1. The Magnitude and Causes of Maternal Mortality in Rural Western Kenya, 2003-2005 Peter Ofware, Peter Ouma, Amek Nyanguara, Adazu Kubaje, Milton Njeru, T. Akun, Vandenhoudt Hilde, Mary Hamel and Kayla Laserson KEMRI/CDC Field Research Station

2. Background (1) Maternal mortality remains disturbingly high in developing countries Each year ≈ 529,000 women, mainly from developing countries, are estimated to die from complications of pregnancy (UNFPA, 2004)

3. Background (2) The recent inclusion of maternal health as one of the key UN Millennium Development Goals (MDGs) has increased its visibility on the world agenda Estimates for Kenya: –414 maternal deaths/100,000 live births (KDHS, 2003)

4. Demographic Surveillance System (DSS) v v v v v 01020Kilometers Lwak H. Asembo Gem Karemo Bondo D. H. Kombewa Sub D.H. Siaya D. H. Yala Sub D.H. * * Kisian Kisumu Continuous demographic monitoring of a geographically defined population of 220,000 individuals in Bondo and Siaya districts, Nyanza province

5. Study Rationale No definitive studies have been done to quantify the actual burden of maternal mortality in the DSS Poor health indicators in the study area, thus MMR figures expected to be higher than national average In the DSS, ante-natal care (ANC) is high (90%) but the majority (80%) deliver at home Data would facilitate the design of appropriate interventions and contribute to national policy development

6. Study Objectives To estimate the magnitude of maternal mortality in the DSS during the years 2003- 2005 To describe the causes of maternal mortality in the DSS during the years 2003- 2005

7. Methods 1 (Definitions) Maternal mortality –The death of a woman while pregnant, or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (WHO, 2004). Maternal mortality ratio (MMR) –Number of maternal deaths during a given time period per 100,000 live births during the same period.

8. Methods 2 (Definitions) Direct causes of maternal mortality –Causes resulting from pregnancy and delivery complications Indirect causes of maternal mortality –Maternal deaths not related to pregnancy and delivery

9. Methods (3) Data on births, deaths, in and out-migration collected 3 times a year Causes of death determined by verbal autopsy Analysis was done using SAS software version 9 (SAS, INC, North Carolina, USA Maternal mortality calculated as the ratio of maternal deaths to live-births

10. Magnitude of Maternal Mortality in the DSS 553Overall 3872005 6472004 6222003 MMR per 100,000 LB Year

11. Direct Causes of Maternal Mortality, 2003-2005

12. Indirect Causes of Maternal Mortality,2003-2005

13. Causes of Maternal Mortality During Pregnancy/Delivery, 2003-2005

14. Causes of Maternal Mortality 42 Days After Delivery, 2003-2005

15. Limitations Possible under-reporting of pregnancies Possible under-reporting of maternal deaths and/or live births Accuracy of verbal autopsy reports (respondent recall bias etc.) Accuracy of expert panel review of VA (misclassification) Significant reduction in MMR between 2004 and 2005 not fully explained

16. Conclusions Overall 43% of the total maternal deaths occurred as a result of direct causes –Direct: Puerperal sepsis and abortion- miscarriage were the leading causes of death (28% and 17%) –Indirect: HIV/AIDS was the leading single cause of maternal mortality in the area (40%) Maternal mortality in the study area is significantly higher than national average (553 vs. 414, P< 0.05) but decreasing

17. Recommendations To reduce the direct causes, emphasis on safe abortion/miscarriage and “clean deliveries" could reduce MMR Scaling up of HIV prevention and care could also reduce maternal mortality

18. Acknowledgments Communities in Asembo and Gem All the DSS Community interviewers All the DSS Data management team KEMRI/CDC Scientific team VA expert panel group