), Zambia is behind in achieving the third SDG of a maternal mortality ratio of less than 70 maternal deaths per 100,000 live births [3]. To actualize this goal, Zambia must continue comprehensive surveillance of maternal deaths as well as increase access to family planning services, quality antenatal care services, skilled birth attendants, and emergency obstetric care.
Introduction
In 2015 an estimated 303,000 maternal deaths occurred worldwide, the majority of which happened in low and middle income countries [1]. The World Health Organisation (WHO) defines a maternal death as: the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes [4]. Maternal deaths are subdivided into two groups: direct obstetric deaths and indirect obstetric deaths. Direct obstetric deaths are defined as those resulting from obstetric complications during pregnancy, labour and the puerperium, or from interventions, omissions, and incorrect treatment. The cause of direct obstetric deaths is further classified as: pregnancies with an abortive outcome, hypertensive disorders, obstetric haemorrhage, pregnancy-related infection, obstructive labour, and unanticipated complications [4]. Indirect obstetric deaths are those caused by the aggravation of preexisting disease or disease that developed during pregnancy by the physiologic effects of pregnancy. Indirect obstetric deaths may result from cardiac disease, skeletal disease, neoplasms, endocrine conditions, autoimmune disorders, and infections, such as HIV, tuberculosis, and malaria [4]. A systematic review of global maternal deaths found that about three quarters of maternal deaths were due to direct causes and a quarter to indirect causes. Of the direct causes of maternal death, the leading causes were obstetric hemorrhage followed by hypertensive disorders and pregnancy related infections [5].
With an average total fertility rate of 4.98 births per woman among Zambian women ages 15-49 years, the population of Zambia is growing steadily [6]. However maternal mortality is a major cause of death among women. In 2017 maternal associated causes were the fourth leading cause of death in Zambian women of childbearing age [2]. According to the Saving Mothers, Giving Life Maternal Mortality Endline Census in Zambia (SMGL), maternal deaths accounted for 17.2% of all deaths in women ages 15-49 years in surveyed districts [7].
Improving maternal health is included in the third goal of the United Nations Sustainable Development Goals (SDG) framework, to which Zambia
subscribes [3]. Furthermore, maternal health is also highlighted as a primary focus in the UN Global Strategy for Women’s, Children’s and Adolescents’ Health [8]. Between 1990 and 2013, Zambia’s annualized rate of decline in maternal deaths was 0.56%. At its current rate, Zambia is not on track to reach the third SDG’s goal of a maternal mortality ratio of less than 70 maternal deaths per 100,000 live births by 2030 [3]. Understanding the underlying causes of maternal deaths through routine surveillance is crucial for reducing mortality. In this report we present a review of routinely reported maternal deaths from the 2018 Maternal Perinatal Death Surveillance Review reports in an attempt to further comprehend the nature of maternal deaths and help target policy to mitigate the burden.
Methods
Informed by an increase in maternal deaths reported by the Integrated Disease Surveillance and Response reports, we conducted a comprehensive retrospective analysis of maternal mortality data collected using the Maternal Perinatal Death Surveillance Review (MPDSR) reports from public facilities between January 2018 and January 2019. The MPDSR database is compiled by and housed in the Ministry of Health. The epidemiological week, age, location, place of death, parity, gravidity, and cause of death for each maternal death were extracted from the weekly 2018 MPDSR reports and analyzed using Microsoft Excel, Tableau, and qGIS.
Results
Six hundred and seventy four maternal deaths were reported in the 2018 MPDSR reports collated from public facilities. Of those, 38.7% of all deaths were caused
by obstetric hemorrhage, 28.3% by indirect causes, 13.1% by hypertensive disorders, 6.8% by pregnancy related infection, 5.9% by abortive outcomes, 5.3% by unknown or undocumented causes, 1.3% by unanticipated complications, and 0.4% by obstructed labour (Table 1). Maternal deaths occurred at a consistent rate throughout the year (Figure 1). Maternal deaths were reported from public facilities in all ten provinces and 101 of 117 districts throughout Zambia (Figure 2a and 2b). Lusaka province reported the highest number of maternal deaths (115 deaths) followed by Eastern (87 deaths)
and Southern (82 deaths) provinces (Table 1 and Figure 2a). Over three fourths of all maternal deaths were reported from hospitals: 37.5% from district level hospitals, 25.3% from central hospitals, and 15.3% from general hospitals (Table 2). The remaining deaths were reported from health centres (10.7%), health posts (1.8%), and the community (8.8%) (Table 2).
