Association between maternal mortality and caesarean section in Ethiopia: A national cross-sectional study

BMC Pregnancy and Childbirth, Volume 20, No. 1, Year 2020

Interpretation

Background: Several studies concluded that there is a reduction of maternal deaths with improved access to caesarean section, while other studies showed the existence of a direct association between the two variables. In Ethiopia, literature about the association between maternal mortality and caesarean section is scarce. This study was aimed to assess the association between maternal mortality ratios and caesarean section rates in hospitals in Ethiopia. Methods: Analysis was done of a national maternal health dataset of 293 hospitals that accessed from the Ethiopian Public Health Institute. Hospital specific characteristics, maternal mortality ratios and caesarean section rates were described. Pearson’s correlation coefficient was used to determine the direction of association between maternal mortality ratios and caesarean section rate, taking regions into consideration. Presence of a linear association between these variables was declared statistically significant at p-value < 0.05. Results: The overall maternal mortality ratio in Ethiopian hospitals was 149 (95% CI: 136-162) per 100,000 livebirths. There was significant regional variation in maternal mortality ratios, ranging from 74 (95% CI: 51-104) per 100,000 livebirths in Tigray region to 548 (95% CI: 251-1,037) in Afar region. The average annual caesarean section rate in hospitals was 20.3% (95% CI: 20.2-20.5). The highest caesarean section rate of 38.5% (95% CI: 38.1-38.9) was observed in Addis Ababa, while the lowest rate of 5.7% (95% CI: 5.2-6.2) occurred in Somali region. At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates. Similarly, unlike in other regions, there were inverse associations between maternal mortality ratios and caesarean section rates in Addis Ababa, Afar Oromia and Somali, although associations were not statistically significant. Conclusions: At national level, a statistically non-significant inverse association was observed between maternal mortality ratios and caesarean section rates in hospitals, although there were regional variations. Additional studies with a stronger design should be conducted to assess the association between population-based maternal mortality ratios and caesarean section rates. This study was designed to analyse secondary data of the Ethiopian EmONC assessment survey of 2016. Data about all maternal and neonatal health services in hospitals from 1st January 2015 to 31st December 2015 were retrospectively collected from May to December 2016. The Ethiopian Public Health Institute (EPHI) conducted this survey to assess the status of maternal and neonatal health indicators in Ethiopia [20]. Ethiopia is a multicultural country located in the horn of Africa. The country is a Federal Democratic Republic of nine regional states, namely, Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz, Southern Nations Nationalities and People Region (SNNPR), Gambella, and Harari and two city administrations (Addis Ababa city administration and Dire Dawa city council). With a population of 109,302,118, Ethiopia is the second most populous country in Africa after Nigeria. The Ethiopian health system is structured into a three-tier healthcare system, which includes primary, secondary and tertiary level health care. These levels work together through a referral network. Primary level health care comprise of primary health care units (PHCU) that are networked with district hospitals. A PHCU consists of one health center (HC) and five satellite health posts (HPs). A HC, serving approximately 25,000 people, is used as referral center for HPs, the most proximal health facility to the community and serving approximately 5,000 people. HCs are also serving as practical training sites for health extension workers (HEWs), who are health care providers working in HPs. Primary district hospitals provide inpatient and ambulatory services, including comprehensive emergency obstetric care for a population of up to 100,000. Secondary level health care consists of a general hospital and provides general health services for an average of 1,000,000 people. It serves as referral center for primary level healthcare and training center for health officers, nurses and emergency surgeons. Tertiary level health care is the highest level and has a specialized hospital, which serves an average of five million people. It provides specialized services and is used as a referral center for general hospitals [21]. CS is provided in hospitals at all levels, in primary hospitals by emergency surgical officers (health officers trained in emergency surgery) [22] in consultation with obstetricians and in general and tertiary hospitals by obstetricians. Cases are referred to higher levels of care based on severity. In the last two decades, significant maternal and child health improvements have been observed as the government of Ethiopia invested mainly in health system strengthening. As a result, in 2016, the MMR reduced to 412 per 100,000 live births from a very high baseline of 1,400 per 100,000 live births in 2000 (a 69% reduction). Total fertility rate dropped from 7.7 to 1990 to 4.1 in 2014, which may be explained by an increased contraceptive prevalence rate from 3–42% in the same period. In Ethiopia, trends of maternal health utilization have been increasing over the last two decades. For example, antenatal care from skilled providers increased by 46% over the last 14 years (from 28% in 2005 to 74% in 2019). Over the same period, births in health facilities increased by 43% from 5% in 2005 to 48% in 2019, and the percentage of women who meet the Safe Motherhood Program’s recommendation of receiving postnatal care checks within two days of birth increased to 34% in 2019 from 4.6% in 2005 [23, 24]. Generally, all public and private health facilities, which offered EmONC services, were included in the survey. All 293 private and public hospitals in Ethiopia were among the 3,804 facilities in the survey. This analysis used data of the 293 hospitals’ maternal health indicators, such as number of obstetric complications, maternal deaths, total births, live births and number of CS. The majority of the hospitals were located in the four largest regional states: Oromia (24.9%), SNNPR (20.5%), Amhara (19.1%) and Tigray (13.3%). Slightly more than half, 160 (54.6%), were primary district hospitals, while specialized tertiary hospitals accounted for 30 (10.2%) (Table 1). Regional distribution of hospitals in the 2016 Ethiopian EmONC survey All maternal deaths and all births by CS in the 293 hospitals in 2015 were included in the analysis, irrespective of the type, managing authority and location of the hospitals. Hospitals were included in the survey according to the following eligibility criteria: (1) the hospital provided delivery services in the last 12 months; and (2) the hospital was functional at the time of the data collection period. EPHI collected data about performance of the EmONC signal functions in all Ethiopian hospitals using a standardized questionnaire. Data from hospitals’ registers and patient records included number and mode of births, number of women admitted with specific obstetric complications, and number of all maternal deaths. The dependent variable is MMR in hospitals. The association between CS rates and magnitude of MMR was calculated. Assessment of the association between the dependent and the independent variables was performed by taking regional variation into account. Healthcare professionals with at least a bachelor degree were recruited and deployed to conduct data collection. During recruitment, factors such as prior experience with data collection, clinical experience and level of education were considered. They were given intensive training on interview techniques, survey tools, field procedures and a detailed review of the questionnaire. The survey was conducted under close supervision of the Technical Working Group (TWG) consisting of Averting Maternal Death and Disability (AMDD), Ethiopian Ministry of Health (MOH) and other collaborators including UNICEF, JHPIEGO, JSI, and the Ethiopian Midwives Association (EMA). In addition, regional coordinators supervised the data collection process and conducted spot-checking to ensure data quality. Initially, descriptive analysis, including frequency tables, percentages and ratios, was conducted to present facility specific characteristics, MMRs and CS rates. Then, Pearson’s correlation coefficient was performed to assess linear association between MMRs and CS rates, considering regions as covariate. Data analysis was performed with Stata version 15 software. The direction of a linear association between variables was measured using Pearson’s correlation coefficient and an association was declared statistically significant at p-value < 0.05.

