AUDIT of maternal deaths using longitudinal data – case of rufiji hdss By Illah Evance

Introduction Complications of childbirth and pregnancy is a leading cause of death among women of reproductive age (15-49 yrs) (Romero et al. 2007). Hence it has remained a core issue in the focus of international development efforts. Improved maternal health and safety is named as a target for the fifth millennium development goal (MDG5) set for accomplishment by the year 2015. (WHO 2007)

Introduction cont…… (MMR) in developed countries range from 5.4 to 12 per 100 000 live births while middle income countries such as Mexico reports 106 maternal deaths per 100 000 live births. (Berg et al. 2003; Dimitrakakis et al. 2001; Meili 2003) Studies have rated Africa’s maternal mortality ratio as ranging from 424 to 2151 per 100 000 live births. Tanzania - Demographic Health Survey 2004-2005 reported MMR as 578 per 100 000 live births

Justification Estimates of maternal mortality over time are critical in that it helps in planning of sexual and reproductive health programs and advocacy. In Tanzania the main source of maternal mortality estimates are Demographic and Health Surveys, due to their small samples it is not possible to produce estimates at district level. Need to use longitudinal data through the HDSS to identify the causes of maternal death and risk factors which are important in targeting interventions.

Objectives To establish the level of maternal mortality in Rufiji HDSS during the period 2002-2006. To determine the main causes of maternal deaths. To determine the risk factors associated with maternal mortality

Methodology A longitudinal study design. It involved secondary data analysis from Rufiji HDSS during the years 2002 – 2006. Sample included; All women of reproductive age between 15-49 years of age as at 1st Jan 2002 – 31st Dec 2006 Cox proportional hazard regression – risk factors

Study Variables Outcome variable Maternal death Exposure variables Marital status Maternal age Occupation Socioeconomic status Place of delivery Maternal education level

Descriptive Results There were 26 427 women ; Person Years 107 872 Total deaths 767 64 obstetric causes ; 703 non obstetric causes 15 548 Live births MMR 412 per 100 000 Live births

Obstetric causes of maternal death n = 64 Deaths

Non Obstetric causes of maternal death n = 703 Deaths

Analysis of maternal risk factors Univ. (HR P-value 95% CI ) Mult(HR P-value 95% CI ) Maternal age <19 20-29 30-39 >=40 Maternal education None primary Primary Post primary Marital status Unmarried Ever married 1 1.42 0.332 (0.697-2.906) 2.18 0.034 (1.062- 4.471) 0.90 0.837 (0.333-2.436) 1.17 0.553 (0.698-1.959) 1.40 0.488 (0.538-3.669) 0.49 0.044 (0.248-0.982) 1.56 0.316 (0.654-3.721) 2.54 0.050 (1.001-6.445) 0.82 0.779 (0.205-3.287) 0.38 0.016 (0.176-0.839)

Analysis of maternal risk factors Univ. (HR P-value 95% CI ) Mult.(HR P-value 95% CI ) Occupation unemployed Business Student Casual Employed Farm workers Cant work Other Place of delivery Health facility Outside health facility 1 1.31 0.685 (0.359-4.747) 3.04 0.145 (0.681-13.587) 0.76 0.702 (0.181-3.165) 0.90 0.904 (0.150-5.362) 0.70 0.547 (0.213-2.267) 2.67 0.396 (0.277-25.650) 1.86 0.450 (0.373-9.265) 0.93 0.807 (0.536-1.624)

Analysis of maternal risk factors Univ. (HR P-value 95% CI ) Mult.(HR P-value 95% CI ) Socio economic Quintile Poorest Poor Least poor 1 0.75 0.492 (0.328-1.708) 0.83 0.647 (0.371-1.850)

Conclusion In Rufiji - rural Tanzania Maternal mortality ratio - 412 per 100 000 live births. This was driven by high rate of haemorrhage and eclampsia which agitates us that there is an urgent need for better antenatal and obstetric care for women over thirty years. HIV/ TB, malaria and anaemia also contributed to a large proportion of deaths.

Conclusion cont…. Maternal age and marital status – were identified as risk factors for maternal deaths therefore would play a major role in identifying women of reproductive age who are at a higher risk of maternal mortality.

Recommendations Hemorrhage - should enhance prompt and appropriate life saving care which includes massage of the uterus to stimulate contractions, blood transfusion where necessary or administration of drugs. Eclampsia – do propose an urgent need for training in managing hypertensive disorders of pregnancy either through use of magnesium sulphate or other anticonvulsant drugs including careful monitoring during pregnancy.

Recommendations Cont… There is need to establish a confidential enquiry of maternal deaths (CEMD) to make extensive efforts to identify all maternal deaths through active surveillance of pregnancy related deaths as present in developed countries such as United Kingdom (UK) and South Africa.

Acknowledgments INDEPTH Network for funding and support Dr. Godfrey Mbaruku Dr. Kathleen Kahn Dr. Honorati Masanja Field and data management of Rufiji HDSS Kisumu HDSS