Seventeen percent of the maternal deaths reported among first-time pregnant women (primegravidas) were due to obstetric hemorrhage. However, hemorrhages accounted for 34% of maternal
deaths among women classified as multiparas (1-3 previous births) and nearly half (51%) of maternal deaths reported among women classified as gradmultiparas (four or more previous births) (Table 1). The most common cause of death among first-time pregnancies was indirect causes (39.0%). Indirect causes were also the most common cause of death among pregnant women ages 10-19 and 20-29 years of age (Table 1). Obstetric hemorrhage was the most common form of death among pregnant women
Figure 2:
Table 1: Overview of maternal deaths in Zambia (2018)
Table 2: Maternal deaths by delivery site (2018)
Discussion
Over six hundred maternal deaths were reported in 2018, of which the primary causes were obstetric hemorrhage and indirect causes. Obstetric hemorrhage was most common among older women and women who had experienced multiple pregnancies; whereas indirect causes were the leading cause of maternal deaths in younger women and first-time pregnant women
Most maternal deaths are preventable. Obstetric hemorrhages are often observed in regions with poor access to health services and can be exacerbated by comorbidities such as anemia, malnutrition, and malaria. Risk factors for obstetric hemorrhage include multiple pregnancies, being over 30 years of age, anemia, abnormal placental attachment, and prior caesarean section [9]. The indirect causes of maternal death consisted of anemia, malaria, HIV related complications, cancers, and cardiac disease. Previous reports have shown that malaria contributes significantly to maternal mortality in Zambia [10]. Most maternal deaths can be avoided by addressing inadequacies in antenatal care (ANC), delays in treatment, and lack of emergency obstetric care during the delivery.
In 2016, an estimated 92% of pregnant women in Zambia received antenatal care (ANC) from a skilled provider, such as a doctor or midwife, while 6% received care from a person with no formal training. Only 2% of pregnant women reported not having sought any form of ANC [7]. Data from the MPDSR for 2018 revealed that 25% of pregnant women attended their first ANC visit during the first trimester, 27% in the second trimester, and 29% in the third trimester. Suggesting that while pregnant women are receiving ANC, many are beginning care at a late stage in their pregnancies. Furthermore, an assessment of ANC care indicated that nearly 70% of women who sought ANC in Zambia received suboptimal services [11].
In 2016, an estimated 92% of pregnant women in Zambia received antenatal care (ANC) from a skilled provider, such as a doctor or midwife, while 6% received care from a person with no formal training. Only 2% of pregnant women reported not having sought any form of ANC [7]. Data from the MPDSR for 2018 revealed that 25% of pregnant women attended their first ANC visit during the first trimester, 27% in the second trimester, and 29% in the third trimester. Suggesting that while pregnant women are receiving ANC, many are beginning care at a late stage in their pregnancies. Furthermore, an assessment of ANC care indicated that nearly 70% of women who sought ANC in Zambia received suboptimal services [11].
A case study of maternal deaths in Lundazi district in Eastern province, Zambia found that delays in access to care were the primary factors associated with maternal deaths and complications [12]. The 2015-2016 Zambia Sample Vital Registration with Verbal Autopsy Report (SAVVY) examined which delays involving access to care were associated with the greatest risk of maternal mortality. Delays associated with the decision to seek medical care were sited by 68.4% of maternal deaths reported. Delays associated with accessing or reaching a health facility were reported by 31.5% of maternal deaths, and delays associated with access to treatment upon reaching a health facility were sited by 28.4% of reported maternal deaths [13]. In Lundazi, the majority of maternal deaths lived more than five kilometres from a health facility and had low levels of literacy, indicating that long distances, and lack of maternal education may have resulted in delays to care [12]. Additional reports also found that long distances from health facilities with emergency obstetric care capability was a major risk for maternal death in Zambia [14]. Delays in decisions to seek care in Zambia were also influenced by ingrained cultural birth practice beliefs [15,16].
Poor case management and lack of skilled personnel was identified as a leading cause of maternal deaths in an assessment of maternal deaths in Copperbelt province [17]. In our review, over 90% of the maternal deaths reported occurred within a health facility. However, MPDSR data indicated that skilled birth attendants only conducted 59% of institutional deliveries in 2018. Better staffing of health facilities, training of personnel, and infrastructure to provide emergency obstetric care are required to decrease maternal mortality.
Continued surveillance of maternal deaths is required to identify gaps in antenatal and maternal care accessibility and quality. Upon reporting of a maternal death in Zambia, an investigation is launched within 24 hours to determine the cause of death. Currently, the Ministry of Health coordinates the MPDSR database. Maternal deaths are also electronically documented using the District Health Information System 2 (DHIS2) and the national Health Management Information System (HMIS) as well as captured on a weekly basis in the Integrated Disease Surveillance and Response (IDSR) reports. In addition to the electronic reporting systems, maternal deaths are reported in a paper-based format and sent to the Ministry of Health on a weekly basis. Discrepancies in the multiple surveillance databases make it difficult to ascertain the true number of maternal deaths, and require a platform on which data from all surveillance systems can be collected and collated. Zambia has already begun enhancing its surveillance efforts. The introduction of Event Based Surveillance is leading to higher reporting of community based maternal deaths. However, electronic integration of national maternal death data is required to provide a comprehensive view of maternal mortality in Zambia.
Conclusions and Recommendations
The review of the 2018 MPDSR indicates a total of over six hundred maternal deaths translating to a MMR of 183 deaths per 100,000 live births. According to the Zambia National Health Strategic Plan, the nation aims to reduce the maternal mortality ratio to less than 100 deaths per 100,000 live births by 2021. In order to decrease the MMR to reach the target established by the ZNHSP, Zambia must continue comprehensive surveillance as well as increase access to family planning services, antenatal care services, skilled birth attendants, and emergency obstetric and neonatal care.
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