AI Digest

Study Justification:

This study aimed to assess the association between maternal mortality ratios and caesarean section rates in hospitals in Ethiopia. The justification for this study is that while some studies have shown a reduction in maternal deaths with improved access to caesarean section, others have found a direct association between the two variables. However, there is limited literature on this association in Ethiopia. Therefore, this study fills a gap in knowledge and provides valuable insights into the relationship between maternal mortality and caesarean section in the Ethiopian context.

Highlights:

– The overall maternal mortality ratio in Ethiopian hospitals was 149 per 100,000 livebirths, with significant regional variation.
– The average annual caesarean section rate in hospitals was 20.3%, with the highest rate observed in Addis Ababa and the lowest rate in the Somali region.
– At the national level, there was a statistically non-significant inverse association between maternal mortality ratios and caesarean section rates.
– Regional variations were observed, with inverse associations between maternal mortality ratios and caesarean section rates in Addis Ababa, Afar, Oromia, and Somali, although not statistically significant.

Recommendations:

– Additional studies with a stronger design should be conducted to assess the association between population-based maternal mortality ratios and caesarean section rates.
– Policy makers should consider the regional variations in maternal mortality and caesarean section rates when developing strategies to improve maternal health outcomes.
– Efforts should be made to improve access to caesarean section services in regions with high maternal mortality ratios.

Key Role Players:

– Ethiopian Public Health Institute (EPHI)
– Averting Maternal Death and Disability (AMDD)
– Ethiopian Ministry of Health (MOH)
– UNICEF
– JHPIEGO
– JSI
– Ethiopian Midwives Association (EMA)

Cost Items for Planning Recommendations:

– Research personnel salaries
– Training and capacity building for data collection
– Data analysis software and tools
– Travel and logistics for data collection
– Supervision and quality control measures
– Publication and dissemination of study findings

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is a national cross-sectional study, which provides a good overview of the association between maternal mortality ratios and caesarean section rates in Ethiopian hospitals. The study used a large dataset of 293 hospitals, which increases the generalizability of the findings. The statistical analysis, including Pearson’s correlation coefficient, was appropriate for assessing the association between the variables. However, the study acknowledges that the observed association was statistically non-significant at the national level, indicating that the evidence is not very strong. To improve the strength of the evidence, future studies could consider using a longitudinal design to assess the association over time. Additionally, including more hospitals and considering other potential confounding factors, such as socioeconomic status and access to healthcare, could provide a more comprehensive understanding of the association.

Abstract

This study was designed to analyse secondary data of the Ethiopian EmONC assessment survey of 2016. Data about all maternal and neonatal health services in hospitals from 1st January 2015 to 31st December 2015 were retrospectively collected from May to December 2016. The Ethiopian Public Health Institute (EPHI) conducted this survey to assess the status of maternal and neonatal health indicators in Ethiopia [20]. Ethiopia is a multicultural country located in the horn of Africa. The country is a Federal Democratic Republic of nine regional states, namely, Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz, Southern Nations Nationalities and People Region (SNNPR), Gambella, and Harari and two city administrations (Addis Ababa city administration and Dire Dawa city council). With a population of 109,302,118, Ethiopia is the second most populous country in Africa after Nigeria. The Ethiopian health system is structured into a three-tier healthcare system, which includes primary, secondary and tertiary level health care. These levels work together through a referral network. Primary level health care comprise of primary health care units (PHCU) that are networked with district hospitals. A PHCU consists of one health center (HC) and five satellite health posts (HPs). A HC, serving approximately 25,000 people, is used as referral center for HPs, the most proximal health facility to the community and serving approximately 5,000 people. HCs are also serving as practical training sites for health extension workers (HEWs), who are health care providers working in HPs. Primary district hospitals provide inpatient and ambulatory services, including comprehensive emergency obstetric care for a population of up to 100,000. Secondary level health care consists of a general hospital and provides general health services for an average of 1,000,000 people. It serves as referral center for primary level healthcare and training center for health officers, nurses and emergency surgeons. Tertiary level health care is the highest level and has a specialized hospital, which serves an average of five million people. It provides specialized services and is used as a referral center for general hospitals [21]. CS is provided in hospitals at all levels, in primary hospitals by emergency surgical officers (health officers trained in emergency surgery) [22] in consultation with obstetricians and in general and tertiary hospitals by obstetricians. Cases are referred to higher levels of care based on severity. In the last two decades, significant maternal and child health improvements have been observed as the government of Ethiopia invested mainly in health system strengthening. As a result, in 2016, the MMR reduced to 412 per 100,000 live births from a very high baseline of 1,400 per 100,000 live births in 2000 (a 69% reduction). Total fertility rate dropped from 7.7 to 1990 to 4.1 in 2014, which may be explained by an increased contraceptive prevalence rate from 3–42% in the same period. In Ethiopia, trends of maternal health utilization have been increasing over the last two decades. For example, antenatal care from skilled providers increased by 46% over the last 14 years (from 28% in 2005 to 74% in 2019). Over the same period, births in health facilities increased by 43% from 5% in 2005 to 48% in 2019, and the percentage of women who meet the Safe Motherhood Program’s recommendation of receiving postnatal care checks within two days of birth increased to 34% in 2019 from 4.6% in 2005 [23, 24]. Generally, all public and private health facilities, which offered EmONC services, were included in the survey. All 293 private and public hospitals in Ethiopia were among the 3,804 facilities in the survey. This analysis used data of the 293 hospitals’ maternal health indicators, such as number of obstetric complications, maternal deaths, total births, live births and number of CS. The majority of the hospitals were located in the four largest regional states: Oromia (24.9%), SNNPR (20.5%), Amhara (19.1%) and Tigray (13.3%). Slightly more than half, 160 (54.6%), were primary district hospitals, while specialized tertiary hospitals accounted for 30 (10.2%) (Table 1). Regional distribution of hospitals in the 2016 Ethiopian EmONC survey All maternal deaths and all births by CS in the 293 hospitals in 2015 were included in the analysis, irrespective of the type, managing authority and location of the hospitals. Hospitals were included in the survey according to the following eligibility criteria: (1) the hospital provided delivery services in the last 12 months; and (2) the hospital was functional at the time of the data collection period. EPHI collected data about performance of the EmONC signal functions in all Ethiopian hospitals using a standardized questionnaire. Data from hospitals’ registers and patient records included number and mode of births, number of women admitted with specific obstetric complications, and number of all maternal deaths. The dependent variable is MMR in hospitals. The association between CS rates and magnitude of MMR was calculated. Assessment of the association between the dependent and the independent variables was performed by taking regional variation into account. Healthcare professionals with at least a bachelor degree were recruited and deployed to conduct data collection. During recruitment, factors such as prior experience with data collection, clinical experience and level of education were considered. They were given intensive training on interview techniques, survey tools, field procedures and a detailed review of the questionnaire. The survey was conducted under close supervision of the Technical Working Group (TWG) consisting of Averting Maternal Death and Disability (AMDD), Ethiopian Ministry of Health (MOH) and other collaborators including UNICEF, JHPIEGO, JSI, and the Ethiopian Midwives Association (EMA). In addition, regional coordinators supervised the data collection process and conducted spot-checking to ensure data quality. Initially, descriptive analysis, including frequency tables, percentages and ratios, was conducted to present facility specific characteristics, MMRs and CS rates. Then, Pearson’s correlation coefficient was performed to assess linear association between MMRs and CS rates, considering regions as covariate. Data analysis was performed with Stata version 15 software. The direction of a linear association between variables was measured using Pearson’s correlation coefficient and an association was declared statistically significant at p-value < 0.05.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Telemedicine and Teleconsultation: Implementing telemedicine and teleconsultation services can help connect healthcare providers in remote areas with specialists in urban areas. This can improve access to specialized care and allow for timely consultations and advice for complicated cases.

2. Mobile Health (mHealth) Applications: Developing mobile health applications that provide information and resources related to maternal health can empower women with knowledge and help them make informed decisions about their healthcare. These apps can provide information on prenatal care, nutrition, and postnatal care, as well as reminders for appointments and medication.

3. Community Health Workers: Training and deploying community health workers can help bridge the gap between healthcare facilities and remote communities. These workers can provide basic prenatal and postnatal care, educate women on healthy practices, and facilitate referrals to healthcare facilities when necessary.

4. Transportation and Emergency Referral Systems: Improving transportation infrastructure and implementing emergency referral systems can ensure that pregnant women have timely access to healthcare facilities in case of complications. This can involve setting up emergency helplines, providing ambulances or transportation vouchers, and establishing partnerships with local transportation providers.

5. Maternal Waiting Homes: Establishing maternal waiting homes near healthcare facilities can provide a safe and comfortable place for pregnant women to stay during the final weeks of pregnancy. This can ensure that they are close to the facility when labor begins, reducing delays in accessing care.

6. Capacity Building and Training: Investing in the training and capacity building of healthcare providers, particularly in rural areas, can improve the quality of maternal healthcare services. This can include training on emergency obstetric care, neonatal resuscitation, and management of complications during childbirth.

7. Financial Incentives and Insurance Schemes: Implementing financial incentives for healthcare providers who offer quality maternal healthcare services can help improve access and quality of care. Additionally, introducing or expanding insurance schemes that cover maternal health services can reduce financial barriers for women seeking care.

It is important to note that the specific context and needs of Ethiopia should be taken into consideration when implementing these innovations.

AI Innovations Description

Based on the study titled “Association between maternal mortality and caesarean section in Ethiopia: A national cross-sectional study,” the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthen Regional Variation Analysis: Conduct additional studies with a stronger design to assess the association between population-based maternal mortality ratios and caesarean section rates in different regions of Ethiopia. This will help identify specific areas with higher maternal mortality ratios and lower caesarean section rates, allowing for targeted interventions and resource allocation.

2. Improve Emergency Obstetric Care: Enhance the capacity of primary, secondary, and tertiary level healthcare facilities to provide comprehensive emergency obstetric care. This includes ensuring the availability of skilled healthcare providers, necessary equipment, and essential supplies for safe deliveries and emergency interventions.

3. Enhance Referral Systems: Strengthen the referral network between primary, secondary, and tertiary level healthcare facilities to ensure timely access to appropriate levels of care. This can be achieved through improved communication systems, transportation infrastructure, and coordination among healthcare providers at different levels.

4. Increase Awareness and Education: Implement awareness campaigns and educational programs to promote maternal health and encourage women to seek timely and appropriate care during pregnancy, childbirth, and postpartum. This can include educating communities about the importance of antenatal care, skilled birth attendance, and postnatal care.

5. Address Barriers to Access: Identify and address barriers that prevent women from accessing maternal health services, such as geographical distance, cultural beliefs, financial constraints, and lack of transportation. This can involve establishing mobile clinics, providing financial support for transportation, and engaging community leaders and stakeholders in promoting maternal health.

6. Continuous Monitoring and Evaluation: Establish a robust monitoring and evaluation system to track progress in improving access to maternal health services. Regularly collect and analyze data on maternal mortality ratios, caesarean section rates, and other relevant indicators to identify gaps, measure the impact of interventions, and inform evidence-based decision-making.

By implementing these recommendations, Ethiopia can work towards reducing maternal mortality rates and improving access to maternal health services across the country.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase the availability and accessibility of caesarean section (CS) services: This can be achieved by ensuring that all levels of healthcare facilities, including primary, secondary, and tertiary hospitals, have the necessary resources, equipment, and trained healthcare professionals to perform CS procedures. Additionally, efforts should be made to improve transportation infrastructure and referral systems to ensure that women in remote areas can access CS services when needed.

2. Strengthen antenatal and postnatal care services: Improving the quality and coverage of antenatal and postnatal care can help identify and manage potential complications early on, reducing the need for emergency CS procedures. This can be achieved by training healthcare providers, increasing community awareness and education about the importance of antenatal and postnatal care, and providing adequate resources and support for these services.

3. Enhance healthcare workforce capacity: Investing in the training and deployment of skilled healthcare professionals, such as obstetricians, midwives, and emergency surgical officers, can improve the availability and quality of maternal health services, including CS. This can be done through targeted recruitment, training programs, and incentives to attract and retain healthcare professionals in underserved areas.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as CS rates, maternal mortality ratios, antenatal care coverage, and postnatal care coverage.

2. Collect baseline data: Gather data on the current status of these indicators in the target population or region. This can be done through surveys, medical records, and existing databases.

3. Develop a simulation model: Create a mathematical or statistical model that incorporates the identified indicators and their relationships. This model should consider factors such as population demographics, healthcare infrastructure, availability of resources, and geographical distribution.

4. Input intervention scenarios: Introduce the recommended interventions into the simulation model. This can be done by adjusting relevant parameters, such as increasing the number of healthcare professionals, improving infrastructure, or implementing community education programs.

5. Simulate the impact: Run the simulation model with the intervention scenarios to assess the potential impact on the selected indicators. This can be done by comparing the simulated outcomes to the baseline data.

6. Analyze and interpret results: Analyze the simulated results to understand the potential effects of the interventions on improving access to maternal health. This may involve comparing different scenarios, identifying trends, and assessing the statistical significance of the findings.

7. Refine and validate the model: Continuously refine and validate the simulation model based on feedback, additional data, and real-world observations. This will help improve the accuracy and reliability of the model for future simulations and decision-making.

It is important to note that simulation models are simplifications of complex systems and should be used as tools to inform decision-making rather than definitive predictions. The methodology described above provides a general framework, and the specific details and techniques used may vary depending on the context and available data.

Authors & Co-Authors

Statistics:

Citations: 6

Authors: 4

Identifiers:

DOI: 10.1186/s12884-020-03276-1

Research Areas:

Community Interventions, Disability, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Ethiopia, Multi-Countries, Nigeria

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female